prime focus gmc policy

8/2/2019 Prime Focus GMC Policy

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Private & Confidential

Group Mediclaim

&Personal Accident Policy

(with effect from May 18, 2011 to May 17, 2012)


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COVERAGES EXPIRIN G & PROPOSED FEATURES

Family Definition Self + Spouse + 3 Dependent Children + 2 Dependent Parents

PreExisting Ailment Covered Covered For All

30 Days Waiting Period Waived Off1stYr. Exclusion Waived Off

Pre & Post H ospitalization 30 & 60 Days Respectively

Maternity Cover Rs. 30,000/for Normal & 50,000/for Cesarean

9 Months Waiting Period Waived Off

Baby Cover Day One Covered from Day 1

Room Rent Limits Up to 1% of Sum Insured for normal & 1.5% for ICU

Corporate Buffer Rs. 1,000,000/

Terrorism Covered For All



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Policy Terms Particulars

Insurance Company The National Insurance Co. Ltd.

Brokers Futurisk Insurance Broking Co. Pvt. Ltd.

Third Party Administrator (TPA) E-Meditek (TPA) Services Ltd.

Sum Insured As per Grade

Family Scope 1+6

Family Members Covered Employee+Spouse+3 Dependent Children + Dependent Parents

Cashless Facility Yes

Pre &Post Hospitalization 30 & 60 days respectively

Pre Existing Aliments Covered

Maternity Cover Covered without 9 months waiting period

Baby day one Cover Yes



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Eligibility

Sum Insured

(INR)

I >/ = 1 Lac 500000 Employee +Spouse+ 3 Dependent Children(up to age of 25 years) +Parents

1079

IIMore than 50,000

less than 1Lac300000

Employee +Spouse+ 3 Dependent Children

(up to age of 25 years) +Parents581

II IMore than 25,000

upto 50,000200000

Employee +Spouse+ 3 Dependent Children

(up to age of 25 years) +Parents421

IV


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POLICY FEATURES : CASHLESS SERVICE

Thepolicy will behavingcashlessfacility offered byE-Meditek (TPA) ServicesLtd.

TheThird partyAdministrator (TPA)

Every employee and their family members, covered under this policy will be issued an e-card by E-Meditek which will entitle them to avail cashless facility with any of theempanelled hospitals subject totheir getting pre - approval from E-Meditek. There are more than 1500 hospitals on the panel acrossIndia. The service will ensure that members covered under the policy gets treatment at the hospitalempanelled in the Network without having any money to pay, if approved by E-Meditek (Except fornon-medical expenses).

In theevent if member choosing to avail treatment at ahospital not empanelled with theE-Meditek the

claim shall besettled on reimbursement basis. All papers related to such claimswill berouted through theRespectiveHRRepresentativeto CORP-HRfor ensuring timely payment of reimbursement claim.

Note: As per the Insurance policy Any Hospitalization please intimate E-Meditek(TPA) / Futurisk (Broker) 48 hours in advance or mail [email protected].



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Emergency Admission

Network Hospital

Contact E-Meditek (TPA) & Inform aboutthe nature of emergency & your ID No

Get the Admission Request Note from FilledAnd signed by the treating doctor / hospitalAnd signed by you, done in advance

Network hospital will fax the requestto E-Meditek (TPA)

E-Meditek doctors will examine the Pre-AuthorizationRequest form & decide on cashless Availability,as per the policy guideline

All additional requirement letter, denial letter,Issued depending upon plan, benefit & balance sum insuredavailable to the hospital

Planned Admission

Non-Network Hospital

Contact Futurisk Insurance Broking [email protected]& [email protected] intimate the hospitalization

Once discharged then please submit theFollowing documents to HR For further processing

Please submit theORIGINAL papers within aweek after discharge.1.Dully filled & signed Claim Form.2. Hospital bill & Payment receipt3. Discharge Card

4. Prescriptions5. Bills of medicines, surgical items6. Details of Pre-Hospitalization expenses if any7. IPD Papers, if required

Papers will be sent to Futurisk & Settlement canbe expected within 4 weeks from the receipt of allORIGINAL Documents, without any deficiency.

HospitalizationProcedure



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CASHLESS SERVICE

NETWORK H OSPITAL DETAILS

Network Hospital for Cashlessfacility - An exhaustive list of NetworkHospitals isavailableat thewebsiteof E-Meditek : www.emeditek.com

Note: TheHospital list gets updated regularly. All employeesarerequested to check theupdated list on website



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Admission Request Note?

This is a request for cashless hospitalization. The same has to beduly filled up, signed and stamped by treatingdoctor.

