Employee Benefits Manual

1. Start Employee Benefits Manual

2. Luminous Power Technologies What are the Insurance Benefits available to me ? Who are my Insurance Vendors? How do I utilize my benefits

3. Group Medical Next Program Details Provides insurance coverage to employees for expenses related to hospitalization due to illness, disease or injury Eligibility: Note : Employees who are covered under ESIC benefit (except Sales & Service) are excluded from Mediclaim insurance

4. Medical Benefit Coverage Details Enrollment in the program Cashless Process Non-Cashless Non Cashless Claims Process Claims Document List General Exclusions GMC Contact Details

5. Medical Benefit – Benefits Coverage

6. Medical Benefit – Standard Coverage Reimbursement expenses related to • Room, Boarding Expenses as provided by the Hospital / nursing home • Nursing Expenses • Surgeon, Anaesthetist, Medical Practitioner, Consultants, Specialists Fees • Anaesthesia, Blood, Oxygen, Operation Theatre Charges, surgical appliances, Medicines & Drugs, Diagnostic Materials and X-ray. A)The expenses are payable provided they are incurred in India and within the policy period. Daycare expenses B) Expenses on Hospitalisation for minimum period of 24 hours are admissible. However this time limit will not apply for specific treatments under Day Carei.e. Dialysis, Chemotherapy, Radiotherapy, Cataract , Lithotripsy (kidney stone removal), Tonsillectomy, D & C taken in the Hospital and the insured is discharged on the same day of the treatment will be considered to be taken under Hospitalisation Benefit.

7. Pre & Post Hospitalization Expenses Next

8. Maternity Benefits These benefits are admissible in case of hospitalisation in India. Covers first two children only. Those 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. Post 12 weeks of pregnancy, the expenses incurred towards medical termination of pregnancy are covered in case it is medically required and advised by a doctor

9. Emergency Hospitalization Planned Hospitalization Medical Benefit – Cashless Process Cashless means the Administrator may authorize upon a Policyholder’s request for direct settlement of eligible services and it’s according charges between a Network Hospital and the Administrator. In such case the Administrator will directly settle all eligible amounts with the Network Hospital and the Insured Person may not have to pay any deposits at the commencement of the treatment or bills after the end of treatment to the extent as these services are covered under the Policy. Note :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 needs to submitted separately as part of the claims reimbursement. Next

10. Non cashless Hospitalization Process Emergency Hospitalization & Process Step 1 Get Admitted In cases of emergency, the member should get admitted in the nearest network hospital by showing their ID card. P R O C E S S Pre-authorization given by Vipul Member gets admitted in the hospital in case of emergency by showing his ID Card No Step 2 Pre-Authorization by hospital Yes Relatives of admitted member should inform the call centre within 24 hours about the hospitalization & Seek pre authorization. The preauthorization letter would be directly given to the hospital. In case of denial member would be informed directly Member gets treated and discharged after paying all non medical expenses like refreshments, etc. Member/Hospital applies for pre-authorization to Vipul within 24 hrs of admission Hospital sends complete set of claims documents for processing to Vipul Vipul verifies applicability of the claim to be registered and issue pre-authorization Step 3 Treatment & Discharge After your hospitalisation has been pre-authorized the employee is not required to pay the hospitalisation bill in case of a network hospital. The bill will be sent directly to, and settled by Vipul Next

11. Planned Hospitalization Vipul authorizes cashless as per SLA for planned hospitalization to the hospital Step 1 Pre-Authorization Member intimates Vipul of the planned hospitalization in a specified pre-authorization format at-least 48 hours in advance Claim Registered by Vipul on same day Yes All non-emergency hospitalisation instances must be pre-authorized with Vipul, as per the procedure detailed below. This is done to ensure that the best healthcare possible, is obtained, and the patient/employee is not inconvenienced when taking admission into a Network Hospital. No Pre-Authorization Completed Follow non cashless process Step 2 Admission, Treatment & discharge Member produces ID 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 Vipul After your hospitalisation has been pre-authorized, you need to secure admission to a hospital. A letter of credit will be issued by Vipul to the hospital. Kindly present your ID card at the Hospital admission desk. The employee is not required to pay the hospitalisation bill in case of a network hospital. The bill will be sent directly to, and settled by Vipul Claims Processing & Settlement by Vipul & Insurer Next

12. Claim Docs Non-Cashless/ Re-imbursement • Admission procedure • In case you choose a non-network hospital you will have to liaise directly with the hospital for admission. • However you are advised to follow the pre authorization procedure to ensure eligibility for reimbursement of hospitalisation expenses from the insurer. • It should be a minimum 15 bedded hospital registered with the local authority • Minimum 24 hrs hospitalization should be there • Discharge procedure • In case of non network hospital, you will be required to clear the bills and submit the claim to Vipul 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 hospitalisation claim • You must submit the final claim with all relevant documents within 7 days from the date of discharge from the hospital. Next

13. Re-imbursement Claims Process Member intimates Vipul before or as soon as hospitalization occurs Claim registered by Vipul after receipt of claim intimation Insured admitted as per hospital norms. All payments made by member Insured Submits relevant documents to the Help desk within 7 days of discharge A Is claim payable? Is document received within 7 days from discharge Vipul performs medical scrutiny of the documents • Insured will create the summary of Bills (2 copies) and attach it with the original bills. • The envelope should contain clearly the Employee ID & Employee e-mail. Yes Yes No No Claim Rejected Is documentation complete as required ECS Payment will be done directly to the Employee bank a/c. Vipul checks document sufficiency Claims processing done as per SLA Yes No Receives mail about deficiency and document requirement A Next

14. Claims Document List *Please retain photocopies of all documents submitted Next

15. Benefit Extensions – Definitions √ X X √ Next

16. Medical Benefit – General Exclusions • Injury or disease directly or indirectly caused by or arising from or attributable to War or War-like situations • Circumcision unless necessary for treatment of disease • Congenital external diseases or defects/anomalies • HIV and AIDS • Hospitalisation for convalescence, general debility, intentional self-injury, use of intoxicating drugs/ alcohol. • Venereal diseases • Injury or disease caused directly or indirectly by nuclear weapons • Naturopathy • Any non-medical expenses like registration fees, admission fees, Hospital surcharge, charges for medical records, cafeteria charges, telephone charges etc • Any cosmetic or plastic surgery except for correction of injury • Hospitalisation for diagnostic tests only • Vitamins and tonics unless used for treatment of injury or disease • Infertility treatment • Voluntary termination of pregnancy during first 12 weeks (MTP) • OPD Claims • Claims (of high value) submitted without prescriptions/diagnosis • Health foods • Costs incurred as a part of membership/subscription to a clinic or health centre • Cost of appliances, spectacles, contact lenses, hearing aids Next

17. 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 Prudent Utilization of Benefit • 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 hrs) 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) Next

18. Medical Benefit – ContactDetails Next

19. We Care!