Group Medical Insurance Guideline

Restricted Siemens AG 20XX All rights reserved.

siemens.com/answers

Insurance Company, TPA & EB Broker

Policy

Company

TPA

Group Medical - Employees

Bajaj Allianz GIC Ltd

HAT (Bajaj In-house TPA)

Group Medical - Parents

Bajaj Allianz GIC Ltd

HAT (Bajaj In-house TPA)

Employee Benefit Insurance Broker

Marsh India Insurance Broker Pvt. Ltd

Program Details
The Group Mediclaim Program provides insurance coverage to employees of Siemens Group
& their dependents for expenses relating to hospitalization due to illness, disease or injury
subject to a minimum of 24 hours hospitalization.

Group Medical Plan Employees (Policy Details)

Companies Covered
(Group Companies)

Plan Name

Group Medical Policy - Employees

Policy Holder

Siemens

Siemens Ltd

Period of the Cover

12 months

STSPL

Inception Date

1-December-2015

SFSPL

Expiry Date

30 -November-2016

SPPALPL

Insurer

Bajaj Allianz GIC Ltd

SCCPL

TPA

SHPL

HAT (Bajaj In-house TPA)

2A + 2C (Self + Spouse + 2 dependent children up
to 25 years)
India (Covers treatment in India only)

Members Covered
Geographical Limits
Mid-Term Revision of Sum Insured

No

Age-Limit

1 day to 80 Years

Mid-Term Enrollment

Yes (Only for New Born Child & Newly Wedded

Spouse)

Sum Insured Graded as follows

SL

STSPL

Workmen/JE-SE
MG 1-4

2 Lac

3 Lac

MG 5 & above

5 Lac

S6-P2

2 Lac

M 0-4

3 Lac

M5 & above

5 Lac

Group Medical Employee (Features)

Policy Features

Acceptability

Standard Hospitalization

Yes

Pre & Post Hospitalization Expenses

Yes (30 days-60 days)

Maternity Benefits

Yes

New Born Baby cover day 1

Yes

Pre-existing Diseases

Yes (waived)

First 30-days Waiting Period

Yes (waived)

First Year Waiting Period

Yes (waived)

Day Care

Covered as per the

Insurance company's
list

OPD Expenses

No

Health Check Up

Not covered

Room Rent Capping

Policy Features

Domiciliary Hospitalization

Claim Intimation & Submission

Acceptability
To be covered in
case if the patient is
incapacitated to
move or in coma
treatment at home.
Visiting doctor and
nurse charges are to
be paid. Attendant
cost excluded
Document to be
submitted within 30
days from date of
discharge

Septoplasty and stem cell

treatment

Covered without any

capping

Internal congenital, Pandemic,

Oral Chemotherapy

Covered

No Restriction

Co-Pay

No

Ayurvedic Treatment

Ambulance Charges

Covered- limited to
INR 5,000 in cases of
emergency

Covered if treatment
taken at government
Ayurveda hospitals
(only in case of IPDs,
OPD not covered)

Ailment Capping

No

External Congenital

Covered in only life

threatening cases

Group Medical Employee (Features contd)

Policy benefits
Daycare Treatments

Covered as per list. List in later

part of the guideline

Medical Termination of
Pregnancy

All expenses to be covered in

cases of Medical termination of
pregnancy under Medical advice
to save the life or prevent serious
damage to the health of the
mother. However voluntary
medical termination of
pregnancy during the first 12
weeks from the date of
conception not covered

New born babies,

Genetic and Congenital
disorders internal to be
covered from day one for
all types of medical
related expenses

Covered

Day care coverage (over

and above the insurer's
list)

D&C, radiotherapy, Excision of

Cyst/granuloma /Lump (Local
and General Anesthesia) and
endoscopies to be covered on
OPD basis (24 hours
hospitalization to be waived off)

Surgery Treatment for

Thalassemia

Covered

Maternity Policy Features

Coverage

For normal - INR 50,000

and For C-section- INR
70,000

Restriction on No. of children

2 children

9-months waiting period

Waived Off For All

Employees

Pre-Post Natal expenses

Covered up to INR 10,000

within maternity limit

New born baby covered

from day 1

Yes

Additional benefits brought in this year (2015-16):

