Employee Benefits Manual

CHOLAMANDALAM MS GENERAL INSURANCE CO LTD

Content Benefits Manual

Document No CMS/F1/01

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Disclaimer:

This Benefits Manual will serve as a guide to the benefits provided by Cholamandalam MS General Insurance Co.Ltd. The
information contained here is only a summary of the policy documents which are kept by the company. If there is a
conflict in interpretation then the terms & conditions of the pertinent policy will prevail.

All rights reserved. No part of this publication may be reproduced, stored in the retrieval system,
or be transmitted in any form or by any means, electronic or mechanical, photocopying, recording
or otherwise, without the prior written permission of MIBL. Proceed
Main Menu

A. Program Details

B. Contact Details

C. Close

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 A. Program Details

The Group Mediclaim Program provides adequate, pre-

defined insurance coverage to “Cholamandalam MS
1. Group Mediclaim General Insurance Co. Ltd” & their dependents for
expenses related to hospitalization due to illness,
disease or injury

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 1. Group Mediclaim

1.1 Benefit Details

1.2 Enrollment in the program

1.3 Cashless Hospitalization

1.4 Non - Cashless Hospitalization

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 1.1 Benefit Details

Policy Parameters
Insurer The Oriental Insurance Co Ltd
TPA Vidal Health TPA Pvt Ltd
Policy Start Date 01st September 2017
Policy End Date 31th August 2018
Coverage Type (Floater / Individual) Family Floater

Dependent Coverage 1+5 [ Employee + Spouse + 2Children + Parents/In-Laws]

Sum Insured Graded

Benefits covered Benefits covered

Standard Hospitalization Yes Ambulance Services Yes

Pre existing diseases Yes Domiciliary Hospitalization No

Waiver on 1st year exclusion Yes Day Care Yes

Dental & Vision Restricted
Waiver on 1st 30 days excl. Yes
Diagnostics Restricted
Maternity benefits Yes
Deductibles & Co-pay Yes
Pre & Post Natal Expenses Yes
Epidemic Breaks Covered
Baby cover day 1 Yes Terrorism Covered
Pre-Post Hospitalization Exp. Yes

Back Policy Coverage General Exclusion

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 Applicable Members

Employee Yes
Spouse Yes

Children Yes (Up to 2 Dependent Children)

Parents Yes
Parents-in-Law Yes
Siblings No

Others No

Disallowed
Mid Term enrollment of existing Dependents
Mid Term enrollment of New Joinees (New employees +their
Allowed
Dependents)
Mid term enrollment of new dependents (Spouse/Children) Allowed

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 Policy Period

Existing Employees + Dependents

Commencement Date 01st September 2017

31st August 2018 or as & when Employee leaves the

Termination Date
organization.

New Joinees + Dependents

Commencement Date Date of joining

31st August 2018 or as & when Employee leaves the

Termination Date
organization.

New Dependents (due to Marriage / Birth )

Commencement Date Date of such event

31st August 2018 or as & when Employee leaves the

Termination Date
organization.

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 Coverage Levels

Sum Insured – Family Floater Individual Sum Insured

Family Floater Definition Total sum Insured can be utilized by any of the Family members

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 Standard Hospitalization
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 treatment costs

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 Pre & Post Hospitalization expenses

√ Covered

Pre-hospitalisation Expenses
If the Insured member is diagnosed with an Illness which results
in his / her Hospitalization and for which the Insurer accepts a
Definition claim, the Insurer will also reimburse the Insured Member’s Pre-
hospitalisation Expenses for up to 30 days prior to his / her
Hospitalization.
Covered Yes
Duration 30 Days

Post-hospitalisation Expenses
If the Insurer accepts a claim under Hospitalization and
immediately following the Insured Member’s discharge, further
Definition medical treatment directly related to the same condition for
which the Insured Member was Hospitalized is required, the
Insurer will reimburse the Insured member’s Post-
hospitalisation Expenses for up to 60 day period.
Covered Yes
Duration 60 Days

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 Maternity Benefits

Reimbursement of expenses related to maternity as per

 There are special conditions applicable to the Maternity Expenses Benefits as below:
• These benefits are admissible only if the expenses are incurred in Hospital/Nursing Home as in-patients in
India.
• Claim in respect of delivery for only first two children and/or operations associated therewith will be
considered in respect of any one Insured Person covered under the Policy or any renewal thereof. Those
Insured Persons who already have two or more living children will not be eligible for this benefit.
• Expenses incurred in connection with voluntary medical termination of pregnancy are not covered.

