Indian Institute of Technology Guwahati

1. ISO 9001:2008 Certified Company Indian Institute of Technology Guwahati Medical Scheme for the Employees and their Family members & Students. RakshaTPA

2. SALIENT FEATURES OF THE POLICY GMC Policy is through Oriental Insurance Company Ltd. Policy Effective Date :1st August 2017 to 31st July 2018 Policy Covers Employee + Spouse + Dependent Children + 2 dependent Parents /in lawswith a basis Sum Insured of Rs. 2,00,000/- & may opt for Top-up uptoRs. 12,00,000/-. Policy Covers Students with a Sum Insured of Rs. 1,00,000/- & may opt for Top-up uptoRs. 12,00,000/-. RakshaTPA

3. POLICY TERMS AND CONDITIONS Room Rent : Room expenses as provided by the Hospital/nursing home not exceeding 2.0 % of the sum insured per day or actual, whichever is less. ICU Charge: Intensive Care Unit (ICU) / Intensive Cardiac Care Unit (ICCU) expenses not exceeding 4.0 % of the sum insured per day, or actual, whichever is less. Doctor’s fee:Surgeon, Anaesthetist, Medical Practitioner, Consultants’ Specialist fees, and any such fee paid to the doctor shall be reimbursed as per actual. Investigation, Treatment, Drugs, etc charges:MRI, PET Scan, CT scan, Endoscopy, Ultra sound, Anaesthesia, Dialysis, Chemotherapy, Radiotherapy, Blood, Oxygen, Operation Theatre Charges, Surgical Appliances, Medicines & Drugs, Diagnostic Materials, X- ray, Cost of Prosthetic devices implanted during surgical procedure, relevant Laboratory/ Diagnostic test, X- Ray and any such medical expenses related to the treatment shall be reimbursed as per actual. RakshaTPA

4. POLICY TERMS AND CONDITIONS Pre and Post Hospitalization Expenses: Actual expenses incurred subject to 30 days prior to hospitalization and 60 days after discharge. Pre-existing diseases: All pre-existing diseases are covered from day one. Corporate Buffer: The Corporate Buffer is fixed under this policy as Rs. 30 lakhs which shall float on the entire group subject to terms and condition of the policy issued. The Corporate Buffer shall be at the discretion of the Director, IITG, the Insured. In case the sum insured of a member is exhausted but continuation of the treatment is found inevitable, on case to case basis, the Director, IITG, the Insured, may allot certain amount from the Corporate Buffer and recommend the same to the Insurer for utilization of this fund. RakshaTPA

5. OTHER COVERAGES Domiciliary hospitalization means Medical treatment for a period exceeding three days for such illness/disease/injury which in the normal course would require care and treatment at a hospital / nursing home as in‐patient but actually taken whilst confined at home in India under any of the following circumstances namely : i. The condition of the patient is such that he/she cannot be moved to the Hospital/Nursing Home OR ii. The patient cannot be moved to Hospital/Nursing home due to lack of accommodation in any hospital in that city / town / village. 24 Hours Hospitalization Clause: Admission in any Hospital/Nursing Home in India upon the written advice of a Medical Practitioner for a minimum period of 24 consecutive hours. (The time limit of 24 hours will not be applicable for surgeries which require less than 24 hours hospitalization due to advancement in Medical Technology- minor surgery & Day care surgery) RakshaTPA

6. OTHER COVERAGES Alternative Therapy/Ayurvedic Treatment:Reimbursement of Expenses for hospitalization under the recognized system of medicines , viz, Ayurvedic ,Unani, Sidha, Homeopathy , Naturopathy , if such treatment is taken in a clinic /hospital recognized by the central and state government is covered. Ambulance Charge: Ambulance service @ 1% of the sum insured or actual, whichever is less, for every shifting of a patient from residence to hospital vice-versa or from one Hospital/Nursing Home to another Hospital/Nursing Home in connection with hospitalization must be allowed. Cataract: Operation cost as well as actual cost of intra ocular lens (not spectacle/contact lens) limited to Rs. 24,000/- per eye and additional Rs.10,000/- for every Rs. 1 lakh top-up. Domiciliary: Any Domiciliary treatment covered. Congenital/Psychiatric cases: Disorders under this category also be covered. Peritoneal Ambulatory dialysis up to Rs 3,500/- per day Cost of artificial appliances:Cost of artificial appliances including hearing aid, artificial joints, pace maker, artificial limbs, etc. shall be reimbursed as per actual. The maximum admissible limit for cost of hearing aid is Rs. 60,000/- only. RakshaTPA

