Group Mediclaim Policy

1. Group Mediclaim Policy

2. Insurance Company – United India Insurance Co. Ltd.Name of the TPA : Paramount Health Services (TPA) Pvt. Ltd.

3. Scope of the Policy • General Hospitalization Expenses • Room, Boarding and Nursing expenses as provided by the Hospital/Nursing Home not exceeding 1% of the Sum Insured per day or the actual amount whichever is less. This also includes nursing care, RMO charges, IV Fluids/Blood transfusion/injection administration charges and similar expenses. • I.C.U. expenses not exceeding 2% of the Sum Insured per day or Actual amount whichever is less. • Pre and Post hospitalization expenses payable in respect of each hospitalization shall be the actual expenses incurred subject to a maximum of 10% of the sum insured whichever is less. • For Ayurvedic /Homeopathic/ Unani treatment, hospitalisation expenses are admissible only when the treatment is taken as in patient in a Government Hospital/ Medical College hospital.

4. Coverage

5. Policy Cover • Pre & Post Hospitalization cover for 30 days & 60 days respectively. • 30 days waiting period waived off. • 1st year waiting period waived off. • Pre-existing diseases to be covered • Maternity expenses- Covered - with 15,000 for Normal & 25,000 for C Section. • 9 months waiting period is waived off. • Domiciliary hospitalization Deleted. • Room rent restriction 1% of SI max of Rs. 5,000/- for normal hospitalization and 2% of Sum Insured maximum of Rs. 8,000/- for ICU. • 20% co-pay on each & every claim.

6. Ailment wise capping: • Appendectomy: Rs. 25,000 • Cataract/Glaucoma: Rs. 20,000 • Gall Bladder: Rs. 31,250 • Hernia: Rs. 25,000 • Hydrocele: Rs. 15,000 • Hysterectomy: Rs. 31,000 • Joint Replacement including Vertebral joints: Rs. 150,000 • Kidney Stone: Rs. 40,000 • Piles: Rs. 18,750 • Heart Related: Rs. 175,000 • 50% co-pay shall be applicable for cyber knife treatment & Stem Cell Transplantation • Diseases sublimit for kidney stone including DJ stent removal (for the same stone) even if at a later admission would be Rs. 25,000. • Coverage’s for hospitalization arising on account of or related to Psychiatric ailments would be limited to Rs. 30,000 • Septoplasty is beyond scope of coverage, In case of FESS the maximum liability would be up to Rs. 35,000 • Consultation Charges / Investigation Fees and all other related expenses will be paid in accordance with the charges applicable for the authorized room rent limit or actual, whichever is less.

7. Day Care Procedure • Expenses on hospitalization for minimum period of 24 hours are admissible. However, Day Care procedures where 24 Hrs Hospitalization is not required are as follow:- • Adenoidectomy. • Appendectomy. • Ascitic/Pleural tapping. • Auroplasty. • Coronary angiography. • Coronary angioplasty. • Dental surgery only in case of accident. • D & C. • Endoscopies. • Excision of Cyst/granuloma/lump. • Eye surgery. • Fracture/dislocation excluding hairline fracture. • Radiotherapy • Lithotripsy. • Incision and drainage of abcess.

8. Contd.... • Colonoscopy. • Varicocelectomy. • Wound suturing. • FESS. • Haemo dialysis. • Fissurectomy/ Fistulectomy. • Mastoidectomy. • Hydrocele • Hysterectomy. • inguinal/ventral/umbillcal/femoral hernia. • Parenteral chemotherapy. • Polypectomy. • Septoplasty. • Piles/fistula. • prostate. • Sinusitis. • Tonsillectomy.

9. Contd…. • Liver aspiration. • Sclerotherapy • Varocose Vein Ligation. • Further if the treatment/ procedure/surgeries of above diseases are carried out in Day Care Centre which is fully equipped with advanced technology and specialized infrastructure where the insured is discharged on the same day, the requirement of minimum beds will be overlooked provided following conditions are met: • The operation theatre is fully equipped for the surgical operation required in respect of sickness/ailment/injury covered under the policy. • Day Care nursing staff is fully qualified. • The doctor performing the surgery or procedure as well as post operative attending doctors are also fully qualified for the specific surgery/ procedure. • Note: Procedures/treatments usually done in out patient department are not payable under the policy even if converted as an in-patient in the hospital for more than 24 hours.

10. Other Details Network Hospitalization: means the hospital / nursing home or such other medical aid provider that has agreed with the TPA to provide cashless access services to policy holders. The list of Network Hospitals is maintained by and available with the TPA and the same is subject to amendment from time to time. Cashless Facility: means facility whereby the TPA agrees on the insured’s request to settle the admissible claim directly to the network hospital. E -ID Card: means the identity card issued to the insured person by the TPA to avail cashless facility in network hospitals. Day Care Procedure: means the course of medical treatment/ surgical procedure in specialized day care centre which enables the insured to be discharged on the same day.

