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GMC Policy Presentation

VA Tech WABAG

Medi Assist India TPA Pvt. Ltd | Private & Confidential | Not for Circulation 1

Salient features of the Policy are given in this presentation. For Complete Information Please Refer the Policy Documents.

Disclaimer

2Medi Assist India TPA Pvt. Ltd | Private & Confidential | Not for Circulation

The insurance provides cashless/ reimbursement of hospitalization expenses incurred in India for the treatment of illness/diseases or injuries sustained by the insured person during the period of insurance .

What is Mediclaim Insurance ?


Policy Conditions


Sum Insured : The Amount up to which a claim for medical hospitalization can be made. Coverage is individually (Rs. 100000 / Rs 200000 / Rs. 300000)

Current Policy period :16/06/2013 to 15/06/2014Major exclusions applicable for standard policies are waived in this policy.

Hence the policy has wider cover as follows:All pre existing diseases are covered from day oneFirst 30 days waiting period not applicable.1 year, 2 years & 4 years exclusions for specific ailments/treatments not

applicableFamily definition: Self, Spouse , 2 dependent children and 2 dependent

parentsNew born baby covered from day oneInternal Congenital disease covered under life threatening circumstance

Any institution in India established for Indoor care and treatment of sickness and injuries and which either:

• has been registered as a hospital or nursing home with the local authorities and is under the supervision of a registered and qualified medical practitioner

OR• Should comply with minimum criteria as under:ü At least 15 in-patient beds (for class C cities 10) ü Fully Equipped operation Theatre of its own wherev

er surgical Operations are carried out.ü Fully Qualified Nursing staff under its employment

round the clock

The term Hospital/Nursing home shall not include an establishment ,which is a place of rest, a place for the aged , a place for drug addicts or for alcoholics , a hotel or a similar place

Hospital / Nursing Home


The below given medical Expenses are payable If any insured person suffers an illness or accident during the policy period which requires the hospitalization as an inpatient

Room Rent, Boarding Expenses & Nursing: 1% of S.I + Rs.2000 *Intensive care Unit:2% of S.I + Rs.4000 *A Medical practitioner,Anesthesia, Blood , Oxygen, Operation theatre charges , surgical appliances Medicines, drugs and consumables Diagnostics procedures The cost of prosthetic and other devices or equipment if implanted internally

during a surgical procedures Disease wise Capping: Cataract Rs.24000 Per eye and No Capping for other

diseases Hospitalization: Admission into hospital for medically necessary treatment as an

inpatient for continuous period of at least 24 hours * Proportionate clause applicable if room rent exceeds eligibility limit

What are the expenses Reimbursable?


Maternity Benefit

Maternity expenses are covered for 2 children. The insured person who are already having two or more living children will not be eligible for this benefit

Normal Delivery Expenses Capped To : Rs.25000

Cesarean (C-section) Delivery Expenses Capped To:Rs.50000

9 months waiting period waivedPre-natal and post-natal expenses are not

covered unless admitted in Hospital/Nursing Home and treatment is taken there

New Born Baby covered from day one


Pre-Hospitalization:

The Medical Expenses incurred due to an Illness in the 30 days immediately before the Insured Person was Hospitalized, provided that:

Such Medical Expenses were in fact incurred for the same condition for which the Insured Person’s subsequent Hospitalization was required

Post-Hospitalization:

The Medical Expenses incurred in the 60 days immediately after the Insured Person was discharged post Hospitalization provided that:

Such costs are incurred in respect of the same condition for which the Insured Person’s earlier Hospitalization was required

Pre and Post Hospitalization


Treatment undertaken in a hospital/Nursing Home on the recommendation of medical Practitioner for the following diseases, Illness or injury which requires hospitalization for less than 24 hours:

DialysisChemotherapyRadiotherapyEye SurgeryLithotripsy (Kidney stone removal)TonsillectomyDilatation & CurettageHydrocele SurgeryHernia Repair SurgerySinusitisCoronary Angiography

Day care procedure


• LASIK surgery for correction of eyesight, Contact lens, Spectacles, Hearing aids including Cochlear implants

• Dental treatment unless arising due to accident• Medical termination of pregnancy / abortion within 12 weeks• Sterilization procedures, treatment of infertility/sub-fertility/ Assisted

conception procedures• Plastic and cosmetic surgery, vaccination, inoculation, circumcision• External “congenital” disease, anomalies, defects• Intentional self injury / suicide attempt, psychiatric and psychosomatic

disorders• Direct / indirect effects of use of alcohol / intoxicating drugs• AIDS and related syndromes• “Technical admission” –Admission for diagnostic/evaluation without active

line of treatment• Expenses on vitamins or general tonics• Naturopathy treatment

Policy Exclusion

• Pre and post expenses related to maternity claim• Unproven procedure/ treatment, experimental or alternative

medicine/treatment including acupuncture, acupressure, magneto-therapy, RFQMR, etc.

• Genetic disorders/stem cell implantation/surgery• External equipments like CPAP, CAPD, infusion Pump etc., ambulatory

devices like walker/ crutches/ belts/ collars/caps/ splints/ slings/ braces/ stockings/ diabetic foot-wear/ glucometer/ thermometer & similar related items & any medical equipment which could be used at home subsequently

• Treatment for obesity or condition arising therefrom (including morbid obesity) and any other weight control program/ services/ supplies.

• Massages/ Steambath/ Surodhara & alike Ayurvedic treatment.• Any kind of service charges/surcharges, admission fees/registration

charges etc. levied by the hospital.

Policy Exclusion

Actionable By Employee:

§ Login to www.mediassistindia.com

§ Click on “Login” link in the website

§ Click on “Corporate Employee”

§ Login through below given credentials

§ Update Your Mobile Number & Email ID under “Employee Contact Details”

§ Check Data under “Beneficiary Details”

§ Change Password by Clicking “Forgot Password” in Login Page

§ Always click “Log out” after accessing your account

Employee login:

§ Username : Empid@vatechwabag

§ Password : vatechwabag

Snapshots are given in following slides for easy reference.

E - Login



E – Login Cont…

Cashless Facility

Emergency AdmissionPlanned Admission(48 hrs in advance)

Insurance Help Desk at the Hospital

Hospital

Admission Insurance Help Desk

Pre-Authorization Process

Please submit the following documents in original along with completed claim form within 15 days from the date of discharge

Discharge SummaryFinal Hospital Bill (with detailed break-up) &

Receipts Medicine Bills along with Doctor’s PrescriptionsInvestigations & Test Reports with Doctor’s

prescriptions. If original is required for future treatment, please submit photocopies duly attested by the treating doctor with his signature & seal

In case of non-availability of prescriptions, kindly ask your Physician to countersign on the reverse of pharmacy bills

Process of Reimbursement


Please send all the documents to


Escalation Matrix


Wish You & Your Family A Healthy & Happy Future !!!

-Team & Medi Assist

Thank you…


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Documents

circulation slide

current policy period

policy documents

medical expenses

medical hospitalization

period of insurance

cataract rs

boarding expenses nursing