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Restricted © Siemens AG 20XX All rights reserved. siemens.com/answers
Group Medical Insurance Guideline
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Insurance Company, TPA & EB Broker
Policy Company TPA
Group Medical - Employees Bajaj Allianz GIC Ltd HAT (Bajaj In-house TPA)
Group Medical - Parents Bajaj Allianz GIC Ltd HAT (Bajaj In-house TPA)
Employee Benefit Insurance Broker Marsh India Insurance Broker Pvt. Ltd
The Group Mediclaim Program provides insurance coverage to employees of Siemens Group
& their dependents for expenses relating to hospitalization due to illness, disease or injury
subject to a minimum of 24 hours hospitalization.
Program Details
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Companies Covered(Group Companies)
Siemens Ltd
STSPL
SFSPL
SPPALPL
SCCPL
SHPL
Plan Name Group Medical Policy - Employees
Policy Holder Siemens
Period of the Cover 12 months
Inception Date 1-December-2015
ExpiryDate 30-November-2016
Insurer Bajaj Allianz GIC Ltd
TPA HAT (Bajaj In-house TPA)Members Covered
2A + 2C (Self + Spouse + 2 dependent children upto 25 years)
Geographical Limits India (Covers trea tme nt in Ind ia o n ly)
Mid-Term Revision of Sum Insured No
Age-Limit 1 da y to 80 Yea rs
Mid-Term Enrollment Yes (Only for New Born Child & Newly WeddedSpouse)
Group Medical Plan – Employees (Policy Details)
Sum Insured – Graded as follows
SL STSPL
Workmen/JE-SE 2 Lac S6-P2 2 Lac
MG 1-4 3 Lac M 0-4 3 Lac
MG 5 & above 5 Lac M5 & above 5 Lac
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Group Medical – Employee (Features contd…)
Maternity Policy Features
Coverage Fornormal - INR 50,000and For C-section- INR70,000
Restriction on No. of children 2 children
9-months waiting periodWaived Off For AllEmployees
Pre-Post Natal expenses Covered up to INR 10,000within maternity limit
New born baby coveredfrom day 1
Yes
Policy benefits
Daycare Treatments Covered as per list. List in laterpart of the guideline
Medical Termination ofPregnancy
All expenses to be covered incases of Medical termination ofpregnancy under Medical adviceto save the life or prevent seriousdamage to the health of the
mother. However voluntarymedical termination ofpregnancy during the first 12weeks from the date ofconception not covered
New born babies,Genetic and Congenitaldisorders internal to becovered from day one forall types of medical
related expenses
Covered
Day care coverage (overand above the insurer'slist)
D&C, radiotherapy, Excision ofCyst/granuloma /Lump (Localand General Anesthesia) andendoscopies to be covered onOPD basis (24 hourshospitalization to be waived off)
Surgery Treatment forThalassemia
Covered
Add it ional benef its broug ht i n this year (2015-16):
•Hormone Therapy for Cancer
treatment•In case of maternity related compli cation leading tolife threatening situ ations, the maternity li mit will not
apply.
• Amb ulance cover revis ed to INR 5000 per p erso nper hospitalization
•No deduction in case of death duringhospitalization
•Coverage of dependent in case of empl oyee death
till the end of poli cy period
•Bio degradable stent up t o 1.5 Lac
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Plan Name Group Medical Policy - Parents
Policy Holder Siemens
Period of theCover
12 months
Inception Date 1-December-2015
ExpiryDate 30-November-2016
Insurer Bajaj Allianz General insurance Co ltd
TPA HAT (Bajaj In-house TPA)
MembersCovered
Natural Parents or in laws of insured employeeonly. Restricted to any 2 parents c overage only
GeographicalLimits
India (Covers trea tme nt in Ind ia o n ly)
Mid-TermRevision of SumInsured
No
Age-Limit 36 to 95 yearsLock in Period 4 years
Group Medical – Parents (Policy Details)
Flexibility Options
Coverage for any set of parents (up to 2parents only)
Option to increasethe sum insured as per
details below
Option provided between floater and nonfloater
Option once selected will be frozenfor 4years.
