HIS User Manual

CMC LIMITED

HIS USER MANUAL

Version 2.0

For CMC Internal use only Confidential

DISCLAIMER:

Any or all provisions of the policy/benefits given in the manual may be modified or withdrawn purely at the

discretion of the MD & CEO without assigning any reason.

DOCUMENT RELEASE NOTICE

HIS User Guide is released for use in CMC with effect from 01-June-2012.

This document is subject to CMC Document Control Procedure.

Soft copy of the latest version of this document is available on SEEK@CMC in Ultimatix.

Notice

This is a controlled document. Unauthorized access, copying, replication or usages for a

purpose other than for which it is intended are prohibited.

REVISION HISTORY

Revision

No.

Guidelines

Effective

Date

Revision Description Rationale for

change

Change Type

(Add/

Modify/Delete)

2.0 01-June-12 Flowcharts, Snapshots, Policy

Summary

Clear and updated

information Modify

Preface

Purpose

The purpose of this manual is to make the user familiar with the Health Insurance Benefits provided to employees by CMC Ltd. through TCS. It describes the detailed information about CMC policy with respect to the Health Insurance Scheme (HIS) It guides the user to follow step-by-step process in accordance with the relevant policy and procedures.

Organization

This manual has been organized in five sections:

1. CMC policy guidelines

2. Procedures

3. Web portal Screenshots

4. HIS helpdesk, SLA and escalation matrix

5. Entities Involved

6. FAQs

Acronyms

Sr. No. Acronyms Full Form

1 FY Financial Year

2 IA International Assignment

3 HIS Health Insurance Scheme

4 TPA Third Party Administrator

5 OMP Overseas Medi claim Policy

6 NIACO New India Assurance Company

7 DOB Date Of Birth

8 MA Medi Assist

Contents

CMC HIS Policy ............................................................................................................................................................................................ 7

1. Introduction .............................................................................................................................................................................. 7

2. Eligibility..................................................................................................................................................................................... 7

3. Coverage and Entitlement:................................................................................................................................................... 7

4. Basic Coverage: ........................................................................................................................................................................ 8

5. Domiciliary: ............................................................................................................................................................................... 8

6. Expenses covered under Domiciliary: ............................................................................................................................. 9

7. Hospitalization: ........................................................................................................................................................................ 9

8. Higher Hospitalization Coverage: ..................................................................................................................................... 9

9. Cumulative Bonus: .................................................................................................................................................................. 9

10. Add on benefits under higher hospitalization: ...................................................................................................... 9

11. Sum Insured under HIS ................................................................................................................................................ 10

12. Premium ............................................................................................................................................................................ 11

13. General Provisions with regards to Premium: .................................................................................................... 12

14. Provisions regarding Dependents: .......................................................................................................................... 12

15. General Provisions HIS .............................................................................................................................................. 12

a. Continuous Period of Medical care:............................................................................................................................................... 12

b. Treatment outside India: .................................................................................................................................................................... 13

16. Exclusions:......................................................................................................................................................................... 13

17. Process Flow -Claim Settlement Procedures ....................................................................................................... 13

a. Domiciliary Claim Process ................................................................................................................................................................. 13

b. Hospitalization Claim Process ......................................................................................................................................................... 14

c. Cashless Hospitalization ..................................................................................................................................................................... 14

18. Guide to Medi Assist Web Portal with Screenshots ........................................................................................... 15

a. Step I: Hospitalization Claim Registration: ................................................................................................................................ 16

b. Step II: Claim Submission: ................................................................................................................................................................. 19

19. Domiciliary Claim Submission: ................................................................................................................................. 23

20. View Claim Details: ........................................................................................................................................................ 26

21. Claim Tracking................................................................................................................................................................. 27

22. Claim History .................................................................................................................................................................... 27

23. Claim Escalation and HIS Helpdesk ......................................................................................................................... 28

24. Addition / Deletion of dependents: This process is facilitated in Ultimatix. ........................................... 29

25. Entities Involved and Roles ........................................................................................................................................ 34

26. FAQs ..................................................................................................................................................................................... 35

Annexure I........................................................................................................................................................................................... 37

Annexure II ......................................................................................................................................................................................... 38

Annexure III ....................................................................................................................................................................................... 38

Annexure IV Exclusions from HIS .............................................................................................................................................. 40

Summary of CMC HIS Policy

NOTE: This is just a summary of the CMC HIS policy. Please refer to HIS policy loaded on SEEK@CMC->Health Insurance Scheme. In case of any dispute, the HIS policy shall be final.

