Policy Over View
You: CAST Software India Pvt. Ltd.,
Me: Aditya Birla Insurance Brokers Ltd.,
Insurer : Reliance General Insurance Company ltd.,
TPA: Family Health Plan Limited .,
Aditya Birla Insurance Brokers
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Definition of Hospital
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An institution established in India for indoor care & treatment of sickness
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Hospital should be Registered with local authorities
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Under supervision of registered & qualified medical practitioner
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Minimum of 15 inpatient beds( In Smaller cities/ towns the same is reduced to 10
beds)
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Fully equipped operation theatre
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Fully qualified nursing staff 24/7
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Fully qualified doctors 24/7
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Maintains daily medical record for each of its patients.
Aditya Birla Insurance Brokers
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MEDI CLAIM POLICY
The Mediclaim Policy Reimburses Expenses
Incurred Due to a Disease, Illness or Accident.
The Mediclaim policy stipulates that a claim is
admissible when the insured (beneficiary) is
admitted in a hospital for a minimum of 24
hours for the treatment of a positive illness
HOSPITALISATION means admission in any
Hospital/Nursing Home in India upon the
written advice of a Medical Practitioner for a
minimum period of 24 consecutive hours.
Aditya Birla Insurance Brokers
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Day Care Treatment
24 hours hospitalization is a must. However this time limit is not
applied to specific treatments i.e. ,
a. Dialysis
b. Chemotherapy
c. Radiotherapy
d. Lithotripsy (Kidney Stone Removal)
e. Dental surgery following an accident
f. Tonsillectomy
g. Dilatation & Curettage (D & C) of Cervix
h. Eye surgery
i. Cardiac Catheterization
j. Hernia repair surgery, TURP (Prostate Surgery)
k. Hydrocele Urinary Tract System
These treatments have to be taken as an inpatient and
discharged on the same day.
Aditya Birla Insurance Brokers
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CAST Policy Benefits
Sum Insured- Rs.5 Lakhs Family Floater sum insure
•Family Definition : Self + Spouse+ 02 Children
•No 30 days waiting period
•All Pre- existing ailments are covered
•First Two / Four year Exclusions - Expenses on treatment of diseases such as Cataract,
Benign Prostrate Hypertrophy, Hysterectomy for menorrhagia or fibromyoma, hernia,
hydroceole, congenital internal diseases, fistula in anus, piles, sinusitis etc and related
disorders are payable.
•Pre-hospitalization medical charges up to 30 days period immediately before the
Insured’s admission to hospital for that illness or injury.
•Post hospitalization medical charges up to 60 days period immediately after the
Insured’s discharge from the hospital for that illness or injury.
Aditya Birla Insurance Brokers
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Maternity Benefits
Maternity Benefits is extended only for Employee & employee
Spouse only
Maternity Capping: Rs. 50000/- for both Normal & C-section
Waiting period of 09 month is waived off
Pre & Post natal expenses OPD expenses are not covered
New born Baby expenses due to complication is covered from
the floater sum insure
Normal baby charges not covered in policy
Maternity benefit is extended to first two events only
Aditya Birla Insurance Brokers
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Expenses Payable
•Room, boarding and nursing expenses as provided by the Hospital
/nursing home are capped : 1% of SI per day normal & 2% of SI for ICU
•Surgeon, Anaesthetist, Medical Practitioner, Consultants’ Specialist fees
should be the part of the main hospital bill
•Anaesthesia, Blood, Oxygen, Operation Theatre Charges, Surgical
Appliances, Medicines & Drugs, Dialysis, Chemotherapy, Radiotherapy,
Artificial Limbs, Cost of Prosthetic devices implanted during surgical
procedure like Pacemaker, Relevant Laboratory/Diagnostic test, X-Ray and
other medical expenses related to the treatment.
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Expenses Not Payable
•Admission/Registration
•Telephone charges
•Attendant's charges
•Home Visit/Nursing charges - at residence after discharge
•Assistant fee/Follow up charges in advance
•Sundry/Medico Legal Charges/Diabetic chart charges
•Thermometer Charges
•Container for Specimen/Disposable Bag charges
•Admission Kit
•External Surgical Aids: Lumbo-sacral/Collar belt /Knee cap/Knee brace/ walker/hot water
bag/baby kit/urine pot / traction kit/ folding commode etc
•Inhaler/ Nebulizer
•Diet charges
•Special/protein diet/health drinks unless prescribed by the doctor
•Documentation/Folder/Stationery/In Patient chart charges
Aditya Birla Insurance Brokers
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General Policy Exclusions
•Injuries or diseases caused by war and war like operations
•Circumcision, Vaccination, Inoculation, Cosmetic treatment, Plastic surgery
•Cost of Spectacles, Contact lenses, Hearing Aids , Braces, equipment or
external prosthetic devises , non durable implants including cochlear
implants are not payable.