Employee Grade BandNew plan design
(Non-floater )
New Plan design for(Floater)
up to P2/SE grade 1 Lac/ 2 Lac/3 Lac/ 4 Lac/ 5 Lac/6 Lac 2 Lac/3 Lac/4 Lac/6 Lac
M0/MG1 – M4/MG4 grade 3 Lac/4 Lac/5 Lac/6 Lac/8 Lac 3 Lac/4 Lac/6 Lac/8 Lac
M5/MG5 & above 3 Lac/4 Lac/5 Lac/6 Lac/8 Lac 3 Lac/4 Lac/6 Lac/8 Lac
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Group Medical – Parents Additional Benefits this year
Addi tional benefi ts brought in this year (2015-16):
Hormone therapy for cancer treatment
Oral Chemotherapy for all types ofcancer
Ambulance cover revised to INR 5000 per person per
hospitalization
Age-Limit covered 36 to 95 years
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Policy Features Acceptabi li ty
Standard Hospitalization Yes
Pre & Post HospitalizationExpenses
Yes (30 days-60 days)
Pre-existing Diseases Yes (waived)
First 30-days Waiting Period Yes (waived)
First Year Waiting Period Yes (waived)
Policy Features Acceptabil ity
Domiciliary Hospitalization No
Day CareCovered as per theInsuranc e company's list
OPD Expenses No
Health Check Up Not covered
Room Rent Capping No Restriction
Co-Pay No
Ayurvedic Treatment Not covered
Septoplasty and stem celltreatment Not covered
Hormone therapy for cancertreatment Covered
• There will be 4 years lock-in period for parents policy. This means once the parents are declared youcannot change the same till 4 years are completed. Only incase of death of any parent/death ofemployee/ resignation/retirement, the parents declaration can be stopped.• This Lock-In period will benefit employee to take policy on a retail mode in the event ofretirement/resignation benefits at par as per the corporate policy (portability option)• The applicable waiting periods in normal retail policies are waived off in the portability option post thecompletion of this 4 years lock in period . e.g. 30 days waiting period, pre-existing diseases, 1st and 2nd years
exclusions are waived off. However, premium would be at discretion of the insurance c ompany
Group Medical – Parents (Features)
Lock in Period - Features
Refractive error or sight
correction (+-) 7
Covered on OPD or IPD basis (lasik
or any injection given on OPD basis
are covered)
Dental and Vision only incase
of accidentsCovered
Internal congenital,
Pandemic, Oral
Chemotherapy
Covered
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Standard Hospitalization
Reimbursement of expenses related to
• Room and boardingcharges
• Doctors/Consulting fees
• Intensive Care Unit
• Surgical fees, operating theatre, anesthesia and oxygen and their administration
• Drugs ,medicines and consumables consumed on the premises.
• Hospital miscellaneous services (such as laboratory, x-ray, diagnostic tests)
• Diagnostic procedures such as Laboratory, X ray and other diagnostic tests
• Costs of prosthetic devices if implanted during a surgical procedure
• Radiotherapy and chemotherapy
• Organ transplantation includingthe treatment costs of the donor but excluding the costs of the organ
Note:
A) The expenses shall be reimbursed provided they are incurred in India and within the policy period. Expenses will be
reimbursed to the covered member depending on the level of cover that he/she is entitled to.
B) Expenses on Hospitalization for minimum period of 24 hours are admissible. However this time limit will not apply
for specific treatments i.e. Dialysis, Chemotherapy, Radiotherapy, Eye surgery, Dental Surgery, Lithotripsy (kidney
stone removal), Tonsillectomy, D & C taken in the Hospital/Nursing home and the insured is discharged on the same
day of the treatment will be considered to be taken under Hospitalization Benefit.
