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Group Mediclaim Policy
Group Mediclaim
Policy details
Benefits details What does Mediclaim Policy cover?

The benefit a Mediclaim Policy will offer is coverage against any Medical Contingency requiring the
Enrollment Procedure member to be hospitalized.
THE BASIC CRITERION FOR TRIGGER OF THIS HOSPITALIZATION POLICY ARE :

Claims Procedure
• The hospitalization should be for more than 24 hours (in certain cases, this time is relaxed, please go
through details of policy to know for which ailments lesser time is acceptable)
Features Of Mediclaim Policy
• It should not be only for evaluation or diagnosis of disease. A positive / active treatment is must during the
hospitalization.
Exclusions
• It’s necessary that hospitalization is must for the treatment & the ailment could not have been treated on
Out Patient basis.
FAQ’s
Note:
Non Medical expenses like Administration Charges, Registration Charges, Telephone charges /fax
charges; food charges if not part of room rent for patient and food charges for relatives/attendant etc are not
Contacts
payable.
Note: Confidential Document

The information contained here is only a summary of the Group Mediclaim Policy. If there is a
conflict in interpretation, then the terms & conditions of the applicable policy document will
prevail.\
Basic Policy Details
Policy Holder DCB Bank Limited
Policy Start & End Date 1st January 2015 to 31st December 2015
Insurer Iffco Tokio General Insurance Co. Ltd
Group Mediclaim Third Party Administrator (TPA) Paramount Health Services (TPA) Pvt. Ltd.
Geographical Limits India (Covers treatment in India only)
Policy details
Benefits details
Descripti
Covered Members Special Condition if any
on
Enrollment Procedure Total Members Covered per Family
4 -
(Including Employee)
Claims Procedure Employee Covered -
Spouse Covered -
2 dependent children only (Up
Child Covered
to 25 years)
Exclusions
On a voluntary basis; premium
Parents / In Laws Covered to be borne by employees.
FAQ’s Premium details on slide 5
Contacts
Policy Benefits
Standard Hospitalization Covered
Sum Insured Family Floater Basis for Self INR 200,000 ; INR 300,000 ; INR 600,000
+Spouse & Dependent Children)
Individual Sum Insured – for Parents INR 100,000 per parent
Group Mediclaim Pre & Post Hospitalization Expenses Covered (30 days & 60 days respectively)
Pre-existing Diseases Covered
Policy details
30 days Waiting Period Waived off
First & Second Year Exclusions Waived off
Benefits details
INR 50,000 (both for Normal Delivery & C Section)
Maternity Benefit Pre & Post Natal expenses covered up to INR 5,000 within
Enrollment Procedure maternity limits
9 months waiting period on maternity claims Waived off
Claims Procedure Baby Cover From Day One (Subject to Intimation )

Ambulance Cover INR1,500 per person per year
Features Of Mediclaim Policy For Employee, Spouse & Dependent Children: 1% of Sum Insured
for normal room & 2% of sum insured for ICU for all the
categories with associate cost
Exclusions For Parents / Parents-In-Laws: 1.5% of Sum Insured for normal
Room Rent Restriction room & 3% of sum insured for ICU for all the categories with
(Including Nursing charges) associate cost
FAQ’s (All expenses will be payable as per the entitled room category. In
case insured opts for higher room rent category. The difference
between charges will be need to be paid by insured) Refer slide no
Contacts 4 for example.
Cataract : INR 25,000 for each eye
Disease Wise Capping (for Parents Only)
Angiography : INR 25,000
Intimation of Claim Within 7 days from the date of admission
Claims Submission Within 20 days from the date of discharge

INCREMENTAL CHARGES CALCULATION SHEET
Particulars Sub Amount Final Amount
Room Rent Capping for an employee with Sum Insured of INR.150,000/- 1,500
Room Rent Charges as per bill per day 2,800
Proportionate Increase in Room Charges as per Policy Terms & Conditions
( 2800-1500=1300) 46.43%
INR 1300/- is 46.43% of INR 2800/-
Proportion
Total Claimed
Incremental Deduction @ 46.43% on Room Rent & other charges Deduction Amount
Amount
@ 46.43%
Room Rent & Nursing Charges 2,800 1,300
Surgeon Charges 18,000 8,357
Operation theater charges 6,000 2,786
Anesthesia & Anesthetist Charges 6,000 2,786
Doctor Visit Charges 4,000 1,857
Investigation charges 0 0
Other Charges 2,600 1,207
Total Other Charges 36,600 16,993
Calculation for other Incremental Charges (Total Other charges / Room rent charges as per bill 16,993
per day * Excess Amount on room rent per day = incremental charges)
Final Payable Amount in the above illustration is Claimed Amount minus Proportionate
19,607
Deduction due to Increase in Room Rent Charges.
Premium Details – Voluntary & Top Up Plans
• All terms & conditions applicable as per base policy only.

