Group Mediclaim Insurance Policy Policy Main Section : Employee Benefits

Objective / Purpose:

To give a clear guideline to employees on the reimbursement of hospitalization expenses

as a claim under the group medical insurance provided by the company

Eligibility: All employees on permanent rolls and employees engaged in fixed term
contract with the company.

Entitlement:

Sr. Grade Sum Family Cover Employee

Insured Contribution (Monthly)
(Rs.)
1 M1-M2 3 Lacs The Employees, spouse, two Rs. 700
2 M3-M5 2 Lacs dependent children (upto 21 yr) Rs. 500
and two dependent parents of
3 P1-S 2 Lacs Rs. 300
the employees will be covered.
4 FTC 1 Lac The Employee only Rs. 100

Employees can avail cashless facility for hospitalization at network hospitals enlisted with
Paramount Health Services (Paramount) or claim reimbursement of expenses upto the
limits specified above.

Visit https://www.paramounttpa.com/ProviderNetwork/ProviderNetwork.aspx to view the

latest updated list of Network Hospitals online

Please see Annexure A for Non Payable Items list (this list is as per IRDA guidelines)

Note:

1) Hospitalisation means admission in a Hospital for a minimum period of 24 hours

Inpatient Care consecutive hours except for specified procedures/ treatments (day
care admission), where such admission could be for a period of less than 24
consecutive hours. All such day care treatments is enlisted in Annexure B

2) The sum insured is for the whole family under a floater concept, i.e., the full limit could
be utilized in a year for the hospitalization of one or more members of the family upto
the sum insured applicable.

Procedure:

Enrollment
The dependent details as provided by employee at the time of joining are
enrolled for group insurance policy subject to family definition as above in
Entitlement section

Any addition/ updation to dependent details should be notified to Divisional HR in

the following Format within the timelines mentioned below:

Sr No Ticket No Employee Name Dependent Name Gender Date of Birth Relationship

Policy No : HR # D-05
Page 1 of 5
Issue Date : 1st July 2019
 Group Mediclaim Insurance Policy Policy Main Section : Employee Benefits

Intimation of Marriage: It will be the responsibility of the employee to send in writing to

his/her HR- Associate requesting Enrolment of the spouse under the group mediclaim policy.
Details to be provided include name/employee no. and Name & Date of Birth of spouse and
Date of Marriage including marriage registration certificate or marriage invitation card. These
details need to be sent within 15 days of marriage to the respective HR Associate.

Enrolment of new born baby: New born baby can be enrolled as a beneficiary and will be
covered under the policy from the date of Birth. Details to be provided are: Employee name
& number with Name and gender of Baby with Date of Birth including birth certificate. These
details need to be sent within 15 days of birth of child to the respective HR Associate. Since
these details are to be sent on immediate basis after childbirth; in case baby’s name is not
decided you may simply mention “son of / daughter of” followed by employee name in place
of name of the new born. Afterwards Baby’s name (as and when finalized) need to be
communicated through respective HR Associate for mentioning in the policy and Mediclaim
e-card.

The Health Card is available online. Following are the steps to view & download the e- Card:

https://www.paramounttpa.com/MarshClient/Thermax/Login.aspx

This portal is a one stop platform for you to know about your policy information, dependent
details, Claim status and much more

Please login (after 10th July 2019) by using

Login ID Password
Your Employee Date of Birth
ID (DD/MM/YYYY)
st
For example, if your DOB is 1 May 1975 then you need to put the password as 01/05/1975.
Please enter employee ID without any ‘zero’ as prefix.

Any discrepancy in the e-card needs to be intimated to your respective HR

Associate immediately.

Mediclaim Procedure
There are two forms available depending on the cases:
1) Cashless Treatment
2) Reimbursement Claim.

Cashless Treatment:-

In each city, Paramount Health Services (Paramount) have an arrangement with

leading hospitals. An employee would need to comply with certain procedure prior to
admission/treatment (bare minimum in the event of an emergency) before getting
admitted in the hospital. After the treatment all the admissible medical expenses will
be settled by Paramount directly with the hospital.

Reimbursement Claim

Policy No : HR # D-05
Page 2 of 5
Issue Date : 1st July 2019
 Group Mediclaim Insurance Policy Policy Main Section : Employee Benefits

In the event of an employee choosing a Hospital of his / her choice which is not in the
empaneled list provided by Paramount, initially the full payment will be have to be borne
by the employee. Subsequently the employee will need to file a claim with Paramount.
All such claims will be settled within 30 Days of receipt by them with all relevant papers.
(Annexure C to be filled and Submitted as claim form to Paramount)

Claim Requirements as per IRDA Regulations –

1. Intimation of claim - Within 3 days of admission or before Discharge from the

Hospital; whichever is earlier by email to pune.ci@paramounttpa.com &
thermax.mediclaim@paramounttpa.com or a call at the dedicated toll free
number 1800 22 5553.Non-compliance of the same can be a reason for claim
rejection.

The details required are –

Employee No. –
Patient Name -
Relationship with Employee –
Name of Hospital
PHS e-card No

For any assistance on claim or policy details, please contact - Mediclaim Insurance
helpdesk:

Paramount Health Services (TPA) Pvt. Ltd.