11. Policy Does not Covers • Injury/disease directly or indirectly caused by or arising from or attributable to War, invasion, Act of Foreign enemy, War like operations (whether war be declared or not) • Cost of spectacles and contact lenses, hearing aids. • Dental treatments except arising out of an accident and requiring hospitalization. • Convalescence, general debility, “Run-down” condition or rest cure, obesity treatment and its complications including morbid obesity, Congenital diseases/defects or Anomalies, treatment relating to all psychiatric and psychosomatic disorders, infertility, sterility, venereal disease, Intentional self-injury and use of intoxicating drugs/alcohol. • All expenses arising out of any condition directly or indirectly caused to or associated with Human T- Cell Lymphotropic Virus Type III (HTLB –III) or Lymphadinopathy 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. • Charges incurred at Hospital or Nursing Home primarily for diagnosis x-ray or Laboratory examinations or other diagnostic studies not consistent with or incidental to the diagnosis and treatment of positive existence or presence of any ailment, sickness or injury, for which confinement is required at a Hospital/ Nursing Home.

12. Expenses on vitamins and tonics unless forming part of treatment for injury or diseases as certified by the attending physician. • Injury or Disease directly or indirectly caused by or contributed to by nuclear weapon/ materials. • Naturopathy Treatment, acupressure, acupuncture, magnetic therapies, experimental and unproven treatments/therapies. • Genetic disorders and stem cell implantation/surgery. • Change of treatment from one system of medicine to another unless recommended by the consultant/hospital under whom the treatment is taken. • Treatment for Age Related Macular Degeneration (ARMD), treatments such Rotational Field Quantum Magnetic Resonance (RFQMR), Enhanced External Counter Pulsation (EECP), etc. • All non medical expenses including convenience items for personal comfort such as charges for telephone, television, ayah, private nursing/barber or beauty services, diet charges, baby food, cosmetics, tissue paper, diapers, sanitary pads, toiletry items and similar incidental expenses. • Any kind of services charges, surcharges, admission fees/registration charges, luxury tax and similar charges levied by the hospital. Contd….

13. Claim Procedure • Claim notice to be given immediately to TPA/ Insurer within 48 hours of Hospitalization on the email id amitabh.naidu@paramounttpa.com & CC to pranali.hanjankar@spagroupindia.com, b.priyadarshini@centrum.co.in • Claim to be filed within 7 days of discharge from hospital • All documents in original viz. bills, receipts, Test Reports, discharge Card etc. to be provided • Any Medical Practitioner appointed by the Insurer will be allowed to examine the insured person • Maximum of 24 hours hospitalization is must except in respect of certain Day-care treatment. It is always advisable to check with TPA for hospitalization of less than 24 hours (Day-care) to avoid rejection of claim.

14. Type of Claims • Cashless • Reimbursement • Post Hospitalization expenses can be claimed separately hence no need to wait till post hospitalization treatment is over.

16. Claim Procedure - Cashless • Cashless – in Network hospitals Only • For Planned Hospitalization, intimate TPA 7 days in advance. • For Immediate Hospitalization, contact TPA by completing form & faxing cashless request to TPA. • TPA authorizes the treatment. • Hospital extends credit based on TPA’s authorization • Hospital sends bills to TPA for settlement. • Member gets discharged from Hospital and signs claim form and final bill • Member has to make full payment for the treatment before discharge for the uncovered services (excluded from the scope of cover)

17. Claim Procedure-Reimbursement • In Non-Network Hospitals • Member gets discharged from Hospital after treatment and submits duly completed claim form with following documents : • Discharge Card • Main Hospital Bill with Receipt for payment • All Investigation Reports • Prescription for all investigation reports. • Prescription for medicines • Bills for medicines and investigations • Break-up of medicines charged in Hospital Bill • Xerox copy of ID Card • Hospital and Doctor’s Registration number is a must • TPA Settles the claim

18. Insured has to arrange for the Admission Request Note to be sent across from respective network hospitalto Paramount. Admission request note is available on admission counter of network hospitals. • Send the Admission request note to PHS 24 x 7 Help Desk (022 – 66620808) Fax: 022 28259743 / 543 / 784 / 489. • On receipt of the completely filled request letter, claim will be registered & a unique claim number (FIR / CCN) will be generated. • In case there is a deficiency, it will be raised in the form of an additional information letter & faxed to respective Hospital. The query & claim status can be obtained from Hospital itself or Call Centre or on the website. • On receipt of deficient documents claim will be reviewed & processed further on as per admissibility. • If the coverage is not established, Intimation (Denial) will be sent to the hospital.

19. Contact Details Insurer TPA UNITED INDIA INSURANCE CO. LTD Address: Chembur Div Office, Natraj Cinema Bldg, 1st flr, N G Acharya Marg, Chembur (East), Mumbai-400071. Contact No: (022) 25223324/25/26 PARAMOUNT HEALTH SERVICES (TPA) PVT. LTD Address: Elite Auto House, 2nd Flr, 54-A, M Vasanji Road, Andheri (East) Mumbai-400093. Contact No: (022) 66620800 Website: www.paramounttpa.com

20. Thank You