Thereafter the hospital will fax it to E-Meditek . The contactdetailsof E-Meditek areavailablein thewebsite.



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CASHLESSSERVICE: FAQ

How to fill theAdmission Request Note?

Part A: To be filled in by treating doctor. Information required are: The

ID No as appearing on the e-card, signs and symptoms of the presentailments, duration of the ailment, diagnosis, pre existing conditions ifany, proposed lineof treatment, tentativedate of admission, approximatedaysof stay and approximate cost of hospitalization.

Part B: To be filled in by claimant authorizing E-Meditek to obtaindetails of treatment and collect documents from thehospital and pay thehospital bill while accepting the terms and conditions of E-Meditekauthorization.



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CASH LESSSERVICE: FAQ

What isan Authorization Letter?

An Authorization letter is the communication Ascertaining theadmissibility or acceptance of the cashless service. The same is issued byE-Meditek subject to admissibility of the claim and availability of balanceSum Insured for themember.

Whether claim hasbeen admitted for cashlessreimbursement or not?

Please note that authorization letter or Denial letter shall be faxed directlyto thehospital with intimation to theinsured by E-Meditek



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NON - CASHLESS CLAIM SETTLEMENTNon Cashless Claim settlement will be facilitated by Futurisk Insurance Brokers India Pvt.Ltd.

NORMS FOR NON CASHLESS CLAIM SETTLEMENT

If cash less facility is not availed, pre-authorization is denied or treatment is availed at a non-network hospital, the insured will have to settle the bills directly with the hospital andsubsequently claim reimbursement by submitting the following documents within 30 daysfrom the date of discharge from the hospital :

1. Claim form duly signed by you2. Original discharge card/ Discharge Summary3. Original Hospital Bills/ Original Payment receipts4. Original report of all investigations5. Prescriptions, Pre hospitalization bills, and bills of medicines and6. Surgical appliances if purchased by you, along with duly stamped receipt7. In- Patient Department (IPD) papers, if required.



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POLICY FEATURES :

PRE-EXISTING DISEASE BENEFIT :

The pre-existing disease benefit helps the members get a complete coverage for all

medical emergencies, including ailments that may have been there before the start ofthis policy. Pre-existing disease benefits will be extended to all members enrolled underthe policy.

WAIVER OF 1 YEAR EXCLUSION FOR ALL INSURED MEMBERS :

First year exclusion for Cataract, Gall Stones, Arthritis & related ailments, Benign

Prostatic Hypertrophy, Hysterectomy, for Menorrhagiaor FibromyomaHernia,Hyderocele, Congenital Internal Disease, Fistula in anus, Piles, Sinusitis and relateddisorders is deleted from our Policy means all claims for above diseases arepayable.



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MATERNITY :

The maternity benefit ensures that female members of the group are covered for medical expenses relating todelivery. This benefit will ensures that delivery related expenses up to amount of Rs, 50,000/ - will be borne bythe insurance company. Pre & Post hospitalization expenses not covered in maternity claim.

Nine months waiting period for maternity claim is not applicable under this section.

NEW BORN BABY COVER :

New Born baby will be covered from Day 1 from the date of birth. However, birth certificate needs to besubittedto Regional HR/ HO HR, with the mediclaim form for the coverage of the New born babyimmediately after birth.

PRE AND POST H OSPITALI SATION EXPENSES COVER BEN EFI T :

Relevant medical expenses incurred during a period up to 30 days prior and 60 days after hospitalization willbe considered as part of claim and therefore settled.

24 HOURS HOSPITALI SATION :Only 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, Eyesurgery, Dental Surgery, Lithotripsy (Kidney Stone removal), Tonsillectomy taken in the hospital/ Nursinghome and the insured is discharged on the same day of the treatment will be considered to be taken underhospitalization benefit.



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PRE & POST HOSPITALIZATION : FAQS

1. What expenditures will generally be covered under the Pre Hospitalization Clause?

Medical expenses incurred for Laboratory Test, Pathological Test and such similaroverheads are usually incurred prior to hospitalization and will be covered underthe pre Hospitalization Clause.

2. What expenditures will generally be covered under the Post Hospitalization Clause?

Medical expenses incurred for recommendation health check up subsequent torelease from hospitalization and other such similar overheads usually incurredpost hospitalization will be covered under the Post hospitalization Clause.



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GENERAL DEFINITI ON1. Medical Practitioner

Medical Practitioner means a person who holds a degree/ diploma of a recognized institution& is registered by Medical Council or respective state of India. The term Medical Practitionerwould include Physician, Specialist & Surgeon (e.g..MBBS, MD, MS).

