Employee Benefits Manual

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About the Employee Benefits Manual
This Employee Benefits Manual is a reference guide to the benefits provided by Hexaware Technologies Ltd.
for complete information on the benefit terms & conditions you please refer to the policy documents/wordings
provided by the respective insurer.

Prepared By :
Benefits Team
Global Insurance Brokers Pvt. Ltd,
One Forbes | 5th Floor |
Dr. V B Gandhi Marg | Kala Ghoda, Note: Confidential Document
Fort | Mumbai | 400001 | India
The information contained here is only a
This Benefits Manual is copyright ©2015 by summary of the employee benefit insurance
Global Insurance Brokers Pvt. Ltd. The policy documents which are kept by the
contents of this Benefits Manual may not be employer. If there is a conflict in
copied, modify, reproduced, distributed, interpretation then the terms & conditions of
republished, downloaded, displayed to third the applicable policy document will prevail.
parties, posted, stored in the retrieval
system, posted in any network computer
without the prior written permission of
Global.

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Benefits Covered

Group Medical - Employees

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Group Medical - Employees
The Group Medical policy covers expenses by the insured persons(employee & family members covered) on
account of hospitalization due to sickness or accident. The policy covers expenses incurred on room rent,
medicines, surgery etc. Expenses for hospitalization are payable only if a 24 hour hospitalization has been
taken. Under a scheme such as this the typical expense heads covered are the following: room/boarding
expenses as provided by the hospital or nursing home ; nursing expenses ; surgeon, anesthetist , medical
practitioner, consultant , specialist fees ; anesthesia, blood, oxygen, operation theater charges, surgical
appliance, medicines and drugs.; dialysis, chemotherapy, radiotherapy, and similar expenses.

Plan Information, Benefit Details & General Exclusions

Hospitalisation Procedure, Claims Document Check List & Attachments

Important FAQs

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Group Medical – Plan Information
Plan Name Group Medical Plan
Policy Holder Hexaware Technologies Ltd.
Period of the Cover Annual
Inception Date 14th August 2018
Expiry Date 13th August 2019 midnight
Insurer The New India Assurance Co. Ltd.
G2, S2-G4,S4,TRN – INR 250,000 (capped for parents upto INR 150,000)
G5,S5 – G6, S6 – INR 300,000 (capped for parents upto INR 200,000)
Sum Insured Limits G7, S7- G10, S10 – INR 350,000 (capped for parents upto INR 250,000)
G11 – G13 – INR 500,000 (capped for parents upto INR 350,000)
G14 and above – INR 1,000,000 (capped for parents upto INR 500,000)

▪ Employee
▪ Spouse
▪ 2 Dependent Children (dependent children up to 21 yrs of age, cover for 3rd child with an additional premium
Members Covered
subject to within the family scope of 1+5)
▪ 2 Dependent Parents (On Voluntary Basis – existing employees are given window period for declaring their
parents).
Geographical Limits India
Mid-Term Enrollment Allowed, only for New Joinee
Children: Day 1 to 21 years
Age-Limit
Parents : No Limit

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Group Medical – Plan Information – Covered Members & Mid Term Enrollment

Covered Members Mid Term Enrollment

Special
Particular Description Special Condition if any Particular Description
Condition if any
Mid-Term Enrollment of
Total Members Existing employees’
6 - Not Allowed
Covered per Family Dependents(as on plan start
date)
Employee Yes -
Within 30 days
Mid-Term Enrollment of New
Spouse Yes - from the date of
Joinees (New Employees Allowed *
Joining of the
+Their Dependents)
Child Yes 2 children only employee

Parent Yes - Newly married

employees’
Parent-in-Laws No - spouse & new
born children
Sibling No - Mid-Term Enrollment of New within 30 days
Dependents Allowed * from the date of
Other No - (Spouse/Children) the event
i.e. date of
marriage and
date of Birth
respectively

• No Individual should be covered as dependent of more than one employee

• Employees have to provide all the details of the new dependents for Mediclaim coverage to the respective HR within 30
days from the date of event
• Dependents once declared cannot be changed during the policy period.
• No midterm inclusion of dependents would be allowed except in case of spouse due to marriage of a employee and birth of child.