C) A security deposit of a minimum of INR 10,000 or more may be collected from the empanelled hospitals which may
be reimbursed fully or partially post deduction of non admissible expenses and once cashless settlement is done by
the Third Party ClaimsAdministrator (TPA)
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Pre & Post Hospitalization expenses
Pre-hospitalization Expenses
Definition
If the Insured member is diagnosed with an il lness
which results in his / her Hospital izat ion and for which
the Insurer accepts a claim, the Insurer will also
reimburse the Insured Member’s Pre-hospital izat ion
Expenses incurred towards that illness for which
hosp itali zation is done for up t o 30 days p rio r to hi s /
her Hospitalization.
Covered Yes
Duration 30 Days
Post-hospitalization Expenses
Definition
If the Insurer accepts a claim under Hospitalization andimmediately following the Insured Member’s discharge,
fur ther medical t reatment direct ly related to the same
condition for which the Insured Member was
Hospitalized is required, the Insurer will reimburse the
Insured member’s Post-hospitalization Expenses for up
to 60 day per iod.
Covered Yes
Duration 60 Days
Covered
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Maternity Benefits
The maximum benefit allowable is INR 50,000 for Normal and INR 70,000 for C-section per delivery within the policy Sum
Insured, max up to 2 children.
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 during the first 12 weeks from the
date of conception are not covered
• Sterilization expenses are not covered
Reimbursement of expenses related to maternity as per policy
Benefit Details
Maximum Benefit allowable For normal - INR 50,000 and For C-section- INR 70,000
Restriction on no. of children Maximum of 2 children
9 Months waiting period Waived off
Pre-Post Natal Expenses on IPD and
OPD basis
Covered upto INR 10,000 within maternity limit
IMPORTANT:
For maternity reimbursements and employees on subsequent maternity leave , please do not wait ti ll you return back to office
to submit a claim as it will cross the claim submission timeframes and claim may be denied. please also immediately inform
HR about the new baby coverage as your dependent as subsequent complication may be a possibility and intimation is
mandatory prior to coverage.
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Pre existing diseases
Definition
Any Pre-Existing Condition or related condition for which care, treatment or
advice 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
Definition
Any disease contracted by the Insured Person during the first 30 days from the
commencementdate of the Policy is also covered.
First Year Waiting period
Definition
During the first year/second year of the operation of the policy, the expenses on
treatment of 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 also
payable.
Covered
Baby Cover Day 1
Definition
Extension to cover the new born child of an employee covered under the Policy
from the time of birth. Not withstanding this extension, the Insured shall be
required to cover the newly born children immediately as additional member. Covered
Customized Benefits
Covered
Covered
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Customized Benefits contd..
Day Care
Definition Day Care Procedure means the course of medical treatment or a
surgical procedure listed in the policy 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.
Restriction List of day care procedures as named in the Policy schedule
Vision & Hearing aid
Defini tion The cost of spectacles and contact lenses, hearing aids
R Restricted
X Not Payable
R Restricted
R Restricted
Dental Treatment
Defini tion Any dental treatment or surgery of a corrective, cosmetic or aesthetic
nature unless it requires Hospitalisation; is carried out under general
anesthesia and is necessitatedby Illness or Accidental Bodily Injury.
Restriction Expenses arising only by way of an accident are payable.
Diagnostics Expenses
Definition Charges incurred at Hospital or Nursing Home primarily for diagnostic,
X-Ray or laboratory examinations or other diagnostic studies
consistent with or incidental to the diagnosis and treatment of the
positive existence of any ailment, sickness or injury for which
confinement is required at a Hospital/Nursing Home are admissible.
However diagnostics on standalone basis are not payable.
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General Exclusions
• Injury or 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) or by nuclear weapons / materials.
• Circumcision (unless necessary for treatment of a disease not excluded hereunder or as may be necessitated due to any
accident), vaccination, inoculation or change of life or cosmetic or of aesthetic treatment of any description, plastic
surgery other than as may be necessitated due to an accident or as a part of any illness.
• Surgery for correction of eye sight, cost of spectacles, contact lenses, hearing aids etc.
