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Employee Health Insurance Program
User Manual
2015-16
1
Employee Insurance Program
This presentation is a summary of the employee benefit
insurance policies offered to the employees by 3i INFOTECH
LTD. It contains the necessary details related to your
insurance policies like benefits available, claims procedures,
enrollment process,.
2
Agenda

Coverage

Exclusions

Points to remember


Reimbursement claims

Cashless claims
Important IL Healthcare details

Contact details

Obtaining Health Cards

Tacking a claim (queried)
Employee Health Insurance Policy
The Group Health Insurance Program provides pre-defined insurance coverage to all employees &
their dependents for expenses related to hospitalization due to illness, disease or injury.
In the event of a hospitalization claim (more than 24 hrs), the insurance company will pay the
insured person the amount of such expenses
as would
fall
under
different
heads
mentioned below, and as are reasonably and necessarily incurred thereof by or on behalf
of such insured person, but not exceeding the sum insured in aggregate mentioned in the
policy:
-
Room Charges,
-
Nursing expenses,
-
Surgeon, Anesthetist, Medical Practitioner, Consultant, Specialists Fees,
-
Anesthesia, Blood, Oxygen, Operation Theatre Charges Surgical Appliances, Medicines &
Drugs, & similar expenses.
4
Health Insurance Policy - Features
Sum Insured type
Family Floater with graded sum insured
Sum Insured (Floater)
T – G2: INR 2,00,000-Self+ any 3 dependents
G3–G7: INR 4,00,000-Self+ any 4 dependents
G8 & above: INR 6,00,000-Self + any 5
dependents
Members Covered
Employee + Spouse + 2 Dependent children
+ 2 dependent Parents (Parents are covered
for employees who have completed 5 years
or more in the organization
Pre - Existing Ailments
Covered
30 days waiting period for
non - accidental claims
Waived Off
Ambulance Charges
Subject to a maximum of RS.1000/-
Domiciliary Hospitalization
Not Covered
5
Health Insurance Policy - Features
Maternity
Benefits
Restrictions
Maternity Benefit
Covered for the first 2 living children
Maternity limit
Sum insured subject to maximum of INR 35,000 for
normal and INR 50,000 caesarian delivery
9 Months waiting period for
Maternity
Waived Off
Baby Cover
Covered from Day 1 up-to Family Sum Insured
Room Rent Limit
1% of the SI, in case of Normal room max upto 5000/& 2% of the SI to max upto 10000/- in case of ICU
admission
Applicability of Co-payment
10% on Employee, Spouse & Children claims
20% on Parental Claims
Domiciliary Hospitalization
Benefit
Not Covered
6
Health Insurance Policy - Features
Existing
Associates +
Dependents
Commencement Date
01st -April-2015
Termination Date
31st -March-2016
New Joiners
+ Dependents
Commencement Date
Date of Joining (Subject to availability of Funds in CD
Account)
Termination Date
31st -March-2016
New
Dependents
on account of
Marriage /
Birth
Commencement Date
Date of such event (subject to declaration of
dependent within 30 days from happening of event)
Termination Date
31st -March-2016
7
General Hospitalization Benefits
Preexisting
Disease
Pre-existing diseases refers to condition or ailments that may have been
contracted before the start of the policy. There is usually a waiting period of
4 years for covering such ailments in standard individual policy.
Covered
from day 1
30 Day
Waiting
Period for
new joiners
Any hospitalization expenses during the first 30 days from the
commencement date of the Policy is not covered for the new joiners. This
exclusion is however, not applicable to any emergency hospitalization
occurring due to an accident.
Waived off
for all
1st/2nd/3rd/4th
Year
Waiting
Period
Medical insurance policies have waiting period of 1/2/3/4 years for
reimbursement of medical expenses for treatment of certain specified
ailments. The specified ailments mainly include Cataract, Benign Prostatic
Hypertrophy, Hysterectomy or prolapsed of uterus, Hernia, Hydrocele,
Fistula in anus, Piles, Sinusitis, Joint Replacement due to Degenerative
condition, Age related osteoarthritis and Osteoporosis, among others.
Waived off
for all
8
General Hospitalization Benefits
Domiciliary
Hospitalizati
on
Day Care
Domiciliary hospitalization means treatment done at home in India for a
period exceeding three days for disease, illness or injury, which in the
normal course, would require hospitalization. This could happen if either
the condition of the patient is such that he/she cannot be moved to
Hospital/ Nursing Home, or the patient cannot be admitted to
Hospital/Nursing Home for lack of accommodation.
Day care procedures refers to such treatment which does not necessarily
require 24 hospitalization due to medical technological advancement. Such
list of ailments are available with insurance companies and are referred to
as Day care ailments.
Not
Covered
Covered
Day Care treatment can be taken in network hospitals –
on a cashless basis or in the form of reimbursement
Ambulance
Charges
Ambulance charges are provided for emergency hospitalization wherein the
patient needs to be rushed to the hospital. Under this extension the policy
will reimburse such expenses as per the pre decided limits.
SUBJECT
TO A
MAXIMUM
OF
RS.1000/-
9
Sub Limits for Ailments/Treatments