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Group Medical – Benefit Details
Policy Benefits Policy Benefits
Standard Hospitalization Covered Diagnostics Expenses Standalone diagnostic not covered
Pre-existing Diseases Covered
First 30-days Waiting Period Waived off 1.5% of Sum Insured for Normal room
Restriction on Room-Rent
2% of Sum Insured for ICU
First Year Waiting Period Waived off
Ambulance Services INR 1,000 per incidence
Pre & Post Hospitalization Expenses 30 days Pre and 60 Days post
Cataract restricted to INR 25,000 per eye.
Disease Limits
Maternity Benefits Covered Medical Management cases – INR 20,000
Maternity Limits (Normal & Caesarian INR 40,000 for Normal Day Care Procedures Covered as per insurer list
Section) INR 50,000 for C-Section
Domiciliary Hospitalization Not Covered
Pre & Post Natal Expenses Covered within maternity limit
Internal Congenital Diseases Covered

9-Months Waiting Period for Maternity Waived Off 20% copay on all claims except capped
Co-payment ailment and will be levied on admissible
Covered from Day one under claim amount.
New Born Baby cover
family sum inured
Available without any medical underwriting
Portability Benefit
requirements for all member

The above are only snapshots of the benefits provided under your group medical plan. Please write to the TPA for specific claims related queries.
IMPORTANT:- Intimation and Submission Timeframes:
Submission of claim :- TPA must receive the claim documents for all reimbursements within 45 days of discharge from hospital

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Group Medical – Additional Benefit Details
Policy Benefits Policy Benefits
Critical Illness Covered only for employees Cyber Knife /Cochlear
Implants/Septoplasty Covered up to 50% of Sum Insured
Enhancement of sum insured to double
Critical illness Sum Insured
the current sum insured.
Mortuary Charges Covered up to INR 10,000 per incident
One time lumpsum benefits of INR 20,000
addition to hospitalization claims
Covered up t o INR 30,000 for IPD
Dental & Vision Only in case accident (hospitalization) Psychiatric Treatment
hospitalization cases

Loss of Pay INR 10,000 per week Expenses for Male & Female Infertility
Infertility Treatment related Treatment up to INR 30K ( No
Bone Marrow Treatment Covered Copay)
Covered upto 50% of respective Sum
HIV Treatment Covered Robotic Surgery
Insured
Covered upto INR 5,000 within maternity
Oral medication for cancer Covered Well Baby Expenses limit and payable only during first 60 days
of childbirth
Covered - ( In the event the power is (-)7 Organ donor expenses and transportation
Lasik Surgery
or (-) 8 and Above. Organ Donor expenses cost to be covered within the scope of the
Covered under life threatening policy.
External congenital circumstance with Sum Limit of INR Cover for Disabled Children without upper
100,000 per incidence Coverage for disabled
age limit within the existing definition of
children
family.

The above are only snapshots of the benefits provided under your group medical plan. Please write to the TPA for specific claims related queries.
IMPORTANT:- Intimation and Submission Timeframes:
Submission of claim :- TPA must receive the claim documents for all reimbursements within 45 days of discharge from hospital

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Group Medical – Standard Hospitalization

If any Insured Person suffers an Illness or Accident during the Policy Period that requires Insured Person’s
hospitalization as an inpatient, then the insurer will reimburse reasonable and customary expenses towards the
below mentioned hospitalization under your group medical plan.

▪ Inpatient Treatment
▪ Room rent and boarding expenses
▪ Doctors fees ( who needs to be a medical practitioner)
▪ Intensive Care Unit
▪ Nursing expenses, Anesthesia, blood, oxygen, operation theatre charges, surgical appliances,
▪ Medicines, drugs and consumables (Dressing, ordinary splints and plaster casts)
▪ Diagnostic procedures (such as laboratory, x-ray, diagnostic tests)
▪ Costs of prosthetic devices if implanted internally during a surgical procedure
▪ Organ transplantation including the treatment costs of the donor but excluding the costs of the organ

The expenses shall be reimbursed provided they are incurred in India and are within the policy period. Expenses will be reimbursed to the covered member
depending on the level of cover that he/she is entitled to. Expenses that are of a diagnostic nature only or are incurred from a preventive perspective with no
active line of treatment and do not warrant a hospitalization admission are not covered under the plan.

