- The document provides an overview of a health insurance program for TiE members that aims to provide comprehensive and affordable coverage through a single window approach. - Key details include the roles of the insurer, TPA, and service provider Medimanage in administering the plan. The document also outlines the various plan benefits, terms, enrollment process, and policy snapshots. - Highlights are a floater sum insured from Rs. 2-10 lakhs, coverage for pre-existing diseases, and cashless claims through an extensive hospital network.

2. • Health Insurance in India – An Overview
• Program Objectives
• Vendors
• Medimanage’s Role for TiE
• Policy Snapshot
• Enrolment Snapshot
• Retail vs Group
• Cover / Terms / Limits / Waiting Period
• Expectations
• Medimanage Profile

3. Health Insurance in India
Health Insurance in West Health Insurance in India
Evolved & Matured, High
Penetration
Still under development,
Penetration is Low (0.8%)
In US, products change for each
state, also, complexity in product
structure
Product Structure is simpler
Efficient delivery systems thru
evolved processes
Delivery systems are inefficient,
Administration is a struggle with
Insurers & TPAs
Desirable Loss ratio is around 65- Desirable Loss ratio is around 8085%, No Underwriting Profits
70%, Underwriting Profits are
since last 20 years
MUST
Broker’s role is More Advisory &
Less Administrative
Broker’s Role is Less Advisory &
More Administrative due to
challenges in the overall delivery
system

4. Program Objective
• To provide comprehensive, flexible and affordable health
insurance covers for TiE members.
• Bring technology into the domain of health insurance
management empowering the customer to make
informed choices and to enable efficient delivery of health
insurance administration services.
• Provide a “single window” approach such that all the
operations are seamlessly & empathetically taken care of.

5. Vendors
• Insurer
– Bajaj Allianz General Insurance
– Risk carrier
• TPA
–
–
–
–
Internal TPA (HAT)
Hospital network owner
Cashless provider
Claims settler
• Service Provider
– Medimanage Insurance Broking
– Your contact for all health insurance related needs.
– Facilitator of enrolments, cashless authorizations, re-imbursement
claims settlements, query management and the entire gamut of
health insurance administration for the TiE Health Plan.

6. Medimanage’s Role
• Plan Administration
– Enrollment of Members & their dependents
– Member Communication management & Query Resolution
– Complete Policy Administration for coordination of Policy &
Endorsements, Additions & Premium Accounting
– Claims coordination with TPAs & Insurers and facilitating timely
payment of reimbursement claims
– Cashless Coordination Service
– Tracking of Premium & Claims
– Escalation management with 3-Tier Escalation matrix within
Medimanage to ensure minimal involvement of TiE

7. Policy Snapshots - Benefits
Benefits
Details
Cover For
E, S, 2C, 2P
Sum Insured (Floater)
2L, 3 L, 5 L, 7 L &10 L
Minimum Initial Enrolment
1,000 families
PED Cover
From Day 1*
Maternity Cover
Covered after 3 mths – 30 K
Room Rent Limit
1% of SI
ICU Rent Limit
2% of SI
Waiting Period
For persons above 55 years
Limits On Procedures
6 Ailments
Co-payment
Parents- 15% of admissible claim
Sum Insure Upgrade
Not allowed
New Member Addition
Pro-rata basis
E-Self | S-Spouse | 2C- Two Children | 2P-Two Parents | * Conditions Apply | Refer Detailed Terms

8. Policy Snapshots - Benefits
Benefits
Details
Deletion
None
Cashless
Available
80D Benefit
Available
Enrollment
Now or Never basis
E-Self | S-Spouse | 2C- Two Children | 2P-Two Parents | * Conditions Apply | Refer Detailed Terms

9. Enrolment Snapshot
• All enrolments through Medimanage portal – Mpower
• TiE member data embedded in the system
• System generated mails to all inviting to enroll
• Each member gets a “My Page”
• Member logs in, selects product and adds family
• Member pays premium on-line to insurer
• Member & family covered after enrolment period of 30 days
• A master policy for all members
• TPA cards uploaded in system
• 80D benefit to each payee

