Policy on Health Insurance

Policy On Health Insurance Date of Issue: 09 October, 2009 Date of Revision: Dec. 2009, April 2010, Dec. 2010,

Human Resource Department For CMC internal Use only - 1 -

Health Insurance Policy Version 3.0

December 2010



2010

This is a controlled document. Unauthorised access, copying and replication are prohibited.

This document must not be copied in whole or in parts by any means, without the written authorisation of the Head – HR, CMC.



Document Release Notice

This policy on Health Insurance, Version 3.0, is released for use in CMC Ltd. with effect from 1st December 2010



Introduction

CMC understands the importance of having a healthy workforce for building a healthy and productive workplace. For CMC, the health and wellbeing of all employees and their family is paramount. Hence, CMC wishes to provide them with easy access to best-in-class medical facilities through a Comprehensive Health Insurance Scheme.

A Health Insurance Scheme (HIS) is protection for an insured person against the costs of Hospitalisationand medical care arising from a medical condition.

Furthermore, CMC is also committed to ensuring continued health and well being of employees and their family post retirement, hence, the benefits of the HIS scheme are also extended to retired employees.

The CMC HIS Policy gives the general guideline which any HIS Scheme offered to CMC employees must address.

The specifics of the Health insurance cover (extent of cover, medical conditions covered, benefits provided, premium payment & employee’s contribution) are all subject to the prevailing scheme. Details of the same are available in the CMC HIS Scheme.

Refer Appendix “A” for details on the HIS Scheme

CMC periodically reviews the scheme and its provisions so as to ensure that the employees are deriving optimal value from the scheme. Hence, these schemes are subject to a revision which may result in a corresponding change in the entitlement, the extent of coverage, the premium to be paid, dependants who can be covered, etc.

Purpose

The purpose of the Heath Insurance policy is as follows:

1. To provide employees and their family prompt & easy access to excellent medical facilities.

2. To minimize any medical risks to the employees, hence secure their good health, wellbeing & productivity.

3. To protect the employee against financial loss from a personal accident or medical condition.

4. To ensure continued health and wellbeing of employees and their family post retirement, hence, foster a sense of belonging to the CMC family.

Eligibility

This policy is applicable to:

- All regular Employees of CMC Ltd. (till the time of their employment with CMC Ltd.)

- Regular Retired Employees of CMC Ltd.

This policy is not applicable to:

- Direct Contracts, Vendor Contracts and Contract Consultants (Retainers)



Provisions

1. General Provisions

a. CMC HIS Scheme is extended through TCS, which has tied up with a reputed Insurance Company to provide benefits of a comprehensive Health Insurance Scheme (HIS).

b. CMC ensures that Employees are covered under HIS during their tenure in CMC.

c. The HIS is same for all employees within a country, however the entitlements under the HIS may vary based on the employee’s grade.

d. For the employee’s convenience, CMC facilitates the processes within the HIS scheme by capturing the details for enrolment and claims requests online through the Mediassist HIS Portal. A dedicated cell/representative will be setup within CMC, with whom the employees can interact for availing the benefits of the scheme. There is no direct interaction between the employee and Insurance Company.

2. Benefits

a. Depending upon the prevailing HIS, various benefits/facilities may be provided by the Insurance Company as follows:

- Basic Cover: This is a provision to claim for reimbursement of expenses incurred towards domiciliary (if opted for Higher Hospitalisation Cover) and hospitalisation expenses up to a specified limit

- Add on benefits under Higher Hospitalisation Cover

i. Higher Hospitalisation Cover: On payment of an additional premium the entitlement limit for an employee increases.

ii. Personal Accident Insurance: This is an indemnity for permanent disabilities and/or death in the event of a personal accident.

b. Cashless Facility: The Insurance Company ties up/empanels specific Hospitals through which a cashless facility is provided to an insured person undergoing treatment at that hospital i.e. the patient can undergo treatment at the hospital without making a direct payment to the hospital. The payment (up to the entitlement limit) is made from the Insurance Company to the Hospital.

3. Individuals who can be covered

a. All Regular Employees on CMC Ltd. payroll are by default covered under the HIS Scheme by CMC.

b. Over and above this, there is a provision to cover Spouse, Dependant Children and Dependant Parents/Parents in-law.

c. Other relatives like brothers, sisters of the employee/Spouse whether dependant or otherwise cannot be covered under any situation.



d. Retired employees will continue the HIS cover post retirement. The premium for self, spouse & upto 2 dependant children will be borne by CMC Ltd.

4. Premium

a. At different points in time CMC offers different Health Insurance Schemes for employees and their dependants, part of the premimum for which may be payable by the employee to the extent decided by CMC.

b. Any premium payable by the employee is at a subsidised cost.

c. Any premium if payable by the employee is deducted from the employee’s payroll and is applicable only for that financial year.

d. For retired employees (retired after 1st April 2010) and their family members , the premium for coverage of spouse and upto 2 dependant children will be borne by CMC Ltd.

e. Premium paid by the employee qualifies for Tax Benefits as per relevant applicable Taxation laws in the country.

f. Employees proceeding on Leave Without Pay (LWP) are advised to ensure that they have paid the applicable HIS premium before they proceed on LWP (contact [email protected]). In case the employee does not pay the premium before proceeding on LWP, the HIS benefits may be withdrawn.

Terms and Conditions

1. An employee will be given one more last opportunity (by 17th April 2011) to decide on whether they want to insure parents/parents-in-law in CMC Insurance scheme. If s/he chooses not to include them or remove them from the list of voluntary dependants it will not be possible to have them covered under the policy later. Modification under parents’ category shall be permissible only on exceptional situations like parent achieving superannuation, coverage of parent-in-laws after marriage, etc. An indicative list of scenarios which may arise and the treatment for the same is covered under the section on “Scenarios related to enrolment” under the procedure section.

2. An employee will be given one more last opportunity (by 17th April 2011) to opt for higher hospitalization cover. If s/he does not choose higher hospitalisation cover now, s/he will not be able to opt for higher hospitalisation cover in future during his/her tenure in CMC.