It is important to note that the Insurer reserves the right to pay the claim as per reasonable and customary clause applicable on Group Mediclaim policy if the
total cost of the claim is higher than the standard cost of the particular treatment.

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Group Medical – Pre & Post Hospitalization Expenses
The pre & post hospitalization expenses are covered under your group medical plan.

If the Insured Person is diagnosed with an Illness which results in his or her Hospitalization and for which the Insurer accepts a
Pre-hospitalization
claim, the Insurer will reimburse the Insured Person’s Pre-hospitalization Expenses for up to 30 days prior to his Hospitalization
Expenses
as long as the 30 day period commences and ends within the Policy Period.

Duration Within 30 days before hospitalization

Such medical expenses must be incurred for the same condition for which the insured person’s subsequent
Restrictions
hospitalization was required.

If the Insurer accepts a claim above and, immediately following the Insured Person’s discharge, he requires further medical
Post-hospitalization
treatment directly related to the same condition for which the Insured Person was Hospitalized, the Insurer will reimburse the
Expenses
Insured Person’s Post-hospitalization Expenses

Duration Within 60 days post discharge

Such medical expenses must be incurred for the same condition for which the insured person’s subsequent
Restrictions
hospitalization was required.

Please note that although you are covered for post hospitalization claims for 60 days after discharge, you are expected to file a reimbursement claim with the
TPA within 45 days of incurring the expense.

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Group Medical – Maternity Benefits

▪ Maternity benefits are admissible only if the expenses are incurred in Hospital / Nursing Home as in-patients
in India.
▪ Those Insured Persons who already have two or more living children will not be eligible for this benefit.
▪ Expenses incurred in connection with voluntary medical termination of pregnancy during the first 12 weeks
from the date of conception are not covered.
▪ Infertility Treatment and sterilization are excluded from the policy.
The maternity benefit is provided under your group medical plan

Maximum Benefit INR 40,000 for Normal and INR 50,000 for C-Section within Sum Insured Limit

Limit Maximum up to 02 maternities

9-months waiting period Waived off

Pre-Post Natal expenses Covered within maternity limit (on OPD basis or in-patient hospitalization)

New born baby covered from day 1 Covered from day1 under family floater sum insured

Expenses incurred for medical Covered under life threatening conditions

termination of pregnancy

Complications arising out of Covered under family sum insured

pregnancy
IMPORTANT :
For maternity reimbursements and employees on subsequent maternity leave , please do not wait till you have returned back to office to submit a
claim as it will cross the claim submission within 45 days to avoid denial of claim.

Please also immediately inform your HR about the new baby coverage as your dependent as a subsequent complication may be a possibility and intimation
is mandatory prior to coverage.

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Group Medical – Other Benefits

