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Provides insurance coverage to employees for expenses related to hospitalization due to illness, disease or injury
Eligibility:
GM & Above
Level
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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Policy Parameter
 Insurer United India Insurance Company
 Third Party Administrator Vipul TPA
 Policy No
 Coverage Type
 Sum Insured
500300/48/11/41/00000090
Family Floater (E+3)
Graded INR 1.5 Lacs ,2 Lacs and 3 Lacs ,4 Lac
Benefits / Extensions Coverage
 Standard Hospitalization • Yes
 TPA services
 Pre existing diseases
• Yes
• Yes
 Waiver on 1 st year exclusion
 Waiver on 1 st 30 days excl.
• Yes
• Yes
 Maternity benefits
Rs. 50,000 covered from day one
Benefits / Extensions Coverage
 Day Care • Yes
 Pre-Post Hospitalization
Exp.


Room Rent
Corporate Buffer
• Yes – 30 / 60 days
Restricted to 2% of
SI per Day, 4% for
ICU
Rs.10,00,000/-
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• 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.
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-hospitalisation Expenses
Definition
Covered
Duration
• 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.
• Yes
• 30 Days
Post-hospitalisation Expenses
Definition
Covered
Duration
• 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.
• Yes
• 60 Days
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Benefit Details
Benefit Amount
Restriction on no of children
9 Months waiting period
Rs. 50,000
• Maximum of 2 children
• 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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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
Toll Free Number : 1800 102 7477
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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Step 1
Get Admitted
In cases of emergency, the member should get admitted in the nearest network hospital by showing their ID card.
P
R
O
C
E
S
S
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
Member gets admitted in the hospital in case of emergency by showing his
ID Card
Member/Hospital applies for pre-authorization to
Vipul within 24 hrs of admission
Preauthorization given by Vipul
Yes
Member gets treated and discharged after paying all non medical expenses like refreshments, etc.
No
Non cashless
Hospitalization
Process
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
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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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
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
Member intimates Vipul of the planned hospitalization in a specified pre-authorization format at-least 48 hours in advance
Pre – Authorization Form www .vipulmedcorp.c
om
Member produces ID card at the network hospital and gets admitted
Claim
Registered by
Vipul on same day
No
Follow non cashless process
Yes
Vipul authorizes cashless as per SLA for planned hospitalization to the hospital
Pre-Authorization
Completed
Member gets treated and discharged after paying all non entitled benefits like refreshments, etc.
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Hospital sends complete set of claims documents for processing to Vipul
Claims Processing &
Settlement by Vipul &
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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.
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Yes
Member intimates Vipul before or as soon as hospitalization occurs
Claim registered by Vipul after receipt of claim intimation
Insured admitted as per hospital norms. All payments made by member
Insured Submits relevant documents to the Help desk within 7 days of discharge
A
Is claim payable?
No
Vipul performs medical scrutiny of the documents
Yes
Is document received within 7 days from discharge
No
Claim Rejected
•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.
Vipul checks document sufficiency
Is documentatio n complete as required
No
Yes
Claims processing done as per
SLA
Receives mail about deficiency and document requirement
ECS Payment will be done directly to the Employee bank a/c.
A
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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
Discharge Report (original)
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
Employee Benefits Manual
Claims Form www.vipulmedcorp.c
om
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Benefits
Pre existing diseases
First 30 day waiting period
For
Luminous
Covered
Not Applicable
X
First Year Waiting period
Not Applicable
X
Baby Cover Day 1
(provided the slab is vacant)
Covered
Definition
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
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
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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• 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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 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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Toll Free No (Vipul)
TPA :
Vipul Medcorp TPA Pvt Ltd
Website : taps.vipulmedcorp.com
Provider List
Primary Contact
1800 102 7477
Ashwini Kumar
Escalation Point
Shahnaz Parveen
Email: corporateservices@vipulmedcorp.co
m
Email: shahnaz@vipulmedcorp.com
Phone : 9311986315
Phone : 9311986326
Broker
Marsh India
Website: http://www.marsh.co.in
Rishi Dua
Email : Rishi.Dua@marsh.com
Ashish A Kumar
Email: ashish.a.kumar@marsh.com
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