Hormone Therapy for Cancer

treatment
In case of maternity related complication leading to
life threatening situations, the maternity limit will not
apply.
Ambulance cover revised to INR 5000 per person
per hospitalization
No deduction in case of death during
hospitalization
Coverage of dependent in case of employee death
till the end of policy period
Bio degradable stent up to 1.5 Lac

Group Medical Parents (Policy Details)

Plan Name

Group Medical Policy - Parents

Policy Holder

Siemens

Period of the
Cover

12 months

Inception Date

1-December-2015

Expiry Date

30 -November-2016

Insurer

Bajaj Allianz General insurance Co ltd

TPA
Members
Covered

Flexibility Options

Coverage for any set of parents (up to 2

parents only)

HAT (Bajaj In-house TPA)

Natural Parents or in laws of insured employee
only. Restricted to any 2 parents coverage only

Geographical
Limits

India (Covers treatment in India only)

Mid-Term
Revision of Sum
Insured

No

Age-Limit

36 to 95 years

Lock in Period

4 years

Option to increase the sum insured as per

details below
Option provided between floater and non
floater
Option once selected will be frozen for 4
years.

Employee Grade Band

New plan design

(Non-floater )

New Plan design for

(Floater)

up to P2/SE grade

1 Lac/ 2 Lac/3 Lac/ 4 Lac/ 5 Lac/6 Lac

2 Lac/3 Lac/4 Lac/6 Lac

M0/MG1 M4/MG4 grade

3 Lac/4 Lac/5 Lac/6 Lac/8 Lac

3 Lac/4 Lac/6 Lac/8 Lac

M5/MG5 & above

3 Lac/4 Lac/5 Lac/6 Lac/8 Lac

3 Lac/4 Lac/6 Lac/8 Lac

Group Medical Parents Additional Benefits this year

Additional benefits brought in this year (2015-16):

Hormone therapy for cancer treatment
Oral Chemotherapy for all types of
cancer
Ambulance cover revised to INR 5000 per person per
hospitalization
Age-Limit covered 36 to 95 years

Group Medical Parents (Features)

Acceptability

Policy Features

Acceptability

Standard Hospitalization

Yes

Domiciliary Hospitalization

No

Pre & Post Hospitalization

Expenses

Yes (30 days-60 days)

Day Care

Covered as per the

Insurance company's list

Pre-existing Diseases

Yes (waived)

OPD Expenses

No

First 30-days Waiting Period

Yes (waived)

Health Check Up

Not covered

First Year Waiting Period

Yes (waived)

Room Rent Capping

No Restriction

Co-Pay

No

Refractive error or sight

correction (+-) 7

Covered on OPD or IPD basis (lasik

or any injection given on OPD basis
are covered)

Ayurvedic Treatment

Not covered

Septoplasty and stem cell

treatment

Not covered

Hormone therapy for cancer

treatment

Covered

Policy Features

Dental and Vision only incase

of accidents
Internal congenital,
Pandemic, Oral
Chemotherapy

Covered

Covered

Lock in Period - Features

There will be 4 years lock-in period for parents policy. This means once the parents are declared you

cannot change the same till 4 years are completed. Only incase of death of any parent/death of
employee/ resignation/retirement, the parents declaration can be stopped.
This Lock-In period will benefit employee to take policy on a retail mode in the event of
retirement/resignation benefits at par as per the corporate policy (portability option)
The applicable waiting periods in normal retail policies are waived off in the portability option post the
completion of this 4 years lock in period . e.g. 30 days waiting period, pre-existing diseases, 1st and 2nd years
exclusions are waived off. However, premium would be at discretion of the insurance company

Standard Hospitalization
Reimbursement of expenses related to
Room and boarding charges
Doctors/Consulting fees
Intensive Care Unit
Surgical fees, operating theatre, anesthesia and oxygen and their administration
Drugs ,medicines and consumables consumed on the premises.
Hospital miscellaneous services (such as laboratory, x-ray, diagnostic tests)
Diagnostic procedures such as Laboratory, X ray and other diagnostic tests
Costs of prosthetic devices if implanted during a surgical procedure
Radiotherapy and chemotherapy
Organ transplantation including the treatment costs of the donor but excluding the costs of the organ
Note:
A) The expenses shall be reimbursed provided they are incurred in India and within the policy period. Expenses will be
reimbursed to the covered member depending on the level of cover that he/she is entitled to.
B) Expenses on Hospitalization for minimum period of 24 hours are admissible. However this time limit will not apply
for specific treatments i.e. Dialysis, Chemotherapy, Radiotherapy, Eye surgery, Dental Surgery, Lithotripsy (kidney
stone removal), Tonsillectomy, D & C taken in the Hospital/Nursing home and the insured is discharged on the same
day of the treatment will be considered to be taken under Hospitalization Benefit.
C) A security deposit of a minimum of INR 10,000 or more may be collected from the empanelled hospitals which may
be reimbursed fully or partially post deduction of non admissible expenses and once cashless settlement is done by
the Third Party Claims Administrator (TPA)

