The document outlines the group medical insurance policy for Presidency University employees, including details such as the insurer, sum insured amounts, covered hospitalization expenses and exclusions from coverage. Standard coverage includes room rent, doctors' fees, surgeries and more, while exclusions apply to cosmetic procedures, dental treatment, and conditions due to alcohol or drug use. The claims process and requirements are also described.

1. Policy Presentation For
M/s . Presidency University

2. This Benefits Manual will serve as a guide to the benefits provided by
M/s.Presidency University. The information contained herein is only a summary of the terms and
conditions agreed with the insurer. If there is a conflict in interpretation, then the terms and conditions
of the policy will prevail.

3. GROUP MEDICLAIM/ GROUP HEALTH INSURANCE
The Group Mediclaim Program provides adequate, pre-defined insurance coverage to
employees & their dependents for expenses related to hospitalization due to illness,
disease or injury.

4. Policy Parameters GMC
Insurer
TPA
Insurance Broker
The New India Assurance Co. Ltd
Medi Assist Insurance TPA (P) Ltd.
Basket Option Insurance Brokers Pvt Ltd.
Policy Period From 31/01/2022 to 01/02/2023
Policy Number Yet to generate
Sum Insured As per allotted
Family Definition Self+Spouse+2kids
SALIENT FEATURES (GMC)

5. SALIENT FEATURES (GMC)
www.boib.in
STANDARD HOSPITALIZATION: 24 HOURS
REIMBURSEMENT OF EXPENSES RELATED TO
• Room and boarding
• Doctors fees
• Intensive Care Unit
• Nursing expenses
• Surgical fees, operating
theatre, anesthesia and
oxygen and their
administration
• Drugs and medicines
consumed on the premises
• Physical therapy
Hospital or nursing home means any institution in India established for indoor care and treatment of sickness and injuries
and which has been registered either as a hospital or nursing home with the local authorities and is under the supervision
of a registered and qualified medical practitioner, or complies with minimum criteria, as follows:
1. Has a minimum of 10 beds if located in towns having a population of less than 10 Lacks (Class C towns) or a minimum
of 15 in-patient beds in other towns
2. Has a fully equipped operation theatre
3. Has a fully qualified doctor in charge and nursing staff around the clock
4. Maintains a daily medical record for each of its patients.
• Hospital miscellaneous services
(such as laboratory, x-ray,
diagnostic tests)
• Dressing, ordinary splints and
plaster casts
• Costs of prosthetic devices if
implanted during a surgical
procedure
• Radiotherapy and chemotherapy
• Organ transplantation charges

6. ROOM RENT
ROOM RENT: Restricted to 2% OF S.I FOR NORMAL AND 4% OF S.I FOR ICU If insured occupies room / ICU
with room rent limit other than eligibility as per insurance policy , then all charges as per eligible room rent /
ICU . Treatment in our network hospitals only, However in the case of Medical Emergencies & Accidents,
treatment can be taken in other Hospitals. In all cases immediate intimation shall be given to our Call Center
within 24 hours of Hospitalization.
• Pre Existing Disease Are Covered From Day One.
• 1st Year, 2nd Year & 3rd Year Waiting Periods Waived Off
• 30 Days Waiting Period waived Off.
Note-If the Insured Member is admitted in a room where the room rent incurred is higher than the room rent limit specified
above, Expenses in the proportion of ‘the room rent actually incurred-room rent limit’ /‘room rent actually incurred’.
This shall be applicable to the total Medical Expenses (including surcharge or taxes thereon) incurred during the stay in the
Hospital Room.