1. Introduction

CMC understands the importance of having a healthy workforce for building a healthy and productive workplace. For CMC, the health and wellbeing of all employees and their family is paramount. Hence, CMC wishes to provide them with easy access to best-in-class medical facilities through a Comprehensive Health Insurance Scheme.

A Health Insurance Scheme (HIS) is protection for an insured person against the costs of hospitalisationand medical care arising from a medical condition.

Furthermore, CMC is also committed to ensuring continued health and well being of employees and their family post retirement, hence, the benefits of the HIS scheme are also extended to retired employees.

The CMC HIS Policy gives the general guideline which any HIS Scheme offered to CMC employees must address. The specifics of the Health insurance cover (extent of cover, medical conditions covered, benefits provided, premium payment & employees contribution) are all subject to the prevailing scheme. Details of the same are available in the CMC HIS Policy.

2. Eligibility

3. Coverage and Entitlement:

As per CMC HIS, all eligible employees are covered under HIS benefits from the date of joining. Employee can

extend the coverage to his/her immediate family members such as spouse, children and dependent parents/

parents-in-laws. Premium for spouse and first two children will be borne by CMC. Premium for parents/parents-

in-law will be borne by employee. Coverage for family members (Spouse /Children /Dependent Parents/Parents

In Laws) is subject to certain conditions as follows:

Dependent Remark

Spouse Should be legally married to the employee

Children

Includes children from legal marriage

Includes Legally adopted children

Policy is applicable to: Policy is not applicable to:

- Full Time Employees of CMC Ltd. Including trainees /probationers. Those DC employees not covered with ESIC

(Till the time of their employment with CMC Ltd.)

Direct Contract employees

covered under ESIC

Retired Employees of CMC Ltd. provided there is no break in the

continuity of coverage after retirement.

Vendor Contract employees

No addition is permitted post retirement. Contract Consultant (Retainers)

Retired employee is not gainfully employed. Apprentices

Includes Children of the spouse from previous marriage

Should be unmarried. Married children or those who get married

subsequently cease to be eligible for coverage from the date of marriage

Parents/ Parents In

Law

Parents or parents in law can be covered. A combination each upto

maximum of two is also permitted i.e. 1parent and 1 parent in law can be

covered

Dependents need to be explicitly enrolled in the scheme and remain covered during employees tenure in

CMC till employee explicitly requests for deletion.

Other relatives like brothers, sisters of employee cannot be included as dependents under any situation.

For retired employees where the family is covered under HIS, dependents coverage can be continued only

for spouse after the death of retired employee.

HIS coverage is automatically renewed by NIACO wef 1st April in each financial year. It continues during

employees entire tenure in CMC and ends only when employee separates from CMC except in case of

retirement.

The HIS offers Insurance coverage as follows:

Basic Coverage Higher Hospitalization (if opted for)

Hospitalization Higher Hospitalization Cover

Domiciliary Cover

Planned Cashless Hospitalization

Emergency Cashless Hospitalization

Add on benefits

Umbrella Cover

Hospitalization Personal Accident Insurance

Domiciliary Hospitalization

Cumulative Bonus

4. Basic Coverage:

The basic cover limit is defined per insured person, hence, if the limit for treatment for an employee or his/her

insured family member remains unutilized, the same may not be used towards treatment of another insured

family member. Basic cover is utilized towards Domiciliary and Hospitalization expenses.

5. Domiciliary (applicable if opted for Higher Hospitalization Cover)

Domiciliary treatment benefits are applicable only when the insured person undergoes treatment at a dispensary

or in a hospital, as an outpatient. The limit defined for domiciliary treatment could be utilized towards any

treatment other than hospitalization (including Dental treatment). Domiciliary coverage is applicable to only

those who have opted for Higher Hospitalization Cover.

6. Expenses covered under Domiciliary:

Pharmacy cost, consulting fees of the doctor, investigatory tests etc.

In case of dental treatment, expenses for extraction, fillings, medicines, consultants fees, and x-rays are reimbursed only under Domiciliary.

Expenses incurred for undergoing Naturopathy are also reimbursed under domiciliary claims, provided a registered Allopathic, Homeopathic or an Ayurvedic practitioner administers it.