Pre & Post Hospitalization expenses

Covered
Pre-hospitalization Expenses

Definition

If the Insured member is diagnosed with an illness

which results in his / her Hospitalization and for which
the Insurer accepts a claim, the Insurer will also
reimburse the Insured Members Pre-hospitalization
Expenses incurred towards that illness for which
hospitalization is done for up to 30 days prior to his /
her Hospitalization.

Covered

Yes

Duration

30 Days

Post-hospitalization Expenses

Definition

If the Insurer accepts a claim under Hospitalization and

immediately following the Insured Members discharge,
further medical treatment directly related to the same
condition for which the Insured Member was
Hospitalized is required, the Insurer will reimburse the
Insured members Post-hospitalization Expenses for up
to 60 day period.

Covered

Yes

Duration

60 Days

Maternity Benefits
Reimbursement of expenses related to maternity as per policy
The maximum benefit allowable is INR 50,000 for Normal and INR 70,000 for C-section per delivery within the policy Sum
Insured, max up to 2 children.
There are special conditions applicable to the Maternity Expenses Benefits as below:
These benefits are admissible only if the expenses are incurred in Hospital/Nursing Home as in-patients in India.
Claim in respect of delivery for only first two children and/or operations associated therewith will be considered in
respect of any one Insured Person covered under the Policy or any renewal thereof. Those Insured Persons who
already have two or more living children will not be eligible for this benefit.
Expenses incurred in connection with voluntary medical termination of pregnancy during the first 12 weeks from the
date of conception are not covered

Sterilization expenses are not covered

Benefit Details
Maximum Benefit allowable

For normal - INR 50,000 and For C-section- INR 70,000

Restriction on no. of children

Maximum of 2 children

9 Months waiting period

Waived off

Pre-Post Natal Expenses on IPD and

OPD basis

Covered upto INR 10,000 within maternity limit

IMPORTANT:
For maternity reimbursements and employees on subsequent maternity leave , please do not wait till you return back to office
to submit a claim as it will cross the claim submission timeframes and claim may be denied. please also immediately inform
HR about the new baby coverage as your dependent as subsequent complication may be a possibility and intimation is
mandatory prior to coverage.

Customized Benefits

Pre existing diseases

Definition

Any Pre-Existing Condition or related condition for which care, treatment or

advice was recommended by or received from a Doctor or which was first
manifested prior to the commencement date of the Insured Persons first Health
Insurance policy with the Insurer

Covered

First 30 day waiting period

Definition

Any disease contracted by the Insured Person during the first 30 days from the
commencement date of the Policy is also covered.

Covered

First Year Waiting period

Definition

During the first year/second year of the operation of the policy, the expenses on
treatment of diseases such as Cataract, Benign Prostatic Hypertrophy,
Hysterectomy for Menorrhagia or Fibromyoma, Hernia, Hydrocele, Congenital
Internal Diseases, Fistula in anus, Piles, Sinusitis and related disorders are also
payable.

Covered

Baby Cover Day 1

Definition

Extension to cover the new born child of an employee covered under the Policy
from the time of birth. Not withstanding this extension, the Insured shall be
required to cover the newly born children immediately as additional member.

Covered

Customized Benefits contd..

Day Care
Definition

Restriction

Day Care Procedure means the course of medical treatment or a

surgical procedure listed in the policy schedule which is undertaken
under general or local anesthesia in a Hospital by a Doctor in not less
than 2 hours and not more than 24 hours.

Restricted

Restricted

Not Payable

List of day care procedures as named in the Policy schedule

Dental Treatment
Definition

Restriction

Any dental treatment or surgery of a corrective, cosmetic or aesthetic

nature unless it requires Hospitalisation; is carried out under general
anesthesia and is necessitated by Illness or Accidental Bodily Injury.
Expenses arising only by way of an accident are payable.