3. In case an employee/retired employee wishes to cover their dependants for heath insurance, the employee/retired employee themselves also have to be covered except for coverage of Spouse of a deceased retired employee.

4. All correspondence/transactions or information required on the HIS is only through CMC. There may be no direct interaction between the employee and Insurance Company. All the claims have to be routed through CMC only.

5. CMC/Insurance Company solely acts as facilitators for the disbursement/administration of the insurance benefits. CMC/Insurance Company undertakes no responsibility in the respect of any eventuality/mishap



during the course of the treatment of insured person at any of the hospitals empanelled by the Insurance Company.

6. CMC understands the sensitivity of personal information and medical records. CMC and the Insurance Company undertake to secure the confidentiality of all medical records, condition and treatment of an insured person from unauthorised disclosure & misuse.

7. The Insurance Company shall not be liable to make any payment under the HIS in respect of any claim, if such a claim is found to be in any manner fraudulent and supported by any fraudulent statement or device whether by the insured or by any other person on their behalf, CMC/The Insurance Company views such cases very seriously and stern action will be taken against the employee, including termination of employees.

Procedure

1. Getting an insurance cover (enrolment)

a. An employee is automatically covered under the HIS scheme for Basic cover. Howerver if an employee wants to opt for Higher Hospitalisation Cover, s/he should choose the Higher Hospitalisation Cover option explicitily in Ultimatix >>> HR management >>> CMC Employee Self Service >>> HIS Dependant Coverage. In case the Higher Hospitalisation Cover option is not selected the employees will be covered under basic coverage only and will not be eligible for domiciliary claims. Once opted out of Higher Hospitalisation Cover, employee will not be allowed to opt for the same in futrue during his/her tenure in CMC.

b. Higher Hospitalisation Cover is mandatory for all new hires joined on or after 1st April 2010.

c. The employee has to explicitly enrol the dependants to cover them under the HIS Scheme. The link to add/delete family members is as follows:

Log on to Ultimatix >>> HR Management >>> CMC Employee Self Service >>> HIS Dependants Coverage

Note:

- Addition of dependants in Ultimatix >>> HR Management >>> Employee information >>> ‘Dependant Details’ is not sufficient for coverage of dependants. ‘HIS Dependants Coverage’ is a separate link and dependant details for the purpose of HIS coverage need to be updated under this link specifically.

- For employees who are married and who want to add their Spouse/Parents-in-Law they should first get their Marital Status updated in Ultimatix. Without this update they will not get the option to add the Spouse/Parents-in-Law under the ‘HIS Dependants coverage’ link.



2. Scenarios related to enrolment

Scenarios for better understanding of the enrolment process are provided below:

New Joinee/ Existing

Employee

Scenario Process for enrolment

New Joinee Employee is single on date of joining and continues to remain single during the financial year

1. Employee him/herself will be automatically covered for basic & higher hospitalizatyion cover w.e.f the date of joining.

2. Employee has a provision to enrol Parents and Children (in case employee is a single parent).

3. No option to enrol Spouse, Parents-in-law. 4. Parents and children should be enroled within first 90 days of date of

joining to get benefit of the cover w.e.f from date of joining. Thereafter there will be no opportunity to enrol parents in the entire tenure with CMC

5. If Children are not enroled within first 90 days, they can be enroled at any point of time, however the coverage will be w.e.f date of enrolment and not from the date of joining.

Employee is single on date of joining and gets married subsequently during the financial year

- For Self, Parents and Children

1. Employee him/herself will be automatically covered for basic & higher Hospitalisation cover w.e.f the date of joining.

2. Employee has a provision to enrol Parents and Children (in case employee is a single parent).

3. Parents and children should be enroled within first 90 days of date of joining to get benefit of the cover w.e.f from date of joining. Thereafter there will be no opportunity to enrol Parents in the entire tenure with CMC..

4. If Children are not enroled within first 90 days, they can be enroled at any point of time, however the coverage will be w.e.f date of enrolment and not from the date of joining.

- For Spouse, Parents-in-law and Children of spouse (from earlier marriage)

1. Spouse, Parents-in-law and Children of spouse (from earlier marriage) should be enroled within first 90 days of date of marriage to get benefit of the cover w.e.f from date of marriage. Thereafter there will be no opportunity to enrol Parents-in-law in the entire tenure with CMC.

2. If Children are not enroled within first 90 days, enrolment may be done at any point of time; however the coverage will be w.e.f date of enrolment and not from the date of marriage.

3. If Spouse is not enroled within first 90 days from date of marriage, s/he can be enroled only during the beginning of the next financial year (during the permitted window period for enrolment).

New Joinee Employee is married on date

1. Employee him/herself will be automatically covered for basic & higher Hospitalisation cover w.e.f the date of joining.



of joining 2. Employee has a provision to enrol Spouse, Parents, Parents-in-law and Children.

3. Spouse, Parents, Parents-in-law and Children should be enroled within first 90 days of date of joining to get benefit of the cover w.e.f from date of joining.Thereafter there will be no opportunity to enrol Parents/ Parents-in-law in the entire tenure with CMC.

4. If Spouse, is not enroled within first 90 days, s/he can be enroled only during the beginning of the next financial year (during the permitted window period for enrolment ).

- If Children are not enroled within first 90 days, they can be enroled at any point of time, however the coverage will be w.e.f date of enrolment and not from the date of joining.

Existing Employee

Status change for an existing employee (i.e. employee gets married during the financial year)

1. Spouse, Parents-in-law and Children of spouse (from earlier marriage) should be enrolled within first 90 days of date of marriage to get benefit of the cover w.e.f from date of marriage. Thereafter there will be no opportunity to enrol Parents-in-law in the entire tenure with CMC.

2. If Children are not enroled within first 90 days, enrolment may be done at any point of time; however the coverage will be w.e.f date of enrolment and not from the date of marriage.

3. If Spouse is not enroled within first 90 days from date of marriage, s/he can be enroled only during the beginning of the next financial year (during the permitted window period).