Benefit Details
Maximum Benefit allowable INR 50,000 for both Normal & C-Section
Restriction on no of children Maximum of 2 children
9 Months waiting period Not applicable
Pre-Post Natal Expenses within Covered
maternity limit

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 Customized Benefits

Pre existing diseases

√
Any Pre-Existing Condition or related condition for which care, treatment or advice Covered
Definition was recommended by or received from a Doctor or which was first manifested
prior to the commencement date of the Insured Person’s first Health Insurance
policy with the Insurer
First 30 day waiting period waiver
Any disease contracted by the Insured Person (except for the “First Year

√
Definition diseases” listed below) during the first 30 days from the commencement date of Covered
the Policy is not covered. This exclusion shall not apply if in the opinion of Panel
of Medical Practitioners constituted by the Company for the purpose, the
Insured person could not have known of the existence of the Disease or any
symptoms or complaints thereof at the timer of making the proposal for insurance
to the Company.
First Year Waiting period waiver
During the first year of the operation of the policy, the expenses on treatment of
Definition diseases such as Cataract, Benign Prostatic Hypertrophy, Hysterectomy for
Menorrhagia or Fibromyoma, Hernia, Hydrocele, Congenital Internal Diseases,
Fistula in anus, Piles, Sinusitis and related disorders are not payable. If these
diseases are pre- existing at the time of proposal, they will not be covered even
√ Covered

during subsequent period or renewal too.

Baby Cover Day 1

√
Extension to cover the new born child of an employee covered under the Policy
Definition from the time of birth till 90 days. Not withstanding this extension, the Insured Covered
shall be required to cover the newly born children after 90 days as additional
member.

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 Ambulance services

√ Applicable

Ambulance Services

The Insurer will pay for Emergency ambulance road transportation by a

licensed ambulance service to the nearest Hospital where Emergency
Definition Health Services can be rendered. Coverage is only provided in the
event of an Emergency.

Amount restriction Max. Limit INR 2,500/- or Actuals whichever is less

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 Domiciliary Hospitalization

X Not Applicable

Domiciliary Hospitalization
DOMICILIARY HOSPITALISATION BENEFIT 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 but actually taken whilst confined at home in India under any of the following circumstances, namely:
Definition
– The condition of the patient is such that he/she cannot be removed to the hospital/nursing home or
– The patient cannot be removed to the hospital/nursing home for lack of accommodation therein

• expenses incurred for pre and post hospital treatment, and

• expenses incurred for the treatment for any of the following diseases:
– Asthma
– Bronchitis
– Chronic Nephritis and Nephritic Syndrome
– Diarrhea and all types of dysentries including Gastroenteritis
Benefits not covered
– Diabetes Mellitus and Insipidus
– Epilepsy
– Hypertension
– Influenza, Cough, and Cold
– All Psychiatric or Psychosomatic disorders
– Pyrexia of unknown origin for less than 10 days
– Tonsillitis and upper respiratory tract infection including Laryngitis and Pharyngitis
– Arthritis, Gout and Rheumatism

Note: When treatment such as Dialysis, Chemotherapy, Radiotherapy is taken in the Hospital/Nursing Home/Clinic and the
Back insured is discharged the same day the treatment will be considered to be taken under Hospitalisation Benefit section.

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 Day Care

R Restricted

Day Care

Definition Day Care Procedure means the course of medical treatment or a surgical
procedure listed in the Schedule which is undertaken under general or local
anesthesia in a Hospital by a Doctor in not less than 2 hours and not more
than 24 hours.

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 Dental & Vision

R Restricted

Dental Treatment

Definition Any dental treatment or surgery of a corrective, cosmetic or aesthetic

nature unless it requires Hospitalisation; is carried out under general
anesthesia and is necessitated by Illness or Accidental Bodily Injury.

Vision & Hearing aid

Definition The cost of spectacles and contact lenses hearing aids are not claimable in
the policy

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 Diagnostics

R Restricted

Diagnostics Expenses
Definition Charges incurred at Hospital or Nursing Home primarily for diagnostic,
X-Ray or laboratory examinations or other diagnostic studies not
consistent with or incidental to the diagnosis and treatment of the
positive existence of presence of any ailment, sickness or injury for
which confinement is required at a Hospital/Nursing Home or
Hospitalization as defined

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 Epidemic Breaks

√ Applicable

Definition Epidemic breaks primarily on account of any ailment, sickness or

injury for which confinement is required at a Hospital/Nursing Home or
Hospitalization is covered under the policy

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 Policy conditions
• Family Definition: Self, Legally Wedded Spouse, Two Living Children and Parents/Parents-in-Laws

• 30 Days and First Year Exclusion waiver off for all employees as well their Dependents

• Pre Existing Disease Coverage from the day one for all employees as well as their dependents

• Maternity Coverage from day one for Employee/Spouse with the Sublimit of Rs. 50,000 for both Normal & C-Section up to
First two living children only