2. Hospital / Nursing Home

Means any institution in India established for indoor care & treatment of sickness & injurieswhich either has been registered as a hospital or nursing home with the local authorities & isunder the supervision of a registered & qualified medical practitioner or should have atleast 15inpatient beds.

Note: If the hospitalization claim doesnt meet the above mentioned criteria then the claim willnot be payable.



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GEN ERAL POLICY EXCLUSIONS

Injury or disease directly or indirectly caused by or arising from or attributable to War,Invasion, Act of Foreign Enemy, Warlike operation (whether war be declared or not).

Cost of Spectacles, Contact Lenses, Hearing Aids.

Dental Treatment or surgery of any kind unless requiring hospitalization on account ofaccidental cases.

Circumcision unless necessary for treatment of the disease, cosmetic or aesthetic treatmentof any description, plastic surgery other than as may be necessitated to an accident or as apart of any illness.

Convalescence, general debility Run Down condition or rest cure, congenital external diseaseor defects or anomalies, Sterility (Infertility), venereal disease, intentional self injury and useof intoxicating drugs / alcohol.

Voluntary medical termination of pregnancy during first 12 weeks from the sate ofconception.



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Acquired Immune Deficiency Syndrome (AIDS)

Injury or disease directly or indirectly caused by or contributed to by nuclear weapon /material

Naturopathy Treatment

Medical Expenses for a Organ Donor

Expenses incurred for disease declared as an Epidemic by Health Authorities.

Charges incurred at Hospital or Nursing Home primarily for diagnostic, X ray orLaboratory examinations not consistent with or incidental to the diagnosis & treatment ofthe positive existence or presence of any ailment, sickness or injury, for which confinementis required at a hospital / nursing home.



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GUIDELINES

Payment of Claim :-All medical / surgical treatments under this policy shall have to be taken in India

and admissible claims thereof shall be payable in Indian Rupees.



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Condition of Membership

This cover will be extended to all Prime Focus employees as per the policy and

guidelines presented above and any other guideline to be issued in due course oftime.

The moment an employee leaves the organization he/ she will be out side the scope

of this cover.



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Group Personal Accident Policy


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Coverage : This cover will be extended to all Prime Focus employees only asper the policy and guidelines presented herein and any otherguideline to be issued in due course of time.

TYPE OF COVER:

Wider Cover Coverage as per the category


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SUM INSURED

Sum Insured

(INR)

I >/ = 1 Lac 500000

IIMore than 50,000

less than 1Lac300000

III

More than 25,000

upto 50,000 200000

IV


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DESCRIPTION ON THE COVERS OFFERED

WIDER COVER

Accidental Death Cover : Wherein on death of the employee on account of anunfortunate event of an accident; entire sum insured is paid out to the nominee of theemployee.

Permanent Total Disablement : The Insured Person in case of permanent totaldisablement because of an accident will receive the total Sum Insured e.g. loss of sight onboth eyes, loss of both hands etc.


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1. Suicide, attempted suicideor self inflicted injury or illness.2. Whilst under theinfluenceof intoxicating liquor or drugs.3. Anydeliberateor intentional, unlawful or criminal act, error, or omission of

themember4. From war (whether declared or not), civil war, invasion, act of foreign

enemies.5. Whilst engaging in aviation or ballooning, whilst mounting into, dismounting

from or traveling in anyballoon or aircraft other than asapassenger (fare

payingor otherwise) in anyduly licensed standard typeof aircraft anywhere intheworld.6. Any losssuffered by themember on account of hisparticipation asthedriver,

co-driver or passenger of amotor vehicleduringmotor racingor trail runs.


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7. Any loss caused either directly or indirectly by nuclear energy, radiation.8. Venereal or sexually transmitted disease.

9. HIV (Human Immunodeficiency Virus) and / or any HIV related illnessincluding AIDS (Acquired Immune Deficiency Syndrome) and / or mutantderivatives or variations thereof however caused.

10. Pregnancy, resulting childbirth, miscarriage, abortion, or complication arisingout of any o the foregoing.

11. The Insureds participation in any naval, military or air force operationswhether in the form of military exercises or war games or actual engagementwith the enemy, whether foreign or domestic.


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If you have any query or need any assistance,

kindly get in touch with :

Futurisk Insurance Broking Co. Pvt. Ltd.

(Ph: 022 40704000)

FuturisksRelationship Manager for Prime FocusMr. Parag Sarode

[email protected]& [email protected]: +91 98339 20286

Prime Focus HR Representativesor

Corporate HR



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THANK YOU
