Group Mediclaim Insurance PolicyVersion 1.0 Oct 1, 2014 Wipro – For Internal circulation only Employee Compensation & Benefits Team ............... 9 Claim Documents...Contents OBJECTIVE .................................................................................................................................................................................................................................................................................................................................................................................................................. 10 Procedure . 4 POLICY TERMS & CONDITIONS................................................................................................................................................................................................................................. 10 E-medical card ..................................................................................................................................................................................... 12 Summary table of Applicable Annual Premium based on employee’s age & Scope of Cover .......... 5 Day Care Procedures ............................................................................................................ 7 Health Insurance Portability .......................................... 7 Definition of hospital and nursing home .............. 13 Accessing Top-Up Application .......................... 3 POLICY BENEFITS ........................................................................... 9 PROCESS FOR CLAIM SUBMISSION ........................................................................................................................................................................................................................................................ 11 TOP COVER ............................................................................................................................................................................................................................................................................. 14 AMENDMENT HISTORY ....................... 3 POLICY OVERVIEW ............................................................................................................................................................................................................................................................. 14 .............. 8 EXCLUSIONS UNDER MEDICLAIM ................................................................................. 3 COVERAGE................................................................................................................................................................ 5 Co-payment ......................................................................................................... 13 Top-Up Policy period ................................................................................................................................. 13 CONTACTS ............................................................................................................................................................................................ 8 Illness .................................................................... 8 CONTRIBUTION .................................................. cost of pace maker. surgical appliance.helpdesk@wipro. chemotherapy. radiotherapy. Ltd. oxygen. medicines and drugs. please write to mediclaim. POLICY OVERVIEW Policy Details Policy Holder Wipro Limited 01st October 2014 -30th September 2015 United India Insurance Co. anesthesia. operation theater charges.OBJECTIVE Group Mediclaim policy provides for reimbursement of hospitalization expenses for illness. spouse and children. medical practitioner. anesthetist. artificial limbs and cost of organs and similar expenses. the typical expense heads covered are the following: room/boarding expenses as provided by the hospital or nursing home. COVERAGE All India based employees of WT. consultant. (Except for select day care procedures. which do not require a 24 hour hospitalization). WC and Eco Energy.com to discontinue premium deduction for one of the member No Restriction on number of Children . Medi Assist India Pvt Limited Policy Start & End Date Insurer Third Party Administrator (TPA) Sum Insured Covered Members Total Members Covered per Family (Including Employee) Employee INR 2 Lakhs per Family Description Employee + Spouse+ Children Covered Covered Spouse Child Covered Special Condition if any This is applicable for all employees in India Payroll only Incase employee’s spouse is also working in Wipro as a full time employee. Under the scheme. nursing expenses. Expenses for hospitalization are payable only if a 24 hour hospitalization has been taken. WI. are covered under the policy. blood. dialysis. diagnostic material and X-Ray. disease or injury sustained by employee. surgeon. specialist