Sum Insured Premium (with service tax) • Top-up sum insured will be triggered on exhaustion of base
sum insured.
Voluntary Parents Plan • For per parents maximum top-up sum insured is INR 100,000
• Top-Up Sum Insured per family (employee + spouse +
INR 100,000 INR 4,500 (per parent / parent-in-law) children) is restricted up to to base sum insured of the family.
• E.g. (i) For employees with base sum Insured range of INR
200,000 - Top Up Sum Insured can be opted for INR 100,000 /
Top Up Plan for Employees + Spouse + Children INR 200,000
• (ii) For employees with base sum insured range of INR
300,000 - Top up Sum Insured can be opted for INR 100,000 /
INR 100,000 INR 2,500 INR 200,000 / INR 300,000
• (iii) For employees with base sum insured range of INR
600,000 - Top up Sum Insured can be opted INR 100,000 /
INR 200,000 / INR 300,000 / INR 400,000
INR 200,000 INR 3,643
• Premium for Voluntary Parents / Parents-in-Laws & Top
Up Plans will be deducted in monthly instalments from
INR 300,000 INR 5,084
employees salary.
INR 400,000 INR 7,500
Top Up Sum Insured only for Parents & Parents-in-laws
INR 100,000 INR 4,566 (per parent / parent-in-law)

Enrolment:
All existing employees will have the opportunity to validate/update their dependent
information. The online window period is open for 30 days from date of commencement
of policy / Date of joining which is ever is latest.
Group Mediclaim
You will also need to choose for the Voluntary Cover for your Parents / Parents-In-Laws
as well as the Top Up plans during the prescribed window period.
Policy details
No changes will be accepted for employees post the closure of the online window
Benefits details period.
New Joiners / Dependent Enrollment during the year:

Enrollment Procedure
 What is the time line to get dependent enrolled for this policy?
Claims Procedure 1. All New Joiners are requested to declare their dependents at the time of joining
DCB Bank.
Features Of Mediclaim Policy 2. All New Joiners will get an user ID & password to access an online window portal
to nominate their dependents. The online portal will be opened for a stipulated
period of 30 days only.
Exclusions
3. Existing employees having new dependents during the year eg. Spouse or
children could add the new dependents by sending an intimation to HR within 30
FAQ’s days from the date of the event (marriage / child birth)
Please refer the Paramount website for detailed process note on the Online
Contacts Enrolment Process.
Group Mediclaim Contact Paramount TPA Relationship
Start Hospitalization Procedure Manger & inform about the nature of
Policy details emergency & your HRMS No.
Benefits details
Enrollment Procedure Network Hospital to fill the

Network hospital will fax/mail the Admission Request Note form
Request to Paramount TPA (The request to be signed by the
Claims Procedure
treating doctor/hospital and
signed by insured in advance).
Planned Hospitalization
Emergency Hospitalization
Reimbursement Paramount doctors will examine the

Pre-Authorization Request form &
Features Of Mediclaim Policy decide on cashless availability, as per
the policy guideline.
Exclusions
FAQ’s
Authorization Letter (AL) / Denial
Contacts Letter / Addition Requirement Letter
issued depending on plan, benefit &
balance sum available to the hospital.
Group Mediclaim Start TPA verifies
Member get admitted in Member / Hospital applicability of
Policy details the hospital in case of applies for pre- the claim to be
emergency by showing authorization to the TPA registered and
his E-Card. Treatment within 24 hrs of issue
Benefits details starts. admission pre-
authorization
Member gets treated Yes
and discharged after
Claims Procedure paying all non entitled
Hospital sends complete benefits like
set of claims documents refreshments, etc.
Planned Hospitalization Pre-
for processing to the TPA
authorization
Emergency Hospitalization given by the
TPA
Reimbursement

