Group Mediclaim Cover for EMCURE PHARMACEUTICAL LTD.

Agenda
Cover

Terminology
Exclusions Settlement

Scope of cover

Disease / Injury

Treated medically /surgically By Hospitalisation Only At Nursing home / hospital in India as inpatient

Age limit

91 Days 65 years

Scope of cover
The sum Insured available per Family
Rs. 200,000

Who are Covered : Employee + Spouse +2 Children

Unmarried employees Self Married employees Self, Spouse, First 2 Living Children

Benefits

Family Floater cover Pre Existing diseases are covered for existing employees but 2 years exclusion for New joinee after 30th April 2010. New born baby cover from 91st Day Room rent is restricted to 1% of the sum insured subject to maximum of Rs 2000 and for ICU 2% of SI subject to max of Rs. 4000. In the event of the insured getting admitted in a category higher than capped mentioned above per day, then the insured will bear the difference of all the medical expenses as in the final hospital bill in the same proportion.

First year exclusion waived off for existing employees but applicable for New joinee after 30th April 2010.
First 30 days waiting period waived off.

Benefits- contd.

Pre and post hospitalisation covered for 30 days and 60 days respectively.
Domiciliary Hospitalization is an exclusion Coverage for hospitalization arising on account of or related to Psychiatric ailments would be limited to Rs 30,000. Disease sub-limit for kidney stone including DJ stent removal (for the same stone) even if at a later admission would be Rs. 25,000. Septoplasty not covered but In case of FESS, the maximum liability would be up to Rs 35,000.

Terms and Conditions

Maximum age is 65 years Maximum Age for children is limited upto 25 Years. The family shall comprise of the insured employee his/her legally wedded spouse first 2 living children only Lasik treatment not covered.

Terms and Conditions Contd

Ayurvedic treatment, naturopathy and Homeopathy are not covered. Administration/administrative, registration/admission, service charges & miscellaneous charges not payable. 50% co-payment is applicable in case of Cyber knife treatment & Stem Cell Transplantation treatment.

Warranted that treatment on trial/experimental basis are not covered under the scope of the policy.

Terms and Conditions Contd

All the Claims documents needs to be submitted to the insurance co. within 30 days from the date of discharge. Any device/instrument/machine that does not become part of the human anatomy/body but would contribute/replace the function of an organ, is not covered. Expenses on fitting of Prosthesis is outside the scope of the policy. Infertility and related ailments including Male sterility is outside the scope of the policy.

Compensation Payable

Reasonable and necessarily incurred Room Expenses in Hospital/Nursing Home Nursing Expenses Medical Practitioner Fee Treatment cost Medicines Blood / Oxygen Cost of Pacemaker / Artificial Limbs / Cost of Organs Operation Theatre Charges Surgical Appliances Diagnostic cost Dialysis, Chemotherapy, Radiotherapy Pre Hospitalisation and Post Hospitalisation expenses Max of Sum Insured

Agenda
Cover

Terminology
Exclusions Settlement

Hospital / Nursing home

Institution For

in India for indoor care

treatment of sickness & injuries

with local authorities

Registered

Supervision

of medical practitioner

Minimum criteria for hospital

Min 15 in-patient beds

Min 10 when population < 1 million

Fully equipped functional operation theatre

Round the clock availability of nursing staff/ doctor.

Institutions which are not hospitals

Place of rest Old age home De-addiction centres Hotel & similar institutions

Hospitalisation

Min period of 24 hrs Time limit not applicable for specific treatment

Dialysis Chemotherapy Tonsillectomy D&C Eye surgery Dental surgery (Only in case of an accident)

Agenda
Cover

Terminology
Exclusions Settlement

General exclusions

War / war group Nuclear perils Plastic surgery Spectacles / Contact lens / Hearing aid Pre Natal and Post Natal Expenses Convalescence / general debility Sterility / veneral disease / circumcision Intentional self injury

General exclusions

Diagnostic / laboratory expenses not consistent with treatment Vitamins / tonic inconsistent with treatment Naturopathy/ Ayurvedic Homeopathy Use of intoxicating drugs / alcohol Aids

Agenda
Cover

Terminology
Exclusions Settlement

Time Line
Activity Cashless Sanction Details Emergency Planned Re-Imbursement Claim Expected TAT 4-5 Hours- from receipt of request at i-healthcare 24 Hours- from receipt of request at i- healthcare 21 Working Days from receipt of Complete Claim Docs in Hyderabad 10 Working Days

Query Letter

Procedure for Cash-less Treatment

Planned treatment in Network hospital Intimation to TPA for approval

Intimation minimum 24 Hrs in advance for approval

Emergency Provide I-Healthcare membership no.

Intimate I-Healthcare for approval Intimation to hospital with in 4-5 hrs from receipt of request at i-healthcare

Re-Imbursement Process
The claimant sends the claim file to i-Healthcare with all relevant

documents: (with in 30 days of the date of discharge)

Claim form duly signed Original detailed discharge summary All Payment receipt (s) in original Copy of Health card and supporting Photo ID (wherever applicable)

Original hospital bill (s) with break upInterim bills and Final Bill
Package break-up (if applicable)

Re-Imbursement Process
Original investigation reports and Bills Pharmacy bills with supporting prescription Consultation Papers with Treatment details Indoor Case Sheet (wherever applicable) ,etc.
Hospital

bill with paid receipt (Revenue stamp if bill amount is more than Rs. 5000). All the relevant deficiency documents towards the claims have to be submitted within 30 days from the date of deficiency intimated by I-Healthcare. In case of delay in submission of claims or deficiency within time limit, claim stands repudiated.

Standard Policy Exclusions

Record/documentation charges

Attendant/Visitor pass charges

Extra bed charges for attendant etc Special nursing charges not authorized by the attending doctor Vitamins, tonic if not forming part of the room rent Service charges not forming a part of the room rent Sanitary items

Standard Policy Exclusions

Charges for extra bed for attendant Bed retaining charges

Charges for T.V, Laundry, radio etc

Telephone/Fax charges Food and Beverages for attendant and visitors Toiletries etc Purchase of Medicines not related to the treatment Stationery, Xerox or certifying charges

Third Party Administrator

I- Healthcare
ICICI Lombard Healthcare, ICICI Bank Tower, Plot No. 12, Financial District, Nanakram Guda, Gachibowli, Hyderabad-500032

Fax: 040-66989160/61 Toll free Fax no: 1800-209-8880 Website: http://www.icicilombard.com/app/ilom-en/icare

Thank you
Hearty wishes for a Healthy life