• Room Rent : 2% of sum Insured or Rs.4,000/- Max for Normal & 3% of the sum insured or Rs.6,000/- Max for ICU

• 9 Months waiting period under Maternity Coverage is waived off for all

• Baby Coverage from the day one

• Pre and Post natal expenses within the maternity limit

• Ambulance charges max. up to 2,500/- or actual whichever is less

• Internal Congenital Diseases Covered

• External Congenital Diseases covered on life threatening

• 20% co-pay option for all Parents/Parents-in-laws

• Stem cell therapy and cyber knife surgery to be covered to be covered up to 50% of the SI only, subject to max of Rs.2 Lacs

• Pre expenses 30 days from date of admission and post 60 days expenses from the date of discharge are covered.

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Policy conditions.. continues
 Terrorism

√ Applicable

Definition Terrorism provides protection towards hospitalization expenses

incurred due to any act of terrorism.

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 General Exclusions

• Injury or disease directly or indirectly caused by or arising from or attributable to War or War-like situations
• Circumcision unless necessary for treatment of disease with prior approval from TPA
• Dental treatment of any kind unless requiring hospitalization

• HIV and AIDS

• Hospitalization for convalescence, general debility, intentional self-injury, use of intoxicating drugs/ alcohol.
• Venereal diseases
• Injury or disease caused directly or indirectly by nuclear weapons
• Naturopathy
• Any non-medical expenses like registration fees, admission fees, charges for medical records, cafeteria charges, telephone
charges, etc
• Cost of spectacles, contact lenses, hearing aids
• Any cosmetic or plastic surgery except for correction of injury
• Hospitalization for diagnostic tests only
• Vitamins and tonics unless used for treatment of injury or disease
• Infertility treatment
• Voluntary termination of pregnancy

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 1.2 Enrollment in the program

You must enroll in order to obtain coverage for yourselves and your eligible dependants. Please contact your HR and
provide relevant enrollment data (viz. name, date of birth, gender). Your enrollment data must reach the Insurer within
30 days of your joining Chola Insurance Services Pvt Ltd.
Please notify HR each time you acquire a new dependent i.e. when your family status changes because of marriage, birth
or adoption of a child. New born child is covered from day 1 up to 30 days however after 30 days he/ she needs to be
enrolled as dependant.
If you fail to enroll within the defined timelines, the next enrollment can be done only at next renewal.

MIBL sends the data to

Provide required HR sends the TPA updates the E-Cards uploaded on
Insurer with proper
details of yourself data to the active member TPA / HRIS website
calculations, Insurer
and your dependents MIBL for database and and downloaded by
updates , endorses member
to the HR endorsements generate the E-cards the employee using
and sends the detail to the
Employee ID
TPA

Notify TPA with Employee

revised details and verifies ID card received by
mailing address for details on employee
corrections the ID card
Error in data
printed on ID Card Ok
card
Back Use card for cashless
hospitalization

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 1.3 Cashless Hospitalization

Cashless hospitalization means the Administrator may authorize (upon an Insured person’s request) for
direct settlement of eligible services and the corresponding charges between a Network Hospital and the
Administrator. In such case, the Administrator will directly settle all eligible amounts with the Network
Hospital and the Insured Person may not have to pay any deposits at the commencement of the
treatment or bills after the end of treatment to the extent these services are covered under the Policy.

List of hospitals in the TPA’s network eligible for cashless hospitalization

Contact Call centre at
List at Website
24 X 7 Customer Service Center
9884604485
1800-425-885/7878
044-42894444

Planned Hospitalization

Back Emergency Hospitalization

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 Planned Hospitalization

Step 2
Step 1
Admission, Treatment &
Pre-Authorization
discharge

After your hospitalization Patients seeking

All non-emergency has been pre-authorized, treatment under cashless
hospitalization instances you need to secure hospitalization are eligible
must be pre-authorized with admission to a hospital. A
to make claims under pre
the Help Desk, as per the letter of credit will be issued
by TPA to the hospital.
and post hospitalization
procedure detailed below.
Kindly present your ID card expenses. For all such
This is done to ensure that
the best healthcare at the Hospital admission expenses, the bills and
possible, is obtained, and desk. The Insured Member other required documents
the Insured Member is not is not required to pay the need to be submitted
inconvenienced when taking hospitalization bill in case of separately as part of non-
admission into a Network a network hospital. The bill cashless claims.
Hospital. will be sent directly to, and
settled by, TPA.

