User Manual

For

BCH Electric Limited

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Enter

Employee Insurance Program

This presentation is a summary of the employee benefit insurance policies offered to the employees by BCH Electric Limited. It contains the necessary details related to your insurance policies like benefits available, claims procedures, enrollment process, as well as contact details of Vantage Representatives.

If you have questions or need any additional information, Vantage team will be happy to assist in all matters concerning to your Insurance Benefits.

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Disclaimer:

This document has been prepared exclusively for BCH Electric Limited and is only for reference of benefits under the Employee Benefit Program. The detailed policy terms & benefits will be always as per the contract between the Insurer & Insured. The contents herein should not be copied or distributed without the prior permission of Vantage Insurance Brokers and Risk Advisors Pvt. Ltd. Any breach of these conditions will be constituted as unlawful and may invite legal action.

Click to Proceed

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Employee Health Insurance Policy

The Group Health Insurance Program provides pre-defined insurance coverage to all employees & their dependents

for expenses related to hospitalization due to illness, disease or injury.

In the event of a hospitalization claim (more than 24 hrs.), the insurance company will pay the insured person the

amount of such expenses as would fall under different heads mentioned below, and as are reasonably and

necessarily incurred thereof by or on behalf of such insured person, but not exceeding the sum insured in

aggregate mentioned in the policy:

Room Charges,

Nursing expenses,

Surgeon, Anesthetist, Medical Practitioner, Consultant, Specialists Fees,

Anesthesia, Blood, Oxygen, Operation Theatre Charges Surgical Appliances, Medicines & Drugs, & similar

expenses.

Know your Health Insurance Program

BCH Electric Limited offers the following Employee Benefit Insurance Policies. Click on the icon below

to know more details of the policy including Benefits , Claims Procedure, Exclusions of the following

Insurance Policies:

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Know your Health Insurance Program

Benefits Offered

Claims - Cashless

Claims: Non-Cashless/ Re-imbursement

Contact Vantage

Exclusions

Providing you the ease of understanding your benefits in detail, you can choose to click on the icons below to know more:

Your Policy at a Glance

Exit

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Your Health Insurance policy at a Glance

Sum Insured Details

Sum Insured type Family Floater

Sum Insured INR 250,000

Members Covered Members Covered

Employee + Spouse + 2 Dependent Children (maximum up to 25 years) + 2 Dep. Parents (Parents covered on voluntary basis subject to premium paid)

General Hospitalization

Benefits

Pre - Existing Ailments Covered from Day one30 days waiting period for non - accidental claims Waived Off

Domiciliary Hospitalization Not CoveredDay Care Procedures CoveredPre & Post Hospitalization Pre 30 days and post 60 days

Cont.…Exclusions

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Your Health Insurance policy at a Glance

Maternity Benefit Covered for the first 2 living childrenMaternity sub-limit INR 50,000 for normal and INR 50,000/- caesarian delivery9 Months waiting period for maternity Waived Off

Baby Cover Covered from day 1 within family floaterPre & Post Natal Cover Covered for max. 5000/- within overall maternity limit

Maternity Benefits

Restrictions

Applicability of Room Rent Limit Limited to 1.5% of Sum Insured per day for normal and ICU as per actuals

Applicability of Co-payment Not ApplicableDeductible Not Applicable

Ailment-wise capping Not Applicable

Exclusions Cont.…

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Your Health Insurance policy at a Glance

Existing Associates + Dependents

New Joiners + Dependents

New Dependents

on account of Marriage /

Birth

Commencement Date 1st Sep 2014(subject to declaration of dependent within the given timelines)

Termination Date 31st August 2015

Commencement Date Date of joining

Termination Date 31st August 2015

Commencement Date Date of such event (subject to declaration of dependent within the given timelines)

Termination Date 31st August 2015

Insurance Partners

Exclusions Cont.…

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Sum Insured

Under the family floater, the insurance cover will be available to all

members of the family unit. The sum insured is available for utilization by

any member of the family with or without any sub limit. It is however

subject to the overall family sum insured for all members put together.

ApplicableFamily Floater

Illustration:The sum insured for any employees is INR 2,50,000. An employee and his spouse meets with an accident and are hospitalized. The hospitalization expenses incurred for the employee is INR 60,000 and for the spouse is INR 30,000.

The entire sum insured will be applicable to the entire family without any sublimit to any member in case of family floater. Hence, employee can use INR 60,000 and spouse can use INR 30,000.

In case of any future hospitalization of any covered members of the family, the remaining sum insured i.e., INR 160,000 will be available for utilization.

