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Employee Benefits Manual
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Luminous Power Technologies
What are the Insurance Benefits available to me ?
Who are my Insurance Vendors?
How do I utilize my benefits
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Program Details
Group Medical
Provides insurance coverage to employees for expenses related to hospitalization
due to illness, disease or injury
Level
Eligibility:
GM & Above
Sr Manager to DGM
Executive to Manager
Sales & service (ESIC emp)
Sum Insured
4 Lac
3 Lac
2 Lac
1.5 Lac
Note : Employees who are covered under ESIC benefit (except Sales & Service)
are excluded from Mediclaim insurance
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Medical Benefit
Coverage Details
Enrollment in the program
Cashless Process
Non-Cashless
Non Cashless Claims Process
Claims Document List
General Exclusions
GMC Contact Details
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Medical Benefit – Benefits Coverage
Policy Parameter
 Insurer
United India Insurance Company
 Third Party Administrator
Vipul TPA
Policy No
500300/48/11/41/00000090
 Coverage Type
Family Floater (E+3)
 Sum Insured
Graded INR 1.5 Lacs ,2 Lacs and 3 Lacs ,4 Lac
Benefits / Extensions
Coverage
Benefits / Extensions
Coverage
 Standard Hospitalization
• Yes
 Day Care
• Yes
 TPA services
• Yes
 Pre existing diseases
• Yes
 Pre-Post Hospitalization
Exp.
• Yes – 30 / 60 days
 Waiver on 1st year
exclusion
• Yes
 Waiver on 1st 30 days
excl.
• Yes
 Maternity benefits
Rs. 50,000 covered
from day one
 Room Rent
 Corporate Buffer
Employee Benefits Manual
Restricted to 2% of
SI per Day, 4% for
ICU
Rs.10,00,000/-
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Medical Benefit – Standard Coverage
Reimbursement expenses related to
• Room, Boarding Expenses as provided by the Hospital / nursing home
•Nursing Expenses
•Surgeon, Anaesthetist, Medical Practitioner, Consultants, Specialists Fees
•Anaesthesia, Blood, Oxygen, Operation Theatre Charges, surgical appliances, Medicines & Drugs,
Diagnostic Materials and X-ray.
A) The expenses are payable provided they are incurred in India and within the policy period.
Daycare expenses
B) Expenses on Hospitalisation for minimum period of 24 hours are admissible. However this time limit will not apply for
specific treatments under Day Carei.e. Dialysis, Chemotherapy, Radiotherapy, Cataract , Lithotripsy (kidney stone
removal), Tonsillectomy, D & C taken in the Hospital and the insured is discharged on the same day of the treatment will
be considered to be taken under Hospitalisation Benefit.
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Pre & Post Hospitalization Expenses
Pre-hospitalisation Expenses
Definition
• If the Insured member is diagnosed with an Illness which results in his /
her Hospitalization and for which the Insurer accepts a claim, the Insurer
will also reimburse the Insured Member’s Pre-hospitalisation Expenses for
up to 60 days prior to his / her Hospitalization.
Covered
• Yes
Duration
• 30 Days
Post-hospitalisation Expenses
Definition
• If the Insurer accepts a claim under Hospitalization and immediately
following the Insured Member’s discharge, further medical treatment
directly related to the same condition for which the Insured Member was
Hospitalized is required, the Insurer will reimburse the Insured member’s
Post-hospitalisation Expenses for up to 90 day period.
Covered
• Yes
Duration
• 60 Days
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Maternity Benefits
Benefit Details
Benefit Amount
Rs. 50,000
Restriction on no of children
• Maximum of 2 children
9 Months waiting period
• Waived off
These benefits are admissible in case of hospitalisation in India.
Covers first two children only. Those 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.
Post 12 weeks of pregnancy, the expenses incurred towards medical
termination of pregnancy are covered in case it is medically required and
advised by a doctor
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Medical Benefit – Cashless Process
Cashless means the Administrator may authorize upon a Policyholder’s request for direct settlement of eligible
services and it’s according 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
as these services are covered under the Policy.