Policy Benefit Definition Covered/Not Covered

Any Pre-Existing Condition or related condition for which care, treatment or advice was recommended
Pre-existing Diseases by or received from a Doctor or which was first manifested prior to the commencement date of the Covered
Insured Person’s first Health Insurance policy with the Insurer
First 30 day waiting Any Illness diagnosed or diagnosable within 30 days of the effective date of the Policy Period if this is
Covered
period the first Health Policy taken by the Policyholder with the Insurer.
During the first year of the operation of the policy the expenses on treatment of diseases such as
Cataract, Benign Prostatic Hypertrophy, Hysterectomy for Menorrhegia or Fibromyoma, Hernia,
First year Waiting
Hydroceie, Congenital Internal Diseases, Fistula in anus, Piles, Sinusitis and related disorders are not Waived off
Period
payable. If these diseases are pre- existing at the time of proposal they will not be covered even
during subsequent period or renewal too
1.5% of the Sum Insured per day for Normal room and 2% of the Sum Insured per day for ICU
Insured employees are requested to use prudence and proper negotiation with Hospital/ Nursing
home in availing the eligible room category.
Room Rent Covered
Please remember, higher the room category higher is the cost of treatment. This may result in faster
exhaustion of your total available eligibility. Employee opting for a higher room catergory will have to
bear the proportionate increase in cost on all categories / heads
Day Care Procedure means the course of medical treatment or a surgical procedure listed in the
Day Care Schedule which is undertaken under general or local anesthesia in a Hospital by a Doctor in not less Covered
than 2 hours and not more than 24 hours.
▪ All diagnostic tests and lab tests as part of hospitalization and pre-post hospitalization including Covered and Only
OPD. incase of 24hr
Diagnostic Expenses
hospitalization related to
▪ Diagnostic tests without treatment or not related to treatment is not covered the treatment
A term used to refer to the commonly charged or prevailing fees for healthcare services within a
geographic area. A fee is generally considered to be reasonable if it falls within the parameters of the
Reasonable and
average or commonly charged fee for the particular service within that specific community. Applicable
Customary Clause
‘Reasonable and Customary (R&C) Charge’ essentially means the same thing as ‘Usual and
Customary (U&C) Charge

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Group Medical – General Exclusions

▪ Injury or disease directly or indirectly caused by or arising from or attributable to War, Invasion, Act of Foreign
Enemy, War like operations (whether war be declared or not) or by nuclear weapons / materials.
▪ Circumcision (unless necessary for treatment of a disease not excluded hereunder or as may be necessitated due to
any accident), vaccination, inoculation or change of life or cosmetic or of aesthetic treatment of any description,
plastic surgery other than as may be necessitated due to an accident or as a part of any illness.
▪ Surgery for correction of eye sight, cost of spectacles, contact lenses, hearing aids etc.
▪ Any dental treatment or surgery which is corrective, cosmetic or of aesthetic procedure, filling of cavity, root canal
including wear and tear etc unless arising from disease or injury and which requires hospitalisation for treatment.
▪ Congenital external diseases or defects/anomalies
▪ Convalescence, general debility, “run down” condition or rest cure, congenital external diseases or defects or
anomalies, sterility, any fertility, sub-fertility or assisted conception procedure, venereal diseases, intentional self-
injury/suicide, all psychiatric and psychosomatic disorders and diseases / accident due to and or use, misuse or
abuse of drugs / alcohol or use of intoxicating substances or such abuse or addiction etc.
▪ Any cosmetic or plastic surgery except for correction of injury
▪ Expenses incurred at Hospital or Nursing Home primarily for evaluation / diagnostic purposes which is not followed
by active treatment for the ailment during the hospitalised period.
▪ Expenses on vitamins and tonics etc unless forming part of treatment for injury or disease as certified by the
attending physician.

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Group Medical – General Exclusions
▪ Doctor’s home visit charges, Attendant / Nursing charges during pre and post hospitalisation period.
▪ Treatment which is continued before hospitalization and continued even after discharge for an ailment / disease /
injury different from the one for which hospitalization was necessary.
▪ Naturopathy treatment, unproven procedure or treatment, experimental or alternative medicine and related
treatment including acupressure, acupuncture, magnetic and such other therapies etc.
▪ Genetical disorders and stem cell implantation / surgery.
▪ External and or durable Medical / Non medical equipment of any kind used for diagnosis and or treatment including
CPAP, CAPD, Infusion pump etc., Ambulatory devices i.e. walker , Crutches, Belts ,Collars ,Caps , splints, slings,
braces ,Stockings etc of any kind, Diabetic foot wear, Glucometer / Thermometer and similar related items etc and
also any medical equipment which is subsequently used at home etc..
▪ All non medical expenses including Personal comfort and convenience items or services such as telephone,
television, Aya / barber or beauty services, diet charges, baby food, cosmetics, napkins , toiletry items etc, guest
services and similar incidental expenses or services etc..
▪ Change of treatment from one pathy to other pathy unless being agreed / allowed and recommended by the
consultant under whom the treatment is taken.
▪ Treatment of obesity or condition arising therefrom (including morbid obesity) and any other weight control
programme, services or supplies etc..
▪ Any treatment required arising from Insured’s participation in any hazardous activity including but not limited to
scuba diving, motor racing, parachuting, hang gliding, rock or mountain climbing etc unless specifically agreed by
the Insurance Company.
▪ Any treatment received in convalescent home, convalescent hospital, health hydro, nature care clinic or similar
establishments.
▪ Any stay in the hospital for any domestic reason or where no active regular treatment is given by the specialist.
▪ Massages, Steam bathing, Shirodhara and alike treatment under Ayurvedic treatment.