Contact
Name Email ID Direct Contact No.
Point
Mr. Yogesh thermax.mediclaim@paramou
First Level 7498886311
Chavan nttpa.com

Marsh India Insurance Brokers Pvt. Ltd.

Direct Contact No.
Contact Point Name Email ID

Ms. Megha 9607921135

First Level megha.singh@marsh.com
Singh

Mr.
Escalation dineshkumar.zende@marsh.com 9860007106
Dineshkumar
Level
Zende

In case you are sending the documents in a docket, please send it by REGD AD or arrange to
take acknowledgement on the photocopies of the documents, if submitting in person. You can
send the documents at the following address –

Marsh India Insurance Brokers Pvt. Ltd.

Office Address: 2nd Floor, GE Plaza, Airport Road, Yerwada, Pune – 411 006 Landline
number : +91 20 67090600

Points to remember –
1. Reimbursement Claims must be filed within 30 days from date of Discharge from
hospital.
Policy No : HR # D-05
Page 3 of 5
Issue Date : 1st July 2019
 Group Mediclaim Insurance Policy Policy Main Section : Employee Benefits

2. Similarly pre- hospitalization expenses (for 30 immediate days before admission

date) and post-hospitalization expenses (for 60 immediate days after discharge date)
claims must be submitted within 30 & 60 days of the admission & discharge dates
respectively.
3. Claim reimbursement will be strictly by Electronic Fund Transfer (EFT) mode, as per
the RBI and Insurance Regulatory Guidelines; hence employees would be required
to submit their bank details in the form of “cancelled cheque “at the time of claim
submission.
4. Intimation of claim settlement would be sent to the employees email address as
mentioned on the claim form, giving details of claim settled and reference of EFT.

This is to ensure accuracy of details provided by you and thereby ensuring quick transfer of
money after claim is approved for reimbursement.

Certain Ceilings Under The Policy

a) Room Rent
Rs 3,000/- per day for normal care and Rs. 6,000/- per day for ICU/CCU. Any
excess opted for by the employee/beneficiary would be borne by the employee at
the time of discharge. Thus, in a Cashless claim, the Insurance company will settle
the bill with room rent restricted to Rs 3,000/- per day and the rest of the amount, if
any, will be recovered by the Hospital in cash from the employee/beneficiary on
discharge. In a reimbursement claim, it will be settled up to the ceiling limit only.

b) Capping of Hospitalization Expenses of those listed below

Category Proposed Cap This includes the total
Cataract surgery (per Rs.25,000/- expenses for the surgery,
eye) room charges, and
Maternity – Normal Rs.45,000/- * medicines etc., i.e.,
delivery total admissible
Maternity – Caesarean Rs.45,000/- * amount
Hernia surgery Rs.45,000/-

*In case there are pre & post-natal complications requiring hospitalization, these
expenses would be restricted to Rs.10,000/- within limit applicable for maternity.

c) Share in Parents Hospitalization Claims for parents will have a 25% co-payment
subject to the balance Sum Insured for that family. This means that Paramount will
pay 75% of the total admissible hospital bill in case of all parental claims & the rest
has to be borne by the employee for that hospitalization. Similar to the method
adopted above, for Cashless claims, the employee/beneficiary will have to settle
25% of the total admissible bill, plus what is not admissible directly with the hospital,
at the time of discharge, and only the balance will be borne by the insurance
company. In reimbursement claims for Parents, 25% of the admissible amount will
be deducted from the total claim and the balance paid to the employee.

Policy No : HR # D-05
Page 4 of 5
Issue Date : 1st July 2019
 Group Mediclaim Insurance Policy Policy Main Section : Employee Benefits

d) However When the capping for the 2 procedures mentioned above viz., Cataract &,
Hernia is applied there will be no further 25% co-payment by the employee for these
hospitalizations.

(To clarify... for example, for Cataract we have agreed to a 'cap' of Rs 25,000/- as
was proposed then. For a Parent since employee shared 25% of expense, the claim
was settled for Rs 15,000/-. Now this will not be done and the claim will be settled for
Rs. 25,000/- only. In case the final hospital bill for parental claim exceeds the
balance sum insured then parental capping of 25% will not be applicable.

(To clarify ..... if the admissible hospital bill exceeds Rs 2 lakhs (i.e., the sum insured
per person) then Rs 2 lakhs will be paid, without deducting 25% co-payment by the
employee. Similarly if the balance sum insured (after a previous claim) is say Rs 0.80
lakh and the admissible claim is Rs 0.90 lakhs then the claim will be settled for Rs
0.80 lakh without applying a further co-payment of 25% )

Effective Date

st
The above Policy will come into effect from 1 July 2019 and would supersede all the earlier
policies and communication in this regard.

Portability Guidelines:

Mediclaim insurance portability benefit is available after 4 years of continuous service (before
retirement / separation) as per IRDA (Insurance Regulatory & Development Authority)
guidelines. You may contact your HR associate 45 days ahead of retirement / separation to
avail Mediclaim insurance continuity benefit.

Policy No : HR # D-05
Page 5 of 5
Issue Date : 1st July 2019