7. SALIENT FEATURES (GMC)
OTHER TERMS-GMC
Coverage
Road ambulance Upto Rs.2000 Per hospitalization
Family transportation Upto Rs.5000
Pre and post hospitalization 30/60 days
Day care procedures Up to sum insured
Domicilary Treatment Upto sum insured
Organ donor Upto sum insured
Maternity No waiting period
a. Normal Rs. 50,000
b. Cesearian Rs. 50,000
c. New born cover No waiting period;
upto sum insured
Corporate Buffer 5L For critical illness
Inpatient consultation for Ayurveda,
Homeopathy, Siddha, Unani
Up to 25% of the sum insured in Gov / Gov rec hospitals
Lasik surgery covered up to +/-7.5,
Oral chemotherapy covered
internal &external, congenital internal
covered, external covered under life threatening situation
Co-pay - No copay

8. GENERAL EXCLUSIONS
• Following charges levied by hospitals will not be payable under the policy:- Admission charge / Surcharge / Service
charges / Miscellaneous charges / Registration fee / Admission Fee /Other Non- medical Charges.
• No Cosmetic procedures are covered under the policy.
• No dental procedures are covered, except if it is due to an accident.
• Hospitalization, if found to be due to the influence of Alcohol, or any intoxicating drink, drugs etc.. Claim will not be
entertained.
• Treatment for HIV / AIDS not covered under the policy.
• Treatment for Psychiatric and Mental disorders are not covered under the policy.
• Suicide and Intentional self inflicted injuries are not covered under the policy.
• Stem Cell, Robotic Surgery, Infertility and Related Ailments Including Male Sterility, Treatment on Trial/Experimental
Basis are Not Covered
• Expenses On Fitting Of External Prothesis, Holter Monitoring/Sleep Study, Any Device/Instrument/ Machine
Contributing/ Replacing The Function Of An External Organ Are Outside The Scope Of The Policy
• However any Life Supporting Device, Which Needs To Be Placed Inside The Body And Is As Advised By a Medical
Practitioner And is Mandatorily Required For Doing The Job/Role of An Organ is Included In The Policy.

9. PROCESS GUIDE

10. CASHLESS HOSPITALIZATION
• Cashless hospitalization 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.
• If the hospital is in network list of the Insurer, request to fill the per-auth request with the help of
treating doctor and inform hospital to send the same to Medi assist for further process of cashless
request.

11. EMERGENCY HOSPITALIZATION
STEP 1
Get
Admitted
STEP 2
Inform Insurance
Desk
STEP 3
Get
Discharge
In cases of emergency,
the member should get
admitted in the nearest
network hospital by
showing their ID card
Relatives of admitted
member should call
BOIB CRM within 24
hours of hospitalization
BASKETOPTION will
assist to get the
preauthorization letter
In case of denial
member would be
informed directly with
reasons
After the hospitalization
has been pre-authorized
the employee is not
required to pay the
hospitalization bill in case
of a network hospital. The
bill will be sent directly
to, and settled by the TPA.
The patient have to pay
only for the non medical
expenses.

12. Claim Documents
• The Insured shall be required to furnish the following for or in support of a claim:
• (i) Duly completed claim form signed by the insured
• (ii) Original bills, receipts and discharge certificate/card from the Hospital
• (iii) Original bills from Chemists supported by proper prescription
• (iv) Original investigation test reports and payment receipts (v) Indoor case papers
• (vi) Medical Practitioner's referral letter advising Hospitalization in non-Accident cases
• (vii) Account details for Electronic Fund Transfer (EFT mandate form and cancelled cheque)
• (viii) Any other document as required by the Company or the TPA to investigate the Claim or the
Company's obligation to make payment for it

13. REIMBURSEMENT CLAIM SUBMISSION
REIMBURSEMENT CLAIM SUBMISSION
• Pre-Hospitalization expenses and Hospitalization expense are to be submitted with in 30 days of the
discharge and all Post-Hospitalization expenses claims are to be submitted on completion of post
hospitalization period or completion of treatment which ever is earlier.
• Document along with completed claim form should be submitted to the address mentioned below within 25
days from the date of discharge:
Claim Express
BASKET OPTION INSURANCE BROKERS PVT. LTD.
#2307, Ground Floor, 12th Main Road, 3rd Block East
JAYANAGAR,Bangalore-560011
Ms.Vijaylakshmi
Asst.Manager Claims
claims@boib.in
Mobile: +91 89714 33277 / +91 96631 68702
LL : +91 80 26951600

14. Please Visit Us: www.boib.in
#2307, Ground Floor, 12th Main Road, 3rd Block East ,
Jayanagar , Bangalore-560 011