7.

3 MEDICAL INSURANCE POLICY :

7.3.1 Medical Insurance Policy

7.3.2 Eligibility

7.3.3 Medical Expenses

7.3.4 Medical Entitlements

7.3.5 Procedure for submitting the medical claims

7.3.6 Reasons for rejection of Medical Claims

7.3.7 Exclusions under Medical Insurance Policy

7.3.8 Exclusions in the Medical Insurance policy

7.3.1 Medical Insurance Policy

The Medical Insurance Policy of the Corporation is underwritten by New

India Assurance Co. Ltd. and is renewed annually in April.

7.3.2 Eligibility

An employee (Management and Non-Management) is eligible for enrolment

under the Medical Insurance Policy along with :

a. His / her spouse provided he/she is not covered / claiming medical benefits
under any other Medical Insurance Scheme.

b. Unmarried dependent children (first two children) provided :-

- They have not reached 30 years of age.

- They are not gainfully employed

- They are residing with the officer

- They are not covered / claiming Medical Benefits under any other Medical
Insurance Scheme.

Note

1. Mentally retarded children irrespective of their age provided they are

totally dependent on their parents are covered, upto life time or
termination of the Medical Insurance scheme.

2. Once the dependent children are deactivated on account of

marriage/jobs, they cannot be reenrolled in medical portal even after
they leave their jobs.

c. Dependent parents provided: -

1. Upto life time or termination of Insurance, whichever is earlier.

2. Their total combined monthly income is less than 9,000/- p.m. where
“Income” includes all regular income such as

 Pension

 Income from house property

  Interest on savings / All type of deposits with Banks and Financial
Institution / Dividend on Investments / Annuities

 Income from Business / Profession / Consultancy

 Income on Investment in PF / Gratuity / Government Prize Bonds

 Agricultural Income

3. They are not covered / claiming medical benefits under any other Medical
Scheme/Insurance Scheme.

4. Parent’s enrollment has to be on both or none basis. For Enrollment

combined income of both the parents is to be considered.

7.3.3 Medical Expenses

All reasonable and customary medical expenses incurred for treatment of

an illness / injury by an insured person are covered under the policy except
for specific exclusions provided in the policy.

For the above purpose, the medical expenses incurred are payable for
treatment within “Geographical Limits” of India.

However, expenses incurred by an employee whilst on official foreign tour

during the period of his / her temporary inhabitation at foreign country not
exceeding 180 days are payable.

7.3.4 Medical Entitlements

The medical entitlements are as follows:-

Sr. Items Management Non-

No. Management
a. Life Time Limit per insured person : ₹ 15.00 lakhs

S.G. 'E1' to 'C'

S.G. 'D' to 'G' ₹ 22.00 lakhs
S.G. 'H' & ‘I’ ₹ 25.00 lakhs
₹ 30.00 lakhs
The above revised Life Time Limit will be applicable only to employee, spouse
and dependent parents.
b. Life Time Limit for dependent ₹ 7.50 lakhs
Children of employees :
(w.e.f. 01.04.2014)

S.G. ‘E1’ to ‘C’

 S.G. ‘D’ to ‘G’ ₹ 11.00 lakhs
S.G. ‘H’ & ‘I’ ₹ 12.50 lakhs
₹ 15.00 lakhs
c. Annual Limit per insured person : ₹ 3.00 lakhs

S.G. 'E1' to 'C'

S.G. 'D' to 'G' ₹ 4.00 lakhs
S.G. 'H' & ‘I’ ₹ 6.00 lakhs
₹ 8.00 lakhs
Note :
The above limits are applicable for expenses incurred during hospitalization,
domiciliary treatment and any other treatment under the Medical Insurance
Scheme including expenses for dental treatment, eye disorders and maternity
benefits.
The life time limit will be invoked in cases where the enrolled person is required
to incur heavy medical expenses due to prolonged illness and other medical
urgencies where annual limit is not sufficient to cover expenses.