Status change for an existing employee (child is born or child is adopted during the financial year)

1. New born child or adopted child should be enrolled within first 90 days of date of birth / date of adoption to get benefit of the cover w.e.f from date of birth / adoption as applicable.

2. If the child is not enrolled within first 90 days, s/he can be enrolled at any point of time; however the coverage will be w.e.f date of enrolment and not from the date of birth / adoption.

Enrolment of Dependant Parents/Parents-in-law

1. An employee will be given only one opportunity to decide on whether they want to insure parents/parents-in-law in CMC Insurance scheme. If s/he chooses not to include them or remove them from the list of voluntary dependants it will not be possible to have them covered under the policy later. Modification under parents’ category shall be permissible only on exceptional situations like parent achieving superannuation, coverage of parent-in-laws after marriage, etc. An indicative list of scenarios which may arise and the treatment for the same is provided below:



a. Existing employee gets married and wants to add Parent-in-law: This may be permitted. In case the employee has already insured his/her Parents and would now like to cover the Parents-in-law instead, this may be permitted too.

b. Parents/Parents-in-law retire during the financial year and hence need to be added: This may be permitted however, dependant parents/parents-in-law who are already insured may not be deleted to accommodate the new inclusions.

Note: If an employee’s Parent/Parent-in-law is slated to retire anytime during the financial year, they may be enrolled in advance at the beginning of the financial year by intimating [email protected]

c. In the event of demise of a Parent/Parent-in-law: In this case any another Parent/Parent-in-law may be included.

All above inclusions cannot be made through the system and have to be routed through [email protected]

3. Procedure for claiming

Employees can submit their Domiciliary or Hospitalisation claims through the url: www.mediassistindia.net/Corporate.

User id: Employee ID and Default Password: Employee ID@DOB (DDMMYYYY) (the default password needs to be changed after the first login)

All reimbursement claims should be raised against the appropriate heads of Domiciliary or Hospitalization, in the portal within 90 days from the date of expense or from the date of discharge (in case of hospitalisation)

Refer the User Manual posted on Ultimatix >>> SEEK@CMC >>> Health Insurance Scheme for detailed information on the usage of this portal and submission of claims.

Note:

- Currently, this is a separate application which can be accessed through Internet Explorer. The process of availing Cashless benefits remains the same.



Appendix - A

Health Insurance Scheme

Introduction

The specifics of the Health insurance cover (extent of cover, medical conditions covered, benefits provided, premium payment & employee’s contribution) are all subject to the current Health Insurance scheme. Details of the same are available in this section. CMC periodically reviews the scheme and its provisions so as to ensure that the employees are deriving optimal value from the scheme. Hence, HIS is subject to revision which may result in a change in the entitlement, the extent of coverage, premium to be paid, dependants who can be covered, etc. Year for the purpose of premium payment and entitlement limits defined is April to March.

About Health Insurance Scheme (HIS)

CMC has tied up with the New India Assurance Company (NIACO) Insurance Company to offer a Health Insurance Scheme (HIS) to its employees. NIACO has in turn appointed MEDIASSIST INDIA PVT. LTD. (MediAssist) as a Third Party Administrator (TPA) of the scheme. The TPA facilitates the HIS claims processing & settlement and cashless hospitalisation on behalf of the Insurance Company. Final discretion and approval of all benefits under the HIS resides with the Insurance Company

Details of the Scheme

The HIS offers two types of Insurance cover:

- Basic cover: All employees of CMC and their enroled family members are insured for a basic cover and entitled to the benefits on payment of applicable premium as per the scheme. Premium for basic coverage of self, spouse and first two dependant children is borne by CMC.

- Higher hospitalisation cover: The coverage limit for hospitalisation is increased for insured family on payment of an additional premium by the employee.

Details of the cover are as follows:

1. Basic Cover

a. Entitlement

- The basic cover may be utilised towards Domiciliary* and/or Hospitalisation expenses.

- The grade wise entitlement per person insured per annum, is as follows:



Type of expenses Grade

Amount Limit

(In Rs.) Per person per annum

Domiciliary* NE2 to E5 Rs. 5,000

Domiciliary* E6 & above Rs. 11,000

Hospitalization NE2 to E5 Rs. 45,000

Hospitalisation E6 & above Rs 1,39,000

* in case existing employee do not opt for Higher Hospitalisation cover, s/he will not be eligible for Domiciliary claims. However their Hospitalization limit will be Rs. 50,000/- per person per annum.

- The limit defined for domiciliary treatment could be utilised towards any treatment other than hospitalization (including Dental treatment).

- In case the limit for domiciliary treatment remains unutilized, the same shall not be used towards hospitalisation expenses and vice versa.

- The basic cover limit is defined per person covered, hence, if the limit for treatment for an employee or his/her insured family member remains unutilized, the same can not be used towards treatment of another insured family member.

b. Premium

- The premium for basic cover is completely borne by CMC for employee, his/her spouse and first 2 dependent children.

- In case the employee wishes to cover parents/parents-in-law/remaining children, s/he may do so on payment of the applicable premium.

- The premium for basic cover is as provided below:

Note: For all the amounts given below the service tax is extra



For employees in NE2 to E5 grades

Individuals Covered under CMC HIS

Total Premium per annum per insured person

(In Rs.)

Premium borne by CMC per annum per

insured person

(In Rs.)

Premium recoverable from the employee per

annum per insured person

(In Rs.)

Employee/Spouse/First two children (all age groups)

2,000 plus service tax


Nil

Remaining 3rd & 4th dependant children (all age groups)


Nil 2,000 plus service tax

Dependant Parents/Parents-in-law (all age groups)


Nil


Retired Employees (up to 65 years of age) & their insured Spouse/2 dependant Children



Nil

Retired Employees (above 65 years) & their insured Spouse/2 dependant Children



Nil

Insured Parents/Parents-in-law (all age groups) of retired employees


Nil




For employees in E6 & above grades

Individuals Covered under CMC HIS

Total Premium per annum per insured

person

(In Rs.)

Premium borne by CMC per annum per

insured person

(In Rs.)