fees. Covered (Only list of select procedures like Dialysis. Detailed prescription.000 per Employee).000.000 for surgical treatment per family).Normal Delivery: INR 30. nature of treatment. Carries 5 percent copay for all day care treatments Covered (INR 10. Expenses related to external aids used for mobility (like walker.000 per tooth inclusive of cost of the crown. (Cosmetic treatment like filling. Out of this. Waived off Covered (INR 1000 per claim for Emergencies only) For Class ‘A’ cities – Normal Delivery: INR 40.000 per case in absence of multi-specialty hospital in a radius of 50 KM for named ailments only. X-ray reports may be asked for if required for justification of admissibility of claim. if required for correction of power is 6. polishing. the sub limit for Root canal treatment is INR 3.000. Within the maternity limit for the normal expenses. capping. Lasik Treatment Covered. pre-numbered receipts are a must for dental treatment claims. Caesarian Delivery: INR 40. Maternity benefit is applicable for first two live births only. Latter should be an established ailment . scaling. Any complication rising from pregnancy will not be covered. Complications which require an admission can be processed under floater.000. chemotherapy. Refer Policy Terms & Conditions for details).genetic or non-genetic. Pre & Post Natal OPD expenses upto INR 5000 within the Maternity Limit is covered.000. In addition.000 . cleaning & treatment of similar nature are not payable. Other cities . (subject to approval of insurer) Mobility Extension Covered(INR 5. radiotherapy and other such specified treatments taken in the hospital/ nursing home where the insured is discharged on the same day. procedures done. dentures. only if it is life threatening but not cosmetic purpose Ayurvedic Hospitalization is covered for treatment taken in registered hospital with a justified admission In-patient treatment of mental ailment.) Covered upto INR 40. Caesarian Delivery: INR 40.0D and above Morbid obesity Ayurveda Mental ailment Treatment for morbid obesity is covered. crutches) upon the prescription of the treating doctor and admissibility of the main claim.POLICY BENEFITS Policy Benefits Standard Hospitalization Pre & Post Hospitalization Expenses Covered Relevant expenses Covered (30 days & 60 days respectively) Refer maternity benefit for maternity related pre and post limits Covered Pre-existing & including internal and external congenital Diseases First 30-days & First Year Waiting Period Ambulance Services Maternity New Born Baby Cover from Day 1 Day Care Procedures Dental Invitro fertilization Emergency Air Ambulance facility Covered for a maximum of first 10 cases throughout the year with a limit of INR 100. A co-pay of 15% will apply where the room rent is between lower room rent cap and the Upper room rent cap A co-pay of 20% will apply where the room rent exceeds the upper room rent cap ‘A’ class cities includes Metros. generally between the rectum and vagina/rectum and urinary bladder. AILMENTS Table 1. Hyderabad. If there are multiple claims during the year by an employee. The Co-pay will be applied on claims above INR10. Class B cities: INR 2100 A Standard Co-pay of 10% will apply where the room rent is up to the Lower Room Rent cap. All procedures other than the ones mentioned below are excluded from the policy if performed using robotics.000 will be borne by the employee and the same shall not be reimbursed under any insurance or ancillary in-house medical scheme run by Wipro. Class B cities: INR 1750 Upper Room Rent Cap Class A cities: INR 2900.1 Surgery Type Cataract (Inclusive of Eye Surgery Lens) Tonsillectomy Throat Surgery Fistula High General Surgery Description A Class B Class cities cities Clouding of vision. List of these procedures vary across hospitals and updated lists are available with the hospitals directly.000 for the year. HIV HIV covered upto sum insured for self.000. POLICY TERMS & CONDITIONS Co-payment The Policy will carry a co-pay from the employee for admissible claim amount over and above INR 10.000 for each and every claim. nose and throat Abnormal connection between two 35000 30000 organs. Bangalore. Co-pay essentially means a percentage of the claim amount over and above INR 10. Co-pay will be applied for aggregate claims crossing INR 10. The policy will carry a co-pay of 5% on all Day Care procedures except in a GIPSA Hospitals for the specified GIPSA procedures Co-Pay limits based on Room Rent categories for non-GIPSA PPN procedures requiring admission: Lower Room Rent Cap Class A cities: INR 2400. No co-pay will be applicable for admissions in GIPSA PPN network hospital for specified GIPSA procedures. .000 for the portion of claim over and above INR 10. Rest of the cities are classified as ‘B’ class cities Sub-limits for Robotics Assisted Surgery The following ailments are capped with the below mentioned sub-limits (specific to A-type & B-type city). glands between