Sr. Items Management Non-

No. Management
d. Hospital Room Charges (per day) - R4,000 /-
‘X’ Class Cities :-

S.G. 'E1' to 'C' R 4,500/-

S.G. 'D' to 'G' R 5,500/-
S.G. 'H' & 'I' R 7,000/-
ICU / ICCU At Actuals
Following cities are categorized as ‘X’
class :-
 Mumbai / Navi Mumbai
 Delhi, Noida, Gurgaon &
Ghaziabad, Faridabad
 Kolkata
 Chennai
 Hyderabad / Secunderabad
 Bangalore
 Pune
 Ahmedabad
e. Hospital Room Charges (per day) – R 2500/-
for other cities :-

S.G. 'E1' to 'C' R 3000/-

S.G. 'D' to 'G' R 4000/-
S.G. 'H' & 'I' R 4500/-
ICU / ICCU At actuals
 Note :
Hospitalization charges including room charges for a period exceeding 100 days
is not payable.
f. Domiciliary Treatment Will be reimbursed Will be reimbursed
in full subject to in full subject to
limits mentioned limits mentioned
above above
Note :
Nursing Attendant (registered with Nursing Council of India) charges (from a
Recognized Registered Agency) in respect of medical treatment to the insured
person, provided he/she is confined to bed at his/her residence at the
recommendation of a Medical Practitioner/ Surgeon will be payable upto a
maximum period of 3 months.

Domiciliary treatment would include all expenses including fees of Medical

Practitioner / Surgeons, cost of medicines and injections, excluding vitamins and
tonics unless forming part of the treatment of any specific illness and diagnostic
materials like X ray, ECG, Pathological and other tests.

Sr. Items Management Non-Management

No.
g. Dental Treatment

Dental treatment would include R 50,000/- per year per R 35,000/- per year
extraction of tooth and other insured person for all per insured person for
expenses such as filling and cities. all cities.
cleaning, implant of tooth but
excluding gold fillings. EDs & above – at
actuals
Reimbursement of cost of At actuals At actuals
dentures, once in lifetime
h. Surgical / Non-Surgical treatment of eyes
Cataract and Glaucoma ₹ 75,000/- for each ₹ 75,000/- for each
operation eye eye
Other Surgical / Non-Surgical At actuals At actuals
treatment
Spectacles inclusive of ₹10,000/- per insured ₹ 7,000/- per insured
consultation person in a financial person in a financial
(w.e.f. 1.4.14) year. However, year. However,
unspent amount of the unspent amount of the
previous year, if any, previous year, if any,
can be claimed along can be claimed along
with entitlement of with entitlement of
 next year in a block of next year in a block of
two years starting from two years starting
2014-15. from 2014-15.

Dependent Parents Dependent Parents

of employees joined of employees joined
after 1/1/2010 are not after 1/1/2010 are not
eligible for eligible for
reimbursement of reimbursement of
non-surgical non-surgical
expenses towards expenses towards
treatment of eyes i.e. treatment of eyes i.e.
cost of plain glasses / cost of plain glasses /
bifocal / contact lens bifocal / contact lens
and cost of frames and cost of frames

EDs & above – at

actuals
i. Maternity :-
(w.e.f. 1.4.14)
Normal Delivery R 40,000/- R 40,000/-
Caesarean Section R 80,000/- R 80,000/-
Note :
Normal delivery or miscarriage or caesarian or extra uterine pregnancy/ services
for pregnancy e.g. dilation and curetting are covered under maternity expenses.

Maternity Limit to exclude prenatal charges and such charges to be paid in

addition to Maternity limit for maximum two maternity.
J. Clubbing of Life time limit coverage, in the event of exhaustion by one member,
with other family member has been modified as follows eff. April 2015 :-
 Clubbing of limits of parents and children to the limit of any other family
member is not allowed.

 The limit of employee and his spouse can be clubbed with each other and
to the other dependent members of his family.