Vision & Hearing aid

Definition

The cost of spectacles and contact lenses, hearing aids

Diagnostics Expenses
Definition

Charges incurred at Hospital or Nursing Home primarily for diagnostic,

X-Ray or laboratory examinations or other diagnostic studies
consistent with or incidental to the diagnosis and treatment of the
positive existence of any ailment, sickness or injury for which
confinement is required at a Hospital/Nursing Home are admissible.
However diagnostics on standalone basis are not payable.

Restricted

General Exclusions

Injury or disease directly or indirectly caused by or arising from or attributable to War, Invasion, Act of Foreign Enemy,
War like operations (whether war be declared or not) or by nuclear weapons / materials.
Circumcision (unless necessary for treatment of a disease not excluded hereunder or as may be necessitated due to any
accident), vaccination, inoculation or change of life or cosmetic or of aesthetic treatment of any description, plastic
surgery other than as may be necessitated due to an accident or as a part of any illness.
Surgery for correction of eye sight, cost of spectacles, contact lenses, hearing aids etc.
Any dental treatment or surgery which is corrective, cosmetic or of aesthetic procedure, filling of cavity, root canal
including wear and tear etc. unless arising from disease or injury and which requires hospitalization for treatment.
Convalescence, general debility, run down condition or rest cure, congenital external diseases or defects or anomalies,
sterility, any fertility, sub-fertility or assisted conception procedure, venereal diseases, intentional self-injury/suicide, all
psychiatric and psychosomatic disorders and diseases / accident due to and or use, misuse or abuse of drugs / alcohol or
use of intoxicating substances or such abuse or addiction etc.
All expenses arising out of any condition directly or indirectly caused by, or associated with Human T-cell Lymphotropic
Virus Type III (HTLD - III) or Lymohadinopathy Associated Virus (LAV) or the Mutants Derivative or Variations Deficiency
Syndrome or any Syndrome or condition of similar kind commonly referred to as AIDS, HIV and its complications
including sexually transmitted diseases.
Expenses incurred at Hospital or Nursing Home primarily for evaluation / diagnostic purposes which is not followed by
active treatment for the ailment during the hospitalised period.
Expenses on vitamins and tonics etc. unless forming part of treatment for injury or disease as certified by the attending
physician.
Any Treatment arising from or traceable to pregnancy, miscarriage, abortion or complications of any of these including
changes in chronic condition as a result of pregnancy except where covered under the maternity section of benefits
Naturopathy treatment, unproven procedure or treatment, experimental or alternative medicine and related treatment
including acupressure, acupuncture, magnetic and such other therapies etc.

General Exclusions contd..

Expenses incurred for investigation or treatment irrelevant to the diseases diagnosed during hospitalisation or primary
reasons for admission. Private nursing charges, Referral fee to family doctors, Out station consultants / Surgeons fees
etc,.
Genetical disorders and stem cell implantation / surgery.
External and or durable Medical / Non medical equipment of any kind used for diagnosis and or treatment including CPAP,
CAPD, Infusion pump etc., Ambulatory devices i.e. walker , Crutches, Belts ,Collars ,Caps , splints, slings, braces
,Stockings etc of any kind, Diabetic foot wear, Glucometer / Thermometer and similar related items etc and also any
medical equipment which is subsequently used at home etc..
All non medical expenses including Personal comfort and convenience items or services such as telephone, television,
Aya / barber or beauty services, diet charges, baby food, cosmetics, napkins , toiletry items etc, guest services and similar
incidental expenses or services etc..
Change of treatment from one path to other path unless being agreed / allowed and recommended by the consultant
under whom the treatment is taken.
Treatment of obesity or condition arising therefrom (including morbid obesity) and any other weight control programme,
services or supplies etc..
Any treatment required arising from Insureds participation in any hazardous activity including but not limited to scuba
diving, motor racing, parachuting, hang gliding, rock or mountain climbing etc unless specifically agreed by the Insurance
Company.
Any treatment received in convalescent home, convalescent hospital, health hydro, nature care clinic or similar
establishments.
Any stay in the hospital for any domestic reason or where no active regular treatment is given by the specialist.
Out patient Diagnostic, Medical or Surgical procedures or treatments, non-prescribed drugs and medical supplies,
Hormone replacement therapy, Sex change or treatment which results from or is in any way related to sex change.
Massages, Steam bathing, Shirodhara and alike treatment under Ayurvedic treatment.
Doctors home visit charges, Attendant / Nursing charges during pre and post hospitalisation period.
Treatment which is continued before hospitalization and continued even after discharge for an ailment / disease / injury
different from the one for which hospitalization was necessary.
The above are only indicative and not exhaustive.