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Group Medical – General Exclusions
▪ Any kind of Service charges, Surcharges, Admission fees / Registration charges etc levied by the hospital.
▪ Out patient Diagnostic, Medical or Surgical procedures or treatments, non-prescribed drugs and medical supplies,
Hormone replacement therapy, Sex change or treatment which results from or is in any way related to sex change.
▪ Expenses incurred for investigation or treatment irrelevant to the diseases diagnosed during hospitalisation or
primary reasons for admission. Private nursing charges, Referral fee to family doctors, Out station consultants /
Surgeons fees etc,.
▪ Vitamins and tonics unless used for treatment of injury or disease
▪ Infertility treatment, Intentional self Injury, Outpatient treatment.
▪ Family planning Operations (Vasectomy or tubectomy) etc
▪ Genetical disorders / stem cell implantation / surgery
▪ All expenses arising out of any condition directly or indirectly caused by, or associated with Human T-cell
Lymphotropic Virus Type III (HTLD - III) or Lymohadinopathy Associated Virus (LAV) or the Mutants Derivative or
Variations Deficiency Syndrome or any Syndrome or condition of similar kind commonly referred to as AIDS, HIV
and its complications including sexually transmitted diseases.
▪ External and or durable Medical / Non medical equipment of any kind used for diagnosis and or treatment like
Prosthetics etc.
▪ Lasik treatment or any other procedure for correction/enhancement of vision is not covered.
▪ Any device/instrument/machine that does not become part of the human anatomy/body but would
contribute/replace the function of an organ is not covered.
▪ Warranted that treatments on trial/experimental basis are not covered under scope of the policy.

Note: Above exclusions are only indicative, please refer Insurance Company Policy Copy for complete Standard Exclusions

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Group Medical
▪ Hospitalisation Procedure, Claims Document Check List & Attachments

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Group Medical – Hospitalization Procedure

You can avail either cashless facility or submit the claim for reimbursement.

Definition of Cashless

▪ Cashless hospitalization means the TPA may authorize (upon an Insured person’s request) for direct
settlement of eligible services and the corresponding charges between a Standard Network / PPN Network
Hospital and the TPA. In such case, the TPA will directly settle all eligible amounts with the Network Hospital
and the Insured Person may not have to pay any deposits at the commencement of the treatment or bills
after the end of treatment to the extent these services are covered under the Policy. Denial of cashless does
not mean that the treatment is not covered by the policy.

Definition of Reimbursement

▪ In case you choose a non-network hospital, you will have to liaise directly with the hospital for admission.
However, you are advised to follow the pre authorization procedure and intimate the TPA about the claim to
ensure eligibility for reimbursement of hospitalization expenses from the insurer.

▪ To know about cashless or reimbursement, please visit the desired section mentioned below:

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Group Medical – Process for Cashless

Cashless hospitalization means the Administrator may authorizes upon a Policyholder’s request for direct
settlement of eligible services and it’s according charges between a Network Hospital and the Administrator. In
such case the Administrator will directly settle all eligible amounts with the Network Hospital and the Insured
Person may not have to pay any deposits at the commencement of the treatment or bills after the end of
treatment to the extent as these services are covered under the Policy.