7. MATERNITY EXPENSES BENEFIT Maximum Maternity benefit Limit : Normal Delivery : Rs .50,000/- Caesarean Section : Rs. 50,000/- Special Conditions : 9 months waiting period waived. Expenses incurred for Medical termination of pregnancy. Missed Abortions, Miscarriage or abortions induced by accidents are covered under the limit of Maternity New Born Baby Cover : New born Baby is Covered from day one. If baby contacts any illness the same shall be considered in the family floater Sum Insured. RakshaTPA

8. EXCLUSIONS – What is not covered? War invasion, Act of foreign enemy, War like operations, Nuclear weapons, ionizing radiation, contamination by radio activity, by any nuclear fuel or nuclear waste or from the combustion of nuclear fuel. Cosmetic or aesthetic treatment devices, circumcision without disease or emergency e.g. in paediatric patient, plastic surgery unless required to treat injury, illness or burnt. Vaccination& Inoculation Cost of braces, equipment or external prosthetic, non-durable implants, eyeglasses, Cost of spectacles and contact lenses, and durable medical equipment's. Bodily injury or sickness due to wilful or deliberate exposure to danger (except in an attempt to save human life), intentional self-inflicted injury, attempted suicide, arising out of non-adherence to medical advice. This condition, however, shall not be applicable to patient undergoing psychiatric treatment. Treatment of any bodily injury sustained whilst or as a result of active participation in any hazardous sports of any kind excluding normal sports activities of the Insured. RakshaTPA

9. EXCLUSIONS – What is not covered? Sexually transmitted diseases, any condition directly or indirectly caused due to or associated with Human T-Cell Lymphotropic Virus Type III (HTLB-III) or Lymphotropathy Associated Virus (LAV) or the Mutants Derivative or Variation Deficiency syndrome or any syndrome or condition of a similar kind commonly referred to as AIDS. Vitamins and tonics unless forming part of treatment for injury or disease as certified by the attending physician. Instrumentused in treatment of Sleep Apnea Syndrome (C.P.A.P.) and Oxygen Concentrator for Bronchial Asthmatic condition. Stem cell implantation Treatment undertaken outside India Experimental treatment or unproven treatment (not recognized by Indian Medical Council). Anti-obesity treatment unless forming part of treatment for disease as certified by the attending physician All non-medical expenses including convenience items for personal comfort such as telephone, television, Ayah, Private Nursing / Barber or beauty services, diet charges, baby food, cosmetics, tissue paper, diapers, sanitary pads, toiletry items, etc. RakshaTPA

10. EXCLUSIONS – What is not covered? Expenses incurred at Hospital or Nursing Home primarily for evaluation / diagnostic purposes which is not followed by active treatment for the ailment during the hospitalised period. Convalescence, general debility, “run down” condition or rest cure, sterility, any fertility, sub-fertility or assisted conception procedure, venereal diseases, intentional self-injury/suicide, and diseases / accident due to and or use, misuse or abuse of drugs / alcohol or use of intoxicating substances or such abuse or addiction etc. Expenses incurred for investigation or treatment irrelevant to the diseases diagnosed during hospitalization or primary reasons for admission. Private nursing charges, Referral fee to family doctors, Out station consultants / Surgeons fees etc. Genetic disorders and stem cell implantation / surgery. External and or durable Medical / Non medical equipment of any kind used for diagnosis and or treatment including CPAP, CAPD, Infusion pump etc., Ambulatory devices i.e. walker, Crutches, Belts, Collars, Caps, splints, slings, braces, Stockings etc of any kind, Diabetic foot wear, Glucometer / Thermometer and similar related items etc. and also any medical equipment which is subsequently used at home etc. All non medical expenses including Personal comfort and convenience items or services such as telephone, television, Aya / barber or beauty services, diet charges, baby food, cosmetics, napkins, toiletry items etc, guest services and similar incidental expenses or services etc. RakshaTPA

11. EXCLUSIONS – What is not covered? Change of treatment from one pathy to other pathy unless being agreed / allowed and recommended by the consultant under whom the treatment is taken. Treatment of obesity or condition arising therefrom (including morbid obesity) and any other weight control programme, services or supplies etc. Any treatment received in convalescent home, convalescent hospital, health hydro, nature care clinic or similar establishments. Any stay in the hospital for any domestic reason or where no active regular treatment is given by the specialist. Out patient Diagnostic, Medical and Surgical procedures or treatments, non-prescribed drugs and medical supplies, Hormone replacement therapy, Sex change or treatment which results from or is in any way related to sex change. Massages, Steam bathing, Shirodhara and alike treatment under Ayurvedic treatment. Any kind of Service charges, Surcharges, Admission fees / Registration charges etc levied by the hospital. Doctor’s home visit charges, Attendant / Nursing charges during pre and post hospitalization period. Treatment which is continued before hospitalization and continued during and after discharge for an ailment / disease / injury different from the one for which hospitalization was necessary. RakshaTPA