Non Payable Expenses under Mediclaim Policy

Admission charges or Kit / Registration/Token/Supplementary /service charges/Pre post Consultants home
visit charges
Any kind of Service charges, Surcharges, Admission fees / Registration charges etc levied by the hospital.
Transportation/Ambulance/Local conveyance charges where ambulance is not required medically and as per
the policy conditions.
Administrative/Charges of Identification Band/Identification card
Attendee or attendance staff /cleaner charges
Amenity of the hospital/water ,electricity, luxurious utility charges/establishment charges/ charges related to
linen/laundry/washing charges/establishment charges/any sort of overhead/lodging charges.
Any charges named as Sundry/Stationary/File/Folder/Documentation/ xerox charges/medico legal charges/
charges of birth or medical certificate or related to any certificate issuance.
Telephone charges/TV charges/Video charges/Cable charges/internet charges/AC
cassette/CD charges in case of endoscopy, color doppler etc/camera and related charges

charges/cost

of

Mess/ Food charges/Diet charges/Nutrition and nutrition planning charges/Diabetic charges/cost related to
mineral water
Input & Output charges/Daily pass charges,/relative stay/extra bed charges/companion stay or related
charges/donor screening/organ harvesting charges/,private nursing charges during hospitalisation.
Biomedical Waste charges/waste maintenance charges
The above are only indicative and not exhaustive. Refer policy terms and conditions. Link for list of non
admissible expenses https://www.bajajallianz.com/Corp/content/claim/nonadmissibleexpenses.pdf

Voluntary Top Up policy

A Top-up policy supplements your existing mediclaim policy, insuring
you for a larger sum insured limit at lower cost
A Top-up cover is initiated when the full sum assured of your base
policy is exhausted (i.e. Threshold limit is reached) it excludes maternity
and maternity related issues.
Sum insured available 2lacs, 3lacs and 5 lacs
Advantages
Customizable top-up cover for each corporate customer

FAQ

Top up
policy

Terms and conditions to be in sync with the base policy

Option with the employee to enroll for the cover
Group Leaver Benefit Employee can continue the same benefits even after he/she quits the
company.
Benefits under section 80D of Income Tax Act.

Enrollment in the program

Employee must enroll in order to obtain coverage for yourselves and your eligible dependents. Employee will
receive a link for Benefit me portal of Marsh where employee can provide relevant enrollment data on the portal
which will be open for 15 days. Post which the data will be shared with Insurer and endorsed and be used for
policy period 2015-16
In case of life events i.e. each time you acquire a new dependent like when your family status changes because of
marriage, birth or adoption of a child. The acquisition of a new spouse and new born must be declared within 30
days of the marriage or child-birth.
If you fail to enroll within the defined timelines, the next enrollment can be done only at next renewal.
The UHID will be uploaded on the portal as well will be shared on email to all employees along with welcome
mailers.
On receipt of e cards employee should verify the details of self & Dependents notify HR & Marsh, post which same
will be rectified with endorsement with insurer and new details will be shared with employee.

Cashless Hospitalization
Cashless hospitalization means the Administrator may authorize (upon an Insured persons request) for direct settlement of
eligible services and the corresponding 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 these services are
covered under the Policy. However, in spite of the above benefits, some hospitals may demand a deposit before admission
and refund of deposit shall be as per hospital policies.
List of hospitals in the TPAs network eligible for cashless hospitalization

Customer Care Center /Toll free no:

List of network hospitals

Toll Free No -1800 22 5858, 1800 102 5858

+91 9731407546
Note: The network hospital is subject to change, hence please
reconfirm with TPA before admission into any hospital or you
may log on to for an updated list

Planned Hospitalization
Step 2
Step 1
Pre-Authorization

All non-emergency
hospitalization instances
must be pre-authorized with
the TPA, as per the
procedure detailed below.
This is done to ensure that
the best healthcare
possible, is obtained, and
the Insured Member is not
inconvenienced when taking
admission into a Network
Hospital.