7. Hospitalization:

Hospitalization benefits are applicable only if the insured person is admitted to a hospital for a minimum of 24

hours. Employee may claim medical expenses incurred 30 days prior to admission to a hospital, during

Hospitalization and up to 30 days from the date of discharge from the hospital, in respect of the same medical

condition. Employee or insured person under HIS can avail the treatment in a listed Hospital without paying any

cash for the treatment.

Four types of Hospitalizations are possible:

Planned Cashless Hospitalization: The insured person seeks cashless hospitalization through planned admission (i.e. with prior intimation and approval).

Emergency Cashless Hospitalization: The insured person is admitted due to a medical emergency at a very short notice and requires urgent treatment (i.e. requests need to given highest priority and approvals need to be obtained immediately).

Hospitalization (Cashless facility not available): The insured person is free to avail of medical treatment from any other hospital of his/her choice, other than the empanelled hospitals (where cashless facility is available) and request for reimbursement of the expenses incurred.

Domiciliary Hospitalization: If the medical condition legitimately requires Hospitalization but the condition of the patient is so serious that he/she cannot be moved to the Hospital OR no accommodation is available in the Hospital, then treatment may be carried out at home provided the duration is for more than 3 days. Any claim under this head should always be accompanied by a certificate from the attending specialist or physician which certifies that the treatment given is tantamount to Hospitalization treatment (and not domiciliary treatment)

(Refer Annexure I - List of Ailments not covered under Domiciliary Hospitalization)

8. Higher Hospitalization Coverage (if opted for):

Higher hospitalization is an additional amount, which the employee may claim in case the hospitalization expenses exceed the limit specified by the basic cover.

The higher hospitalization limit is defined per family, hence, in case a part of the hospitalization entitlement is utilized by one insured family member, the balance may be utilized by the same/other insured family members.

9. Cumulative Bonus:

A provision for cumulative bonus i.e. 5% of Higher Hospitalization Cover is available, year on year, incase no one from the family files any HIS claim.(Domiciliary/ Hospitalization) which is added to employees total Hospitalization coverage in next financial year.

I.e. If a family doesnt claim under HIS during FY 08-09, the hospitalization cover under the higher scheme will increase by 5% (ie.5.25 lacs in the next year FY11-12).

This can increase to a maximum of Rs. 6.5 lacs if a similar scenario is repeated in subsequent years.

10. Add on benefits under higher hospitalization: Apart from domiciliary claims coverage, higher hospitalization cover provides following additional benefits (if opted for by employees):

Remark Umbrella Cover Personal Accident Insurance

Who can avail Employee and dependents covered under

Higher Hospitalization

Employees covered under Higher

Hospitalization. Coverage is extended to

the employees only and not to their

family members.

When is

available

After basic and higher hospitalization cover

is fully exhausted.

Only in the following event due to

accident: 1.

Death,

2. Permanent total disablement ,

3. Permanent partial disablement.

Cover limit Rs.200000/- per family per annum Rs. 18 lacs

Ailments

Covered

(Refer Annexure II for List of Ailments

considered under Umbrella Coverage)

(Refer Annexure III for List of

Indemnities)

Specific

Provision

This cover operates on first come first serve

basis as an overall cap of Rs.2 crores per

annum has been defined. No claim is

processed once overall cap is exhausted.

This is not applicable for Retired

Employees

11. Sum Insured under HIS

Basic cover:

Grade wise entitlement per insured person per annum

Grade Domiciliary/Dental Treatment* Hospitalization Expenses

NE2 to E5 Grade Rs. 5,000 Rs. 45,000

E6 &above Grade Rs. 11,000 Rs. 1,39,000

*If opted for Higher Hospitalization Cover.

Higher Hospitalization Cover:

Higher Hospitalization Entitlement per family per annum

Grade Hospitalization Expenses

NE2 to E5 Grade Rs. 5,00,000/-

E6 & above Grade Rs. 7,50,000/-

12. Premium

Basic cover:

Premium applicable:

Covered under CMC-HIS Total premium per year per insured

Employee, Spouse / First two children

2000/- (+Service Tax)

Remaining Children (other than first two children) 2000/- (+Service Tax)

Dependant Parents /Parents in laws 6000/- (+Service Tax)

Retired Employees/Spouse upto age of 65Yrs. 2000/- (+Service Tax)

Retired Employees/Spouse aged between 66-70 yrs. 3500/- (+Service Tax)

Retired Employees/Spouse/ above 70 yrs. 3500/-(+Service Tax)

Retired Employees Dependent Children (upto 2) 2000/- (+Service Tax)

Retired Employees Dependent Parents 5000/- (+Service Tax)

Higher Hospitalization Cover (If opted for)

Higher hospitalization cover can be availed by the employee on payment of an additional annual premium of Rs. (5,000/- plus service tax) per family.