•Convalescence, General weakness, Congenital external disease, Sterility,
Venereal disease, Alcohol use, Self injury
•AIDS
•Diagnostic expenses not followed by active treatment for the ailment.
•Vitamins and Tonics unrelated to treatment
•Injuries or diseases caused by nuclear weapons
•Abortion during first three months of pregnancy
•Naturopathy treatment
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General Policy Exclusions
•Instruments used in treatment of Sleep Apnoea Syndrome (
C.P.A.P) , C.P.A.D ( Continuous Peritoneal Ambulatory Dialysis)
& Oxygen Concentrator for Bronchial Asthmatic Condition
•Genetic Disorders & Stem Cell Implantation
•Treatment Taken Outside India
•Experimental & unproven treatment( Not recognized by Indian
Medical Council)
•POLICY PARAMOUNT
•At all times the policy issued by the Insurer shall prevail &
supersede this presentation.
Aditya Birla Insurance Brokers
Copyright Aditya Birla Insurance Brokers Ltd 2010
Midterm addition of dependants
• Mid term addition of dependants is only allowed for the below
• New born baby
• New married spouse
• Note :- for above both additions employee need to intimate to the HR
immediately after events and its mandatory
Aditya Birla Insurance Brokers
Copyright Aditya Birla Insurance Brokers Ltd 2010
TPA : ( Family Health Plan TPA Limited ) Services
• ENROLMENT : - Update on receipt of data from insurer
• Updation of BENEFICIARY DETAILS, BENEFITS & ISSUE IDENTITY CARDS
• Employees will be issued with e-card.
• CLAIMS ADMINISTRATION:
• CASHLESS HOSPITALISATION -THROUGH NETWORK HOSPITALS
• REIMBURSEMENT CLAIMS
Aditya Birla Insurance Brokers
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Network Hospitals-(Cashless facility)
Cashless Services can be availed through
network (Reliance General Insurance Company)
Hospitals across the country across India
Please refer to the Current Network hospital
list on www.fhpl.net.
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Cashless hospitalization
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This service enables the customer to avail treatment at the Network Hospital without being
required to pay for the treatment.
All expenses incurred will be paid to the Hospital deducting the non medical expenses
Please produce your Identity Card at the hospital on network where you wish to avail
treatment.
Kindly fill in the TPA (FHPL) Card Number, Name of the Patient, Age & Contact Number in the
Cashless Request Form (attached below)
The treating doctor/ hospital will fill in the remaining part of the Request Form & Fax it to
Medi Assist for approval.
Aditya Birla Insurance Brokers
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Cashless Hospitalisation-Know Your Rights
•Check & Sign the hospital bill.
• Collect Copy of your medical records.
•Avoid informing the hospital your total coverage detailsas hospitals have a tendency to inflate credit bills.
Aditya Birla Insurance Brokers
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Procedure For Reimbursement of Claims
• Please submit the following documents in original within 10 days to the
nominated member in respective HR office with below mentioned basic documents
• Discharge Summary. (Original )
• Final Hospital Bill (with detailed break-up) & Cash paid Receipts (Original)
• Medicine Bills along with Doctor Prescriptions. (Original)
• Investigations & Test Reports. (Original)
• Duly Filled Claim Form with Signature.
• Claim intimation with in 24hrs of hospitalisation
• Download the claim from the link : www.fhpl.net
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Claim Submission details
• Claim
intimation is must for the both GMC claims
with 24 to 48 hours of the incident / hospitalization in
case of reimbursement claims
• The document should reach the HR desk within 10
working days from the date of discharge / treatment
• All the document should be originals only
• Claim intimation ID / copy to be attached along
claim documents
Aditya Birla Insurance Brokers
Copyright Aditya Birla Insurance Brokers Ltd 2010
TPA Call Center
Dedicated member helpline 24 x 7
Nationwide Toll free no . 1-800-425-4033, with IVR Facility
24 X 7days accessible
Electronically supported systems
Managed by professionally skilled manpower
Assistance in information on
 Network hospitals
 Enrollment status
 Support services in an Emergency
 Coverage eligibility
 Claims- documentation support, query handling
 General information on health plan
Aditya Birla Insurance Brokers
Copyright Aditya Birla Insurance Brokers Ltd 2010
Escalation Matrix on emergency / cashless
Escalation .01 : Mr. Sujith Uthaiah. K.B.
Hand phone : 09844506633
E-mail : sujith.uthaiah@adityabirla.com
Escalation .02 : Mdm. Sarita Nair
Hand phone : 09743013111
E-mail : sarita.nair@adityabirla.com
Aditya Birla Insurance Brokers
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Thank You, ABIBL Bangalore.
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