mouth. common in elderly 25000 22000 people Inflammation and infection of 24000 17000 tonsils/adenoids. spouse and children Stem Cell and Cyber Knife treatment Stem cell therapies and Cyber Knife treatment are covered upto 50% of the sum assured. Pune and NCR. Related to male reproductory organ Removal of hydrocele( collection of fluid around testes). one side.resulting due to injury/surgery Fisula Low General Surgery General Surgery Fissurectomy Haemorrhoidectomy (Excluding staples & tackers) Thyroidectomy – HEMI Thyroidectomy – TOTAL Arthroscopy General Surgery Arthroscopic Surgery Orthopaedics Hydroceletomy unilateral Urology Hydroceletomy bilateral Urology General Surgery General Surgery Orthopaedics Coronary Angiogram Cardiology (Including dye) Hernia repair – open General (including mesh) Surgery Hernia repair laparoscopic – General Surgery Appendicectomy open Appendicectomy laparoscopic – General Surgery – General Surgery Cholecystectomy open – General Surgery Cholecystectomy laparoscopic – General Surgery Hysterectomy – open Hysterectomy Gynecology – Gynecology Same as above Repair of a fissure(a crack or a tear in the lining of an organ). requires just a small incision on the abdomen) Removal of gall bladder upon finding stone formation( by cutting open the abdomen) Removal of gall bladder upon finding stone formation( by minimal invasion using laparoscope) Removal of uterus due to any complications( by cutting open the abdomen) Removal of uterus due to any 30000 25000 25000 20000 32000 25000 40000 35000 50000 45000 35000 30000 75000 50000 25000 20000 35000 30000 20000 15000 40000 35000 60000 50000 35000 30000 50000 45000 45000 40000 50000 45000 50000 45000 60000 55000 .sphincterectomy is the correction of a tear on a sphincter( muscle that helps in contraction of an organ) Surgical removal of a haemorrhoid( protrusion of the mucous lining of rectum due to constipation) Partial surgical removal of a thyroid gland( usually done when suffering from cancer) Total surgical removal of thyroid gland A procedure done by inserting a fiberoptic tube into the joints to study the nature of condition causing inflammation Done to treat cartilage tears( cartilage is the tissue lining the joints) Removal of hydrocele (collection of fluid around testes).Related to male reproductory organ An x-ray test done to find out the flow of blood into and out of one's heart( basically to study the nature of blood vessels) Correction of hernia( protrusion of internal organs through weak abdominal muscles) Correction of hernia( protrusion of internal organs through weak abdominal muscles) Removal of appendix by cutting open the abdomen Removal of appendix by laparoscopy( insertion of a laparoscope and removal of appendix by bit by bit. both sides. Eye Surgery. In a normal scenario. Health Insurance Portability Employees will now have an option to carry forward their health insurance policy (with standard benefits) even after leaving the Company/ retirement. s/he will be treated as a new customer and will have to wait for 4 years for getting pre-existing diseases’ coverage. With the feature of portability. Chemotherapy. in case an employee leaves the Company. Radiotherapy. Tonsillectomy. Lithotripsy (Kidney stone removal). Specified Treatment means any treatment involving Dialysis. Also the treatments as mentioned below will form a part of Specified Treatment: ENT o Myringoplasty o Tympanoplasty o Paracentesis (myringotomy) FESS o Tonsillectomy o Tonsillectomy with adenoidectomy EYE o Operations for pterygium o Operations for cataract o Operations for Glaucoma OPERATIONS ON THE DIGESTIVE TRACT o Surgical treatment of anal fistulas o Surgical treatment of haemorrhoids (piles surgery) GENITAL SURGERY o Operation on a testicular hydrocele o Herniotomy / Hernioplasty o Treatment of a varicocele and a hydrocele o Therapeutic curettage (D & C) OTHER OPERATIONS o Lithotripsy / ESWL . Conditions: .laparoscopic complications( by laparoscopy) Day Care Procedures For the purpose of this definition. D&C taken in the Hospital/Nursing Home. Dental Surgery. an employee will be given an option to carry forward the Policy (with standard benefits) with the insurer. subject to certain conditions. Example: In a retail policy from external market. the period during which pre-existing diseases are not covered is referred to as the waiting period. e. neurological conditions and etc. renal failure. Occurrence of same illness after the lapse of 45 days will be considered as fresh illness. Portable policy will be given at the retail rates approved by the Insurer. CONTRIBUTION WIPRO pays the annual premium on behalf of the employees. Portability to be offered to an employee only if s/he has spent minimum 2 years in the organization to be eligible for portability. He has completed 2 years in the Group Policy. progressive and may be irreversible i. Say. he can avail to avail pre-existing coverage. cancer. if he chooses to he will get pre-existing benefits April 2015 onwards. He has quit as of Nov 2014. Employee opting for retail policy will have to undergo pre-policy medical tests. Oct 2016 onwards. Since he has already completed 4 years in the policy (hence waiting period of 4 years is completed). however he will not get pre-existing benefits for next 2 years (so that he completes 4 years of waiting period). full equipped operation theatre . brain. 