 However during clubbing if the entire life time limit of employee and
spouse is likely to be exhausted, 10% of the life time limit of spouse will
be kept separately and not be clubbed.
Sr. Items Management Non-
No. Management
k. Periodical Health Check-up charges

Upto 40 years (Male and Female) – Once in ₹ 3,000/- ₹ 3,000/-

3 years

40 - 50 years (Male) – Once in 2 years ₹ 4,500/- ₹ 4,500/-

40 – 50 years (Female) – Once in 2 years
₹ 5,500/-
50 & above (every year) – Male ₹ 5,500/-
- Female
₹ 4,500/- ₹ 4,500/-
S.G. ‘H’ & Above ₹ 5,500/- ₹ 5,500/-

At actuals
Note : Periodicity for dependent parents will be once in two years
Periodicity for dependent children will be once in 3 years
l. Cost of Vaccination such as BCG, Triple, Hepatitis A & B, Measles etc. are
covered
m. Ayurvedic Treatment
Ayurvedic Treatment covered excluding Panchkarma
Ayurvedic Treatment will be reimbursed based on Doctor’s prescription upto a
max. of ₹ 50,000/- per person per annum.
Hospitalization in case of Ayurvedic/homeopathy/Naturopathy treatment is not
payable.
n. Anemia / Weakness / Giddiness are payable
o. Deficiency of Iron / Calcium tablets are payable
p. Hearing Aids ₹ 1,00,000/- once in ₹ 1,00,000/- once in
two years eff. April two years eff. April
2012 on the 2012 on the
recommendation of recommendation of
Doctor. Doctor.

Dependent Parents of Dependent Parents of

employees joined after employees joined after
1/1/2010 are not 1/1/2010 are not
eligible for
eligible for
reimbursement of
reimbursement of hearing aids.
hearing aids.
Sr. Items Management Non-Management
No.
q. Glucometer Actual, subject to Actual, subject to
maximum of r 2,500/- maximum of r 2,500/-
(in a block of 2 years (in a block of 2 years
eff. April 2012) eff. April 2012)
r. Life Saving Devices such as Nebulizer and Portable Oxygen Cylinder are covered
s. Cost of Medical Devices such as heating pad sets etc. are payable.
t. Lasik Treatment due to relevant diseases (correction of vision and cosmetic
surgery is excluded) are payable.
u. Registration and Admission charges are payable.
v. Service Charges levied by Hospitals on Room Charges and Medicines are
covered.
w. Inclusion of Blood Pressure equipment :
The cost of instrument for measuring Blood Pressure will be reimbursed to
employees once in two years eff. April 2012 within the limit of ₹ 2,500/-, based
on recommendation from the Doctor. However, the reimbursement will be per
employee and not per family member.
x. Inclusion of psychiatric treatment :
Some clinical psychiatric disease which require hospitalization and specialized
treatment will be reimbursed based on recommendation from the Chief Medical
Advisor.
However, depression, sleep disorders and behavioural disorders, use of drugs,
intoxicants will not be covered under the medical insurance plan.
y. IVF Treatment :
Reimbursement towards IVF procedure for maximum of 3 cycles of treatment for
childless couples. The upper limit of reimbursement for each cycle is limited to
Rs.1 lakh including cost of hospitalization, medicines and investigations
z. Lasik Treatment :
One time reimbursement of Lasik treatment for correction of vision for all insured
members. In case of dependent children, upon one time reimbursement towards
Lasik treatment, reimbursement for cost of Glasses/Spectacles will be
discontinued. The upper limit of reimbursement for lasik treatment is Rs 50,000/-
for each insured member.
a.a Buffer Fund:
The cost of treatment including follow up treatment like dialysis, chemotherapy,
radiotherapy, medicines and investigations towards Cancer, Renal failure, Heart
By-pass surgery, organ transplant (excluding cost of organ, if any, paid to donor
and medical expenses of donor), bone marrow transplant procedure and
treatments arising out of accidents involving major surgery, will be considered
separately for reimbursement under Buffer Fund in cases where employee and
Spouse (subject to 10% of life time limit of Spouse kept aside) Combined Life
time limit is over. The reimbursement in such cases will be limited to the extent of
85% of total expenditure.
a.b World-wide coverage on official foreign tour / training :
(w.e.f. 1.4.14)
The policy covers treatment within the geographical limits of the country.
However, Medical expenses incurred by an employee while on foreign official tour
during the period of his / her temporary inhabitation at foreign country but not
exceeding 180 days is covered under the policy. World-wide medical coverage
is not available for employees travelling abroad while on personal tour and
also for ex-employees settled abroad.
7.3.5 Procedure for submitting the medical claims

