Who is eligible to sign up for the program?
- Any company which is a NASSCOM member is eligible for signing up for this program.
How does a company select a plan?
- A company can select a plan from among the 16 options available.
- Each company can select from among 4 sum insured options (1 Lac to 3 Lac) and 4 coverage options (A to D).
- In case a company has selected plan A (Employee only) and 1 Lac sum insured and an employee wishes to cover spouse, children and parents, the employee can do so by paying additional premium.
- Premium payable for the optional cover can be paid through net-banking/credit card/debit card through a secure payment gateway.
- A company can select grade wise sum insured provided there are a minimum of 50 employees per grade selected
How does the enrolment happen?
- The company sends the employee data to as per the format provided.
- Medimanage sends mails to employees inviting them to add the family members.
- Medimanage computes the premium for the base plan and communicates to the company.
- The company has the option of paying the premium for the base plan as well as the members added by the employee or allow the employee to pay for members not part of the base plan.
- In the event the company pays for the family members opted by the employee, Medimanage will provide a bifurcation of premium to the company.
- The company issues the cheque in the name of “The Oriental Insurance Company Ltd”.
- If the employee is paying for the optional cover he/she can use the payment gateway on the Medimanage site and pay to Oriental Insurance.
Will there be a premium received confirmation?
- Yes, there will be a premium received confirmation by e-mail and SMS.
Will the cover be from day 1?
- Yes, the cover will be from day 1 subject to the member being enrolled, premium balance being available in the CD account and the relevant terms of the policy.
Who all can an employee cover?
- Other than self an employee can cover upto 7 members in this policy.
- The family members could be spouse, first 2 children, parents and parents in law.
Is there a flexibility of paying in installments?
- No, the premium has to be paid in one go.
What will be the policy period?
- Each company will have a 12 month policy starting from the date premium is paid to the insurer.
- So, if a company joins the program on 1st April 2012, the policy for that company will come up for renewal on 31st March 2013.
What will a company receive after paying premium?
- A premium receipt in 03 workings days.
- A policy document in 10 working days.
What will a company receive on a month on month basis from the insurer?
- Endorsement document (if any) listing the members added, members deleted and premium collected.
- CD statement.
How will the refund happen to a company?
- This will be at the end of the policy period.
- The net of the total additions and deletions will be refunded vide cheque.
How will the refund happen to employees leaving the organization?
- This is applicable only to those employees who have paid premium.
- A monthly statement giving the details of the premium received from the company and from the employee will be provided.
- This list will also have the deletions and the pro-rata premium refund figures for employees who have paid the premium.
- The company pays the monies to the employee and collects the same at the end of the year from the insurer through the refund cheque.
When does the Insurance cover end for an employee & family members?
- At the end of the policy period.
- When the employee leaves the organization.
What happens if an employee has not logged in and enrolled for any of the options?
- The employee will be covered in the policy by default.
- Family members will be covered from the date of enrolment.
- Any claim for a family falling before the enrolment date will be repudiated.
- Every employee has a period of 30 days from the date of policy inception or his DOJ (as the case may be) to enroll family from the available options.
Can parents / parents in law be enrolled in the middle of the policy period?
- Parents/parents in law can be enrolled in the middle of the policy period.
- Exclusions listed in the policy will be applicable till the end of the policy term.
- If they are included at the policy inception or DOJ then the exclusions are not applicable.
Can an employee add 1 parent and 1 parent in law?
- No. It has to be either parents or parents in law.
Is there a facility for cover of self + spouse + children + parent-in-laws?
- Yes, an employee can cover parents in law.
- Please note the cover is either for parents or in-laws. You cannot cover one parent and one in-law.
What is the add-on cover?
- The add-on cover is for a set of parents / parents in law. It is an optional cover.
- This cover can be used along with the base cover.
- This cover will come into play once the base sum insured is exhausted.
- The employee must cover the parents/parents in law in the base plan to opt for this cover.
How does the add-on cover work?
- An employee is covered under a 1 Lac E+S+2C base plan.
- He/she adds parents to this plan to make it E+S+2C+2P.
- Now, the employee opts for the 2 Lac add-on cover for the parents.
- This makes the available sum insured for the parents is 1 + 2 = 3 Lacs.
- All terms and conditions (including the room limits) will be as per the base policy.
- The add-on sum insured will kick in once the base sum insured is exhausted.
Can the add-on cover be taken midterm?
- Yes, the ad-on cover can be taken midterm.
- This will be subject to the policy conditions
Would the premium differ if only one kid or one parent is to be insured?
- No, the premium is on a floater basis and hence will not differ for one child or one parent.
Can maternity benefit be availed for the 3rd child?
- No, it is available for the first 2 children only.
- The employee will have to make a declaration in the cashless form.
Are there any limits in this plan?
Yes, there are some limits.
- Co-pay on parent claims - 10% on all admissible claims.