50% of medical test expenses subject to a maximum of INR375 would be borne by the insurer when the proposal accepted by the insurance company. cardiac disease. Portability cannot be given if employee is suffering from any chronic illness at the time of enrollment in portable policy. Example: Say Ram joined the Company on 1st Oct 2012. Ram can therefore continue with the same policy. Illness Any one illness will be deemed to mean continuous period of illness and it includes relapse within 45 days from the date of last consultation. The contribution would be based on Marital Status of the employee. Definition of hospital and nursing home Hospital & nursing home where treatment is availed means any institution in India established for indoor care and treatment of sickness and injury which is registered with the local authority having 15 inpatient beds . fully qualified nursing staff and doctor round the clock. Krishna decided to separate from the organization as of April 2015. He has completed 4 years in the organization.(In class 'C' towns No of beds be reduced to 10). It is strongly advisable to check with Medi Assist customer care number or Mediclaim Helpdesk to check the hospital status. The list of network hospitals is dynamic (subject to addition and deletion). as given below: Employee Category Monthly Premium . the contribution from the employees towards this premium is accumulated on a monthly basis by way of deduction through salary. organ transplant. Chronic illnesses are conditions or illnesses which are prolonged or recurrent. This condition can be waived in case of very small towns. Krishna joined the Company on 1st Jan 2011. which is proved by submission of Ultra Sonographic report and Certification by Gynaecologist that it is life threatening one if left untreated PROCESS FOR CLAIM SUBMISSION Remember to declare your family members at the time of a life changing event like marriage. Regular communication will be sent out on the available programs and we urge you to make the most out of them. venereal disease. unani. Treatment related like hysterolaparoscopy. Treatment arising from or traceable to pregnancy. ovarian drilling . Charges incurred at Hospital or Nursing Home primarily for diagnostic. invasion. Expenses on vitamins and tonics unless forming part of treatment for injury or disease as certified by the attending Medical Practitioner. hearing aids. chocolate cyst. accident or injuries directly or indirectly caused by or arising from or attributable to war. illness. Termination of pregnancy within 12 weeks of the gestational period. Virus Type III (HTLV –III) or Lymphadinopathy Associated Virus (LAV) or the Mutants Derivative or Variations Deficiency Syndrome or any Syndrome or condition of a similar kind. plastic surgery unless necessary for treatment of a disease not excluded by the terms of the policy or as may be necessitated due to treatment of an accident. illness. miscarriage. Family planning surgeries are not covered. Naturopathy treatment. Convalescence. The cost of spectacles and contact lenses. pranic healing. Circumcision whether or not necessitated by vaccination or inoculation or change of life or cosmetic or aesthetic treatment of any description. run-down condition or rest cure. diagnostic d and C are not covered IVF Pre and Post or any other infertility related treatment is not covered. childbirth.” EXCLUSIONS UNDER MEDICLAIM Diseases. Diseases. except abdominal operation for extra uterine pregnancy (Ectopic pregnancy). endometriosis. . yogic healing etc. intentional self-injury (whether arising from an attempt to suicide or otherwise) and use of intoxicating drugs and/or alcohol. holistic healing.Individual (Single) INR 230 Married (Family) INR 480 “A nominal amount is collected every month in excess of the medical insurance premium component. act of foreign enemy. abortion or complications of any of these including caesarean section. war like operations (whether war be declared or not). accident or injuries directly or indirectly caused by or contributed to by nuclear weapons/materials or contributed to by or arising from ionising radiation or contamination by radioactivity by any nuclear fuel or from any nuclear waste or from the combustion of nuclear fuel. child birth etc. general debility. sterility/family planning surgeries both vasectomy and tubectomy/ infertility. X-Ray or laboratory examinations or other diagnostic studies not consistent with or incidental to the diagnosis and treatment of the positive existence or presence of