• Any dental treatment or surgery which is corrective, cosmetic or of aesthetic procedure, filling of cavity, root canalincluding wear and tear etc. unless arising from disease or injury and which requires hospitalization for treatment.
• Convalescence, general debility, “run down” condition or rest cure, congenital external diseases or defects or anomalies,
sterility, any fertility, sub-fertility or assisted conception procedure, venereal diseases, intentional self-injury/suicide, all
psychiatric and psychosomatic disorders 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.
• All expenses arising out of any condition directly or indirectly caused by, or associated with Human T-cell Lymphotropic
Virus Type III (HTLD - III) or Lymohadinopathy Associated Virus (LAV) or the Mutants Derivative or Variations Deficiency
Syndrome or any Syndrome or condition of similar kind commonly referred to as AIDS, HIV and its complications
including sexually transmitted diseases.
• Expenses incurred at Hospital or Nursing Home primarily for evaluation / diagnostic purposes which is not followed byactive treatment for the ailment during the hospitalised period.
• Expenses on vitamins and tonics etc. unless forming part of treatment for injury or disease as certified by the attending
physician.
• Any Treatment arising from or traceable to pregnancy, miscarriage, abortion or complications of any of these including
changes in chronic condition as a result of pregnancy except where covered under the maternity section of benefits
• Naturopathy treatment, unproven procedure or treatment, experimental or alternative medicine and related treatment
including acupressure, acupuncture, magnetic and such other therapies etc.
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General Exclusions contd..
• Expenses incurred for investigation or treatment irrelevant to the diseases diagnosed during hospitalisation or primary
reasons for admission. Private nursing charges, Referral fee to family doctors, Out station consultants / Surgeons fees
etc,.
• Genetical 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..
• Change of treatment from one path to other path 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 required arising from Insured’s participation in any hazardous activity including but not limited to scuba
diving, motor racing, parachuting, hang gliding, rock or mountain climbing etc unless specifically agreed by the Insurance
Company.
• 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 or 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.
• Doctor’s home visit charges, Attendant / Nursing charges during pre and post hospitalisation period.
• Treatment which is continued before hospitalization and continued even after discharge for an ailment / disease / injury
different from the one for which hospitalization was necessary.
• The above are only indicative and not exhaustive.
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Non Payable Expenses under Mediclaim Policy
•Admission charges or Kit / Registration/Token/Supplementary /service charges/Pre – post Consultants homevisit charges
•Any kind of Service charges, Surcharges, Admission fees / Registration charges etc levied by the hospital.
•Transportation/Ambulance/Local conveyance charges where ambulance is not required medically and as per the policy conditions.
•Administrative/Charges of Identification Band/Identification card
•Attendee or attendance staff /cleaner charges•Amenity of the hospital/water ,electricity, luxurious utility charges/establishment charges/ charges related tolinen/laundry/washing charges/establishment charges/any sort of overhead/lodging charges.
•Any charges named as Sundry/Stationary/File/Folder/Documentation/ xerox charges/medico legal charges/charges of birth or medical certificate or related to any certificate issuance.
•Telephone charges/TV charges/Video charges/Cable charges/internet charges/AC charges/cost of cassette/CD charges in case of endoscopy, color doppler etc/camera and related charges
•Mess/ Food charges/Diet charges/Nutrition and nutrition planning charges/Diabetic charges/cost related tomineral water
•Input & Output charges/Daily pass charges,/relative stay/extra bed charges/companion stay or relatedcharges/donor screening/organ harvesting charges/,private nursing charges during hospitalisation.
•Biomedical Waste charges/waste maintenance charges
•The above are only indicative and not exhaustive. Refer policy terms and conditions. Link for list of nonadmissible expenses https://www.bajajallianz.com/Corp/content/claim/nonadmissibleexpenses.pdf
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Voluntary Top Up pol icy
A Top-up policy supplements your existing mediclaim policy, insuring
you for a larger sum insured limit at lower cost
A Top-up cover is initiated when the full sum assured of your base
policy is exhausted (i.e. Threshold limit is reached) it excludes maternity
and maternity related issues.