This premium is uniform irrespective of number of individuals covered, age or grade of the insured person.

For employees separating during a financial year, premium will be applicable for entire year.

Higher cover is optional for employees as on 31st Mar 10. If they opt out for higher cover they will not able to get higher cover in future during their tenure in CMC.

Higher Hospitalization Cover is mandatory for new joinees. Higher Hospitalization premium for employees joining CMC during the financial year will be prorated as follows

Prorated Higher Hospitalization Premium (To be borne by employee)

Joined in Between Premium (Sales Tax Exclusive)

April June (Q1) Rs.5,000/-

July September (Q2) Rs.3750/-

October December (Q3) Rs.2,500/-

January March (Q4) Rs.1,250/-

13. General Provisions with regards to Premium:

Premium for entire year is applicable for any inclusions made during a financial year.

Annual Premium for basic cover for dependents declared by the employee will be deducted from employees salary.

If employee resigns during a financial year, applicable premium (if not recovered) is recovered in full and final settlement.

Premium paid by the employee will qualify for deduction under section 80 D of the Income Tax Act.

14. Provisions regarding Dependents:

Inclusion of Dependents:

There is a specific link in Ultimatix which can be used for inclusion /deletion of dependents. Ultimatix Home Page -> HR Managemet -> CMC Employees self service-> HIS Dependents details.

The addition of spouse, parents/parents-in-law can be done only during the open window period as announced by Corporate HIS Team normally during the start of the financial year. Children can be added anytime during the year, however the date of coverage of children shall be date of addition of children in the HIS link.

Addition of dependants (newly married spouse/and newly born child) can also be made during the financial year, where the coverage will be effective from the date of updation in system.

For existing employees the spouse, parents/parents-in-law cannot be added during the FY. Employees have been given only opportunity to decide on whether they want to insure parents/parents-in-law in CMC Insurance scheme during Apr 2012 window period. If employee chooses not to include parents into HIS then it will not be possible to have them covered under the policy later.

There is no maximum age limit for the dependent parents/ parents-in-laws.

New Born baby is covered from the 1st day of birth if the details are added in HIS link within 3 months from the date of birth.

Deletion of Dependents:

Dependants can be deleted from the HIS coverage only in the given time frame, (when the link is activated for such deletion) to be effective from first day of the policy year (i.e. 1st April). In such case the premium will not be recovered from the employee. Parents/parents-in-law once deleted, cannot re-enter HIS during tenure in CMC.

No deletion is allowed during the policy period. Any deletion will be taken up only in the next policy period if the request is made after the given time frame.

The premium cannot be refunded in case of any deletions during the policy period / Financial Year.

15. General Provisions HIS

a. Continuous Period of Medical care:

Period of Medical care is the period commencing on the first day on which an insured person is under the care of a Medical Practitioner for the treatment of any particular medical condition while the policy is in force and terminating on the expiry of 45 days from the day the insured person resumes normal work or activities.

In case the insured person is hospitalized twice during the Period of Medical Care for the same ailment/medical condition, any claims for treatment availed during this period can be claimed as a single request.

b. Treatment outside India:

If the employee is covered by an Overseas Medi claim Policy (OMP), benefits should be first availed against the OMP and only then claimed under the HIS subject to maximum of Rs.45000/- per insured person (irrespective of the employees grade and coverage under higher hospitalization)

If not covered by an OMP, the employee may claim benefits under the Basic HIS policy of Rs.45000/- per insured per annum.

Hospitalization treatment taken outside India by insured persons who travel out of India on official work is covered under Basic HIS Policy.

The claim amount should be in equivalent Indian Rupees only and a settlement will be done in equivalent Indian Rupees only.

16. Exclusions:

There are certain exclusions in HIS due to which NO benefits are payable. This list of exclusions is only indicative

and not exhaustive.

(Refer Annexure IV - List of Ailments not covered under HIS)

17. Process Flow -Claim Settlement Procedures

Drop boxes are being deployed at Regional head offices, where employees can drop their claims after registering the

claims in the Medi Assist web portal. Medi Assist (MA) representative will visit once in a week to collect the claims

from the drop box. The flow chart for different type of claim process is as follow:

a. Domiciliary Claim Process

Employee submits claim in MA portal

Employee drops the claim documents in Drop Box; MA

representative will visit the location and collect the documents*

MA -HO Evaluates the settlement details.