Admission,
Treatment &
discharge

After your hospitalization has

been pre-authorized, you
need to secure admission to
a hospital. A letter of credit
will be issued by TPA to the
hospital. Kindly present your
Mediclaim card at the
Hospital admission desk. The
Insured Member is not
required to pay the
hospitalization bill in case of
a network hospital. The bill
will be sent directly to, and
settled by, TPA.

Patients seeking treatment

under cashless
hospitalization are eligible to
make claims under pre and
post hospitalization
expenses. For all such
expenses, the bills and
other required documents
need to be submitted
separately as part of noncashless claims.

Pre-Authorization
Member approaches TPA
counter of the Hospital with
planned hospitalization
details filled in a specified
pre-authorization format 48
hours prior to hospitalization

Hospital in turn
intimates the TPA
& Claim is
Registered by the
TPA on same day

Yes

TPA issues letter of credit

within 12 hours for planned
hospitalization to the
hospital

No

Follow non
cashless process

For Pre-Authorization Claim Form please find the link

https://www.bajajallianz.com/Corp/content/health/health_claim_forms/cashless_request_form.pdf

Pre-Authorization
Completed

Admission, Treatment & Discharge

Member produces E-card at

the network hospital and
gets admitted

Member gets treated and

discharged after paying all
non entitled benefits like
refreshments, etc.

Hospital sends complete set

of claims documents for
processing to the TPA

Release of payments to the

hospital

Claims Processing by TPA

(with approval by Insurer)

Note: Employee /Insured is requested to check details of the Final Bill for its correctness before signing the
same

Emergency Hospitalization
Step 2

Step 3

Get Admitted

Pre-Authorization by
hospital

Treatment &
Discharge

In cases of emergency, the

member should get
admitted in the nearest
network hospital by showing
their E-card. The treatment
should not be put on hold
irrespective of the time of
receipt of pre-authorization.

Relatives of admitted
member should inform the
call center /TPA Helpdesk
within 24 hours of
hospitalization & seek pre
authorization. The letter of
credit would be directly
given to the hospital. In
case of denial, relative
/member would be informed
directly by TPA.

Step 1

After your hospitalization

has been pre-authorized,
the employee is not required
to pay the hospitalization bill
(except for the nonmedical/non-payable
expenses) in case of a
network hospital. The bill
will be sent directly to and
settled by TPA to the
hospital

Emergency Hospitalization Process

Member gets admitted in the

hospital in case of
emergency by showing his
E-card. Treatment starts

Member / Hospital applies

for pre-authorization to the
TPA within 24 hrs of
admission

Hospital sends complete set

of claims documents for
processing to the TPA

Member gets treated and

discharged after paying all
non entitled benefits like
refreshments, etc.

TPA verifies applicability of

the claim to be registered
and issue pre-authorization

Preauthorizatio
n given by
the TPA

No
Claims Processing by TPA &
Insurer

Release of payments to the

hospital

Follow non
cashless process

Non-Cashless Hospitalization

Admission procedure
In case you choose a non-network hospital, you will have to liaise with the hospital directly for admission.
You are advised to intimate TPA of the hospitalization for their records
Discharge procedure
In case of non network hospital, you will be required to clear the bill and submit the claim to TPA for
reimbursement from the insurer. Please ensure that you collect all necessary documents such as
discharge summary, investigation reports etc. for submitting your claim
Submission of hospitalization claim
1.

After the hospitalization is complete and the patient has been discharged from the hospital, you must
submit the final claim within 30 days from the date of discharge from the hospital.

2.

Under hospitalization claims, you are also permitted to claim for treatment expenses 30 days prior to
hospitalization and 60 days after the date of discharge. This is applicable for both network and nonnetwork hospitalization. You are advised to file for reimbursement within 7 days from the completion
of 60 days post discharge

Non cashless Hospitalization Process

Member intimates TPA
before or as soon as
hospitalization occurs

Is claim
admissible?
(coverage /
applicability
)

Yes

Claim registered by TPA

after receipt of claim
intimation

TPA performs medical

scrutiny of the
documents

Insured admitted as per

hospital norms. All
payments made by
member

Yes

Insured will create the summary of Bills

(2 copies) and attach it with the bills
The envelope should contain clearly
the Employee Name, Employee Code
& Employee e-mail & contact