Sum insured available 2lacs, 3lacs and 5 lacs
Advantages
Customizable “top-up” cover for each corporate customer
Terms and conditions to be in sync with the base policy
Option with the employee to enroll for the cover
“Group Leaver Benefit” – Employee can continue the same benefits even after he/she quits the
company.
Benefits under section 80D of Income Tax Act.
FAQ
Top up
policy
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Employee must enroll in order to obtain coverage for yourselves and your eligible dependents. Employee will
receive a link for Benefit me portal of Marsh where employee can provide relevant enrollment data on the portal
which will be open for 15 days. Post which the data will be shared with Insurer and endorsed and be used for
policy period 2015-16
In case of life events i.e. each time you acquire a new dependent like when your family status changes because ofmarriage, birth or adoption of a child. The acquisition of a new spouse and new born must be declared within 30
days of the marriage or child-birth.
If you fail to enroll within the defined timelines, the next enrollment can be done only at next renewal.
The UHID will be uploaded on the portal as well will be shared on email to all employees along with welcome
mailers.
On receipt of e cards employee should verify the details of self & Dependents notify HR & Marsh, post which samewill be rectified with endorsement with insurer and new details will be shared with employee.
Enrollment in the program
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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. However, in spite of the above benefits, some hospitals may demand a deposit before admission
and refund of deposit shall be as per hospital policies.
List of hospitals in the TPA’s network eligible for cashless hospitalization
Customer Care Center /Toll free no:
Toll Free No -1800 22 5858, 1800 102 5858
+91 9731407546
List of network hospitals
Note: The network hospital is subject to change, hence please
reconfirm with TPA before admission into any hospital or you
may log on to for an updated list
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Planned Hospitalization
Step 1Pre-Authorization
Step 2 Admission,
Treatment &
discharge
All non-emergency
hospitalization instancesmust be pre-authorized with
the TPA, as per the
procedure detailed below.
This is done to ensure that
the best healthcare
possible, is obtained, and
the Insured Member is not
inconvenienced when taking
admission into a Network
Hospital.
After your hospitalization has
been pre-authorized, you
need to secure admission toa hospital. A letter of credit
will be issued by TPA to the
hospital. Kindly present your
Mediclaim card at the
Hospital admission desk. The
Insured Member is not
required to pay the
hospitalization bill in case of
a network hospital. The bill
will be sent directly to, andsettled by, TPA.
Patients seeking treatment
under cashlesshospitalization are eligible to
make claims under pre and
post hospitalization
expenses. For all such
expenses, the bills and
other required documents
need to be submitted
separately as part of non-
cashless claims.
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Pre-Authorization
Member approaches TPA
counter of the Hospital with
planned hospitalization
details filled in a specified
pre-authorization format 48
hours prior to hospitalization
Hospital in turn
intimates the TPA
& Claim is
Registered by the
TPA on same day
Follow non
cashless process
No
TPA issues letter of credit
within 12 hours for planned
hospitalization to the
hospital
Yes
Pre-Authorization
Completed
For Pre-Authorization Claim Form please find the link
https://www.bajajallianz.com/Corp/content/health/health_claim_forms/cashless_request_form.pdf
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Admission, Treatment & Discharge
Member produces E-card at
the network hospital and
gets admitted
Member gets treated and
discharged after paying all
non entitled benefits like
refreshments, etc.
Hospital sends complete set
of claims documents for
processing to the TPA
Claims Processing by TPA
(with approval by Insurer)
Release of payments to the
hospital
Note: Employee /Insured is requested to check details of the Final Bill for its correctness before signing the
same
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Emergency Hospitalization
Step 1Get Admitted
Step 2Pre-Authorization by
hospital
Step 3Treatment &
Discharge
In cases of emergency, the
member should get
admitted in the nearest
network hospital by showing
their E-card. The treatment
should not be put on hold
irrespective of the time of
receipt of pre-authorization.