Exclusions Cont.…

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Members Covered

Parameter Coverage Detail

Total No. of people Insured * 6 per family(Employee + Spouse **+ 2 Dependent children** + 2 Dep. Parents***)

Employee Yes

Spouse Yes

Children *** Yes (the first Two live births are covered)

Parents*** Yes

Siblings No

Others (viz. Grand-parent, Aunt, Uncle, Nephew, Niece, etc.) No

* No Individual should be covered as dependent of more than one employee ** Dependent's coverage subject to them being enrolled in the policy within the given timelines*** Should be financially dependent on the employee, Parents cover is on voluntary basis subject to premium paid

Exclusions Cont.…

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General Hospitalisation Benefits

Pre-existing diseases refers to condition or ailments that may have been contracted before the start of the policy. There is usually a waiting period of 4 years for covering such ailments.

Covered for all enrolled

members from day 1

30 Day Waiting Period for new

joiners

Any hospitalization expenses during the first 30 days from the commencement date of the Policy is not covered for the new joiners. This exclusion is however, not applicable to any emergency hospitalization occurring due to an accident.

Waived off for all

1st/2nd/4th Year Waiting Period

Medical insurance policies have waiting period of 1/2/3/4 years for reimbursement of medical expenses for treatment of certain specified ailments. The specified ailments mainly include Cataract, Benign Prostatic Hypertrophy, Hysterectomy or prolapsed of uterus, Hernia, Hydrocele, Fistula in anus, Piles, Sinusitis, Joint Replacement due to Degenerative condition, Age related osteoarthritis and Osteoporosis, among others.

Waived off for all

Pre- existing Disease

Cont.…Exclusions

Day care procedures refers to such treatment which does not necessarily require 24 hospitalization due to medical technological advancement. Such list of ailments are available with insurance companies and are referred to as Day care ailments.

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General Hospitalisation Benefits

DomiciliaryHospitalization

Domiciliary hospitalization means treatment done at home in India for a period exceeding three days for disease, illness or injury, which in the normal course, would require hospitalization. This could happen if either the condition of the patient is such that he/she cannot be moved to Hospital/ Nursing Home, or the patient cannot be admitted to Hospital/Nursing Home for lack of accommodation.

Not Covered

Day Care Covered

Cont.…..Exclusions

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Pre & Post Hospitalisation Expenses

If the Insured member is diagnosed with an Illness which results in his / her Hospitalization and the claim is admissible, the Insurer will also reimburse the Insured Member’s Pre-hospitalization Expenses.

Covered for 30 days prior to

date of admission

Post Hospitalisation

Expenses

Relevant expenses for 60 days post discharge from hospital for an admissible hospitalization claim will be reimbursed in the policy.

Covered for 60 days post the

date of discharge

Pre Hospitalisation

Expenses

The expenses incurred in relation to the condition of hospitalization, generally 30 days prior to the date of hospitalization as well as 60 days post the discharge are reimbursed under the Pre & Post Hospitalization Clause.These expenses include things like medication prescribed at the time of discharge, follow up treatment etc.

Exclusions

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Maternity Benefits

Maternity Expenses

Any Maternity or pregnancy related expense other than those excluded (like voluntary termination of pregnancy in the first 12 weeks of delivery) will be payable. The maternity benefit is applicable for Normal / Cesarean delivery within the overall Sum Insured for the first two live births.

INR 50,000/- for Normal and INR 50,000/- for C-

section

The maximum benefit allowable is INR 50,000/- for Normal and INR 50,000/- for C-section per delivery within the overall Sum Insured for the first two live births . There are special conditions applicable to the Maternity Expenses Benefits as below:

• Claim in respect of delivery for only first two live births and/or operations associated therewith will be considered.

• Expenses incurred in connection with voluntary medical termination of pregnancy during the first 12 weeks from the date of conception are not covered.

9 Month Waiting Period

There is usually a 9 month waiting period for new joiners to claim Maternity Benefits under Group Health Policy.

Waived off. Maternity

benefit available to all

employees from day 1.

Cont…Exclusions

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Maternity Benefits

Baby Cover

On Delivery of a child, the child is prone to many health disorders like jaundice or expenses incurred for incubator for pre-mature births or any other complication to the child. Usually there is a 90 days waiting period for covering baby in the policy.

Covered from Day 1 within family floater.

The normal baby expenses like

pediatrician visit, nursery charges, etc.

prior to discharge from hospital post delivery is

not payable.

Exclusions

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Restrictions

Room Rent Capping

Room rent is capped to a certain limit in the policy. Employees/dependents choosing to go for higher room category than what is specified in the policy will need to bear the incremental room rent amount. This would also apply to related expenses such as nursing charges, doctor’s fees, etc. which is associated with the room category. This limit may differ for ICU.

