Medical Insurance Benefits Manual2011-2012

The Group Mediclaim Program provides adequate, pre-defined insurance coverage to Collabera Solutions Pvt. Ltd. employees & their dependents for expenses related to hospitalization due to illness, disease or injury.

Insurer United India Insurance Company Ltd.

Third Party Administrator (TPA) Medi Assist India TPA Pvt. Ltd.

Policy Start Date 03rd July 2011

Policy End Date 02nd July 2012

Coverage Type (Floater / Individual) Floater Type

Dependent Coverage 1+5 [Employee + Spouse + 2 Children + 2 Parents / Parents-In-Law] (Combination not permitted)

Sum Insured INR 2,00,000/- per family

Benefits coveredStandard Hospitalization with TPA Services

Pre-existing diseases : Any ailment ruled out prior to the date of Inception is covered

Pre-Post Hospitalization Expenses (Pre - 30 & Post - 60 days)

Maternity benefits up to INR 50,000/- for C-Section and INR 35,000/- for Normal Delivery. There is no waiting period. A maximum of

the first two children will be covered. (Incase of baby complications during delivery separate set of Discharge summary & IP bill & other

supporting documents are required to claim)

Pre & Post Natal Expenses up to INR 5,000/- (applicable only in case of minor complications which warrants inpatient admission for Min 24hrs

within the maternity limit as mentioned above)

Day Care means the course of medical treatment or a surgical procedure which is undertaken under general anesthesia in a Hospital, which is

not

less than 2 hours nor more than 24 hours. Ailments like Dialysis, Chemotherapy, Radiotherapy, Eye surgery, Hernia operation

Lithotripsy (kidney

stone removal), Tonsillectomy, etc. are covered. For any ailments not mentioned in the list above, please check with your TPA

provider .

Cap on Room Rent INR 3000/- for normal hospitalization and INR 5000/- for ICU hospitalization. Any case if it exceeds employee should pay the

room difference as well as subsequent charges

Reimbursements of expenses related to hospitalization, room and boarding :

- Doctors’ fees

- Intensive Care Unit

- Nursing expenses

- Surgical fees, operating theatre, anesthesia and oxygen and their administration

- Physiotherapy as a followed up of Hospitalization treatment..

- Drugs and medicines consumed on the premises

- Hospital miscellaneous services (such as laboratory, x-ray, diagnostic tests)

- Dressing, ordinary splints and plaster casts (as a part of in patient admission)

- Costs of prosthetic devices if implanted during a surgical procedure,

-Organ transplantation (Except Donor charges)/Radiotherapy and Chemotherapy

Benefits not covered

Diagnostics charges incurred at Hospital or Nursing Home primarily for diagnostic, x-ray or laboratory examinations or other

diagnostic studies not consistent with or incidental to the diagnosis and treatment of the positive existence of any ailment,

sickness or injury for which confinement is required at a Hospital / Nursing Home

Ambulatory Services

Dental treatment of any kind unless accidental Injuries requiring min 24hrs hospitalization

Cost of spectacles ,contact lenses and hearing aids

Deductibles (First 3000/- INR of every hospitalization should be paid by the claimant/Employee)

Domiciliary Hospitalization

Injury or disease directly or indirectly caused by or arising from or attributable to war or war-like situations

Circumcision unless necessary for treatment of disease

Congenital external diseases or defects / anomalies

HIV and / or AIDS

Hospitalization for convalescence, general debility, rest cure, intentional self-injury, use of intoxicating drugs / alcohol

Venereal diseases

Injury or disease caused directly or indirectly by nuclear weapons

Naturopathy/ Homeopathy/ Ayurveda treatments

Any non-medical expenses like registration fees, admission fees, charges for medical records, cafeteria charges, telephone

charges, any re-usable items (crutches/crepe bandages/Thermometer/bedpan/walker) etc.

Any cosmetic or plastic surgery except for correction of injury

Contd …

Benefits not covered

Vitamins and tonics unless used for treatment of injury or disease

Infertility treatment

Voluntary termination of pregnancy during first 12 weeks (MTP)

All Psychiatric or Psychosomatic disorders

Epilepsy

Expenses incurred for pre and post hospital treatment more than 30 & days respectively, and expenses incurred for the

treatment of any of the following diseases unless warrants for Inpatient admission with active line of treatment - Asthma

- Bronchitis

- Chronic Nephritis and Nephritic Syndrome

- Diarrhea and all types of dysenteries including Gastroenteritis

- Diabetes Mellitus and Insipidus

- Hypertension

- Influenza, Cough, and Cold

- Pyrexia of unknown origin for less than 10 days

- Tonsillitis and upper respiratory tract infection including Laryngitis and Pharyngitis

- Arthritis, Gout and Rheumatism

Excess-Employee Contribution

Excess

Definition Excess is a special cost containment measure, wherein claims are not payable up to a certain amount as mentioned in the policy. For Example, if the policy says a deductible of INR 5,000, the claims below INR 5,000 are not payable.

Excess Amount for Collabera policy Rs.3,000/-

Applicable for Deductible of the first 3000/-of each & every claim or series of claims

for the same ailment/same line of treatment or series of

hospitalization or day care treatments including Pre-post

hospitalization expenses.

Capped Ailments: Deductible is not Applicable for

• Cataract Surgery for Rs.20,000/- per eye.

