Advance policy for medical

1. Mediclaim Insurance
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2. Slide Title
Family Definition
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• Self
• Spouse
• Children (unemployed sons up to 25 years / unmarried
daughters)
• Parents- If they are dependents

3. Slide Title
Salient Features of the Policy
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• This Mediclaim Policy renewed with Star Health Insurance will be valid for a period for 1
year (from 22/04/2021 to 28/02/2022).
• The policy covers all employees, family (spouse & children) and dependent parents posted
at out-locations other than Belpahar and Karuppur operations.
• Children are covered up to the age of 25 and no insurance coverage is given to other
family members like grandmother, grandfather, brother, sister etc.
• All pre-existing diseases of employees, family members and parents is covered in the
policy and no discrimination will be made in between pre-existing and post-existing
deceases while settling the bills.
• The policy covers both 1. Out-Patient Department (OPD) 2. In Patient Department (IPD)
expenses.

4. Slide Title
OPD Treatment
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• An insurance coverage of Rs.6000/- per person is given in the policy towards OPD along with
family floater. For e.g:- in a family if there are 5 persons , the total coverage would be
Rs.30000/-.(Rs.6000x5) Per family per year.
• The policy has a corporate buffer of Rs.15 lakhs. In case if family sum insured as mentioned
above is exhausted, then corporate buffer shall trigger. The amount will be paid out of
corporate buffer subject to availability of the corporate buffer balance. In case if any
employee utilize corporate buffer , then 20% copayment clause will be applied.
• OPD treatment can be taken in any network hospitals of Star Health Insurance, clinics or
private hospitals. The treatment includes consultation, investigations and medicines advised
& Prescribed by doctors.
• Some treatments such as cosmetic teeth treatment, dental crowns, braces, frames & glasses
in eye treatment, any kind of investigations, diagnostic tests, treatment without doctor
prescriptions & symptoms, cosmetic medicines, contraceptives, birth control methods &
equipment, annual health check-up, alternate treatments other than allopathic treatments,
general tonic, infertility treatment, vaccination & immunization are not covered in the policy.

5. Slide Title
IPD (In Patient Department)Treatment
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1. Admission in any of the Network Hospital.
2. Treatment upto Rs.2.5 Lakhs per family (Self, spouse, eligible children & Parents).
3. Beyond Rs.2.5 Lakhs, corporate buffer amount will be triggered, and 20% co-payment
clause will be applied.
4. Employee must pay 20% of the bill over and above of Rs. 2.5 Lakh at the time of
discharge.
5. Balance 80% will be paid by Star Health Insurance after proper approval from our end.
6. In cashless transaction, Star Health Insurance will clear discharge formalities within 4
hours.
7. Cabin : AC/Non-AC – E3 & E4 – Rs. 8000/- per day (max)
Twin Sharing: AC/Non-AC – E1 & E2 – Rs. 5000/- per day (max)
General Ward – Workmen – Rs. 3000/- per day (max). All room rent condition will be
subject to whichever is less. Parents will enjoy same room rent condition.
8. For parents, limit is up to Rs. 2.5 Lakh for parents on total family floater basis only.
9. Beyond Rs. 2.5 Lakh expense in case of parents , employee must bear the entire amount
at the time of discharge.

6. Slide Title
IPD (In Patient Department)Treatment
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Maternity Hospitalization (Cashless) • Normal delivery - Rs.35,000/ (max)
• Cesarean section - Rs.60,000/ (max)
• No corporate Buffer will trigger in these
cases; employee has to bear extra cost

7. Slide Title
Mediclaim Scheme- Turn Around Time (TAT)
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TAT Details
Description TAT
OPD claim documents
Within 14 working days of submission of
documents
Hospitalization claim documents
Within 14 working days of submission
of documents
Cashless approval (24X7)
4 hrs.

8. Slide Title
Difference between the Previous and New Policy
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Difference
Previous Policy (ICICI Lombard) New Policy (Star Health Insurance)
1 NO CHANGES AT ALL

9. Slide Title
Parent Coverage in details
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Parent Coverage
IPD OPD
1 Insurance coverage for parent is Rs.
2,50,000/- per year, in case the amount
exceeds Rs. 250000/- in a year, the
excess amount is to be paid by the
employee directly to the hospital.
No difference in the treatment or
reimbursement of expenses of employees and
parent in case of OPD, i.e. 6000 X no. of family
member including parents.
2 Room rent category in case of
hospitalization would be as per the
employees' eligibility.
NA
3 Corporate buffer can not be used to get
extra amount over and above Rs.
250000/-.
On triggering corporate buffer 20% co-payment
clause will be applied with necessary approval
and subject to the availability of the corporate
buffer.
4 Inclusion of parent under this scheme is optional, those want to opt this scheme for
parent, 50% of the premium (calculated for parent only) to be borne by the individual
employee for officer category, in case of workmen category 30% of the premium to be
borne by the employee for this scheme. The premium will be deducted in the month of
April & May 2021 from the salary, if the premium amount is more than 10,000/- (ten
thousand only) then this will be deducted in two instalments.