1. Separate claims to be made for each illness / each insured person

and submitted within 15 days from the date of completion of the
treatment.

2. In case of hospitalization, copy of discharge card from the hospital

should be attached to the medical claim.

3. Each claim should be supported by the Doctor’s prescription, original

cash memos and copies of Pathological reports, if any, (X-ray film
should not be attached with the medical claim).

4. The claim form should be completed in all respects.

5. In case of partial / continuous claims, xerox copy of the prescription

should be attached along with the original bills.

6. In case of Doctor’s fees exceeding ₹ 5,000/-, the same should be

affixed with revenue stamp of Re.1.

7. In case medical treatment is taken abroad, while on official tour /

training not exceeding 180 days, it is requested to convert the
medical expenses incurred in Indian rupees as per the exchange rate
prevalent at the time of the treatment and a copy of the passport to
be attached, specifying details of departure and arrival in the country.
This clause should be read along with clause 7.3.3

8. Kindly note, in case of death of an employee / dependent in the

hospital, death summary needs to be attached along with the claim.

9. Ayurvedic and Homeopathy treatments (hospitalization charges are

not payable under these treatments) should specify very clearly the
diagnosis / medicines prescribed by the doctor. The bill should
specify separately consultation fees, medicines etc. and the same
should be supported with proper receipts.

10. Please ensure that the claim amount tallies with the bills submitted
along with the claims.
7.3.6 General Reasons for Rejection / Short settlement of Medical Claims

1. Discharge Card not attached, in case of hospitalization.

2. Death Summary not attached, in case patient died in the hospital.
3. Lab reports / Pathology / X-ray reports / Diagnostics / Line of treatment
and clinical reports not submitted.
4. Prescriptions not attached.
5. Original bills / original Cash receipts / original hospital bills not attached.
6. Separate claims to be submitted for each treatment.
7. Composite bills are not accepted. Bills should give a proper break-up
viz. consultation fees / medicines / any other line of treatment.
8. Diagnosis to be mentioned on prescription by attending Doctor.
9. Requisition for the services of a nurse at home should be supported by
Doctor’s letter and the nurse should be registered with Nursing Council
of India and hired from a Govt. / Registered Agency.
10. Advice for Physiotherapy treatment (as a follow up treatment) should be
supported by Doctor’s prescription and the physiotherapy bill (of
licensed physiotherapist) should clearly state the number of sessions
and the dates.
11. Receipts issued by the attending doctor for treatment taken should be
on Letter Head.
12. Claims rejected if Maternity / Eye / Dental limit is exhausted.
13. Claims rejected if Annual / Life time limit is exhausted.
14. The claim amount does not tally with the bill amount submitted along
with the claim.
15. Treatment falls under medical exclusion category (Please refer Clause
7.3.7 and 7.3.8)
7.3.7 Exclusions of certain treatments/items under Medical Insurance
Policy

All the benefits listed in health insurance policy are only payable. The
treatment of items not listed in schedule of benefits are not payable.
However indicative list for major exclusions are attached.