• Hip & Knee Replacement for Rs.1,25,000/- for each Leg/Knee/Hip.

1.1 Cashless HospitalizationCashless hospitalization means the Administrator may authorize 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

Click on below ICON for Network list - https://www.mediassistindia.com/HealthCareProviders.html#

Select - Medi Assist Network Hospitals

For Latest List kindly check in this URL https://www.mediassistindia.com

Contact Customer Service Line

Toll Free No: 1800 4259 449

Toll Free Fax:1800 4259 559Mediassist Network

Hospitals

Emergency Hospitalization

Step 1Get Admitted

Step 2Pre-Authorization by

hospital

Step 3Treatment &

Discharge

In cases of emergency, the member should get admitted in the nearest network hospital by showing their ID card.

Relatives/care takers of admitted member should get in touch with the Insurance desk/Billing authority in hospital & Seek pre authorization by sending cashless form to Medi Assist. The preauthorization approval/denial letter would be directly given to the hospital.

After your hospitalization has been pre-authorized the employee is not required to pay the hospitalization bill in case of a network hospital. The bill will be sent directly to, and settled by the TPA

Process

Member gets admitted in the hospital in case of emergency

by showing his ID Card

Member/Hospital applies for pre-authorization to the TPA within 24 hrs of admission

TPA verifies applicability of the claim to be registered and issue pre-authorization

Pre-authorization given by the

TPA

No

Member gets treated and discharged after paying all non

entitled benefits like refreshments, etc.

Hospital sends complete set of claims documents for processing to the TPA

Claims Processing by TPA & Insurer

Release of payments to the hospital

Emergency Hospitalization Process

Non cashlessHospitalization

Process

1.2 Non-Cashless Hospitalization

Admission procedure

In case you choose a non-network hospital you will have to liaise directly for admission.

Discharge procedure

In case of non network hospital, you will be required to clear the bill and submit a claim to Medi Assist for

reimbursement from the insurer. Please ensure that you collect all necessary documents such as - discharge

summary, investigation reports etc. for claim processing.

Submission of hospitalization claim

1. After the hospitalization is complete and the patient has been discharged from the hospital, you must submit

the final claim within 20 days from the date of discharge from the hospital.

Claims Process Claim Docs

Claims ProcessInsured admitted as per

hospital norms. All payments made by

member

Insured sends relevant documents to Prudent office within 15 days of

discharge

•Insured will create the summary of Bills (2 copies) and attach it with the bills•The envelope should contain clearly the Employee ID & Employee e-mail

Is document received within 15

days from discharge

Claim RejectedNo

TPA performs medical scrutiny of the documents

Is claim liable

(coverage/ applicabilit

y)

Yes

TPA checks document sufficiency

NoYes

Is documenta

tion complete

as required

Claims processing done within 21 working days

Medi Assist will send mail about deficiency and document

requirementEmployee

Employee

Payment to be made to HR. The discharge voucher and copy of payment receipt to

be sent to HR.Yes

No

Procedure to access information and e-Cards (ID Cards)

To print cards please follow the below mentioned steps:

Step 1: Go to https://www.mediassistindia.com via the Internet

Step 2: `Click on to Login’ at the top left of main sheet

Step 3 : Select corporate employee option

Step 4: Log on with the help of username and password

Step 5: You can now view the details of your dependents

Step 6: To print cards click on the e-card status link

Step 7: Click on the `Print ID card` for each member

Step 8: Log off once the e-Card is printed

User ID : Employment Number@collabera.com (e.g. Coll1213)

Password : collabera (The password is case sensitive)

In addition to access your soft copy of e-card and policy details, the following is also available via the UHC Web site: Claims check list - for submission of claims for reimbursementClaims document requirement - Ready reckoner Claims status - for claims related to yourself and covered family members for claims made starting Network hospital list - for the hospitals in the Medi Assist network (more than 4800+ Hospitals across PAN India)

Claims Document List

Signed Claim form

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

Discharge Summary (original)

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

Original reports, Bills and Receipts for Medicines, Investigations along with Doctors prescription in Original and Laboratory

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

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 nurses round the clock.

In non- network hospitalization, you may have to get the hospital and doctor’s registration number in Hospital letterhead and get the same signed and stamped by the hospital, if required.

Claims Form

AT webhttps://www.mediassisndia.com

Click the below icon for claim form

*Documents mentioned are mandatory. Claim will not be

processed without these .

*Please retain photocopies of all documents submitted

Check list

Reimbursement claim form

Prudent Contact Details

First Level Contact

Mr. Arun Kumar G.E Support Manager – Employee Benefits Practice E-mail id: arun.kumar@prudentbrokers.com Mob Number: 09611102770

Escalation : 1st Level

Mr. Anil. K Assistant Vice President – Employee Benefits Practice E-mail id: anil.k@prudentbrokers.com Mob Number: 097400 98660

Mr. Gurpal Singh Dhingra Vice President E-mail id: gurpal@prudentbrokers.com Mob Number: 099001 78500

Collabera Contact Details:

HR Contact Person

Name : Waseem Pasha / Hema JContact No : Ext.. 8522 / 8511E-Mail ID : waseem.pasha@collabera.com / hemavathij@collabera.com

In case of emergency you could also reach on: 9886911525 / 9880129477

Contact Details

Thank You