MA Representative forwards the claim to their local branch for

further processing.

If claim is rejected, documents will be sent back to the employee.

MA forwards domiciliary claims to System House for Technical scrutiny . System House does the Technical scrutiny and accordingly provides the settlement details to the MA.

*Detailed schedule of MA representative visit will be made available to employee along with the PDF claim form

Approval

MA will credit the settlement amount in employees bank

account.

Approval

Yes

Yes

No

No

b. Hospitalization Claim Process

c. Cashless Hospitalization

Show your CMC employee ID card to Hospital representative. Fill Cashless request form available in MEDI ASSIST network hospital.

Mention details as follows:

MEDI ASSIST ID CMC employee no.

Policy No Policy No. (Available in TPA portal)

Hospital authorities fax request form to MEDI ASSIST

HO, Blore

MEDI ASSIST HO, Blore will fax the sanction /denial

letter to network hospital authorities.

Remaining details are to be filled by hospital authorities

Make sure you go to a Medi Assist networked hospital. List of empanelled hospitals is there in the portal.

18. Guide to Medi Assist Web Portal with Screenshots

The employee logs on to the application through a web link: www.mediassistindia.net/Corporate.

Note: It is mandatory that the CMC employee should change the password after first Login as a security measure.

Note DOB is dd/mm/yyyy format.

1. Enter Employee Number@tcs as a User ID

2. Enter DOB in dd/mm/yyyy

fromat as a Password

a. Step I: Hospitalization Claim Registration:

Click here

for

registration

This screen allows the employee to communicate his/her

intention to make a Hospitalization claim in advance (Just

intimation before actual claim submission). The screen displays

all dependants eligible for HIS benefits under the policy along

with a Radio button. Claim Registration is required only for

Hospitalization claim)

Enter the required details

On submission, the system

generates a unique ID which would

be the sole reference number for

the employee towards the said

claim.

b. Step II: Claim Submission:

Using the unique number generated earlier, the employee

can register the claim under this link. On clicking this

link, the Claim Submission screen opens out. All

intimations recorded earlier towards the HIS claim get

displayed here.

Each Registration ID will have two links.

Registration ID link is to Submit Claim documents

Edit link to edit registered

details. Editing of the

details using Edit link is

permitted only once per

registration

The employee clicks on the appropriate intimation number to record the claim

submission details. On click of Intimation Number, the Claim Submission Screen

is displayed.

Claim Submission screen will allow him / her to enter details like ailment, available

documents, number of documents, amount related to those documents etc.

Click here

Tick here

After submitting claim details the following screen will get populated with two vital buttons. One is to edit the claim

details and the other one to generate claim form and this claim form will be the acknowledgement for submission of

claim. Employees need to cross verify all the details and if it requires any modification, use Edit Claim Details button

and submit the modified details. The employee has to print this form, attach supporting documents and put the

same in the drop boxes provided for it or send it to Medi Assist cubicles designated at the respective branches.

The associate needs to be insured that the claim form is signed by himself.

Edit claim details if

required

Generate Claim Form

CMC

Hospitalization Claim Form

CMC

19. Domiciliary Claim Submission:

Claim Intimation / Registration Process is not required for Domiciliary claim submission. Unique Registration ID

for identifying the Domiciliary Claim is generated.

1. Click here

2. Enter necessary

details

4. Click here

3. Employee has to agree to

this

Note: The employee has to print this form, attach supporting documents and put the same in the drop boxes provided

for it at the respective branches. Editing of claim details is allowed only once per Claim. The employee needs to

ensure that the claim form is signed by him.

The system redirects to View page with two buttons, one for Editing claim

details and the other for Generating Claim form.

4. Click here to

Generate Claim

Form

Click here to

Edit Details

Domiciliary Claim Form

CMC

CMC

20. View Claim Details:

Hospitalization:

Domiciliary:

21. Claim Tracking

22. Claim History

Claims History displays past 3 years claim(s) details. In the first

sheet current year claims will get listed and an option is

provided to check the remaining claims history with a simple

buttons which will indicate the policy years.

All Reimbursement claims will be displayed in this window to help employee to track his / her submitted claims, once the technical scrutiny has commenced against each and every entry.