List of hospitals in the TPA’s network eligible for cashless hospitalization

Hospital Network List Email ID
1. Click on Website – https://www.healthindiatpa.com/ For Intimation: TPA email ID:
2. Click on Network Hospital Lists [email protected]
3. You may save this excel file on your workstation, preferred to view online For Assistance : 022-66131199
as it is updated regularly

Contact Call center at 24 X 7 Customer Service Center -

1800-2201 02
Toll Free no.’s for Senior Citizen - 1800226970

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Group Medical – Cashless Hospitalization

Planned Emergency
Hospitalization Hospitalization

Approach hospital 72 hrs. prior to

admission , produces Health India Admission in Hospital
(TPA) e-card and complete pre-
authorization formalities

The Hospital TPA helpdesk will Pre-Authorization formalities to

Fax Pre-Authorization letter to be completed within 24 hrs and
Health India for Approval send to Health India for Approval

If all the documents are in order, If all the documents are in order,
Health India will issue Health India will issue
authorization letter to hospital authorization letter to hospital
within 3 hours within 3 hours

If the case is declined, Denial If the case is declined, Denial

Letter will be issued to hospital Letter will be issued
(denial of cashless does not mean (denial of cashless does not mean
denial of treatment or claim) denial of treatment or claim)

Incase additional information is Incase additional information is

required, Health India will inform required, Health India will inform
the Hospital / Employee the Hospital / Employee

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Group Medical – Reimbursement

Collects all original

Insured visits non network Takes discharge , pays for documents, receipts and
hospital for treatment treatment investigation reports from
Hospital

Submits all original TPA Helpdesk Incase additional

Hospital documents along acknowledges receipt of information is required,
with filled claim form claim documents via email TPA will inform the
within 30 days from date and commences claim employee via email with 3
of discharge to TPA process reminders

If claim is declined, denial

If claim is payable, mail will be sent. If
payment will be made to documents are not
employee via NEFT submitted within 45 days,
claim may be declined

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Group Medical – Claims Document Check List & Attachments
No. Document Required (All in ORIGINAL)

1 Signed Claim form (KYC form is mandatory for claims above INR 100,000)

2 Main Hospital bills in original (with bill no; signed and stamped by the hospital) with all charges itemized and the original receipts

3 Discharge Card (original)

4 Attending doctors’ bills and receipts and certificate regarding diagnosis (if separate from hospital bill)

5 Original reports or attested copies of Bills and Receipts for Medicines, Investigations along with Doctors prescription in Original and Laboratory

6 Follow-up advice or letter for line of treatment after discharge from hospital, from Doctor.

7 Break up with details of Pharmacy items, Materials, Investigations even though it is there in the main bill

In case the hospital is not registered, please get a letter on the Hospital letterhead mentioning the number of beds and availability of doctors and
8
nurses round the clock.

In non- network hospitalization, please get the hospital and doctor’s registration number in Hospital letterhead and get the same signed and
9
stamped by the hospital.

10 In case of accidents, please note FIR or MLC (medico legal certificate) is mandatory.

Note: Kindly retain photo copies of all the documents. KYC – Government issued Photo ID and Address proof
The above is an indicative list and additional documents can be requested for to process a claim.

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Group Medical
▪ Important FAQs

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Group Medical – Important FAQs
▪ What are network hospitals? What should I do when I reach the hospital (NETWORK)?
These are hospitals where TPA has a tie up for the cashless hospitalization. There are two kinds of network
hospitals; PPN Network hospitals where cashless services can be obtained for emergency and planned
treatments and Standard (Non PPN) network hospitals where cashless services can be obtained for planned
hospitalisation.
Once you have reached there please show your ID card for identification. TPA will also send a letter of credit
(on pre-authorization) to the hospital to make sure that they extend credit facility. Please complete the pre-
authorization procedure listed earlier. If the pre-authorization is not done, you must collect all reports and
discharge card when you get discharged. Please make sure that you sign the hospital bill before leaving the
hospital. You can then submit the claim along with all the necessary supporting documents to TPA as a
reimbursement . If however you go to a non network hospital , it is still advisable to fill the preauthorization form
( use the copy attached with the Benefits Manual). Please fill the claim form, attach the relevant documents and
send it to TPA office for reimbursement.

▪ How can I claim my pre & post hospitalization expenses?