10. Slide Title
Check and Balance process including approval
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• Every month Insurance Company will share the claim MIS to monitor the expenditure
trend and better control.
• Insurance Company will send alert on certain claim which are fictitious in nature or trend
seems to be not appropriate.
• Claim not having appropriate bill or manual bill or without proper credentials of a bill
will be hold for verification and necessary action and the amount will not be paid. Bills
need to be printed having a bill number, batch number, GST no and other details as
deemed.
• Prescription without proper diagnosis will not be entertained. For, example prescription
only having medication without any details case history or diagnosis will not be
entertained.
• Frequently changing the doctors for the same disease may attract disallowance.
• In case of hospitalization only eligible room category will be allocated under any
circumstances . In case , individual opts for room with higher rent than eligibility , the
concerned individual must pay the proportionate billing difference amount to the
hospital directly at the time of discharge.

11. Slide Title
DO’S & DON’T’S
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DO’S & DON’T’S
DO’S DON’T’S
1 Claim your OPD & IPD treatment
expenditure in the prescribed claim
form of the Star Health Insurance.
Do not claim any expenditure which is not
pertaining to the treatment.
2 Enclose all the original bills, reports,
copy of the prescription and all other
relevant documents.
Do not attached copy of bill or duplicate bill.
3 Provide Bank details and ID details one
time at the time of reimbursement of
claim (cancel cheque should be
attached)
Do not attach the bank details of your
dependent.
4 Treatment at the network hospital of
the Star Health Insurance and procure
medicine from the recognized
pharmacy only.
Do not purchase medicine from the local
pharmacy where authentic bills are not
provided.

12. Slide Title
DO’S & DON’T’S
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DO’S & DON’T’S
DO’S DON’T’S
5 Check the Name and other details
appearing in the E- Card, if there any
correction needed or addition of
member, mail us the wrong entry along
with the corrected one, with a copy of
the said document.
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6 Any change in the family member must
be notified immediately.
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7 Claim your expenditure in periodic term
i.e., monthly or quarterly.
Do not claim your expenditure too frequently.
8 In case of hospitalization avail the room
category as per your eligibility.
Do not avail higher category room rent than
your eligibility.

13. Slide Title
DO’S & DON’T’S
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DO’S & DON’T’S
DO’S DON’T’S
9 Do all the investigation as per the
prescription only
Do not do the pathological test or any other test
on your own.
10 Get advice from your Doctors only. Do not change your doctor frequently for the
same disease.
11 Go through the exclusion and details of
the policy information shared time to
time.
Do not claim anything which is not covered in
this policy.

14. Slide Title
Exclusions Under Mediclaim Policy
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1. Injury or Disease directly or indirectly caused by or arising from or attributable to War,
Invasion, Act of Foreign Enemy, Warlike operation (whether war be declared or not).
2. Circumcision unless necessary for treatment of a disease not excluded hereunder or as may
be necessitated due to an accident, vaccination or inoculation or change of life or cosmetic
or aesthetic treatment of any description, plastic surgery other than as may be
necessitated due to an accident or as a part of any illness.
3. Cost of spectacles and contact lenses, hearing aids.
4. Cosmetic Dental treatment or surgery of any kind
5. Expenses on vitamins and tonics unless forming part of treatment for injury or disease as
certified by the attending Physician.
6. Expenses in respect of harvesting & storage of stem cells when carried out as a preventive
measures against possible future illnesses
7. Medical expenses for ectopic pregnancy are not covered under maternity benefit.

15. Slide Title
Exclusions Under Mediclaim Policy
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8. Convalescence, general debility ‘Run-down' condition or test cure, congenital external disease or defects
or anomalies, sterility, venereal disease, intentional self injury and use of intoxicating drugs/alcohol.
9. All expenses arising out of any condition directly or indirectly caused to or associated with Human T-Cell
Lymphotropic Virus type III (IITLB-III) or Lymphadenopathy Associated Virus (LAV) or the Mutants
Derivative or Variations Deficiency Syndrome or any Syndrome or condition of a similar kind commonly
referred to as AIDS.
10. Some of the treatments such as cosmetic treatment of teeth, dental crowns, braces, frames & glasses in
cases involving eye treatment, any kind of investigations, diagnostic tests, treatment without doctor
prescriptions & symptomatic treatment, cosmetic medicines, contraceptives, birth control
methodologies & equipment, annual health check-up, alternate treatments other than allopathic
treatments, general tonic, infertility related treatment, vaccination and immunization are not covered in
the policy.
11. Charges incurred at Hospital or Nursing Home primarily for diagnostic, X-ray or laboratory examinations
not consistent with or incidental to the diagnosis and treatment of the positive existence or presence of
any ailment, sickness or injury, for which confinement is required at a Hospital/Nursing Home.
12. Voluntary medical termination of pregnancy during first 12 weeks from the date of conception.
12. Naturopathy treatment, Homeopathy & Ayurvedic treatment.
13. Weight management services and treatment related to weight program's including treatment of obesity
will not be payable.

16. Slide Title
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Thank You