10. Retail Vs Group - Bajaj
Retail
Group
Parents cannot part of E+S+2C Plan
Parents can be part of E+S+2C plan
Pre-existing cover after 4 yrs
Pre-existing cover from day 1*
30 day waiting applicable
30 day waiting waived
4 yr waiting applicable
4 yr waiting waived*
Pre policy medical required – 45 yrs
No pre-policy medical
Congenital Internal Ailments not covered
Congenital Internal Ailments covered
Co-pay 10% - Non network hosp
Co-pay 20% - 55 yrs and above
15% for parents
Maternity not covered
Maternity covered
New born not covered midterm
Midterm cover of new born allowed
Max cover 5 Lakhs upto 55 yrs
Max cover 10 Lakhs
Premium 2 L – 7378 (E+S+2C)
Premium 2 L - 8251
Premium 3 L – 9955 (E+S+2C)
Premium 3 L - 9736
With 12% more premium for 2 L Maternity & Pre-existing ailments covered.
Premium for 3 L is 2% lower than retail premium

11. The Cover
Sum Insured
2,00,000
3,00,000
5,00,000
7,00,000
10,00,000
E
A1
A2
A3
A4
A5
PLANS
E+S+2C
B1
B2
B3
B4
B5
E+S+2C+2P
C1
C2
C3
C4
C5
E+2P
D1
D2
D3
D4
D5
E-Self | S-Spouse | 2C- Two Children | 2P-Two Parents |
•Each person shall select one of the options from A1 to D5 and from sum
insured 2 Lakhs to 10 Lakhs.
•The premium is paid for by the individual vide credit/debit card.
•E+2P is permitted for unmarried persons only. Married persons must cover
parents under E+S+2C+2P plan. Deviation will result in claim rejection.
•Sum insured once selected cannot be changed.

12. Terms
•
This policy is available only for TiE members.
•
All existing members will qualify for the enrolment & will get 60 days to enrol
self, employees & family members. If a member fails to enrol during this
period the waiting period mentioned in Slide 19 shall be for a period of 2
years and maternity shall be covered after 9 months.
•
Sum insured is on a floater basis.
•
Self, Spouse, first 2 children and parents can enrol.
•
Pre-existing ailments & Congenital internal ailments are covered.
•
There will be no waiting periods except for persons who are 55 years and
above of age at the time of policy commencement.
•
There are limits on 6 procedure – Slide 18.
•
Day care procedures are covered.
•
Room rent will be 1% of sum insured limited to INR 5 k / day.
•
ICU rent will be 2% of sum insured limited to INR 10 k / day.

13. Terms
•
All charges (Doctor fees, Surgeon fees etc) linked to class of occupancy.
•
Maternity is covered after 3 months from enrolment for INR 30 K (subject to
point 2 in Slide 1)
•
Baby cover from day 1 in the main policy.
•
Pre & Post hospitalization covered (30 days & 60 days).
•
Cashless facility available
•
Co-pay of 15% on all admissible parent claims. No co-pay for Self, spouse and kids.
•
2 children upto 25 years can be covered.
•
The max age at which a person (Primary, Secondary or Parent) can enter
this plan is upto 75 years. Persons above 75 years cannot enter this plan.
Persons (Primary, Secondary or Parents) who are 55 years and above will
have a 1 year waiting for the following ailments listed below. – Slide 19
•
Cover will cease when a person reaches 85 years of age.

14. Terms
•
A member can enter this policy only after 6 months from being inducted as a
member of TiE. Proof of membership to be provided at the time of enrolment.
•
In case Self & Spouse are both members of TiE they will be given a single
cover.
•
New member enrolment drive will be opened from the 07th of every month
and closed on the 28th. The cover for these members will commence from
the 1st of the next month provided that day not a holiday.
•
Failure to enroll within timeframe shall attract increased waiting periods as
mentioned in Slide 12 point 2.
•
Parents will be covered on NOW Or Never basis. This means any member
who has not covered parents in this plan during the enrolment period for that
member will not be allowed to cover them at any point in future.