Claims Processing by TPA
Exclusions & Insurer No
FAQ’s
Claims Processing by TPA &
Insurer
Contacts
Release of payments to
the hospital
Group Mediclaim Employee submits all the TPA will check
Employee intimates about the
Start original documents to the for the eligibility
hospitalization by mentioning
Policy details HRMS No., Employee Name, DCB Bank HR, Mumbai and
Patient’s Name, Hospital Name, within 20 days of admissibility of
Date of Admission and Ailment discharge from the the claim as per
Benefits details hospital policy terms
name to the Paramount
Relationship Manger within 7 days
Enrollment Procedure from data of admission.
No
Claims Procedure Insurance Company Is Claim

sends denial letter to the payable
Planned Hospitalization TPA will process the employee. ?
claim and pay the
Emergency Hospitalization reimbursement amount
Reimbursement through NEFT, along with
the settlement letter Yes Yes
Features Of Mediclaim Policy TPA will check

whether all the
documents are
Exclusions in order
No
FAQ’s
Employee submits the
shortfall documents to
Contacts TPA within 7 working TPA will ask for the
days from the receipt of additional/missing
intimation documents
No. Documents Required
Group Mediclaim
1 Signed claim form of the insured person.
Policy details
Original Bills (with bill no; signed and stamped by the hospital) (including but not
limited to pharmacy purchase bills, consultation bills, diagnostic bills) and any
Benefits details 2
attachments thereto like receipts or prescriptions in support of any amount claimed
which will then become TPA property.
All reports, including but not limited to all medical reports, case histories,
3
investigation reports, treatment papers, discharge card & discharge summaries.
Claims Procedure
Detailed Original Discharge Card providing precise diagnosis of the treatment for
Planned Hospitalization 4
which a claim is made.
Emergency Hospitalization
A detailed list of the individual medical services and treatments provided and a unit
5
Reimbursement price for each.
Prescriptions that name the Insured Person and, in the case of drugs, the drugs
6 prescribed, their price and a receipt for payment. Prescriptions must be submitted
with the corresponding Medical Practitioner’s invoice.
Exclusions
Break up with details of pharmacy items, materials, investigations even though it is
7
there in the main bill
FAQ’s
In case the hospital is not registered, please get a letter on the hospital letterhead
8 mentioning the number of beds and availability of doctors and nurses round the
Contacts
clock.
In case of non- network hospitalization, please get the hospital and doctor’s
9 registration number in hospital letterhead and get the same signed and stamped by
the hospital.
What is Pre Existing Disease Coverage?

Group Mediclaim
In the policy Pre Existing disease coverage is offered to all members without any
waiting period. This helps the member get a complete coverage for all medical
Policy details emergencies, including ailments that may have been there before the start of this
policy.
Benefits details What is Waiver of 1 Year Waiting Period for nine specified disease?
In the policy there is no one year waiting period for the nine specified aliments which
Enrollment Procedure are present in outside polices- Cataract, Benign Prostatic Hypertrophy,
Hysterectomy for Menorrhagia or Fibromyoma Hernia, Hydrocele, Congenital
Internal disease, Fistula in anus, Piles, Sinusitis and related disorders .
Claims Procedure
What is Waiver of 30 days waiting period for non accidental claims?
Features Of Mediclaim Policy In the policy there is no 30 days waiting period for enrolled members for filing any
claim due to illness.
Policy Features Is Maternity Benefit Covered under the Policy ?
Continue… Yes, it is covered. The maternity Benefit ensures that female members of the group
are covered for medical expenses relating to first two live births. This benefit will
Exclusions ensure that delivery related expenses up to INR 50,000/- for both Normal &
Caesarian Section will be borne by the insurance company. This benefit will be
available to all female members insured under the policy. Female employees and
FAQ’s spouses of all male employees are covered from day one.
New Born Baby Covered in the policy ?
Contacts
New born baby will be covered from Day1 i.e. from the date of birth. [subject to
intimation to Insurance Co. or TPA within 30 days from the date of birth]
# Note :- In Maternity, Pre & Post Hospitalization expenses are covered upto Rs. 5,000/- within the
limit of Rs. 50,000/-.
What is Pre & Post Hospitalization Benefit ?