Limited to 1.5% of Sum Insured for normal and

ICU as per actuals

Cont.…

Illustration: There is a room rent restriction of INR 3,750 per day for any employee. An employee is suffering from a particular disease and is hospitalized. The hospital package for the ailment as per various room categories are as follows:

If the employees goes for Package C, then the payable expenses under the policy would be INR 38,750 only. He will have to bear the additional INR 7,250. The associated charges with the increase in room rent will have to be borne by the employee.

Parameters Package A Package B Package C

Room Rent 2,000 3,750 6,000

Surgeon Charges 20,000 22,000 25,000

Operation Theatre Charges 6,000 9,000 10,000

Anaesthesia & Anaesthetist Charges 3,000 4,000 5,000

Other Charges 0 0 0

Total Charges 31,000 38,750 46,000

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Claims – Cashless administration

Cashless service ensures that the covered employee gets treatment at the hospital empanelled in the TPA Network without having to pay any money. This is however, subject to approval from the TPA based on the benefits covered under the policy.

Click for Planned Hospitalization

Click for Emergency Hospitalization

Exclusions

For Updated List of hospitals please visit www.rakshatpa.com

24 X 7 Customer Care Center of Raksha (TPA) Toll Free Nos.Call Center Toll: 1800-180-1444

Helpline No : 0129 – 4289999

Fax No: 0 11 - 66173411,45823411, 0129-4289988

you may also contact Vantage representative on the following number:

Manjusha Dhuper - 9873660277

E mail ID - manjusha.dhuper@vantageindia.co.in

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Cashless - Planned Hospitalisation

Member intimates TPA / Vantage of the

planned hospitalization in a specified pre-

authorization form 48 hours prior to hospitalization

Member intimates TPA / Vantage of the

planned hospitalization in a specified pre-

authorization form 48 hours prior to hospitalization

Claim Registered by the TPA

Claim Registered by the TPA

Follow non cashless process

Follow non cashless process

TPA issues letter of Approval within 24 hours for planned hospitalization to

the hospital

TPA issues letter of Approval within 24 hours for planned hospitalization to

the hospital

Pre-Authorization Completed

Pre-Authorization Completed

Member produces ID card at the network

hospital and gets admitted

Member produces ID card at the network

hospital and gets admitted

Member gets treated and discharged after paying for all non-entitled expenses like the deductions based on the policy terms, the cost of non payableitems etc. to the hospital.

Member gets treated and discharged after paying for all non-entitled expenses like the deductions based on the policy terms, the cost of non payableitems etc. to the hospital.

NoNo

YesYes

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Cashless - Emergency Hospitalisation Process

In case of a sudden requirement of Hospitalization, the cashless process is as follows:

Member get admitted in the hospital in case

of emergency by showing his health card and ID Card . Treatment starts.

Member get admitted in the hospital in case

of emergency by showing his health card and ID Card . Treatment starts.

Member / Hospital applies for pre-

authorization to the TPA within 24 hrs of

admission

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

TPA verifies applicability of the

claim to be registered and issue pre-authorization

Pre-authorization given by the

TPA

Pre-authorization given by the

TPA

Follow non cashless process

Follow non cashless process

NoNo

Member gets treated and

discharged after paying all non

entitled benefits like refreshments, etc.

Member gets treated and

discharged after paying all non

entitled benefits like refreshments, etc.

YesYes

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Claims - Reimbursement Benefit

Admission procedure

In case of a non-network hospital, the patient will need to be admitted to the hospital and take

the treatment.

Discharge procedure

In case of non network hospital, employee will be required to clear the bills and submit the

claim to TPA through Vantage for reimbursement. Please ensure that all necessary documents

such as discharge summary, investigation reports, payment receipts, reports etc. are collected

in original for submitting your claim.

Submission of hospitalization claim

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

submitted within 15 days from the date of discharge from the hospital.

2.Under hospitalization claims, you are also permitted to claim for treatment expenses 30 days prior to

hospitalization and 60 days after the date of discharge. This is applicable for both network and non-network

hospitalization.