Premium recoverable from the employee per

annum per insured person (In Rs.)

Employee/Spouse/First two children (all age groups)

5,500 plus service tax 5,500 plus service tax

Nil

Remaining 3rd & 4th dependant children (all age groups)

5,500 plus service tax Nil 5,500 plus service tax

Dependant Parents/Parents-in-law (all age groups)

6,000 plus service tax Nil


**Retired Employees (all age groups) & their insured family members

5,500 plus service tax 5,500 plus service tax

Nil

Note: **For Retired employees, the HIS coverage for a dependant Spouse only will continue after the death of a retired employee subject to payment of applicable premium.

- Premium for the entire year is applicable for any addition/deletion of dependents made during the financial year (i.e there will be no refund of premium) for any reasons including the following:

i. Marriage/Divorce

ii. Birth of a child

iii. Insured Family member’s employment starts or ends

iv. Insured Family member loses employer-provided coverage

v. Dependant child is no longer eligible for coverage

vi. Employee Separation

vii. Death of an insured person



2. Higher Hospitalisation Cover

a. Entitlement

- Higher hospitalisation is an additional amount which the employee may claim by paying addition premium towards Higher Hospitalisation cover, in case the hospitalisation expenses exceeds the limit specified by the basic cover

- The limit for higher hospitalisation is grade based as follows:

Grade Amount Limit (in Rs) per family per annum

NE2 to E5 Rs. 5,00,000

E6 & above Rs. 7, 50,000

- The higher hospitalisation amount is over and above the limit specified as per the basic cover

- Those employees who did not opt for Higher Hospitalization cover will have one more last chance to opt for Higher Hospitalization cover during the initial HIS window period for financial year 2011-12. If not opted out of Higher Hospitalisation Cover, they will not be able to opt for Higher Hospitalisation Cover thoughout their tenure in CMC. They will be covered with only basic cover and will not be eligible to claim Domiciliary.

- New joinees with effect from 1st Apr 2010 are covered under the Higher Hospitalisation scheme by default from the date of joining

- In case the employee has covered remaining children and/or dependant Parents/Parents-in-law this cover is automatically extended to such additions

- The higher hospitalisation limit is defined per family, hence, in case a part of the hospitalisation entitlement is utilised by one insured family member, the balance may be utilised by the same/other insured family members

Note: Illustration - If an insured person in the family, after first exhausting the basic cover limit of Rs.45,000, avails a further Rs.80,000 out of the Higher Hospitalisation Cover of Rs.5,00,000; the remaining Rs.4,20,000 is available for the other insured persons in the family. This example is for those employees who have opted for Higher HospitalisationCover.

b. Premium

- Total Annual premium for higher hospitalisation cover is Rs. 5,000 (plus service tax) per family.

The entire annual premium of higher hospitalisation cover is borne by the employees.



- This premium is uniform irrespective of number of individuals covered, age or grade of the insured person.

- Higher Hospitalisation premium for employees joining CMC during the financial year is prorated as follows:

Note: For all the amounts given below the service tax is extra

Date of Joining Total Premium per annum per family

(In Rs.)

April to June Rs. 5,000/-

July to September Rs. 3,750/-

October to December Rs. 2,500/-

January to March Rs. 1,250/-

- Premium for the entire year is applicable for any Employee Separation during the financial year (i.e there will be no refund of premium)

c. Add-on benefits for Higher Hospitalisation cover

- Umbrella Cover

i. For all employees covered under the higher hospitalisation scheme, an add-on benefit of an Umbrella Cover is available for them and their families at no additional cost

ii. The Umbrella Cover may be availed only after exhausting the basic and higher hospitalisation cover

iii. The Umbrella cover is limited to a fixed sum of Rs. 2,00,000 per family per annum.

iv. An overall cap of Rs.2 crores per annum has been defined for the Umbrella cover. Once the overall cap is exhausted. No further requests for assistance under the umbrella cover will be processed.

v. The Umbrella Cover operates on a ‘first come first serve’ basis and expenses are reimbursed subject to availability of funds.

vi. The cover is applicable only for the following tertiary ailments:



Cancer, Nephritis of any etiology plus bacterial renal failure requiring kidney transplantation and dialysis, Cerebral or vascular strokes, Open and closed heart surgery, Malignant diseases confirmed by histopathological reports, Viral encephalitis, Brain surgery, Total replacement of joints, Liver cirrhosis associated with hepatitis B\C, Compound\multiple fracture of femur, Intra cranial injury, Coma, Spinal injury resulting in paraplegia, Cerebral hemorrhage and Third degree burns.

Note: Illustration - In the event that an insured person’s hospitalisation expenses overshoot, the maximum hospitalisation cover is Rs. 5,45,000 as available under the Basic and Higher Hospitalisation Cover. The Umbrella Cover can provide a further aid of up to a maximum of Rs. 2,00,000, in case of tertiary ailments (as mentioned earlier) This takes the aggregate hospitalisation cover to Rs.7,45,000. This example is for those employees who have opted for Higher Hospitalisation Cover.

- Personal Accident Insurance (in case of Death, Permanent Total Disablement (PTD) and Permanent Partial Disablement (PPD) of employee)

i. For all employees who are covered under the higher hospitalisation scheme, insurance company provides an add-on benefit of Personal Accident Insurance Cover for the employee at no additional cost to the employee

ii. Personal Accident cover is applicable only in the event of personal accident of an employee and not of any other insured family member. Refer Appendix ‘B’ for schedule of indemnities and % of sum insured

iii. Personal Accident Insurance scheme is not applicable for Retired employees

iv. The Personal Accident Insurance cover includes Permanent Total Disablement (PTD), Permanent Partial Disablement OR Death arising from a personal accident

v. If at any time during the occurrence of this policy, an employee sustains any bodily injury solely and directly from accident caused by external violent and visible means, then the Insurance Company will pay to insured or insured’s nominee / legal heirs / legal personal representative, as the case may be, sum or sums as per the following limits (Sum Insured’s).

Grade Amount Limit

(In Rs.)