Hospitals in the network (please refer to the website for the updated list)
For Updated List visit to .vipulmedcorp.com
Emergency Hospitalization
Toll Free Number :1800 102 7477
Planned Hospitalization
Note : Patients seeking treatment under cashless hospitalization are eligible to make claims under pre and post hospitalization expenses. For all such
expenses the bills and other required documents needs to submitted separately as part of the claims reimbursement.
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Emergency Hospitalization & Process
Step 1
Get Admitted
In cases of emergency, the member
should get admitted in the nearest
network hospital by showing their ID
card.
Step 2
Pre-Authorization by hospital
Relatives of admitted member
should inform the call centre within
24 hours about the hospitalization &
Seek pre authorization. The
preauthorization letter would be
directly given to the hospital. In
case of denial member would be
informed directly
Step 3
Treatment & Discharge
After your hospitalisation has been
pre-authorized the employee is not
required to pay the hospitalisation
bill in case of a network hospital.
The bill will be sent directly to, and
settled by Vipul
P
R
O
C
E
S
S
Member gets admitted in
the hospital in case of
emergency by showing his
ID Card
Preauthorization
given by Vipul
No
Non cashless
Hospitalization
Process
Yes
Member/Hospital applies
for pre-authorization to
Vipul within 24 hrs of
admission
Member gets treated and
discharged after paying all
non medical expenses like
refreshments, etc.
Vipul verifies applicability of
the claim to be registered
and issue pre-authorization
Hospital sends complete set
of claims documents for
processing to Vipul
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Planned Hospitalization
Step 1
Pre-Authorization
All non-emergency hospitalisation
instances must be pre-authorized
with Vipul, as per the procedure
detailed below. This is done to
ensure that the best healthcare
possible, is obtained, and the
patient/employee is not
inconvenienced when taking
admission into a Network Hospital.
Step 2
Admission, Treatment &
discharge
Claim
Registered by
Vipul on same
day
Member intimates Vipul of the
planned hospitalization in a
specified pre-authorization format
at-least 48 hours in advance
Member produces ID card
at the network hospital
and gets admitted
Vipul authorizes cashless as
per SLA for planned
hospitalization to the
hospital
No
Pre – Authorization Form
www.vipulmedcorp.c
om
Yes
Follow non cashless
process
Member gets treated and
discharged after paying
all non entitled benefits
like refreshments, etc.
After your hospitalisation has been
pre-authorized, you need to secure
admission to a hospital. A letter of
credit will be issued by Vipul to the
hospital. Kindly present your ID
card at the Hospital admission
desk. The employee is not required
to pay the hospitalisation bill in case
of a network hospital. The bill will be
sent directly to, and settled by Vipul
Pre-Authorization
Completed
Hospital sends complete
set of claims documents
for processing to Vipul
Claims Processing &
Settlement by Vipul &
Insurer
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Non-Cashless/ Re-imbursement
Admission procedure
• In case you choose a non-network hospital you will have to liaise directly with the hospital for admission.
• However you are advised to follow the pre authorization procedure to ensure eligibility for reimbursement of
hospitalisation expenses from the insurer.
•It should be a minimum 15 bedded hospital registered with the local authority
•Minimum 24 hrs hospitalization should be there
Discharge procedure
• In case of non network hospital, you will be required to clear the bills and submit the claim to Vipul for
reimbursement from the insurer. Please ensure that you collect all necessary documents such as – discharge
summary, investigation reports etc. for submitting your claim.
Submission of hospitalisation claim
• You must submit the final claim with all relevant documents within 7 days from the date of discharge from the
hospital.
Claim Docs
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Re-imbursement Claims Process
Member intimates Vipul before
or as soon as hospitalization
occurs
Yes
Is claim
payable?
Claim registered by Vipul after
receipt of claim intimation
Insured admitted as per hospital
norms. All payments made by
member
Vipul performs medical scrutiny
of the documents
Yes
No
Is document
received
within 7 days
from
discharge
No
Claim Rejected
Vipul checks document
sufficiency
Is
documentatio
n complete
as required
Yes
Claims processing done as per
SLA
Insured Submits relevant
documents to the Help desk
within 7 days of discharge
A
•Insured will create the
summary of Bills (2 copies)
and attach it with the
original bills.