Relatives of admitted
member should inform the
call center /TPA Helpdesk
within 24 hours of
hospitalization & seek pre
authorization. The letter of
credit would be directly
given to the hospital. In
case of denial, relative
/member would be informed
directly by TPA.
After your hospitalization
has been pre-authorized,
the employee is not required
to pay the hospitalization bill
(except for the non-
medical/non-payable
expenses) in case of a
network hospital. The bill
will be sent directly to and
settled by TPA to the
hospital
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Member gets admitted in the
hospital in case of
emergency by showing his
E-card. Treatment starts
Member / Hospital applies
for pre-authorization to the
TPA within 24 hrs of
admission
TPA verifies applicability of
the claim to be registered
and issue pre-authorization
Pre-
authorizatio
n given by
the TPA
Follow non
cashless process
No
Member gets treated and
discharged after paying all
non entitled benefits like
refreshments, etc.
Hospital sends complete set
of claims documents for
processing to the TPA
Claims Processing by TPA &
Insurer
Release of payments to the
hospital
Emergency Hospitalization Process
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Non cashless Hospitalization Process
Member intimates TPA
before or as soon as
hospitalization occurs
Insured admitted as per
hospital norms. All
payments made by
member
Claim registered by TPA
after receipt of claim
intimation
Insured sends relevant
documents to TPA office
within 30 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 Name, Employee Code
& Employee e-mail & contact
Is
documentreceived
within 30
days from
discharge
Claim RejectedNo
TPA performs medical
scrutiny of the
documents
Is claim
admissible?
(coverage /
applicability
)
Yes
TPA checks document
sufficiency
NoYes
Is
document-
ation
complete
as required
Claims processing done
within 10 working days
Send mail about deficiency
and document requirement A
A
NEFT payment to the
employee shall be made. An
auto mailer will be sent to
your email id the following
day after NEFT is done
Yes
No
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Claims Document List
Signed Claim form
Main Hospital bills in original (with bill no; signed and
stamped by the hospital) with all charges itemized and the
original receipts
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 forMedicines, 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 andavailability of doctors and nurses round the clock.
In non- network hospitalisation, please get the hospital and
doctor’s registration number in Hospital letterhead and get
the same signed and stamped by the hospital.
Cancelled copy of cheque or NEFT details
Note: Please attach the completed document check-
list along with claim form and claim documents and
submit the same to TPA within the timeline specified.
Member needs to retain a photocopy of all thedocuments he is submitting for future reference
To download claim Form click on the links below
https://www.bajajallianz.com/Corp/content/health/health_claim_forms/ReimbursementFormA+B2013.pdf
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Prudent Utilization of Benefit
Health Insurance is a benefit for the employee and their dependents. One has to utilize the benefit with utmost
caution and prudence.
The ever increasing cost for the benefits require a proactive involvement from all of us.
The following steps are recommended, ensuring the benefits is prudently utilized by the employee and
dependents covered
Please ensure to crosscheck the final bill sent to the TPA for the following:
You are Billed only for the services util ized for e.g. category of room, diagnostics undergone ,
medicines consumed
Total of the bill
In case of any planned hospitalization, approach the hospital in advance(48 hours) and request pre
authorization- this enables TPA to further negotiate the rates
To approach hospitals with caution – most expensive is not necessarily the best.
To cross check the tariff with the Bench Mark Rates provided- the benchmark rates would give an
idea the general spend for the treatment or procedure.
Try to negotiate
Ask WHY & WHAT is billed to you ( as a consumer , we have the right to know)
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Timelines for submission of documents
Type of document
Intimation of reimbursement claims-
Documents of hospitalisation and pre-hospitalisation
Documents of post-hospitalisation
Timeline for submission
No Intimation required
Within 45 days from the date ofdischarge
Maximum within15 days from the date
of completion of 60 days from
discharge or completion of treatment
whichever is earlier
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FAQ contd..
• Is pre authorization necessary?