23. Claim Escalation and HIS Helpdesk

Voice Support

For Cashless help

Toll free No. 18004259449 24 hours

08032989055 / 022-67783448 (From 9:30 am to 6:00 pm, Mon to Sat)

For Domiciliary claims queries

022-28378905/022-32921066/ (From 9:30 am to 6:00 pm, Mon to Sat)

For Hospitalization claims queries

022-67783448 (From 9:30 am to 6:00 pm, Mon to Sat)

E-mail support

For Hospitalization queries please write to [email protected]

For domiciliary claim queries please write to [email protected]

Always mention your Employee ID in subject line while writing to the helpdesk. If the query is related to claim which is already raised in the Medi Assist portal then mention claim registration number in e-mail.

Please make note of some of important service level agreement (SLA):

S.No. Activity SLA

1. Response to employees e-mail queries Within 2 working days.

2. Reflection of eligible dependents in Medi Assist portal after adding in Ultimatix->HR management

Within 15 days from payroll process date.

3. Settlement of claim in the employees salary bank account

Within 30-45 days from the receipt of the claim documents by Medi Assist.

Claim Escalation Matrix

a) 1st Escalation [email protected], if not resolved within 3 working days

b) 2nd Escalation [email protected], if not resolved within 3 working days

c) 3rd Escalation [email protected] & [email protected]

24. Addition / Deletion of dependents: This process is facilitated in Ultimatix

Employees can add/delete their dependants in the system for the coverage of their family members. The window

period for adding/deleting the dependants details will be communicated from time to time.

Ultimatix Home Page

1. Click on HR

Management

2. Click here

3. Click on Employee Self

Service

4. Click on HIS Dependent

Coverage

8. Click on Submit

HIS Dependent Details page is displayed

5. Enter the

details

6. Click on Add check box

for addition.

7. Click on

Delete

check box for

deletion.

25. Entities Involved and Roles

NIACO:

NIACO is the final approval and discretion authority for all benefits provided under HIS to CMC employees. It

has appointed a third party administer for facilitating claim processing on its behalf. It is responsible mainly for

following activities:

Provide DOs and DONTs to CMC with respect to HIS scheme.

Ensure that TPA empanels with leading and reputed hospitals having all basic facilities like ICU, emergency ward, special pediatrics ward etc. in those places where CMC operates in India.

NIACO maintains sufficient float funds with TPA to enable the later to make disbursement of claims.

SYSTEM HOUSE:

MEDI ASSIST has outsourced System House for scrutiny of the domiciliary claims. It is responsible for first level

scrutiny of all documents submitted by employees.

MEDI ASSIST:

MEDI ASSIST acts as a TPA (third party administrator) and facilitates HIS claims processing/ settlement and

cashless hospitalization on behalf of NIACO. MEDI ASSIST is an integral part of HIS claim settlement process as

all the claim requests and payment procedures are routed through MA. It is responsible for:

First level scrutiny of the domiciliary as well as hospitalization claims raised by employees.

Processes all CMC claims from its central processing center at TCS-Vikhroli.(Mumbai)

MEDI ASSIST representatives are available at different CMC locations for smooth functioning of claims settlement process.

Corporate HIS:

CMC facilitates the processes within the HIS scheme by capturing the details for enrolment and claims requests

online. For the employees convenience, Corporate HIS - a dedicated cell has been set up by CMC whom the

employee can interact with for availing the benefits of the scheme. Hence Corporate HIS cell is a common link

between an employee and Insurance Company. There is no direct interaction between the employee and

NIACO.

CMC HIS cell (HR & Corporate Finance) is mainly responsible for following activities:

26. Frequently Asked Questions (FAQs)

1. Will I get Health Insurance Card for myself & my family members?

Health cards are not required. Your CMC ID card or CMC Employee ID will be sufficient to get cashless facility or to perform any transaction with Medi Assist or any of the entities.

2. What is the period to submit the claim?

An employee needs to submit the claim within 90 days from the date of discharge from the hospital.

3. Can I get some money as advance before undergoing treatment?

No, in such scenario, an employee may connect with the networked hospitals and avail cashless

hospitalization benefits. List of hospitals is available on www.mediassistindia.com.

4. If during FY, I claimed some amount for reimbursement, can the balance entitlement be carried forward to next FY?

No, it will get lapsed.

5. If my claim gets settled partially, how can I get the settlement details?

For any query related to HIS claim Settlement, employees may connect with the Regional MediAssist SPOC and

get the status details. Regional HR will help you in getting touch with local Medi Assist SPOC.