- Cap on 6 ailments – As per detailed policy
- Co-pay on procedures – non tertiary care procedures carried out in tertiary care centers attract 10% co-pay. List as per detailed policy
- Maternity upto INR 50K for normal as well as cesarean section.
- Room Rent (Nursing & boarding charges) limited to 2% of the sum insured per day or INR 5,000/= whichever is lower.
- ICU Charges limited to 4% of the sum insured per or INR 10,000 per day whichever is lower.
- Other charges linked to room rent (Doctor Fees, Surgeon fees, Anaesthesia charges, OT Charges, etc will be as per entitled class of occupancy).
Opt for a room whose rent is within one’s eligibility. In case, one opts for a room higher than the eligibility, the entire claim amount would be deducted in proportion of the room rent availed & the eligible room rent.
Is there any Income tax benefit for an employee paying part/the entire premium?
- Yes, under section 80 D, limited to INR 15,000/= for self, spouse, kids.
- Additional INR 15,000 for parents (if they are not senior citizens).
- INR 20,000 if the parents are senior citizens.
What is the age eligibility criterion for children, parents or parent-in-laws?
- a. Children of age below 21 years and parents/parents-in-laws below 80 yrs can only be covered under this plan.
How does an employee know that family members are insured?
(Please note that each insured family member gets individual card. So if one of the family members does not get a card, chances are that the member is not insured. In such events, immediately contact our Health Plan Coordinator through our portal OR get in touch with their voice contacts as mentioned at the end of this document.)
- After enrolment, an ID card from the TPA will be made available on the portal.
- This is a confirmation that the employee & family members are insured.
Can an employee cover spouse and children in the middle of the policy period?
- Yes, an employee can cover spouse within 30 days of marriage and child within 30 days of child birth.
- If an employee fails to cover the within this time period then the cover can be taken only at the time of renewal.
- If an employee is covered under the E+S+2C plan for which premium has already been paid, spouse and children can be covered midterm. Any claim for the member/s falling before the enrolment date will be repudiated
An employee has insured spouse & parents on an optional basis under the E+S+2C+2P plan. Is there a need to intimate insurer when the first Child is born? Is there a need to pay additional premium?
- Yes, to get the insurance cover for the baby from day one of his/her birth, the employee MUST intimate Medimanage (thru’ My Communication tab on Dashboard on portal www.medimanage.com ) at least 2 months in advance or must intimate within 30 days from the date of birth of new born.
- need The employee not have to pay any extra premium.
What are the broad benefits under Hospitalization Benefit Plan?
- Self, the eligible & insured family members would get paid expenses incurred due to hospitalization. The hospitalization must fulfill following conditions:
- Total stay in hospital should be more than 24 hours
- Hospitalization is applicable for treatment of a disease or illness and the treatment given could not have been administered on Out-Patient basis.Total stay in hospital should be more than 24 hours
- Hospital should have more than 15 beds in Metro Cities OR is registered with the local authorities (this condition is relaxed to 10 beds for Non-Metro cities)
- Hospitalization covers various components of expenses like Stay Charges, Operation charges, and Doctor’s fees, Nursing Charges, Investigations & Diagnostics Charges and Medicines etc.
- Daycare procedures are covered.
What are the additional benefits under this Plan?
Please note that Pre & Post-Hospitalization expenses are not payable when the claim is towards Maternity Benefit (they are called Pre-natal & Post-natal expenses when the hospitalization is for Maternity)
- In addition to the expenses being paid for the hospitalization, one can get reimbursement of expenses incurred for same disease/illness 30 days prior to the Date of Admission to Hospital (Called Pre-Hospitalization Expenses). This could be the doctor’s fees, Preliminary investigations & diagnostics and the medicine charges. One can also get reimbursement of expenses incurred for same disease / illness 60 days after the Date of Discharge from the hospital (Called Post- Hospitalization Expenses). This could be follow-up consultations with doctors, Medicines & confirmatory diagnostics etc.
What is Co-pay and how does it work?
- Co-pay essentially means sharing of expenses by the employee and insurance company. E.g. a 10% co-pay means for every 100 rupees payable by the insurer on hospitalization by the employee, 90% will be borne by the insurer and 10% will be borne by the employee.
- The co-pay is applicable on the admissible claim.
Will Co-pay be applied on all the claims submitted?
- No, Co pay will be applicable only on parental claims
What is an admissible claim?
- An unmarried employee has insured both of my parents for INR 300,000. The father was hospitalized and the total hospital bill was 100,950. The non-medical expenses (like food, telephone bill & registration charges etc. are INR 950. The room rent per day was INR 3,000 only. Now, how much money will admissible as claim?
- The non-medical charges are INR 950 would be deducted making it a total admissible claim value of INR 100,000 (i.e. Total Bill of INR 100,950 – Non-medical charges of INR 950).