Group Mediclaim
Relevant medical expenses incurred during a period up to 30 days prior to and 60
days after hospitalization (Date of Discharge) will be considered as part of claim and
Policy details therefore settled as per policy guidelines.
What expenditures will generally be covered under the Pre Hospitalization
Benefits details Clause?
Medical expenses incurred for Laboratory Test, Pathological Test and such similar
Enrollment Procedure overheads are usually incurred prior to hospitalization and will be covered under the
Pre Hospitalization Clause.
Claims Procedure What expenditures will generally be covered under the Post Hospitalization
Clause ?
Features Of Mediclaim Policy Medical expenses incurred for recommended health check up subsequent to release
from hospital and other such similar overheads usually incurred post hospitalization
Policy Features will be covered under the Post Hospitalization Clause.
Continue…
Exclusions
FAQ’s
Contacts
• Vaccination and inoculation.
• Cosmetic treatment.
Group Mediclaim
• Cost of spectacles, contact lenses, and hearing aids.
Policy details
• Treatment for HIV/AIDS.
Benefits details • Treatment for illnesses due to war and nuclear perils.
Enrollment Procedure • Naturopathy treatment.

• Injury or disease directly or indirectly caused by or arising from or
Claims Procedure
attributable to War, Invasion, Act of Foreign Enemy, War like
operations (whether war be declared or not) or by nuclear
weapons / materials.
Exclusions • Circumcision (unless necessary for treatment of a disease not
excluded hereunder or as may be necessitated due to any
FAQ’s
accident), change of life or cosmetic or of aesthetic treatment of
Contacts
any description, plastic surgery other than as may be
necessitated due to an accident or as a part of any illness.
• Cosmetic surgery for correction of eye sight, etc.
• Any dental treatment or surgery which is corrective, cosmetic or
of aesthetic procedure, filling of cavity, root canal including 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
Group Mediclaim 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
Policy details 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
Benefits details
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
Enrollment Procedure or condition of similar kind commonly referred to as AIDS, HIV and its complications
including sexually transmitted diseases.
Claims Procedure
• Expenses incurred at Hospital or Nursing Home primarily for evaluation / diagnostic
purposes which is not followed by active treatment for the ailment during the
Features Of Mediclaim Policy hospitalized period.
• Expenses on vitamins and tonics etc. unless forming part of treatment for injury or
Exclusions disease as certified by the attending physician.
FAQ’s • Naturopathy treatment, unproven procedure or treatment, experimental or alternative

medicine and related treatment including acupressure, acupuncture, magnetic and such
other therapies etc.
Contacts
• 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,
Group Mediclaim
braces, Stockings etc of any kind, Diabetic foot wear, Glucometer / Thermometer
and similar related items etc and also any medical equipment which is
Policy details subsequently used at home etc.
Benefits details • 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.
Claims Procedure • Change of treatment from one pathy to other pathy unless being agreed /
allowed and recommended by the consultant under whom the treatment is
Features Of Mediclaim Policy taken.
• Treatment of obesity or condition arising therefrom (including morbid obesity)

Exclusions and any other weight control programme, services or supplies etc.
FAQ’s • Any treatment required arising from Insured’s participation in any hazardous
activity including but not limited to scuba diving, motor racing, parachuting, hang
Contacts 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

Group Mediclaim active regular treatment is given by the specialist.
Policy details • Out patient Diagnostic, Medical and Surgical procedures or

treatments, non-prescribed drugs and medical supplies, Hormone
Benefits details replacement therapy, Sex change or treatment which results from
or is in any way related to sex change.
• Treatment which is continued before hospitalization and

Claims Procedure
continued during and after discharge for an ailment / disease /
injury different from the one for which hospitalization was
necessary.
Exclusions
• Massages, Steam bathing, Shirodhara and alike treatment under
FAQ’s Ayurvedic treatment.
Contacts • Any kind of Service charges, Surcharges, Admission fees /

Registration charges etc levied by the hospital.
• Genetical disorders and stem cell implantation / surgery.