No

No

TPA checks document

sufficiency

Is
document
received
within 30
days from
discharge

Insured sends relevant

documents to TPA office
within 30 days of
discharge

Claim Rejected

Is
documentation
complete
as required

Yes

No

Claims processing done

within 10 working days

Send mail about deficiency

and document requirement

NEFT payment to the

employee shall be made. An
auto mailer will be sent to
your email id the following
day after NEFT is done

Claims Document List

Signed Claim form
Main Hospital bills in original (with bill no; signed and
stamped by the hospital) with all charges itemized and the
original receipts
Discharge Card (original)
Attending doctors bills and receipts and certificate
regarding diagnosis (if separate from hospital bill)
Original reports or attested copies of Bills and Receipts for
Medicines, Investigations along with Doctors prescription in
Original and Laboratory

Note: Please attach the completed document checklist along with claim form and claim documents and
submit the same to TPA within the timeline specified.
Member needs to retain a photocopy of all the
documents he is submitting for future reference

Follow-up advice or letter for line of treatment after

discharge from hospital, from Doctor.
Break up with details of Pharmacy items, Materials,
Investigations even though it is there in the main bill
In case the hospital is not registered, please get a letter on
the Hospital letterhead mentioning the number of beds and
availability of doctors and nurses round the clock.
In non- network hospitalisation, please get the hospital and
doctors registration number in Hospital letterhead and get
the same signed and stamped by the hospital.

Cancelled copy of cheque or NEFT details

To download claim Form click on the links below
https://www.bajajallianz.com/Corp/content/health/health_claim_forms/ReimbursementFormA+B2013.pdf

Prudent Utilization of Benefit

Health Insurance is a benefit for the employee and their dependents. One has to utilize the benefit with utmost
caution and prudence.
The ever increasing cost for the benefits require a proactive involvement from all of us.
The following steps are recommended, ensuring the benefits is prudently utilized by the employee and
dependents covered

Please ensure to crosscheck the final bill sent to the TPA for the following:
You are Billed only for the services utilized for e.g. category of room, diagnostics undergone ,
medicines consumed
Total of the bill
In case of any planned hospitalization, approach the hospital in advance(48 hours) and request pre
authorization- this enables TPA to further negotiate the rates
To approach hospitals with caution most expensive is not necessarily the best.
To cross check the tariff with the Bench Mark Rates provided- the benchmark rates would give an
idea the general spend for the treatment or procedure.
Try to negotiate
Ask WHY & WHAT is billed to you ( as a consumer , we have the right to know)

Timelines for submission of documents

Type of document

Timeline for submission

Intimation of reimbursement claims-

No Intimation required

Documents of hospitalisation and prehospitalisation

Within 45 days from the date of

discharge

Documents of post-hospitalisation

Maximum within15 days from the date

of completion of 60 days from
discharge or completion of treatment
whichever is earlier

Definitions, Links etc

Attachments
Important Websites
General Definitions

Day Care List

List

IRDA (Insurance Regulatory

and Development Authority)

http://www.irdaindia.org/

Marsh India Private Limited

www.marsh.co.in

FAQ

What are network hospitals? What should I do when I reach the hospital (NETWORK)?
These are hospitals where TPA has a tie up for the cashless hospitalization. There are two kinds of network hospitals; PPN
Network hospitals where cashless services can be obtained for emergency and planned treatments and Standard (Non
PPN) network hospitals where cashless services can be obtained for planned hospitalisation.
Once you have reached there please show your ID card for identification. TPA will also send a letter of credit (on preauthorization) to the hospital to make sure that they extend credit facility. Please complete the pre-authorization procedure
listed earlier. If the pre-authorization is not done, you must collect all reports and discharge card when you get discharged.
Please make sure that you sign the hospital bill before leaving the hospital. You can then submit the claim along with all the
necessary supporting documents to TPA as a reimbursement . If however you go to a non network hospital , it is still
advisable to fill the preauthorization form ( use the copy attached with the Benefits Manual). Please fill the claim form, attach
the relevant documents and send it to TPA office for reimbursement.

What are claim reimbursements?

In the event where cashless hospitalization is not availed, you need to submit all original bills along with the claim forms to
the insurance company/TPA and the hospitalization expenses will be reimbursed to you.

How can I claim my pre & post hospitalization expenses?

