Employee Benefits Manual - Helping Clients Manage Employee Benefits 24x7x365

1. Employee Benefits Manual Helping our clients manage employee benefits 24 x 7 x 365 days a year

2. Disclaimer Disclaimer: This Benefits Manual will serve as a guide to the benefits provided by GMS ALUMINI. The information contained herein is only a summary of the terms and conditions agreed with the insurer. If there is a conflict in interpretation, then the terms and conditions of the policy will prevail.

3. Main Menu 1. 0 Group Mediclaim 2.0 Contacts at Prudent Insurance Brokers Pvt. Ltd

4. 1.0 Group Mediclaim Insurance

5. Benefit Summary

6. Standard Hospitalization: 24 hours Reimbursement of expenses related to • Room and boarding • Doctors fees • Intensive Care Unit • Nursing expenses • Surgical fees, operating theatre, anesthesia and oxygen and their administration • Physical therapy • Drugs and medicines consumed on the premises • Hospital miscellaneous services (such as laboratory, x-ray, diagnostic tests) • Dressing, ordinary splints and plaster casts • Costs of prosthetic devices if implanted during a surgical procedure • Radiotherapy and chemotherapy • Organ transplantation charges Hospital or nursing home means any institution in India established for indoor care and treatment of sickness and injuries and which has been registered either as a hospital or nursing home with the local authorities and is under the supervision of a registered and qualified medical practitioner, or complies with minimum criteria, as follows: Has a minimum of 10 beds if located in towns having a population of less than 10 lacs (Class C towns) or a minimum of 15 in-patient beds in other towns, 2) has a fully equipped operation theatre, 3) has a fully qualified doctor in charge and nursing staff around the clock, and 4) maintains a daily medical record for each of its patients.

7. Day Care Procedures: 140+ Dialysis Radiotherapy Kidney stone removal

8. Pre- and Post-Hospitalization Expenses Period Reimbursement of expenses related to 30 days 60 days The policy covers pre-hospitalization expenses made prior to 30 days of hospitalization and incurred towards the same illness/ disease due to which hospitalization happens (Eg. Investigation, Medicines, and Consultations). It also covers all medical expenses for up to 60 days post discharge as advised by the Medical Practitioner. All the bills with summary have to be submitted within 10days after 60days.

9. OTHER BENIFITS

10. Pre Existing Ailments Exclusion

11. First 30 Days Exclusion

12. First, Second Year and Fourth Year Diseases Exclusions

13. Room Rent

14. Maternity

15. Baby Cover from Day 1

16. Mid-Term Enrollment for New Joiners, Newborns and Spouses

17. Customized Benefit: Ambulance Services

18. General Exclusions • Circumcision unless necessary for treatment of disease • Cosmetic & dental treatment • HIV and AIDS • Hospitalization for convalescence, general debility, rest cure, intentional self-injury, use of intoxicating drugs / alcohol. • Venereal diseases • Laser treatment • Injury or disease caused directly or indirectly by nuclear weapons • Naturopathy • Any non-allopathic treatment • Infertility treatment • Congenital external diseases • Any non-medical expenses like registration fees, admission fees, charges for medical records, cafeteria charges, telephone charges, and disposable items, etc. • Any cosmetic or plastic surgery except for correction of injury caused by accident • Charges incurred primarily for diagnostic, X-Ray or laboratory examinations or other diagnostic studies not consistent with or incidental to the diagnosis and treatment of any ailment, sickness or injury. • Vitamins and tonics unless used for treatment of injury or disease • Injury or disease directly or indirectly caused by or arising from or attributable to War or War-like situations

19. Cashless Hospitalization

20. Planned Hospitalization: Pre-Authorization Form and Process 48 hours prior to hospitalization At least 48 hours prior to planned hospitalization, your treating doctor must complete the pre-authorization form and the hospital’s TPA Help Desk should fax it to the TPA. The TPA will approve cashless within 2 working hours, subject to the prescribed protocol meeting policy coverage terms and conditions. Should the TPA raise any queries, the treating doctor must answer them before the TPA can approve cashless hospitalization.

21. Emergency Hospitalization: Pre-Authorization Form and Process 24 HRS In the event of an emergency, admit the patient immediately and submit the pre-authorization form within 24 hours, regardless of whether the hospital is empanelled. If the hospital is empanelled, the TPA will authorize cashless as per the process described in the previous slide. If the hospital is not empanelled, the TPA can still advise on the admissibility of expenses. You can file for reimbursement after the patient is discharged within 20 days of the date of discharge.

22. Reimbursement Claims Submit all reimbursement bills, original reports, and prescriptions along with the claim form and checklist within 30days of the date of discharge for pre-hospitalization claims and hospitalization claims, and within 10 days of discharge for post-hospitalization claims.

23. Kindly send all the below mentioned mandatory documents along with the dully filled & signed claim form attached within 20 days form the Date of Discharge: 1. Original Discharge Summary 2. Original Inpatient Bill 3. Original Inpatient Bill break up 4. Original Receipt for the Inpatient Bill 5. All original medicine bills 6. All original prescription for the submitted bills 7. Original Laboratory reports with the requisitions. 8. Cancelled cheque for NEFT with the account name printed on it Please do courier or hand over to the below address- To,Miss.Nikitha BG Prudent Insurance Brokers Pvt Ltd,3rd Floor, "Sai Shakti",2207 HAL Stage III, 80 Ft Road, Kodihalli, Bangalore - 560008 Note: Please retain a copy of all the documents submitted. Reimbursement Claim Procedure

24. Claims Process A Insured admitted as per hospital norms. All payments made by member Insured sends relevant documents to Prudent office within 25 days of discharge • Insured will create the summary of Bills (2 copies) and attach it with the bills • The envelope should contain clearly the Employee ID & Employee e-mail Is claim liable (coverage/ applicability) Is document received within 30 days from discharge TPA performs medical scrutiny of the documents Yes Claim Rejected No No Yes Is documentation complete as required Payment to be made to employee thru NEFT TPA checks document sufficiency Claims processing done within 21 working days Yes TPA will send mail about deficiency and document requirement A No

25. Prudent Insurance Brokers Pvt Ltd – Contact Details Single Point Of Contact Nikitha B G Support Manager – Employee Benefits Practice Mobile : +91 9900034072 Mail Id- nikitha.bg@prudentbrokers.com Escalation: Ms. Sarita Nair Asst. Vice President-Employee Benefits Practice Mobile Number :91 89715 96999 Mail Id- sarita.nair@prudentbrokers.com For Cashless claims assistance: Level one : 9902223300 Level two : 9901677334 For all Reimbursement claims assistance, please write to us on : bangaloreclaims@prudentbrokers.com Group E-mail ID : gmsalumini@prudentbrokers.com

26. Thank you.