Is 24 hour Hospitalization mandatory for filing a claim in the Mediclaim Policy?
Yes, 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, Eye surgery
Group Mediclaim (Cataract only) Lithotripsy (kidney stone removal), Tonsillectomy 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.
Policy details What is meant by a Networked / Empanelled Hospital?
The hospitals which have a tie up with the TPA servicing the Mediclaim policy is called a network /
empanelled hospital. An exhaustive list of Network Hospitals is available on
Benefits details https://www.paramounttpa.com/dcbbank/ website.
What is the Admission Request Note (ARN)?
Enrollment Procedure This is a Request for Cashless Hospitalization. ARN is available at the network hospital and has to be
duly filled up, signed and stamped by the Treating Doctor. Thereafter the hospital will fax/mail it to
Paramount TPA. Members are requested to confirm with TPA the receipt of the fax sent and also inform
Claims Procedure Paramount Relationship Manager that he/she is availing cashless benefit for further assistance if
needed.
How to fill an Admission Request Note (ARN)?
Part A: To be filled in by the Treating Doctor. Information required are : The PHS ID No. as printed on
the E-Card, Signs and Symptoms of the present aliment, duration of the aliment, diagnosis, pre existing
conditions if any, proposed line of treatment, approx date of admission, approx duration of stay and
Exclusions
approx cost of hospitalization.
Part B: To be filled in by the claimant–Consent of the Claimant to the Terms and Conditions of
FAQ’s Paramount; authorizing Paramount to obtain details of treatment / collect documents and also authorize
Paramount to pay the hospital bill & reimburse itself / receive the amount of claim receivable from the
insurance company.
Contacts
What is an Authorization Letter?
Authorization Letter is the Communication ascertaining the Admissibility or Acceptance of the Cashless
Service. The same is issued by Paramount subject to admissibility of the claim and availability of balance
sum insured for the member.
How do I know whether my Claim has been admitted for Cashless or not?
Authorization Letter or Denial Letter will be faxed directly to the Hospital. For an update member can
contact Paramount Relationship Manager.
Contact Details (Paramount TPA)
Group Mediclaim Haresh Kadam
LEVEL-1 haresh.kadam@paramounttpa.com
09322033178
Policy details
Mahesh Joshi
Benefits details LEVEL – 2 mahesh.joshi@paramounttpa.com
07498563115
Address for Sending Reimbursement and Deficiency documents
Claims Procedure
DCB Bank Limited
HR Operations Department
9th Floor, Tower A, Peninsula Business Park,
Address
Senapati Bapat Marg,
Exclusions Lower Parel,
Mumbai – 400013
FAQ’s
Please mention on the top of the envelope
Note
“MEDICLAIM DOCUMENTS”
Contacts
THANKS & STAY HEALTHY

Tere MDF Mad

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Group Mediclaim Policy

Benefits details What does Mediclaim Policy cover?

THE BASIC CRITERION FOR TRIGGER OF THIS HOSPITALIZATION POLICY ARE :

Note: Confidential Document

Claims Procedure Baby Cover From Day One (Subject to Intimation )

Intimation of Claim Within 7 days from the date of admission

Claims Submission Within 20 days from the date of discharge

• All terms & conditions applicable as per base policy only.

INR 400,000 INR 7,500

Top Up Sum Insured only for Parents & Parents-in-laws

INR 100,000 INR 4,566 (per parent / parent-in-law)

New Joiners / Dependent Enrollment during the year:

Enrollment Procedure Network Hospital to fill the

Reimbursement Paramount doctors will examine the

Features Of Mediclaim Policy

Claims Procedure Insurance Company Is Claim

Features Of Mediclaim Policy TPA will check

What is Pre Existing Disease Coverage?

What is Pre & Post Hospitalization Benefit ?

Enrollment Procedure • Naturopathy treatment.

FAQ’s • Naturopathy treatment, unproven procedure or treatment, experimental or alternative

• Treatment of obesity or condition arising therefrom (including morbid obesity)

• Any treatment received in convalescent home, convalescent hospital, health

• Any stay in the hospital for any domestic reason or where no

Policy details • Out patient Diagnostic, Medical and Surgical procedures or

• Treatment which is continued before hospitalization and

Contacts • Any kind of Service charges, Surcharges, Admission fees /

• Genetical disorders and stem cell implantation / surgery.

THANKS & STAY HEALTHY

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