PROCEDURE FOR GROUP MEDICAL INSURANCE POLICY FOR THE REGULAR EMPLOYEES AND PENSIONERS OF INDIAN INSTITUE OF SCIENCE AND THEIR DEPENDENT FAMILY MEMBERS

Name of the Insurance Company: (Note: This changes every year as the tenure of the Insurance is from 1st August to July end every year

M/s GO DIGIT Co., Ltd.,

Help Desk: Mr. Mohammed Tajuddin 9028382257
Email: corporate@godigit.com

Note: For E-card contact Mr. Mohammed Tajuddin [9028382257]

For any further clarification, Contact:

Health Center:
Ph. No. 2293 2234/3617.

Dr. C Satish Rao, Chief Medical Officer, Health Centre
Ph. No. 2293 2226, health.center@iisc.ac.in, satishrao@iisc.ac.in

Mr. K Gopi, Assistant Registrar (HC)
Ph. No. 2293 3617

This is the procedure for the group Medical Insurance Policy and a part of the Institute Contributory Health Service Scheme:

1. CONTRIBUTION: The rate of contribution is 0.75% of the Basic Pay and DA in 7th CPC. In case of pensioners/family pensioners the contribution will be 0.75% of the Basic Pay and DA in 7th CPC that he/she would have drawn (at the time of retirement) by him/her had he/she continued in service now but for his/her retirement/death. This contribution covers both the inpatient (including group medical insurance) and outpatient services.

2. BENEFICIARIES: The regular employees and pensioners of the Institute with their dependents. The Insurance coverage is PAN INDIA.

Note: The members are requested to verify the list of insured kept in Human Resources Section for Faculties and for staff of B,C, & D Group.

3. DEFINITION OF FAMILY:

A. ‘Family’ in respect of employees

  • (a) Husband/Wife
  • (b) Parents or parents-in-law. A female employee has a choice to include either her parents or her Parents-in-law. Option exercised can be changed only once during the service period.
  • ( c ) Children including legally adopted children, stepchildren and children taken as wards subject to the following conditions:
    1. Unmarried Son: Till he starts earning or attains the age of 25 years, whichever is earlier.
    2. Daughter: Till she starts earning or gets married, whichever is earlier, irrespective of the age limit.

B. ‘Family’ in respect of pensioners: –

  • (a) In case of regular pensioners – Spouse only. If Pensioner has dependents with a permanent disability (Physical/Mental) as per Govt. of India rules, they will also be covered.
  • (b) In case of family pensioners (after the death of the pensioner) – only self
  • (c ) In case of family pensioners (death while in service) - till the date of normal retirement of the employee– self and dependent children. Beyond that date, self only.

C. The coverage under the policy would be without any upper age limit.

D. Dependency

The income limit for dependency of the family members (other than spouse) is Rs. 9,000/- per month plus the Dearness Relief admissible on Rs. 9,000/- on the date of consideration of the claim.

NOTE: The definition of dependent shall be governed as per guidelines issued by the Central Government from time to time.

E. Addition & Deletion of Family Members during the Running Policy

  • (a) Addition to the family is allowed in following contingencies during the policy:
    1. Marriage of the beneficiary (requiring inclusion of spouse’s name)
    2. New born Baby from day one.
  • (b) Deletion from Family is applicable in following contingencies:
    1. Death of beneficiary.
    2. Divorce of the spouse.
    3. Member becoming ineligible (on condition of dependency).

F. New Employees:

As regards to the new incumbents, the coverage in the group insurance scheme starts from date of submission of the family declaration and subsequent intimation to the Insurance Company. The family declaration should be submitted within 15 days from

the date of joining the Institute.

4. IDENTIFICATION OF BENEFICIARIES:

Beneficiaries shall be identified by a “Identity Card” issued by the Institute/Insurance company.

5. SUM INSURED AND BUFFER/CORPORATE SUM INSURED:

  • (a) Sum Insured : The Scheme shall provide coverage for meeting all expenses relating to hospitalization of beneficiary members up to Rs. 5,00,000/- per family per year in any of the registered Hospital/Nursing Home/Day Care Unit. The benefit shall be available to each and every member of the family on floater basis i.e. the total reimbursement of Rs. 5,00,000/- (Rupees Five Lakh only) can be availed either by one individual or collectively by all members of the family.
    If the employee/pensioner has also opted for the additional insurance, then the insurance coverage for the member plus family will be basic insurance of Rs. 5,00,000 + additional insurance.
  • (b) Buffer/Corporate floated: An additional Sum Insured of Rs. 35 lakhs shall be provided by the Insurance company as Buffer/Corporate Floater. In case hospitalization expenses of a family exceed the original sum insured of Rs. 5,00,000/- plus the additional sum insured if any, the beneficiary is required to inform the IISc Authority with the details. On case to case basis, the IISc., Authority will decide the distribution and disbursement of the buffer amount. The maximum buffer amount would be Rs. 5,00,000/- in case of Cancer, Kidney and Cardiac Ailments and in all other cases it would be limited to Rs. 50,000/- only. The buffer amount can be authorized only along with the basic coverage and exclusive buffer authorization is not admissible.
  • (c) Limitations:
    1. (i) Room Rent Limit: 2% of the Sum Insured i.e. including Top-up (subject to a maximum of Rs. 10,000/- per day) for hospitalization and no cap for ICU.
    2. (ii) The cost of maternity procedure is limited to Rs. 1,25,000/- for both normal and Cesarean Section.
    3. (iii) Cataract surgery is limited to Rs. 50,000/- per eye.