- Now, as the co-pay for claim is 10%, INR 10,000 would be the employee’s share (i.e. Total admissible claim of INR 100,000 x 10% = INR 10,000) and TPA will issue a cheque amounting to INR 90,000.
What are the steps involved to avail the cashless treatment?
- Identify the hospital & confirm whether the same is part of Network Hospital list of Mediassist, the TPA. This can done by referring to the hospital list available at your office OR by contacting the helpline provided by Mediassist. You can write to Medimanage OR get in touch with the Medimanage voice contacts as mentioned at the end of this document.
(As this hospital list gets constantly updated, check with Medimanage before availing the facility)
- Fill up the Cashless Request Form & get it faxed to Mediassist, at least 3 days before the date of hospitalization
- In case, Mediassist requests for submission of additional documents, please do furnish the same. Cashless request would be rejected if these documents are not provided. For assistance if required, please call Medimanage voice contacts.
- Upon scrutiny of this form, Mediassist would either accept or reject the request. On acceptance, it would send the Authorization letter to hospital stating the amount approved. This is the amount up to which the expenses would be paid for directly by Mediassist. Mediassist could also reject the request. In such events, please call Medimanage to understand why the same was done.
- For payment of Non-Medical expenses, the employee/relative may have to pay Security Deposit to hospital.
- In case, the hospitalization expenses exceed the Authorized Limit (AL), the employee may send request for additional Authorization OR pay the balance and get it reimbursed after your discharge.
How does one claim if the hospitalization is in a Non-network hospital?
- Send claim intimation 3 days before hospitalization to firstname.lastname@example.org.
- In case for any reason the claim intimation has not been sent before hospitalization, it must be sent within 48 hours of admission in the hospital. Failure to do so will lead to rejection of the claim.
- Collect all the documents (document list available on control central) & submit the same to the Medimanage office closest to you. Medimanage offices are located in Mumbai, Chennai, Bengaluru, Delhi and Pune.
- Please refer to the Claim Settlement Process under the Reference Central on the portal.
- The settlement cheque should reach the employee in 21 working days from the date of submission of all documents.
- All documents to be submitted within 30 days from Date of Discharge from hospital. In case you delay in submitting the claim, the same may not be paid for.
If 2 employees (husband & wife), are covered under the same plan
• Will the maternity sum insured be 50 K + 50 K = 100 K?
• Will the sum insured be added up in case of a hospitalization?
- No, the maternity sum insured would be max INR 50,000.
- The maternity limit is per event per policy benefit wherein the benefit limit is fixed and that’s the maximum amount that you can claim.
- Both the policies can be used one after the other. However, in case both policies need to be used the all the limits will be as per the lower base plan among the two.
How will the CD account be maintained?
- Every company will provide up to 10% of the premium paid towards CD account.
- This is to ensure 64VB compliance and coverage from day 1.
- Medimanage will maintain a record of all the additions and deletions for each company and provide each company a monthly / quarterly statement depending on the size of the company.
- At the end of the year, the difference of all the credits and debits will be tallied and this amount refunded to each company.
- The refund cheque will be made by Oriental Insurance.
What are the exclusions under this plan?
- Injury or Disease directly or Indirectly caused by or arising from or attributable to War/nuclear weapons (Clause 4.4)
- 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(Clause 4.5)
- Cost of Spectacles or Contact Lenses, Correction of eye sight, Hearing Aid etc. (Clause 4.6)
- Dental Treatment of any kind unless requiring Hospitalization (Clause 4.7)
- Convalescence, General Debility, Run Down condition or Rest Cure Congenital external diseases or defects or anomalies, Intentional Self-Injury, Use of intoxicating drugs/alcohol, Venereal Diseases (Clause 4.8)
- HIV and AIDS (Clause 4.9)
- Any hospitalization for Evaluation/Diagnostic tests only (Clause 4.10)
- Expenses on Vitamins/Tonics unless forming part of treatment (Clause 4.11)
- Voluntary Termination of Pregnancy during first 12 weeks from the date of conception (Clause 4.12)
- Naturopathy treatment, experimental or alternative medicine and related treatment including acupressure, acupuncture, magnetic and such other therapies etc. or treatment, experimental or alternative medicine and related treatment including acupressure, acupuncture, magnetic and such other therapies etc. (Clause 4.13)
- 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, (Clause 4.14)
- 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.. (Clause 4.17)
- 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 (Clause 4.20)
- Massages, Steam bathing, Shirodhara and alike treatment under Ayurvedic treatment. (Clause 4.24)
- Any kind of Service charges, Surcharges, Admission fees / Registration charges etc levied by the hospital. (Clause 4.25)
How would the queries be handled?
- Medimanage would be the single point of contact for all issues regarding this Health Plan.
- The employee / HR could get in touch with Medimanage for any of the following issues:
- Mediassist Card
- Cashless hospitalization
- Reimbursement claim status
- Changes to be incorporated (if any)
- Any other query regarding this Health Plan.