The policy covers pre-hospitalization expenses made prior to 30 days of hospitalization and incurred towards the same
illness/ disease due to which hospitalization happens. It also covers all medical expenses for up to 60 days post discharge
as advised by the Medical Practitioner. All bills with summary have to be sent to TPA as a reimbursement,

FAQ contd..

Is pre authorization necessary?

Yes. This will help you in the following ways:
1) You will be informed in advance regarding your coverage for the treatment and whether it is covered under your
medical plan or not . This will help you know in advance if your claim may get rejected at a later stage and you do not end
up paying out of pocket.
2) It will help you ensure that the treatment cost is appropriate and not inflated. as the TPA will be able to cross check
costs with the hospital in question. This will also help TPA in planning your hospitalization expenditure such that you do
not run out of the cover that you are entitled to.
3) It will help TPA in registering the impending claim with the insurer.

What are the key points I must remember when using benefits under this policy
Please ensure that all your dependents are covered and have a valid card at the outset itself as it will not be possible
to add dependents at a later stage
Submit your reimbursement claims within timelines from the hospital. Please do not postpone this till later as it may
mean that your claim gets rejected due to late submission .
Please check that your documents are submitted completely at the first instance itself and originals are submitted
wherever requested for . Do note that incomplete submissions will not be considered as exceptions by the insurers
and will only delay the process further for you and a delay may lead to the claim getting closed.
Please retain a copy of all claim documents submitted to the insurer
Please do a pre-authorization for all claims including a proposed reimbursement as it will clarify issues regarding
coverage for you well in advance of an expense being undertaken.

FAQ contd..

What are the key reasons why a claim under the medical policy could be completely rejected under the plan?
The following are some common reasons for rejection although these are NOT the only reasons why a claim could be
rejected :
1) Treatment taken after leaving the organization. (If you have been transferred from one business to another please
confirm with your HR that you have been included for coverage under your new entity)
2) Treatment that should have been taken on an outpatient basis (unnecessary inpatient admission and / or no active
line of treatment.) or where hospitalization has been done primarily from a preventive perspective. Please remember that
on occasion your personal doctor may recommend hospital admission for observation purposes however such
admissions are not covered under your medical plan
3) Treatment taken is not covered as per policy conditions or excluded, under the policy. Please go through the list of
standard exclusions listed earlier. (for e.g. : Ailment is a because of alcohol abuse is a standard exclusion, similarly
cosmetic treatments or treatments for external conditions like squint correction etc are not covered) . Hospitalization taken
in a hospital which is not covered as per policy conditions (Ex. less than 10 bed hospitals), Admission is before/after the
policy period or details of the member are not updated on the insurers list of covered members . Additionally in case
original documents are not submitted as per the claim submission protocol,

What are the key reasons why a claim under the medical policy could be reduced v/s sum insured ?
The following are some common reasons for rejection although these are NOT the only reasons why a claim could be
reduced : (1) Limits for the specific ailment exceed the reasonable cap on ailments listed in the manual,
(2) Claim amount exceeds the permissible limit under the policy for you ( denied to the extent of the excess),
(3) Some expense items are non payable for e.g. toiletries , food charges for visitors etc.

Contact Details
TPA Contact Details
Bajaj Allianz General Insurance
Co Ltd.
Insurer Website:
https://www.bajajallianz.com

1st Level Contact

Toll Free Nos
1800 22 5858
1800 102 5858
Fax Number of Cashless Dept: 020-30512224/6/7
Pre Auth Mail Id: Preauth@bajajallianz.co.in.

Bajaj Allianz General Insurance

Co ltd Health Care TPA Address
for sending reimbursement
claim documents:

Relationship manager Bajaj Allianz :

Shwetambari Rane
Email: shwetambari.rane@bajajallianz.co.in
Phone no:+917738367194

Health Claim Dept

Bajaj Allianz General Ins Co Ltd
Rustomjee Aspire, 3rd Floor, Everad
Nagar-2 ,Near APEX Honda,
Priyadarshini Circle,
Off Eastern Express Highway,
Chunabhatti Sion,Mumbai-400022

Vikhyat Rai
Email: vikhyat.rai@bajajallianz.co.in

Insurer

Marsh India Insurance Broker Pvt Ltd

Relationship Manager
Name: Ajay Shetty
Email: ajay.shetty@marsh.com
Phone no-7507606228
Escalation point
Name: Beena Nair
Email: Beena.nair@marsh.com