Process Process
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 Pre-Authorization

Member intimates TPA of Claim

TPA issues letter of credit
the planned hospitalization Registered Yes within 12 hours for planned
in a specified pre- by the
hospitalization to the
authorization format 48 TPA on
hospital
hours prior to hospitalization same day

No
Pre – Authorization Form
Pre-Authorization
Follow non cashless
Form process Completed

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 Admission, Treatment & Discharge

Member produces ID card at Member gets treated and

the network hospital and discharged after paying all Hospital sends complete set
gets admitted non entitled benefits like of claims documents for
refreshments, etc. processing to the TPA

Release of payments to the Claims Processing by TPA

hospital (with approval by Insurer)

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 Emergency Hospitalization

Step 2 Step 3
Step 1
Pre-Authorization by Treatment &
Get Admitted
hospital Discharge

In cases of emergency, the Relatives of admitted After your hospitalisation

member should get member should inform the has been pre-authorized,
admitted in the nearest call centre within 24 hours the employee is not
network hospital by about the hospitalization & required to pay the
showing their ID card. The seek pre authorization. The hospitalisation bill in case of
treatment should not be put pre authorization letter a network hospital. The bill
on hold irrespective of the would be directly given to will be sent directly to, and
time of receipt of pre- the hospital. In case of settled by, TPA.
authorization. denial, member would be
informed directly.

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Process
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 Emergency Hospitalization Process

Member get admitted in the Member / Hospital applies

hospital in case of TPA verifies applicability of
for pre-authorization to the
emergency by showing his the claim to be registered
TPA within 24 hrs of
and issue pre-authorization
ID Card. Treatment starts. admission

Member gets treated and

Pre-
Hospital sends complete set discharged after paying all
authorizati
of claims documents for non entitled benefits like
on given
processing to the TPA refreshments, etc.
by the TPA

No

Claims Processing by TPA & Release of payments to the Follow non cashless
Insurer hospital process
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 1.4 Non-Cashless Hospitalization

Admission procedure
In case you choose a non-network hospital, you will have to liaise directly for admission.
However, you are advised to follow the pre authorization procedure to ensure eligibility for reimbursement of
hospitalization expenses from the insurer.

Discharge procedure
In case of non network hospital, you will be required to clear the bill and submit the claim to TPA for
reimbursement from the insurer. Please ensure that you collect all necessary documents such as discharge
summary, investigation reports etc. for submitting your claim.

Submission of hospitalization claim

1. After the hospitalization is complete and the patient has been discharged from the hospital, you must submit the
final claim within 15 days from the date of discharge from the hospital. (Applicable in case of Non Network
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.

Back Process Claim Docs

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 Non cashless Hospitalization Process

Member intimates TPA

Claim registered by TPA
Insured admitted as per Insured sends relevant A
before or as soon as hospital norms. All documents to TPA office
hospitalization occurs after receipt of claim
payments made by within 30 days of
(but no later than 7 intimation
member discharge
days)

•Insured will create the

Is claim Is summary of Bills (2 copies)
liable document and attach it with the bills
TPA performs medical Ye •The envelope should
(coverage received
scrutiny of the s contain clearly the
/ within 15
documents Employee ID & Employee
applicabilit days from
y) discharge e-mail

No No
Yes Claim Rejected

Is Claims cheque sent to HR

TPA checks document
document- Ye Claims processing done along with Discharge
ation voucher and copy of
sufficiency
complete
s within 15 working days
payment receipt for
as required
claimant’s sign-off.

Back Send mail about deficiency

A
and document requirement
No 31
 Claims Document List

Signed Claim form

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

Discharge Card (original)

Attending doctors’ bills and receipts and certificate

regarding diagnosis (if separate from hospital bill)

Original reports or attested copies of Bills and Receipts for

Medicines, Investigations along with Doctors prescription in
Original and Laboratory

Follow-up advice or letter for line of treatment after

discharge from hospital, from Doctor.

Break up with 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 hospitalisation, please get the hospital

Back and doctor’s registration number in Hospital letterhead
and get the same signed and stamped by the hospital.

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 B. Contact Details
Group Mediclaim
Insurer :
National Insurance Co Ltd Contact Person
Website:
Mr. Lathapoorni
http://nationalinsurance.com
Sr. Divisional Manager

Group Mediclaim

TPA :
Contact Person Escalation Point
Vidal Health TPA
Mr. Suresh Mr.Vidya
Website:
8939891103 8939891108
www.vidalhealthtpa.com [email protected]
[email protected]
Cashless Toll free :
9884604485
1800-425-8885-7878

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 B. Contact Details

Group Mediclaim

Contact Person 1st Escalation Point

Broker :

Mr.Mageshwaran Ms.Rajalakshimi
Mahindra Insurance Brokers Ltd

7299777883 9790966495

2nd Escalation Point

Mr. Anand Rathinam

9884908766

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THANK YOU

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