NE2 to E5 Rs. 18 Lakhs

E6 & above Rs. 50 Lakhs



Provisions

Following are provisions of the HIS Scheme which provides further explanation on the benefits, inclusions/exclusions and the terms and conditions of the scheme:

a. Coverage

First time Enrolment

- Employee is covered from date of joining for both Basic and Higher Hospitalisation cover (those joinings after 1st Apr 2010)

- Dependants need to be explicitly enroled in the scheme.

Renewal

- For employees and insured family members who are enroled under HIS, the insurance provider automatically renews the coverage for insurance starting from the 1st of April each financial year

a. Basic Cover is renewed for each insured person

b. Higher hospitalisation cover is renewed for those who have opted for it.

Deletion from HIS cover

- Employee continues to be covered year on year during his/her tenure in CMC. The cover ends only when the employee separates from CMC (except in case of retirement, wherein the employee will continue to be covered post retirement)

- Dependants who are covered will continue to remain covered during the employee’s tenure in CMC, unless the employee explicitly requests for deletion in the permitted window period at the beginning of the financial year. The cover ends only when the employee separates from CMC (except in case of retirement, wherein the employee may opt to continue the cover for self and for the dependant post retirement)

- Dependant parents/parents-in-law once deleted from the HIS or not opted for, will not be able to re-enter in HIS in futrue during employees entire tenure with CMC.



b. Individuals Covered

- Coverage for family members is subject to the following conditions:

Family Member

Conditions

Spouse - Should be legally married to the employee

- May or may not be employed with another organisation

- In case employed in another organisation may claim benefits subject to the following:

i. In case the Spouse does not get medical benefits/insurance cover from that organisation, s/he may claim benefits under this scheme.

ii. In case medical benefits/insurance cover is provided by that organisation, s/he must first recover the expenses from that Organisation to every extent possible. After this limit is exhausted, the employee may claim for the remaining amount under the HIS Scheme

- An employee whose spouse is also a CMCite should ensure that; both of them do not enrol each other and same dependants for HIS coverage. Such enrolment is considered as dual coverage, which is not permitted under any circumstances and will invite disciplinary action.

Children - Includes Legally adopted Children

- Includes Children of the Spouse from previous marriage

- Should be unmarried. Married Children or those who get married subsequently cease to be eligible for coverage from the date of marriage

- Should not be gainfully employed for wages or profit in any service, business or profession.

- Children are covered on an “ALL OR NONE (upto 4 children only)” basis. ‘ALL OR NONE” means that in case the employee has more than 2 children, CMC will pay the entire premium for the first two children only provided the employee explicitly covers the remaining children. Cost of premium for remaining children will be borne by the employee. In case the employee does not cover the remaining children, CMC will also not cover the first two children.



Parents/Parents-in-law

- Should not be gainfully employed for wages or profit in any service, business or profession or will retire or cease to be in the service, business or profession at any time in the financial year from April to March.

- All employees have the option to cover Parents OR Parents-in-law OR a combination of each upto a maximum of two i.e. they can cover 1 Parent and 1 Parent-in-law

c. Cumulative Bonus (only for those opting for Higher Hospitalization Cover)

- The scheme has a provision for cumulative bonus i.e. 5% of Higher Hospitalisation Cover is available, year on year, in case no one from the family files any HIS claim (domiciliary /hospitalisation). This 5% is then added to the employee’s total cover in the next financial year. i.e. If a family doesn’t claim under HIS during FY 08-09, the hospitalisation cover under the higher scheme will increase by 5% to 5.25 lakhs in the next year.This can increase to a maximum of Rs. 6.5 lakhs if a similar scenario is repeated in subsequent years.

d. Domiciliary Treatment

- Domiciliary treatment benefits are applicable only when the insured person undergoes treatment at a dispensary or in a hospital, as an outpatient.

- Domiciliary treatment includes pharmacy cost, consulting fees of the doctor, investigatory tests, etc.

e. Hospitalization

Definitions related to Hospitalizattion:

i. Day Care Procedures – Day Care procedure means the course of medical treatment or surgical procedure in specilaized Day Care Centers which enable the insured to be discharged on the same day. Typically Day Care procedures are not covered under hospitalization benefits since Hospitalization benefits are applicable only if the insured person is admitted to a hospital for a minimum of 24 hours. However, there are a few Day Care Procedures specified by the insurance provider which may not require 24 hours of hospitalization but which are being covered under Hospitalization benefit.

Refer ‘Appendix C’ for the list of Day Care Procedures which do not require 24 hours of Hospitalization, but which are still covered under Hospitalization Benefits.

ii. Hospital/Nursing Home – Hospital/Bursing Home means any institution established in India for Indoor Care and treatment of Sickness and Injuries. The Institution should be registered as a Hospital or Nursing Home with the local Municipal or State Authorities and under the



Supervision of a Registered and Qualified Medical Practioner. Alternatively an Institution may qualify as Hospital or Nursing Home if all of the following criteria is met:

a. Minimum of 10 in-patient beds if located in towns haing population of less than 10 lacs and minimum 15 in-patient beds if located in towns having population of more than 15 lacs

b. Fully equipped operation theatre of its own whenever surgical operation are carried out.

c. Fully qualified Nursing Staff and fully qualified Medical Practioner available round the clock.

d. Maintenance of daily Medical Records of each patient.

Note: The above definition of Hospital/Nursing Home may not be applicable for Ayurvedic/Homoeopathic/Unani procedures which may not require the typical set up of a Hospital/Nursing Home.

iii. Medical Practioner – Medical Practioner means a person who holds a degree/diploma of a recognized institution and is registered by the Medical Council of the respective State of India. The term ‘Medical Practioner’ also includes Physician, Specialist, Surgeon etc, who are certified Medical Practioners who hold the requisite qualification as mentioned earlier.

iv. Surgical Operation – Surgical Operation means manual and/or operative procedures for correction of deformities/defects, repair of injuries, cure of diseases, relief of suffering and prolongation of life.

v. Active Line of Treatment – Treatment that is directed immediately to the cure of the disease or injury is called active line of treatment. If admission to a hospital is mainly for diagnosis of an ailment which can as well be done as an outpatient or for a routine evaluation of the patient and the treatment involves few oral medications only, all these will not be covered under Hospitalization Benefits.