any diseases. illness or injury whether or not requiring Hospitalisation/ Domiciliary Hospitalisation. The excess will be utilized towards wellness programs and preventive healthcare interventions. employee must apply for an approval of the estimated hospital expenses directly with the TPA at least 4-5 days prior to the date of hospitalization. room and rate with help of TPA. Employee needs to fill ‘Pre-Authorization form for Cashless Claim’(Available in Section 10. Below process can be followed for registering claim incase of an emergency hospitalization: . If you receive approval from your TPA after paying the cash deposit. You will need to fill the form and drop the supporting documents in Wividus Drop box. Please refer the portal for the detailed checklist ailment wise: www. you would be required to furnish the following for or in support of a claim: a) Duly completed claim form b) Bills. d) Test reports and payment receipts. hospital will take up your caseTPA on a fast TPA send the final approval to hospital which allows the employee to get discharged by paying all non medical expenses. This would help you get the best services.com for claims processing or for any clarification. Incase of delay in receiving the approval or when you cannot wait for receiving the approval owing to medical urgency you can undertake the treatment by paying the necessary cash deposit. For any claims effective 1st Oct 2013. please write to mediclaim. if track basis with your TPA and is likely to receive approvals within 4 hours during any working day. Below process can be followed for registering claim incase of a planned hospitalization (Cashless if approved by TPA): Employee to call up TPA to plan the hospitalization Employee Approaches the Hospital with medical ID card Hospital Intimates TPA and sends Pre-Authorization Request with approximate cost of the treatment TPA issues letter of credit (for cashless) with approval for partial amount as per Eligibility and Coverage to the hospital At the time of Discharge hospital sends the final Sto bill and the discharge p summary for the final approval to the (ii). For cashless treatment it is mandatory for the hospital to have an approval from your TPA. Planned Hospitalization: In the case of a planned [email protected] Procedure Depending on the need and condition of hospitalization. receipts and discharge certificate/card from the Hospital c) Bills from Chemists supported by proper prescription. please use the claim form available in myWipro My Information Source People Practice India Policies My Financial Mediclaim Medical Insurance Claim form. Emergency Hospitalization : In case of emergency hospitalization. In such a case.Claim Documents In the event of a claim.mediassistindia. Forms). you are entitled for refund of the cash deposit (as per reimbursement process mentioned in point (iii)). doctor must have been consulted first and would in turn have advised on the probable date of hospitalization. employee can go for 3 forms of hospitalization: (i). etc. d) Test reports and payment receipts.mediassistindia. TPA verifies applicability of the claim to be registered and issue preauthorization Yes Preauthoriza tion given No Claims Processing by TPA & Insurer Release of payments to the hospital Employee will be him/herself to the hospital and claim reimbursement from Insurer through TPA. receipts and discharge certificate/card from the Hospital c) Bills from Chemists supported by proper prescription. Reimbursement: Incase any hospital does not accept cashless facility. Please refer the portal for the complete document checklist on ailment wise: www. Treatment Member / Hospital applies for pre-authorization to the TPA within 24 hrs of admission Hospital sends complete set of claims documents for processing to the TPA Member gets treated and discharged after paying all non entitled benefits like refreshments. d) Medi-Assist will process and settle the claim within 14 working days of receipt of complete documents. Health Check.com a) You would need to log the claim in myWipro under My Financials MAS. Any late submission shall not be considered. Stop (iii).Member get admitted in the hospital in case of emergency by showing his Medical /ID Card. Medi-cards & Insurance claim (WISH) b) All relevant documents along with the claim form need to be dropped in the nearest Wividus drop box. employee can register the claim as reimbursement. c) Documents must be submitted within 30 days of completion of hospitalization treatment. E-medical card You can print yours & your family’s e-card yourself on the link provided below: . Below mentioned documents for or in support of a claim need to be submitted within 30 days of hospitalizatio: a) Duly completed claim form b) Bills. failing which CMAP benefit may not be released by the Company.000 over and above the existing sum insured.000.000.myWiproMy FinancialsMAS. Critical Illness Cover (Please note – it is important to top-up your