6. If I want to edit few details from HIS link, what is the procedure?

You need to write to [email protected] with your request.

7. If I want to delete any of the dependents details will I be able to do it any time during a financial year?

No. An employee will be able to delete his dependent details only in a stipulated time period every year as notified in Ultimatix .

8. Can I opt floater only for my parents?

No, Higher Hospitalization coverage is provided for all insured persons who are covered under basic HIS coverage. It is a family coverage. Employee cannot opt out of it.

9. How can I avail cashless hospitalization?

An employee may avail the cashless hospitalization facility in any of the linked hospitals as per the Medi Assist list. These hospitals will provide the necessary form. Kindly mention all the details and submit.

E.g.: TPA Medi assist, Policy No CMC Policy, Medi assist id No- Your Employee No. The hospital will in

turn fax this form and the necessary documents to the Head Office of Medi assist at Bangalore, whereas on

receipt of this information Medi assist will give a pre authorization of a certain amount at first and will settle

the outstanding amount at the time of discharge.

10. Can I delete my dependent now and add them up again when the hospitalization is required in future?

Policy does not permit to delete dependents during a financial year. Moreover, you need to declare dependent

parents/parents-in-law by 14th June 2010. If you are not able to do so, then your parents/parents-in-law will

not be allowed to enter HIS in future during your tenure in CMC.

11. I am at onsite and I am paying higher hospitalization coverage premium, then why only the basic coverage (Rs.45000/-) is provided to me. I have no dependent at offshore.

As per the terms and conditions of NIACO and HIS policy, coverage is upto Rs.45000/- only for a treatment outside India.

12. My father is already having the insurance policy with other Insurance Company, can I still enroll him under the HIS policy.

Yes if he/she is purely dependant as per the policy.

13. My parents are already working with the Government/ Private sector; can I enroll them as dependents?

Since your parents are employed with another company, they cannot be your dependents.

14. My dependents are going to onsite tour (Not Official) will I able to get the coverage for any hospitalization?

Yes. For any treatment outside India, coverage will be to the extent of Rs.45000/- provided the same has not been exhausted earlier in that particular year.

15. My wife and I are CMCite, can we update each other as a dependents?

No.

Annexure I

List of Ailments not covered under Domiciliary Hospitalization

1. Asthma

2. Bronchitis

3. Chronic Nephritis & Nephrotic Syndrome

4. Diarrhea & all types of dysenteries including gastro-enteritis

5. Diabetes Mellitus & Insipidus

6. Epilepsy

7. Hypertension

8. Influenza, Cough & Cold

9. All Psychiatric & Psychosomatic Disorders

10. Pyrexia of Unknown Origin

11. Tonsillitis & Upper Respiratory Tract Infection including laryngitis & Pharingitis

12. Arthritis, Gout & Rheumatism

Annexure II

Anne

xure

III

Sum assured in case of Death, Permanent Total Disablement (PTD) Table 1

Event % of Sum Insured

Death Only 100

Loss of two limbs two eyes or one limb and one

eye 100

Ailments considered for Umbrella cover

No. Ailments

1 Cancer

2 Nephritis of any etiology plus bacterial renal failure requiring kidney transplantation and

dialysis

3 Cerebral or vascular strokes

4 Open and closed heart surgery

5 Malignant diseases confirmed by histopathological reports

6 Viral encephalitis

7 Brain surgery

8 Total replacement of joints

9 Liver cirrhosis associated with hepatitis B\C

10 Compound\multiple fracture of femur

11 Intra cranial injury

12 Coma

13 Spinal injury resulting in paraplegia

14 Cerebral hemorrhage and Third degree burns.

Loss of one limb or one eye 50

Permanent Total Disablement from injuries

other than those named above (PTD) 100

Permanent Partial Disablement (PPD) as per

percentage of Sum Insured as in Table 2. 100

Sum assured in case of Permanent Partial Disablement (PPD) Table 2

Parts Lost % of Sum Insured

Loss of toes all 20

Great both phalanges 5

Great one phalanx 2

Other than great, if more than one toe-lost, each 1

Loss of hearing both ears 75

Loss of hearing one ear 30

Loss of four fingers and thumb of one hand 40

Loss of four fingers 35 35

Loss of thumb-both phalanges one phalanx 25

Loss of indeed finger three phalanges or two

phalanges or one phalanx 10

Loss of middle finger three phalanges or two


Loss of ring finger three phalanges or two


Loss of little finger three phalanges or two


Loss of metacarples first or second (additional)

or third, fourth or fifth (additional) 3

For any other Permanent Partial Disablement percentage is assessed by the Panel Doctor of the Insurance Company.