Disease Wise Capping










Appendix - 20,000
Eye related - 20,000
Hernia - 20,000
Hydrocele - 12,000
Hysterectomy - 50,000
Piles - 15,000
Cholecystectomy - 35,000
Tonsilectomy - 15,000
Kidney/Urinary Stones - 25,000
FESS – 35000

50% Co-Pay for cyberknife treatment/Stem Cell Transplantation

Cochlear Implant treatment shall be restricted to 50% of the SI
Pre/Post Hospitalisation
The expenses incurred in relation to the condition of hospitalization, generally 30 days prior to the date of
hospitalization as well as 60 days post the discharge are reimbursed under the Pre & Post Hospitalisation Clause.
These expenses include things like medication prescribed at the time of discharge, follow up treatment etc.
Please Note: Pre & Post Hospitalization expenses is applicable in case of Maternity in this policy only in Inpatient
basis.
Pre Hospitalization
Expenses
Post Hospitalisation
Expenses
If the Insured member is diagnosed with an Illness which
results in his / her Hospitalization and the claim is admissible,
the Insurer will also reimburse the Insured Member’s Prehospitalization Expenses.
Covered for
30 days
prior to date
of
admission
Relevant expenses for 60 days post discharge from hospital for
an admissible hospitalization claim will be reimbursed in the
policy.
Covered for
60 days
post the
date of
discharge
11
Maternity Benefits
The Maternity expenses limit allowable is INR 35,000 per Normal delivery & INR 50,000 per
Caesarean Delivery within the overall Sum Insured for the first two live births . There are
special conditions applicable to the Maternity Expenses Benefits as below:
Claim in respect of delivery for only first two live births and/or operations associated
therewith will be considered.
Expenses incurred in connection with voluntary medical termination of pregnancy during
the first 12 weeks from the date of conception are not covered
Maternity
Expenses
Maternity or pregnancy related expense of hospitalization
other than those excluded (like voluntary termination of
pregnancy in the first 12 weeks of delivery) will be
payable. The maternity benefit is applicable for Normal /
Cesarean delivery within the overall Sum Insured for the
first two live births
Covered up to a limit of
INR 35,000 for Normal &
INR 50,000 for
Caesarean
9 Month
Waiting
Period
The 9 month waiting period waived off for new joiners to
claim Maternity Benefits under Group Health Policy.
Waived off. Maternity
benefit available to all
employees from day 1.
12
Baby Coverage
On Delivery of a child, the child is
prone to many health disorders like
jaundice or expenses incurred for
incubator for pre-mature births or
any other complication to the child.
Usually there is a 90 days waiting
period for covering baby in the
policy.
Covered from Day 1. The normal baby expenses like pediatrician visit, nursery charges, etc.
prior to discharge from hospital post delivery is covered within the family Sum Insured.
Vaccination charges are not payable.
13
Exclusions

Mid term addition of dependents except


Spouse (should be intimated within 1 month of marriage)
New born (should be intimated within 1 month of delivery)

Hospitalization for investigation only not covered

Lasik surgery, Septoplasty, Infertility treatment are
not covered

Administration, registration, miscellaneous and
service charges are not covered

Treatment on experimental/trial basis is not covered

Dental treatment is not covered except in case of an
accident
Exclusions
cont

Holter Monitoring are outside the scope
of the policy

Treatment on account of or related to
psychiatrist ailment

Expenses related to Prosthesis is outside
the scope of the policy

Expenses related to the external medical
devices are out of the scope of the
policy