6. INSURANCE COVERAGE:

(A) In-patient benefits – The insurance scheme shall pay expenses (subject to policy limitations) incurred in course of medical treatment availed of by the beneficiaries in a registered Hospitals/Nursing Homes within Bangalore, arising out of either illness/disease/injury and/or sickness. The treatment must require at least 24-hours hospitalization (excluding day care procedures). A list of empanelled hospitals/nursing homes are in Annexure I. Any addition/deletion of Hospitals will be notified.

(B) Coverage of pre-existing diseases – Pre-existing diseases, if any, shall be covered from day one under this insurance scheme.

(C) Pre and Post hospitalization benefit – All expenses (subject to sum insured and expenses not covered and policy exclusions) during the Pre-hospitalization period up to 30 days and Post-hospitalization period of up to 60 days required due to the treatment of the sickness for which hospitalization was done would be covered in this scheme.

(D) Day Care procedures-

The scheme would also provide for day care facilities (which require less than 24 hours hospitalization) for identified procedures. List of such procedures are in Annexure II.

(E) MATERNITY AND NEWBORN BENEFITS

A. Maternity Benefit

  • (a) Maternity benefit is without 9 months waiting period.
  • (b) Includes maternity related procedure/treatments arising from childbirth (including both normal delivery/Caesarean section, including miscarriage or abortion induced by accident or other medical emergency)
    This benefit would be limited to only first two living children in respect of Dependent Spouse/Female Employee
    The new born baby will be covered by the insurance policy from the day one without any waiting period.
    The parents/guardians of the baby must report the birth of the child to appropriate IISc authority at the earliest.
    The cost of maternity procedure is limited to Rs. 1,25,000/-
  • (c) Treatment for infertility – covered up to maternity limit.
  • (d) Internal Congenital Diseases – Covered, External is also covered in case of life threatening.

B. Newborn Benefit

Newborn child (single/twins) to an insured mother would be covered under the scheme from day one for the expenses incurred for treatment taken in registered Hospitals/Nursing Homes/Day Care Clinics as an in-patient.

If, in first pregnancy, twins are born then the benefit stand ceases for second pregnancy. However, if in second pregnancy twins are born then both the children will be covered.

7. PROCESS FOR AVAILING CASHLESS CLAIM:

1. In each of cashless case IISc team will be intimate the insurance team.

2. Claims in respect of Cashless Services will be through the list of the network/empanelled Hospitals/Nursing Homes.

3. Cashless services for all planned medical treatment are subject to Insurance E-card, which is provided by Health Center and any photo Identity Card of the user to be produced at the time of admissions to the Network Hospitals.

4. In case of emergency, the Insurance Company should be contacted immediately after admission preferably through the hospital/ nursing home. The Insurance Company will send the authorization directly to the Hospital after obtaining the pre-authorization details from the Hospital.

5. The Insurance company shall pay the hospital expenses up to the sum insured (including basic coverage + additional insurance + buffer authorized, if any) and the employee/pensioner himself has to pay the balance amount to the hospital. The Institute will not take any responsibility in payment of the balance amount to the Hospital.

Please contact the Health Center for further details on procedures, forms etc.,

8. Claim Documents for non-Cashless Services:

Claim documents in original as per details below should be submitted to the Health Centre Pre-hospitalization 30days and Post-hospitalization 60 days for the particular illness from the Hospital to enable the Institute to forward the same to Insurance company for reimbursement. However, for Post-hospitalization treatment it shall be within 60 days from the date of completion of Post-hospitalization treatment.

Hospital Main Bills
Hospital Detailed Bills
Prescriptions
Cash Bills
Discharge Summary
Investigation Reports
X-ray and Scan reports
Cash Paid Vouchers

Note: All in Original

9 (a) EXPENSES NOT COVERED UNDER THE POLICY

  1. Diet charges
  2. Telephone charges
  3. Any other charges which were exclusively mentioned in the Policy.

(b) PERMANENT POLICY EXCLUSIONS

  1. Injuries or diseases caused by war and war like operations. Circumcision, Vaccination, Inoculation, Cosmetic treatment, Plastic surgery (other than as may be necessitated due to an accident or as a part of illness)
  2. Spectacles, Contact lenses, Hearing Aids, Crutches, wheel chairs, walking stick & collar
  3. Convalescence, General weakness, Congenital disease, Sterility, Venereal disease, Alcohol use, Self injury
  4. Diagnostic expenses not followed by active treatment for the ailment
  5. Vitamins and Tonics unrelated to treatment
  6. Injuries or diseases caused by nuclear weapons
  7. Abortion/voluntary termination during first three months of pregnancy
  8. Naturopathy Homeopathy and Unani treatments.
  9. Injuries sustained due as a result of active participation in any hazardous sports
  10. Diagnostics, X-Ray or Laboratory examination not consistent with or incidental to diagnosis of positive existence and treatment of any ailment, sickness or injury for which confinement is required at Hospital/Nursing Home
  11. Instrument used in treatment of Sleep Apnea Syndrome and Continuous Peritoneal Ambulatory Dialysis and Oxygen Concentrator for Bronchial Asthmatic Condition
  12. Genetic disorders and stem cell implantation/surgery
  13. Experimental and unproven treatment

All non medical expenses including convenience items for personal comfort such as telephone, television, Ayah, Private Nursing/Barber or beauty services, Diet Charges, Baby Food, Cosmetics, Tissue Papers, Diapers, Sanitary Pads, Toiletry items etc.

All expenses arising out of any condition directly or indirectly caused by or associated with Human T-Cell Lymphotrophic Virus type III (HTLD-III) or Lymphdanopathy associated virus(LAV) or the mutant derivative or variations deficiency syndrome or any syndrome or condition of similar kind commonly referred to as AIDS.

Domiciliary hospitalization

Dental treatment except in case of accident