12. Important Points for availing the Benefit • Claim Intimation & Submission As per the process the reimbursement claims are required to be intimated to Raksha TPA with in 24 hour of hospitalization and compulsory have to be submitted original documents within 30 days of discharge from the hospital. This will ensure claims pay ability else the claims wouldn't be payable under intimation/submission clause. RakshaTPA

13. How to intimate? • Via writing mail by insured/relative/HR to Raksha (claimintimation@rakshatpa.com;raktim.phukan@rakshatpa.com;anirban@rakshatpa.com) with below mentioned information: • Member ID: • Patient Name • Hospital Name and Address • Diagnosis • Date of Admission • Requested Amount RakshaTPA

14. How to intimate online? • Online Registration • Login to www.rakshatpa.com • Click on Claim Intimation link. • Punch in desired details like member id, date of admission, hospital name etc. • Acknowledgement No. (i.e. your claim no.) shall reflect, please keep a copy of the same. RakshaTPA

15. RakshaTPA Click here on Claim Intimation

16. RakshaTPA Fill the form & submit for intimation

17. Steps to download E-card & Check Claim Status • Step 1: Log in to www.rakshatpa.com • Step 2: Click on the link " Real Time Status ”. • Step 3: Fill your member id in ID Card number (IN CAPS), For Example: O556(Emp. id/Roll No.)IITG. • Step 4:  Insured and dependant details will be reflected on screen, Please clink on print E card for download E card & Claim details to check claim status. Select whose E card need to be viewed or printed and then click show E card.  • Step5: E cards will be reflected, please take print of the same as and when required. RakshaTPA

18. ClickHere On Real time Status RakshaTPA

19. Click here when you entered your member id RakshaTPA

20. Click here to view E-Card Click here to check claim status RakshaTPA

21. Here you can download your E Card. RakshaTPA

22. Process Flow For availing Cashless Benefit. • In case of planned hospitalization, please inform the TPA at least two days before hospitalization. • You may visit www.rakshatpa.comand click on providers network for updated list of network hospital with contact details for availing cashless benefit. • Ensure to keep copy of government photo id proof of patient along with IIT employee id. • In case of emergency, please ensure the treatment starts ASAP. Some hospitals have a policy of asking an advance for treatment start. The same is refundable once the cashless approval is received • Please intimate the TPA in case of all hospitalization, even if you are paying for same and claiming later. The reimbursement claims are payable only in case the TPA is intimated within 24 hours of hospitalization and documents in original are submitted within 30 days from date of discharge. • Please keep a photo copy of all claim documents before taking discharge. • Please review all bills at time of discharge and recheck consultant no. of visits against billed visits. • Initial approval given is not the final approval and may vary with estimate cost given by hospital, final decision is given post adjudication of discharge summary which is issued at time of discharge. RakshaTPA

23. Hospitalization Through Networking Hospital Employee Approaches Network Hospital with Raksha TPA ID Card Hospital Intimates Raksha TPA and sends Pre-Authorisation Request Employee Bears Outpocket Expenses if Hospitalisation Not Covered Under Policy Conditions Raksha TPA issues Authorisation Letter As per Eligibility and Coverage • Advantages: • -Regulated Payouts in form of medical expenses • -Access to Top Quality Service Providers( Hospitals) • -No Arrangement of Funds required for hospitalisation At The Time Of Discharge Employee Leaves Back All The Documents - Minimum TAT of 2 Hours and in emergencies 1 Hour. - Incase of planned hospitalisation intimation at least 2-3 days before admission and incase of emergency as early as possible RakshaTPA

24. REIMBURSEMENT HOSPITALISATION SERVICES Insured Gets Hospitalised In Non-network Hospital Claim Folder Is Sent To Raksha TPA If Documents Are Insufficient Immediately Intimated To Employee/Student Claim is Processed Claim Passed / Rejected Maximum Turn Around Time Subject To Availability Of All Necessary Documents Will Be 10 working days RakshaTPA

25. How to submit the documents for Reimbursement? • Documents need to be submitted within 30 days from date of discharge from the hospital . • In case of query is being raised while processing the claim, satisfactory query reply need to be submitted within 30 days from query raised date failing to which file will be closed and insurer consent would be required to reopen the claim file. • Pre (30 days from date of admission) & Post (60 days from date of discharge) claim need to be submitted within 30 days after completion of such treatment. RakshaTPA

26. THANK YOU RakshaTPA