Yes. This will help you in the following ways:
1) You will be informed in advance regarding your coverage for the treatment and whether it is covered under your
medical plan or not . This will help you know in advance if your claim may get rejected at a later stage and you do not end
up paying out of pocket.
2) It will help you ensure that the treatment cost is appropriate and not inflated. as the TPA will be able to cross check
costs with the hospital in question. This will also help TPA in planning your hospitalization expenditure such that you donot run out of the cover that you are entitled to.
3) It will help TPA in registering the impending claim with the insurer.
• What are the key points I must remember when using benefits under this pol icy
• Please ensure that all your dependents are covered and have a valid card at the outset itself as it will not be possible
to add dependents at a later stage
• Submit your reimbursement claims within timelines from the hospital. Please do not postpone this till later as it may
mean that your claim gets rejected due to late submission .
• Please check that your documents are submitted completely at the first instance itself and originals are submitted
wherever requested for . Do note that incomplete submissions will not be considered as exceptions by the insurers
and will only delay the process further for you and a delay may lead to the claim getting closed.
• Please retain a copy of all claim documents submitted to the insurer
• Please do a pre-authorization for all claims including a proposed reimbursement as it will clarify issues regarding
coverage for you well in advance of an expense being undertaken.
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FAQ contd..
• What are the key reasons why a claim under the medical policy could be completely rejected under the plan?
The following are some common reasons for rejection although these are NOT the only reasons why a claim could be
rejected :
1) Treatment taken after leaving the organization. (If you have been transferred from one business to another please
confirm with your HR that you have been included for coverage under your new entity)
2) Treatment that should have been taken on an outpatient basis (unnecessary inpatient admission and / or no active
line of treatment.) or where hospitalization has been done primarily from a preventive perspective. Please remember thaton occasion your personal doctor may recommend hospital admission for observation purposes however such
admissions are not covered under your medical plan
3) Treatment taken is not covered as per policy conditions or excluded, under the policy. Please go through the list of
standard exclusions listed earlier. (for e.g. : Ailment is a because of alcohol abuse is a standard exclusion, similarly
cosmetic treatments or treatments for external conditions like squint correction etc are not covered) . Hospitalization taken
in a hospital which is not covered as per policy conditions (Ex. less than 10 bed hospitals), Admission is before/after the
policy period or details of the member are not updated on the insurer’s list of covered members . Additionally in case
original documents are not submitted as per the claim submission protocol,
• What are the key reasons why a claim under the medical poli cy could be reduced v/s sum insured ?
The following are some common reasons for rejection although these are NOT the only reasons why a claim could be
reduced : (1) Limits for the specific ailment exceed the reasonable cap on ailments listed in the manual,
(2) Claim amount exceeds the permissible limit under the policy for you ( denied to the extent of the excess),
(3) Some expense items are non payable for e.g. toiletries , food charges for visitors etc.
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Contact Details
TPA Contact Details
Insurer
Bajaj Allianz General Insurance
Co Ltd.
Insurer Website:
https://www.bajajallianz.com
Bajaj Allianz General InsuranceCo ltd Health Care TPA Address
for sending reimbursement
claim documents:
Health Claim DeptBajaj Allianz General Ins Co Ltd
Rustomjee Aspire, 3rd Floor, EveradNagar-2 ,Near APEX Honda,
Priyadarshini Circle,
Off Eastern Express Highway,Chunabhatti – Sion,Mumbai-400022
Marsh India Insurance Broker Pvt Ltd
Relationship Manager
Name: Ajay Shetty
Email: [email protected]
Phone no-7507606228
Escalation poin t
Name: Beena Nair
Email: [email protected]
1st Level Contact
Toll Free Nos
1800 22 5858
1800 102 5858
Fax Number of Cashless Dept: 020-30512224/6/7
Pre Auth Mail Id: [email protected].
Relationship manager Bajaj Alli anz :Shwetambari Rane
Email: [email protected]
Phone no:+917738367194
Vikhyat Rai
Email: [email protected]