1. Panchkarma, Mud Therapy, Oil Massage

2. Speech Therapy / Shock Therapy
3. Cosmetic treatment (hair loss, acne etc.)
4. Cosmetic Surgery
5. Tricycles
6. Cell / Batteries for hearing aid
7. Plastic Surgery
8. Naturopathy
9. Vitamins / tonics unless it forms part of treatment of any specific illness
10. Telephone charges
11. Canteen charges
12. Diet charges
13. Attendant / Aaya charges
14. Fertility treatment / voluntary termination of pregnancy
15. Insomnia / Depression / weakness
16. Belt / Walker / Wheel-chair / Diaper / Accessories
17. Electro–magnetic device / equipment
18. Hospitalization charges under Ayurvedic & Homeopathy treatment
19. Charges for Massages
20. Certain Consumable during treatment which are not classified as
medicines are not payable under the policy.
A tentative list (As per IRDS) of such items is as under for reference-

List of Consumable not covered

Alpha bed, Colgate, brush, cotton, powder, pads, towel, aloe vera
Diaper, Gloves, Stocking, cotton roll, bed bath, razor, crepe bandage, thermometer.
Stockings, wet wipes, protein powder, under pad, olive oil, bandage, plain sheet, mayos
trolley cover, urine bag, easy bath, surgeon gown, instrument table cover, plastic apron,
visitors pass, food.
drinking water, Neonatal sheet, coffee cup, plastic spoon, ounce glass, full gown
shaving blade, tissue paper, hand body wash, head cap, urinal pot, guedel airway
Zandu Balm, Dettol/Savlon, Churna Charges, Glucometer Strips
handwash, mouthwash, tooth brush, tooth paste, extension lines, drainage bags, plastic
sheet, urometer, gamjee pads, gamjee rolls, gauze squares, butter: chiplet, dvd disk, mask
oxygen, microshield handrub, spirometer, mask face, air fresheners

An exhaustive list of exclusions is mentioned as Annexure 9 under Welfare.

7.3.8 GENERAL EXCLUSIONS :

The Insurance company shall not be liable to make any payment under this
policy in respect of any expenses whatsoever incurred by any insured
person in connection with or in respect of the following :

1. Any disease or illness contracted by any insured person during the

first 30 days from the commencement date of this policy or the date
of his/her inclusion under the policy, whichever shall be later.

2. Circumcission - unless necessary for treatment of a disease not

excluded hereunder or any genetal disease as a result of an accident
- strictures - change of life, beauty treatment of any descriptions,
plastic surgery other than as may be necessitated due to an accident.

3. Convalescence, nervous breakdown (which expression shall also

cover general debility “run down” conditions and general “overhaul”)
or rest cure - veneral diseases, insanity, intentional self-
injury/intemperance or the use of intoxicating drugs or liquors or any
disease directly or indirectly due to any one or more of them,
 expenses incurred towards anaemia unless it is part of treatment for
any sickness or illness.

4. Injury or a disease or illness of the insured person directly or

indirectly caused by or contributed to by or arising from ionising
radiations or contamination by radioactivity from any source
whatsoever. The indemnity provided by this policy shall not apply to
nor include any accident or disease or illness directly or indirectly
caused by or contributed to by or arising from nuclear weapons
material.

5. Injury, disease Injury Injury, disease or illness directly or indirectly

due to or arising from war invasion, act of a foreign enemy, hostilities
or war like operations (whether war be declared or not), riot or civil
commotion or breach of law or hunting, steeple chasing, polo or
winter sports or riding or driving in races or employment in military,
naval or air service or engaging in aviation or ballooning or entering
travelling or leaving any aircraft or balloon but this exclusion shall not
apply to injury resulting from an accident due to a duly licenced
standard type of aircraft, operated by a recognized airlines on a
regular schedule, air route in which the insured person is travelling
as a bonafide passenger.

6. All expenses arising out any condition directly or indirectly caused to

or associated with Human T cell Lymphotropic Virus type III (HTLB
III) or Lymphadinoplalthy Association Virus (LAV) or the Mutants
Derivative or Variations Deficiency Syndrome or any Syndrome or
condition of a similar kind commonly referred to as AIDS and
Naturopathy treatment. Any services in respect of injury at accident
arising out of or in course of the insured’s employment for wage or
profit.

7. Naturopathy treatment.