- A claim made under 'Hospitalisation', would cover medical expenses incurred 30 days prior to admission to a hospital, during Hospitalisation and up to 60 days from the date of discharge from the hospital (post hospitalisation) for employee spouse and children and for one month in cace of parent in respect of the same medical condition.

- The eligible room category at the time of hospitalisation is single private AC room. In case of hospitalisation in a room category higher than this ( eg: Deluxe, super deluxe, suite, etc) , the employee will have to bear the excess amount that is proportionately higher under all bill items in the hospital final bill.

- The Insurance Company through the TPA provides a Cashless Hospitalisation facility at specific hospitals (empanelled by the TPA). An Insured person who is hospitalised at any of the empanelled hospital can avail of this facility



Note: The list of hospitals made available by the TPA is not exhaustive and is amendable from time to time

- Four types of Hospitalisation are possible:

i. Planned Cashless Hospitalisation: The insured person seeks cashless hospitalisation through planned admission (i.e with prior intimation and approval).

ii. Emergency Cashless Hospitalisation: The insured person is admitted due to a medical emergency at a very short notice and requires urgent treatment (i.e. requests need to given highest priority and approvals need to be obtained immediately).

iii. Hospitalisation (Cashless facility not available): The insured person is free to avail of medical treatment from any other hospital of his/her choice, other than the empanelled hospitals and request for reimbursement of the expenses incurred.

iv. Domiciliary Hospitalisation:

- If the medical condition legitimately requires Hospitalisation but the condition of the patient is so serious that s/he cannot be moved to the Hospital OR there is no accommodation available in the Hospital, then treatment may be carried out at home

Note: Illustration - The condition of a patient with a heart problem may, in the opinion of the attending physician be such that, the patient could not be moved to a hospital without causing harm to his/her health.

- Claims in respect of such medical conditions will be considered under the 'Hospitalisation' category of HIS, provided the duration is for more than 3 days

- Any claim under this head should always be accompanied by a certificate from the attending specialist or physician which certifies that the treatment given is tantamount to Hospitalisation treatment (and not domiciliary treatment)

- The following ailments shall not be covered under the domiciliary Hospitalisation benefits:

1) Asthma 2) Bronchitis 3) Chronic Nephritis & Nephrotic Syndrome 4) Diarrhea & all types of dysenteries including gastro-enteritis 5) Diabetes Mellitus & Insipidus 6) Epilepsy 7) Hypertension 8) Influenza, Cough & Cold 9) All Psychiatric & Psychosomatic Disorders 10) Pyrexia of Unknown Origin 11) Tonsillitis & Upper Respiratory Tract Infection including laryngitis & Pharingitis 12) Arthritis, Gout & Rheumatism



f. Maternity Benefits

- Routine Checkups and diagnostic tests conducted during the maternity period will not be covered under domiciliary or hospitalisation under HIS.

- The total amount payable for any maternity related hospitalization followed by hospitalization resulting in normal delivery/instrumental delivery (forceps/vacuum etc) will be limited to Rs. 50,000 for entire maternity related hospitalization episodes.

- The total amount payable for any maternity related hospitalization followed by hospitalization resulting in C-Section delivery will be limited to Rs. 75,000 for the entire maternity related hsopitalization episodes.

- Those employees who have not opted for Higher Hospitalisation cover will have Rs. 50,000/- under hospitalisation expenses. In case of C-section also their cover will be limited to Rs.50,000/-

- The overall limit as mentioned as against each of the delivery types is inclusive of pre-hospitalization and post hospitalization expenses, incurred one month prior and post delivery.

- IVF treatment will be covered under Maternity expenses. However, the limit of IVF will be fixed within the Maternity expenses limit for Normal Delivery which is capped at Rs. 50,000. No Maternity claim will be payable wherever claim for IVF is paid, during the same financial year.

- The above limits on hospitalisation expenses excludes the expenses incurred on the new born child.

g. Dental Treatment

- Major dental surgeries such as maxillo facial surgery are covered under Hospitalisation, provided that hospitalisation is for more than 24 hours. However, cosmetic surgeries and tooth implants are not covered under the scheme

- Expenses for extraction, fillings, medicines, consultants’ fees, and x-rays are reimbursed only under Domiciliary

h. Cataract Treatment

- An upper limit on Hospitalisation expenses (including higher hospitalisation) has been defined at Rs 30,000 towards correction of cataract in a single eye. This is inclusive of all the expenses incurred towards correction of cataract including the lens charges, pre and post hospitalisation expenses if any.

i. Naturopathy

- Expenses incurred for undergoing Naturopathy are also reimbursed under domiciliary claims (for those opted for higher hospitalisation cover), provided a registered Allopathic, Homeopathic or an Ayurvedic practitioner administers it

- Only the cost of medicines is reimbursed and not the expenses incurred on special diets, such as fruit juices, milk, ghee, and so on



j. Continuous Period of Medical care

- “Period of Medical care” shall be deemed to mean the period commencing on the first day on which an insured person is under the care of a Medical Practitioner for the treatment of any particular medical condition while the policy is in force and terminating on the expiry of 45 days from the day the insured person resumes normal work or activities. In case the insured person is hospitalised twice during the Period of Medical Care for the same ailment/medical condition, any claims for treatment availed during this period can be claimed as 1 request

- In case the medical condition/treatment had commenced prior to the date of insurance, for the purpose of reimbursement, the medical condition shall be deemed to commence from the first day of coverage

Note: Illustration - If the date of cover is with effect from June 1st and the insured person has been undergoing treatment for an medical condition prior to June 1st, all the expenses relating to the medical condition will be covered w.e.f. June 1st.