Click for Process Click for Claim Docs

Exclusions

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Member intimates TPA before or as

soon as hospitalization

occurs (within 24 hours of admission)

Member intimates TPA before or as

soon as hospitalization

occurs (within 24 hours of admission)

Insured admitted as per hospital

norms. All payments made

by member

Insured admitted as per hospital

norms. All payments made

by member

Claim registered by TPA after

receipt of claim intimation

Claim registered by TPA after

receipt of claim intimation

Documents received by TPA within 15 days *

from discharge

Documents received by TPA within 15 days *

from discharge

Claim Closed/ RejectedClaim Closed/ Rejected

NoTPA performs

medical scrutiny of the documents for admissibility of the claim

TPA performs medical

scrutiny of the documents for admissibility of the claim

Yes

TPA checks document sufficiency

TPA checks document sufficiency

No

Yes

Claims processing done within 21 working days

Claims processing done within 21 working days

Sends mail about deficiency and

document requirement for re-submission

Sends mail about deficiency and

document requirement for re-submission

Claims cheque is sent to the

employee/ client

Claims cheque is sent to the

employee/ client

Yes

Claims - Reimbursement Process

No

Documentation complete as

required

Documentation complete as

required

* Note: claim should be intimated to us within 24 hours from hospitalization and documents should be submitted to us within 15 days from date of discharge. If deficiency is not submitted within the given timelines, the same will be considered as closed.

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Claims - Reimbursement Documents• Claim form duly filled and signed by the claimant

• Original Discharge Summary

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

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

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

• All original payment receipts must be taken from the hospital including invoices for implants and stickers in case of lenses

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

• Break up 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, please get the hospital and doctor’s registration number in Hospital letterhead and get the same signed and stamped by the hospital.

Note: there may be additional documents other than the above mentioned list, required by the TPA, based on specific treatments.

Cont.…

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General Exclusions

2. Circumcision unless necessary for treatment of the disease, cosmetic or aesthetic treatment of any description, plastic surgery other than as may be necessitated due to an accident or as a part of any illness.

3. Surgery for correction of eyesight, cost of spectacles, contact lenses, hearing aids.

4. Dental Treatment or surgery of any kind unless requiring hospitalization on account of Accident Cases.

5. Convalescence, general debility ‘run-down' condition or test cure, congenital external disease or defects or anomalies, sterility, venereal disease, intentional self injury, all psychiatric and psychosomatic diseases/disorders, accident due to misuse of drugs/alcohol or use of intoxicating substance.

6. Acquired Immune Deficiency Syndrome (AIDS).

7. Naturopathy, unproven procedure/treatment, experimental or alternative medicine/treatment including acupuncture, acupressure, magneto therapy etc.

8. Out patient diagnostic/medical/surgical procedures/treatments, non-prescribed drugs/medical supplies/hormone replacement therapy, sex change or any treatment related to this.

9. Any kind of service charges/surcharges, admission fees/registration charges etc. levied by the hospital.

10. Doctor’s home visit charges/attendant, nursing charges during pre and post hospitalization period except in case of domiciliary hospitalization.

Cont.…

1. Injury or disease directly or indirectly caused by or arising from or attributable to War, Invasion, Act of Foreign Enemy, Warlike operation or disease directly or indirectly caused by or contributed to by nuclear weapons/materials.Exclusions

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General Exclusions

11.Expenses on irrelevant investigations/treatment; private nursing charges, referral fee to family physician, outstation doctor/surgeon/consultant’s fees etc.

12.Genetic disorders/stem cell implantation/surgery.

13. External/durable medical/non medical equipment's of any kind used for diagnosis/treatment including CPAD, CAPD, infusion pump etc., ambulatory devices like walker/ crutches/ belts/ collars/ caps/ splints/ slings/ braces/ stockings/ diabetic foot wear/ glucometer/ thermometer & similar related items & any medical equipment which could be used at home subsequently.

14. Non medical expenses including personal comfort/ convenient items/ services such as telephone/ television/ barber/ beauty services/ diet charges/ baby food/ cosmetics/ napkins/ toiletries/ guest services etc.

15.Treatment for obesity or condition arising there from (including morbid obesity) and any other weight control program services/supplies.

16.Injury arising from any hazardous activity including scuba diving, motor racing parachuting, hand gliding, rock or mountain climbing etc.

17. Treatment received in convalescent home/hospital, health hydro/nature care clinic and similar establishments.

Payment: All medical/surgical treatments under this policy shall have to be taken in India and admissible claims thereof shall be payable in Indian currency.

Note: The above list is an illustrative list of exclusions and not an exhaustive list of all exclusions.

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Contact Vantage

For any query related to Insurance, Associates are requested to address all mails to manjusha.dhuper@vantageindia.co.in .

Following are the contact details of Vantage Representatives:

Role Name Contact Number Email ID

Gurgaon

1st Point of Contact Manjusha Dhuper 9873660277 manjusha.dhuper@vantageindia.co.in

Gurgaon

Escalation Point 1 Arvind Kumar 9873660273 Arvind.kumar@vantageindia.co.in

Escalation Point 2 Sangeeta Singh 8860084462 Sangeeta.singh@vantageindia.co.in

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Thank You