Annexure IV Exclusions from HIS

There are certain exclusions in HIS due to which NO benefits are payable. This list of exclusions (enumerated below) is only indicative and not exhaustive;

i. Expenses towards cost of spectacles, contact lens, any foreign body, beauty treatment, normal health check-up, external congenital defects and anaemia, vaccination etc. are not covered by this policy.

ii. Lasik surgery and advanced surface ablation surgery is not covered under the domiciliary as well as under the Hospitalisation.

iii. Vaccination, Inoculation, Circumcision (other than on medical grounds), Strictures, Change of Life (beauty treatment of any description) Plastic Surgery other than as may be necessitated due to an accident.

iv. Depression, Convalescence (which expression shall cover also general debility run down condition and general over haul) or Rest Cure, Congenital defects or Anomalies, Venereal Disease, Insanity, Intentional self injury, Intemperance or the use of intoxicating drugs or liquors or any disease directly or indirectly due to any one or more of them.

v. Eye refractions or contact lenses or eyeglasses or fittings thereof or cost thereof.

vi. Health routine check up examination / Master Check-up unless necessary positive existence for treatment of any medical condition.

vii. Injury, disease or illness directly or indirectly due to or arising from ionising radiation or contamination by radioactivity from any nuclear fuel or from any nuclear waste or from the combustion of nuclear fuel (solely for the purpose of this exclusion, combustion shall include any self sustaining process of nuclear fission), War, Invasion, Act of Foreign Enemy, Hostilities or Warlike Operation (whether war be declared or not), Riot or Civil Commotion or Breach of Law or hunting. Steeple chasing, Polo or winter sports or riding or driving in races or employment in Military, Naval or Air Services or engaging in Aviation or Ballooning or entering into, travelling in or leaving any aircraft or balloon.

viii. Treatment arising out of infertility, sterility, family planning.

ix. Maternity related expenses beyond first two live births.

x. Check up and diagnostic Tests done during maternity period.

xi. Self Injury, Suicide, Attempted suicide whilst under the influence of intoxication liquor, drugs insanity, war and allied perils, Ionising radiation, flying of an aircraft etc.

xii. This exclusion shall not apply to injury resulting from an accident to a fully licensed standard type of aircraft operated by a recognised airline on a fully regular scheduled air route in which the insured person is travelling as a bonafide passenger

- In case of Hospitalisation, the following services are not reimbursable:

i. Registration/Admission Fees

ii. Telephone charges

iii. Visitors charges, attendants charges, ambulance charges

iv. Service charges

v. Diet charges which are not part of the administered treatment

vi. Non-medical expenses.

1. Introduction2. Eligibility3. Coverage and Entitlement:4. Basic Coverage:5. Domiciliary (applicable if opted for Higher Hospitalization Cover)6. Expenses covered under Domiciliary:7. Hospitalization:8. Higher Hospitalization Coverage (if opted for):9. Cumulative Bonus:10. Add on benefits under higher hospitalization: Apart from domiciliary claims coverage, higher hospitalization cover provides following additional benefits (if opted for by employees):11. Sum Insured under HIS12. Premium13. General Provisions with regards to Premium:14. Provisions regarding Dependents:15. General Provisions HISa. Continuous Period of Medical care:b. Treatment outside India:

16. Exclusions:17. Process Flow -Claim Settlement ProceduresDrop boxes are being deployed at Regional head offices, where employees can drop their claims after registering the claims in the Medi Assist web portal. Medi Assist (MA) representative will visit once in a week to collect the claims from the drop box...a. Domiciliary Claim Processb. Hospitalization Claim Processc. Cashless Hospitalization

18. Guide to Medi Assist Web Portal with Screenshotsa. Step I: Hospitalization Claim Registration:b. Step II: Claim Submission:

19. Domiciliary Claim Submission:20. View Claim Details:21. Claim Tracking22. Claim History23. Claim Escalation and HIS Helpdesk24. Addition / Deletion of dependents: This process is facilitated in Ultimatix25. Entities Involved and Roles26. Frequently Asked Questions (FAQs)Annexure IAnnexure IIAnnexure IIIAnnexure IV Exclusions from HIS

HIS User Manual

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