•The envelope should
contain clearly the
Employee ID & Employee email.
ECS Payment will be done directly
to the Employee bank a/c.
No
Receives mail about deficiency
and document requirement
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Claims Document List
Completed Claim form with Signature
Hospital bills in original (with bill no; signed and stamped by
the hospital) with all charges itemized and the original receipts
Claims Form
Discharge Report (original)
www.vipulmedcorp.c
om
Attending doctors’ bills and receipts and certificate regarding
diagnosis (if separate from hospital bill)
Original reports or attested copies of Bills and Receipts for
Medicines, Investigations along with Doctors prescription in
Original and Laboratory
Follow-up advice or letter for line of treatment after discharge
from hospital, from Doctor.
Provide Break up details including 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 and
availability of doctors and nurses round the clock.
In non- network hospital, you may have to get the hospital
and doctor’s registration number on Hospital letterhead and
get the same signed and stamped by the hospital, if required.
*Please
retain photocopies of all documents submitted
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Benefit Extensions – Definitions
Benefits
Pre existing
diseases
First 30 day
waiting period
For
Luminous
Covered
Any Pre-Existing ailments such as diabetes, hypertension, etc or related ailments 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
Not Applicable
Any Illness diagnosed or diagnosable within 30 days of the effective date of the Policy Period if this is the first Health
Policy taken by the Policyholder with the Insurer. If the Policyholder renews the Health Policy with the Insurer and
increases the Limit of Indemnity, then this exclusion shall apply in relation to the amount by which the Limit of
Indemnity has been increased
√
X
Not Applicable
First Year Waiting
period
Baby Cover Day 1
(provided the slab
is vacant)
Definition
X
Covered
√
During the first 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 not payable. If these diseases are pre- existing
at the time of proposal they will not be covered even during subsequent period or renewal too
In consideration of additional premium, this policy is extended to cover the new born child of an employee covered
under the Policy from the time of birth till 30 days. Not withstanding this extension, the Insured shall be required to
cover the newly born children after 30 days as additional member as mentioned elsewhere under this Policy.
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Medical Benefit – General Exclusions
•
•
•
•
Injury or disease directly or indirectly caused by or arising from or attributable to War or War-like situations
Circumcision unless necessary for treatment of disease
Congenital external diseases or defects/anomalies
HIV and AIDS
•
•
•
•
•
Hospitalisation for convalescence, general debility, intentional self-injury, use of intoxicating drugs/ alcohol.
Venereal diseases
Injury or disease caused directly or indirectly by nuclear weapons
Naturopathy
Any non-medical expenses like registration fees, admission fees, Hospital surcharge, charges for medical records, cafeteria
charges, telephone charges etc
• Any cosmetic or plastic surgery except for correction of injury
•
•
•
•
•
•
•
Hospitalisation for diagnostic tests only
Vitamins and tonics unless used for treatment of injury or disease
Infertility treatment
Voluntary termination of pregnancy during first 12 weeks (MTP)
OPD Claims
Claims (of high value) submitted without prescriptions/diagnosis
Health foods
• Costs incurred as a part of membership/subscription to a clinic or health centre
• Cost of appliances, spectacles, contact lenses, hearing aids
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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 utilized 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 hrs) 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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Medical Benefit – Contact Details
Provider List
Primary Contact
Escalation Point
Toll Free No (Vipul)
1800 102 7477
TPA :
Vipul Medcorp TPA Pvt Ltd
Website : taps.vipulmedcorp.com
Ashwini Kumar
Shahnaz Parveen
Email:
[email protected]
m
Email: [email protected]
Phone : 9311986315
Phone : 9311986326
Broker
Marsh India
Website: http://www.marsh.co.in
Rishi Dua
Ashish A Kumar
Email : [email protected]
Email: [email protected]
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We Care!
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