Infertility & Related ailments including
male sterility is out of the scope of the
policy
Cashless claims





For planned hospitalization it is recommended that
cashless approval is taken one day prior to hospitalization
Please ensure that pre authorization form has correct UHID
along with the updated mobile no.
Please note that stand alone investigation/ diagnostic
procedure for evaluation is not covered under the policy.
Once the fax is sent, it is advisable to confirm the receipt of
the same from the call centre
If a revert is not received in 4-5 hours from the time of
confirmation of fax receipt, please get in touch with HR
team who in turn will ensure co-ordination with ICICI
Lombard.
Cashless claims
conti…

Please also note that initial
approval from insurance company
comes for a part of the estimated
cost of treatment, which will be
enhanced as per the progress in
the treatment based on the
progress report provided by the
hospital to IL Healthcare.

At the time of discharge final bill
should be sent to ILHealthcare 3-4
hours before the time of discharge
so that last minute problems can
be avoided.
Reimbursement claims




Main hospitalization claims documents should be
submitted within 30 days from date of discharge.
Post hospitalization claim can be submitted within 60 days
from date of discharge or 30 days from date of end of
treatment whichever is earlier
Please ensure that claim form is filled properly and signed.
Please also do not forget to mention the UHID on claim
form along with your latest mobile no.
In some cases indoor case papers might be required hence
it is advisable that a copy of indoor case papers is collected
at the time of discharge from the hospital.
Reimbursement claims

cont…
Please ensure that following documents are submitted in
original along with the claim form (additional documents
may be required depending on the case):

Original Discharge card mentioning date of
admission, date of discharge, investigations done,
findings, detailed line of treatment
 Original bills & paid receipt
 Bills & paid receipt should be
supported by:

Medicine bills,
 Prescriptions for medicines
 Original Investigation reports
IL Healthcare contacts




Toll Free Call Center No.: 1800 2666
Fax: 040-66989160/61
Toll free Fax no: 1800-2666
E mail: [email protected]
Address for sending the reimbursement claims:
ICICI Lombard General Insurance Company Ltd.
ICICI Lombard Health Care, ICICI Bank Tower, Plot No. 12,
Financial District, Nanakram Guda,
Gachibowli, Hyderabad,
Andhra Pradesh- 500032
Obtaining Health Cards




Follow the below mentioned path:
www.icicilombard.com >claims corner >IL Healthcare
Click on Print I card, mentioned under the head claims,
subhead services.
Enter your UHID no. in the box and click on search.
You can take a print out of the card displayed or save it as a
PDF document for your future reference.
You can also click on or copy the below mentioned URL to
go directly to the print I card page:
http://24x7.icicilombard.com/ghi/iHealthCare/iCare_Wfrm_Sear
chPrintICard.aspx?Login=N
Tracking a Claim (queried)

You can track the status of your claim by following the
below mentioned path, in case the claim is queried:
www.icicilombard.com >claims corner >IL Healthcare
 Click on Track your claim, mentioned under the head
claims, subhead services.
 Enter the claim number provided to you at the time of the
query & click on search.
You can also click on or copy the below mentioned URL to go
directly to the print I card page:
http://24x7.icicilombard.com/ghi/iHealthCare/iCare_wfrm_Clai
mStatus.aspx?Login=N
I Healthcare important links

I health care- https://www.icicilombard.com/IL-Health-Care/icare.html

Process for claims: https://www.icicilombard.com/health-insurance/floaterclaims.cms

Claim Form- https://www.icicilombard.com/Content/ilomen/Hospital_list/click2mail/sendDetails.asp?val=claims_form

Claim form(PDF): https://www.icicilombard.com/Content/ilomen/Downloads/Health/Claim_Form_iHealthcare.pdf

Network hospital list : https://www.icicilombard.com/Content/ilomen/Hospital_list/search.asp

Track your claim :
http://24x7.icicilombard.com/ghi/iHealthCare/iCare_wfrm_ClaimStatus.aspx?Login=
N

Print I card :
http://24x7.icicilombard.com/ghi/iHealthCare/iCare_Wfrm_SearchPrintICard.aspx?L
ogin=N
Thank You