15. Terms
•
Spouse & Kids of married members will be covered on NOW Or Never basis.
This means any married member who has not covered spouse & kids (if
there are kids) in this plan during the enrolment period for that member will
not be allowed to cover them at any point in future.
•
A married member, who has covered himself/herself under the Self+S+2C or
Self+S+2C+2P plan, will be allowed to add the new born in course of the
policy period at no extra cost. This enrolment must happen in 30 days from
date of event.
•
An unmarried member who is covered under the Self or Self+2P plan can, on
marriage, cover spouse in course of the policy period by paying the
differential premium. This enrolment has to be done within 30 days from the
date of event.
•
Members who exit this plan at any point will not be allowed to enter the plan
again.

16. Terms
•
There will be no deletion.
•
Cashless hospitalization is available in all the network hospitals.
•
Claims to be submitted within 30 days from the date of discharge.
•
Claim intimation time of 7 Days or before discharge whichever is earlier.
Claims will be rejected on account of delay in submission.
•
Domiciliary care is excluded & standard exclusions apply.
•
Claims will be rejected if the age mentioned at the time of a claim is different
that the age calculated for the same period based on the age provided at the
time of enrolment and this difference is greater than 1 year.
•
The premium paid during monthly enrolments shall be for a period of 12
months. The cover shall also be for a period of 12 months.

17. Terms
•
This program will commence only with a minimum of 1000 primary members.
This means the sum total of all the primary members (Self) excluding the
family members should be 1,000.
•
80D benefit under the income tax act of 1961 can be claimed through the
certificate of insurance issued by the insurer to each payee.
•
Each member shall confirm participation by filling the enrolment form.
•
Once the critical mass is reached, Medimanage will send a payment gateway
link through which the member should make the payment.
• Post your queries to tiehealth@medimanage.com
• Point of contact – Sahana Shetty
• Tel - +912230770101

18. Procedure Limits
•
Limits on 6 procedures per life per occurrence.
•
Cataract
: INR 30,000 per eye
•
Hernia
: INR 45,000
•
Hysterectomy
: INR 45,000
•
Joint replacement : INR 1,75,000 per joint per year.
•
TURP for BPH
•
Coronary angiogram: INR 25,000
•
Co pay is not applicable for the above procedures.
: INR 42,000

19. 1 Yr Waiting Period

20. Premium
Sum Insured
2,00,000
3,00,000
5,00,000
7,00,000
10,00,000
BAJAJ (excluding Taxes )
E
E+S+2C E+S+2C+2P
3,173
8,251
18,151
3,744
9,736
21,419
4,718
12,267
26,988
5,898
15,333
33,734
7,254
18,861
41,493
E-Self | S-Spouse | 2C- Two Children | 2P-Two Parents |
E+2P
10,154
11,982
15,098
18,872
23,213

21. Expectations
•
Policy will be issued in 15 working days from the date of completion of
enrolment of all persons at inception.
•
Endorsements to be issued in 15 working days from the date of completion
of enrolment for the previous month.
•
TPA cards will be uploaded in 10 days from the date of policy / endo
issuance.
•
Reimbursement claims to be settled in 20 working days from the date of
submitting all valid documents.

22. Medimanage Profile
• Only dedicated Health Insurance Broker in India
• Offices at Mumbai, Bangalore, Chennai, Delhi & Pune
• Team strength of 117 members (all key members are either with
Insurer and/or TPA background)
• Promoted by Engineers, Strong on Systems & Processes
• Niche player as HR BPO for Health Insurance Administration
• Facilitate more than 10,000 cashless admissions
• Handle more than 40,000 reimbursement claims
• Managed more than 150,000 employee queries over Phone, Email &
Online Platform.

23. Few of our delighted clients

24. Disclaimer
TiE India is only a facilitator of this program
and is not liable for any issues arising out of
this contract. Such issues if any have to be
directly settled by the concerned parties with
the agencies involved.