The policy covers pre-hospitalization expenses made prior to 60 days of hospitalization and incurred towards
the same illness/ disease due to which hospitalization happens. It also covers all medical expenses for up to 60
days post discharge as advised by the Medical Practitioner. All bills with summary have to be sent to TPA as a
reimbursement.

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Group Medical – Important FAQs
▪ What are claim reimbursements?
In the event where cashless hospitalization is not availed, you need to submit all original bills along with the
claim forms to the insurance company/TPA and the hospitalization expenses will be reimbursed to you.
▪ Is pre authorization necessary?
Yes. This will help you in the following ways:
1. You will be informed in advance regarding your coverage for the treatment and whether it is covered
under your medical plan or not . This will help you know in advance if your claim may get rejected at a later
stage and you do not end up paying out of pocket.
2. It will help you ensure that the treatment cost is appropriate and not inflated. as the TPA will be able to
cross check costs with the hospital in question. This will also help TPA in planning your hospitalization
expenditure such that you do not run out of the cover that you are entitled to.
3. It will help TPA in registering the impending claim with the insurer.
▪ What are the key points I must remember when using benefits under this policy
▪ Please ensure that all your dependents are covered and have a valid card at the outset itself as it will not
be possible to add dependents at a later stage
▪ Submit your reimbursement claims within timelines from the hospital. Please do not postpone this till later
as it may mean that your claim gets rejected due to late submission .

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Group Medical – Important FAQs
Please check that your documents are submitted completely at the first instance itself and originals are
submitted wherever requested for . Do note that incomplete submissions will not be considered as exceptions
by the insurers and will only delay the process further for you and a delay may lead to the claim getting closed.
▪ Please retain a copy of all claim documents submitted to the insurer
▪ Please do a pre-authorization for all claims including a proposed reimbursement as it will clarify issues
regarding coverage for you well in advance of an expense being undertaken.
▪ What are the key reasons why a claim under the medical policy could be completely rejected under
the plan?
The following are some common reasons for rejection although these are NOT the only reasons why a claim
could be rejected
1. Treatment taken after leaving the organization. (If you have been transferred from one GE business to
another please confirm with your HR that you have been included for coverage under your new entity)
2. Treatment that should have been taken on an outpatient basis (unnecessary inpatient admission and / or
no active line of treatment.) or where hospitalization has been done primarily from a preventive
perspective. Please remember that on occasion your personal doctor may recommend hospital admission
for observation purposes however such admissions are not covered under your medical plan

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Group Medical – Important FAQs
3. Treatment taken is not covered as per policy conditions or excluded, under the policy. Please go through
the list of standard exclusions listed earlier. (for e.g. : Ailment is a because of alcohol abuse is a standard
exclusion, similarly cosmetic treatments or treatments for external conditions like squint correction etc are
not covered) . Hospitalization taken in a hospital which is not covered as per policy conditions (Ex. less
than 10 bed hospitals), Admission is before/after the policy period or details of the member are not updated
on the insurer’s list of covered members . Additionally in case original documents are not submitted as
per the claim submission protocol,
▪ What are the key reasons why a claim under the medical policy could be reduced v/s sum insured?
The following are some common reasons for rejection although these are NOT the only reasons why a claim
could be reduced
1. Limits for the specific ailment exceed the reasonable cap on ailments listed in the manual,
2. Claim amount exceeds the permissible limit under the policy for you ( denied to the extent of the excess),
3. Some expense items are non payable for e.g. toiletries , food charges for visitors etc.

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Point of Contact details for GMC policy
Contact
Vendor Vendor Name Level Name Email ID
Number

Level 1 Nitin Pandey [email protected] 7710048096

Third
Health India
Party
Insurance Level 2 Dr. Prajakta Damkale [email protected] 8828129863
Adminis
(TPA)
trator
[email protected]
Level 3 Dr. Vinay Chimad 7738899954

Level 1 Neelam Patel [email protected] 9833301813

Global
[email protected]
Broker Insurance Level 2 Komal Baranwal 022-61845685
.in
Broker Pvt Ltd

Level 3 Aditi Biswas [email protected] 022-61415133

Note: Only the GMC policy claim documents and queries are to be sent to Health India team.

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