cover in order to be eligible for this benefit): Amount of cover – INR 2 lacs (over and above sum insured and top up) This benefit is for the employee only The critical illnesses covered are as below: Cancer of specified severity First Heart Attack Coronary artery surgery open chest (CABG) Heart valve replacement Coma of specified severity Kidney Failure Stroke resulting in permanent symptoms Major organ/Bone marrow transplant Multiple Sclerosis Motor Neuron disease with permanent symptoms Permanent paralysis of limbs Loss of Pay Cover (Please note – it is important to top-up your cover in order to be eligible for this benefit): This benefit is for employees only Amount – INR 5000 per week This benefit will commence immediately on the day ‘Loss of Pay’ (due to medical exigencies) begins and will be paid till employee returns to work or for 52 weeks. whichever is earlier New Employees have to opt for top-up cover within 45 days from the date of joining or on returning from abroad. Health Check.000. The premium payable calculated will be proportionate to the number of months the policy will be effective. Employee can increase sum insured upto INR 100. INR 500. Employees will have option of buying a top-up cover over and above the floater cover at their own expense.000.000 OR INR 1. INR 200. Please note that it is important to top-up your cover in case you have a chronic pre-existing ailment. INR 700. A one-time premium would be deducted from payroll in the month this additional coverage is opted for. INR 300. . Medi-cards & Insurance claim (WISH) Medicard.000. Top up is a limited period offer and available from 1st Oct to 15th Nov in 2014. Do remember to print the card(s) and share with family right away as medical contingency hits unplanned most of the time. TOP COVER Top up Cover Policy Features Top Up Cover offers you an option to increase your Mediclaim Insurance for furthering your financial protection benefit under this plan. The Top up Cover lapses in the event of Separation due to resignation / Termination from the company as in the case of default coverage. The Top up policy is applicable from 1st October 2014 to 30th September 2015 if applied during the window mentioned above. Summary table of Applicable Annual Premium based on employee’s age & Scope of Cover Unmarried Amount INR 100.000 INR 500. The premium payable calculated will be proportionate to the number of months the policy will be effective.45 Years 950 1790 2320 2923 3508 4209 1030 1940 2520 3175 3810 4572 Above 45 Years 1260 2400 3590 4523 5428 6514 Top-Up Policy period The Top up policy is applicable from 1st October 2014 to 30th September 2015. For a new joinee / returnee from Long term onsite assignment. Top up is applicable from 1st of the following month in which you choose Top up Cover in myWipro.000 INR 1000.000 Below 35 Years 36 . please log onto myWipro My Financials Top Up Cover. .000 INR 200. the top up window will be open for 45 days from date of joining / date of return. For new joinees/Long Term assignee return cases.000 INR 700. top up is applicable from 1st of the following month in which you choose Top up Cover in myWipro. Top up option.45 Years 450 850 1110 1399 1678 2014 490 930 1200 1512 1814 2177 Married Above 45 Years 700 1320 1710 2155 2586 3103 Below 35 Years 36 .000 INR 300. myWipro Top up Coverage application will be accessible from the 1st to the 20th of every month (only for a new joinee / returnee from Long term onsite assignment). The top-up cover can be utilized only after exhausting the main cover. Accessing Top-Up Application myWipro Top Up Cover module will only be accessible from the 1st to the 20th of every month (only for a new joinee / returnee from Long term onsite assignment). There will be no refund of Top up premium paid in such event. You have an option to apply for Top up from 1st Oct 2014 to 15th Nov 2014 only. once selected on myWipro cannot be cancelled. To choose Top up Cover. E-mail Id's First point of contact for all enquiries and Cashless claims: Contact No.com First level of escalation: escalation.To choose Top up Cover.com +91 9379260825 and 7022969803 24 / 7 Final level of escalation: [email protected] Nature of Changes Renewed Policy for year 2014-15 Top [email protected] +91 9739519191 Working hours and for emergencies 24X7 Visit myWipro My Information Sources People Practices India Other Benefits Healthcare services to know about the existing offers across the network of hospitals/ clinics. please log onto myWipro My Financials MoreTop up Cover. Please refer to the Editorial section for further information on how to raise a request on myWipro. CONTACTS For any further information with regards to the Policy. Timings 080 32413698 Wipro Working hours +91 9341625893 24 / 7 wipro@mediassistindia. Visit Channel W Fit for Life to take proactive care of your health! Top AMENDMENT HISTORY Amendment Date Policy Version Author Approved By Oct 1. 2014 C&B Team Head – C&B 1.