- A certificate from the attending Medical Practitioner will have to be produced certifying that the member had recovered from the medical condition and is fit to resume normal work or activities and stating the date thereof.

k. Treatment outside India

- In case the employee is covered by an Overseas Mediclaim Policy (OMP), benefits should be first availed against the OMP and only then claimed under the HIS subject to maximum of Rs. 45,000 per insured person (irrespective of the employee’s grade and coverage under higher hospitalisation)

- In case not covered by an OMP, the employee may claim benefits under the Basic HIS policy of Rs. 45,000 per insured per annum. This is applicable only for hospitalisation treatment.

- Hospitalisation treatment taken outside India by insured persons who travel out of India on official work is covered under Basic HIS Policy.

- All claims for treatment outside India will have to be made in the usual claim form with the supporting evidence. The same has to be sent to the respective MediAssist representative. The claim should be made in the same financial year that the employee undergoes for treatment.

- The claim amount should be in equivalent Indian Rupees only and a settlement will be done in equivalent Indian Rupees only.

l. Exclusions

- There are certain exclusions in HIS due to which NO benefits are payable. This list of exclusions (enumerated below) is only indicative and not exhaustive;

i. Expenses towards cost of spectacles, contact lens, any foreign body, beauty treatment, normal health check-up, external congenital defects and anaemia, vaccination etc. are not covered by this policy.



ii. Lasik surgery and advanced surface ablation surgery is not covered under the domiciliary as well as under the Hospitalisation.

iii. Vaccination, Inoculation, Circumcision (other than on medical grounds), Strictures, Change of Life (beauty treatment of any description) Plastic Surgery other than as may be necessitated due to an accident.

iv. Depression, Convalescence (which expression shall cover also general debility “run down” condition and general “over haul”) or Rest Cure, Congenital defects or Anomalies, Venereal Disease, Insanity, Intentional self injury, Intemperance or the use of intoxicating drugs or liquors or any disease directly or indirectly due to any one or more of them.

v. Eye refractions or contact lenses or eyeglasses or fittings thereof or cost thereof.

vi. Health routine check up examination / Master Check-up unless necessary positive existence for treatment of any medical condition.

vii. Expenses incurred at Hospital or Nursing Home primarily for evaluation/diagnostic purposes which is not followed by ‘Active Line of Treatment’ for the ailment during the hospitalized period. (Refer definition of ‘Active Line of Treatment’ in the section on Hospitalization)

viii. Injury, disease or illness directly or indirectly due to or arising from ionising radiation or contamination by radioactivity from any nuclear fuel or from any nuclear waste or from the combustion of nuclear fuel (solely for the purpose of this exclusion, combustion shall include any self sustaining process of nuclear fission), War, Invasion, Act of Foreign Enemy, Hostilities or Warlike Operation (whether war be declared or not), Riot or Civil Commotion or Breach of Law or hunting. Steeple chasing, Polo or winter sports or riding or driving in races or employment in Military, Naval or Air Services or engaging in Aviation or Ballooning or entering into, travelling in or leaving any aircraft or balloon.

ix. Expenses on Vitamins and tonics etc unless forming part of treatment for injury or disease as certified by the attending physician.

x. Genetic Disorders like color blindness, Sickle cell anaemia, Hemophilia, Down Syndrome etc and stem cell implantation or surgery.

xi. Instruments such as CPAP for treatment of sleep apnoea, CAPD for treatment of Dialysis, external equipments or prosthetic devices.

xii. Experimental and unproven treatment, not recognized by the Indian Medical Council such as Rotational Frequency Quantum Magnetic Resonance therapy, external enhanced counter pulsation therapy etc.

xiii. Procedures and treatments usually done in out patient department are not payable under the policy even if converted to day-care surgery/procedure or as in-patient in the hospital for more than 24 hours. Example – intravitreal injections, remicade injections etc.



xiv. Non – medical expenses such as telephone, television, ayah, private nursing, diet charges, baby food, cosmetics, tissue paper, diapers, sanitary pads, toiletary items and similar expenses.

xv. Treatment arising out of infertility, sterility, family planning unless it is an IVF procedure for infertility treatment and covered under Maternity benefits. Refer the section on Maternity Benefits to know more details on Hospitalization coverage for IVF procedure.

xvi. Maternity related expenses beyond first two live births.

xvii. Check up and diagnostic Tests done during maternity period.

xviii. Self Injury, Suicide, Attempted suicide whilst under the influence of intoxication liquor, drugs insanity, war and allied perils, Ionising radiation, flying of an aircraft etc.

xix. This exclusion shall not apply to injury resulting from an accident to a fully licensed standard type of aircraft operated by a recognised airline on a fully regular scheduled air route in which the insured person is travelling as a bonafide passenger

- In case of Hospitalisation, the following services are not reimbursable:

i. Registration/Admission Fees

ii. Telephone charges

iii. Visitor’s charges, attendant’s charges, ambulance charges

iv. Service charges and any other charges like Medico Legal Charges (MLC), Medical Records Charges etc.

v. Diet charges which are not part of the administered treatment

vi. Non-medical expenses.



Appendix - B

Schedule of Indemnities and % of Sum Insured

1. Sum assured in case of Death, Permanent Total Disablement

Events % Of Sum Insured

1. Death 100

2. Loss of two limbs two eyes or one limb and one eye 100

3. Loss of one limb or one eye 50

4. Permanent Total Disablement from injuries other than those named above (PTD)

100

5. Permanent Partial Disablement (PPD) as per percentage of Sum Insured as shown below.

100

2. Sum assured in case of Permanent Partial Disablement

Parts Lost Compensation

As percentage of Sum Insured

1. Loss of toes all 20

Great both phalanges 5

Great one phalanx 2

Other than great, if more than one toe-lost, each 1

2. Loss of hearing - both ears 75

3. Loss of hearing - one ear 30



4. Loss of four fingers and thumb of one hand 40

5. Loss of four fingers 35

6. Loss of thumb-both phalanges one phalanx 25

7. Loss of indeed finger three phalanges or two phalanges or one phalanx 10

8. Loss of middle finger three phalanges or two phalanges or one phalanx 6

9. Loss of ring finger three phalanges or two phalanges or one phalanx 5

10. Loss of little finger three phalanges or two phalanges or one phalanx 4

11. Loss of metacarpals first or second (additional) or third, fourth or fifth (additional)

3

12. Any other Permanent Partial Disablement Percentage as assessed by the Panel Doctor of the Insurance Company.



APPENDIX – C

List of Day Care Procedures where Hospitalization benefits are applicable:

Surgeries/Procedure –

1. Anti Rabies vaccination

2. Appendicectomy

3. Coronary Angiography

4. Coronary Angioplasty

5. Dental Surgery following accident

6. Dilatation and Curetting of Cervix

7. Cataract Surgery

8. Fracture/Dislocation excluding hairline fracture

9. Surgery on Gastrointestinal Tract System

10. Haemodialysis (Dialysis)

11. Hysterectomy

12. Hernia Repair – Inguinal/Ventral/Umbilical

13. Lithotripsy (Kidney Stone Removal)

14. Perentereal Chemotherapy

15. Surgery for Piles/Fistula

16. Surgery for Prostate

17. Radiotherapy

18. Surgery for Sinus

19. Surgery for removal of Stones in Gall Bladder, Pancreas and Bile Duct

20. Surgery for the Urinary Tract System

21. Any other Surgical Procedure agreed by the Insurer/TPA which requires less than 24

hours hospitalization due to advancement in Medical Technology.



ANNEXURE – Revision List

Revision

Version No.

Policy effecti

ve date

Document Release/Revision

Date

Revision

Description

Section

No.

Rationale for

change

Change type

(add/modify/delete)

Policy revision/ Document revision

3.0

01-April-2010

1st Dec 2010

Personal accident sum insured for NE2 to E5 grade has been revised

from 15 lakhs to 18 lakhs.

Personal accident insurance

Periodic review of the policy

and scheme

modified

Policy revision

3.0

01-Dec-2010

1st Dec 2010

Inclusion of IVF treatment under maternity benefits

Hospitalization – maternity

benefits


and scheme

added

Policy revision

3.0

01-Dec-2010

1st Dec 2010

Pre-hospitalization and post – hospitalization expenses payable

for maternity reasons

Hospitalization – maternity

benefits


and scheme

added

Policy revision

3.0 01-

April-2010

1st Dec 2010

Definitions of the key terms included in the policy document

Hospitalization

Clarity to employees

added Document revision

3.0

01-Dec-2010

1st Dec 2010

List of exclusions under the scheme updated

exclusions

Explicitly mentioned

in the policy to provide clarity

added

Document revision



2.0 01-April-2010

01-April-2010

An employee will be given only one opportunity to decide on whether they want to parents/parents-in-law in CMC Insurance scheme. If he or she chooses not to include them or remove them from the list of voluntary dependants it will not be possible to have them covered under the policy later. Modification under parents’ category shall be permissible only on exceptional situations like parent achieving superannuation, coverage of parent-in-laws after marriage, etc.

Terms & Conditions, Procedure

Review of the policy and scheme

Modified Policy revision

2.0 01-April-2010

01-April-2010

An employee will be given only one opportunity to decide on whether he/she want to opt for Higher Hospitalisation cover or not. He will not be able to opt for Higher hospitalisation cover in future during his tenure in CMC. Those not opting for higher hospitalisation cover will not be eligible for domicilary claims.

Terms & Conditions, Procedure



2.0 01-April-2010

01-April-2010

The annual premium for coverage of parents/parents-in-law has been revised from Rs 5,000 to Rs.6,000 per parent/parent-in-law at all grades.

Appendix A - Details of the Scheme 1b





2.0 01-April-2010

01-April-2010

The annual premium towards basic coverage of employee/spouse/first two children (all age groups) and remaining dependant children has been revised from Rs 1,400 to Rs.2, 000 at NE2 to E5 grades.




2.0 01-April-2010

01-April-2010

The annual premium towards basic coverage of retired employees (up to 65 years of age) & their insured spouse/dependant children has been from Rs 1,400 revised to Rs.2, 000

The age slab of retired employees has been changed and the annual premium towards basic coverage of retired employees (above 65 years) & their insured Spouse/dependant Children has been revised from Rs3,000 to Rs.3, 500. The premium for the coverage of spouse and upto 2 dependant children of retired employees will be borne by CMC Ltd. for employees retiring after 1 st Apr 2010, provided retired employee has enrolled his/her dependants from the date of launch of the policy.




2.0 01-April-2010

01-April-2010

The annual premium towards higher hospitalisation coverage of employees has been revised from Rs 3,200 to Rs.5,000 at all grades per family.

Higher Hospitalization Cover

Appendix A

Scheme 2b





2.0 01-April-2010

01-April-2010

The annual premium towards higher hospitalisation applicable to new joinees based on their date of joining has been revised based on the employee and employer contribution of the premium.

Higher Hospitalisation Cover

Appendix A

Scheme 2b



2.0 01-April-2010

01-April-2010

Total expenses on Hospitalisation (including higher hospitalisation) for delivery of the child have been capped at Rs. 50,000 for normal delivery and 75,000 for C-section surgery.

Provisions

Maternity Benefits


Added Policy revision

2.0 01-April-2010

01-April-2010

A Total expense on Cataract treatment (including higher hospitalization) has been capped at Rs. 30,000

Provisions

Cataract Treatment



2.0 01-April-2010

01-April-2010

Claims made under 'Hospitalisation, would cover medical expenses up to 60 days from the date of discharge from the hospitalin respect of the same medical condition.

Provisions

Hospitalistion



2.0 01-April-2010

01-April-2010

Eligible room category at the time of Hospitalization has been explicitly defined in the policy.

Provisions

Hospitalistion





2.0 01-April-2010

01-April-2010

Routine Checkups and diagnostic tests conducted during the maternity period will be not be covered under domiciliary or hospitalisation under HIS

Provisions

Maternity Benefits

Documentation of the existing practice

Added Document Revision

1.0 1-Nov-2009

1-Nov-

First Release of the policy. NA NA NA NA

Policy on Health Insurance

Documents

Transcript of Policy on Health Insurance