Regional office, Bhubaneswar

FAQs FOR GROUP MEDICLAIM POLICY FOR EMPLOYEES OF PSUs

UNDER GOVT. OF ODISHA

Health Insurance
The term ‘Health Insurance’ relates to a type of insurance that essentially covers your medical
expenses. A health insurance policy like other policies is a contract between an insurer and an
individual / group in which the insurer agrees to provide specified health insurance cover at a particular
“premium” subject to terms and conditions specified in the policy.

What a Health Insurance policy would normally cover

A Health Insurance Policy would normally cover expenses reasonably and necessarily incurred under
the following heads in respect of each insured person subject to overall ceiling of sum insured (for all
claims during one policy period).
a) Room, Boarding expenses
b) Nursing expenses
c) Fees of surgeon, anesthetist, physician, consultants, specialists
d) Anesthesia, blood, oxygen, operation theatre charges, surgical appliances, medicines, drugs, diag-
nostic materials, X-ray, Dialysis, chemotherapy, Radio therapy, cost of pace maker, Artificial limbs,
cost of prosthetic devices implanted during surgical procedure like pacemaker, orthopaedic implants,
infra cardiac valve replacements, vascular stents, relevant laboratory/diagnostic tests, X-ray and other
medical expenses related to the treatment.

Q. Why is Health Insurance important?

A. All of us should buy health insurance and for all members of our family, according to our needs.
Buying health insurance protects us from the sudden, unexpected costs of hospitalization (or other
covered health events, like critical illnesses) which would otherwise make a major dent into household
savings or even lead to indebtedness. Each of us is exposed to various health hazards and a medical
emergency can strike anyone of us without any prior warning. Healthcare is increasingly expensive,
with technological advances, new procedures and more effective medicines that have also driven up the
costs of healthcare. While these high treatment expenses may be beyond the reach of many, taking the
security of health insurance is much more affordable.

Q. What type of health policy is being offered to cover employees of State PSU.
A. Tailor made group health floater policy has been designed as per requirements of employee group.
The policy provides benefits up to the sum insured in a policy year to state PSUs serving & retired
employees and their dependent family members as per policy terms on floater basis. Outsourced
employees are excluded for coverage under the policy.

Q. Who can be covered under the policy?

A. Following persons can be covered under the policy:
Serving / Retired employee of state PSUs, who are member of OSPSEWS
Serving/ Retired employee of administrative departments of state PSUs, PE dept. who are
enrolled members of OSPSEWS

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Dependent legal spouse of the employee
Dependent first two children of the employee
Dependent parent/ parent-in-law of the employee subject to maximum two in number and no
inter/intra change of Parents / Parent-in-laws are not allowed.
(Total maximum six in number per family unit).

Q. Who are considered as dependent on employee for coverage under the policy?
A. Legal spouse, first two children, parents/ parents-in-law whose income from all sources shall not
exceed Rs 5,000/- per month.

Q. Whether dependent parents-in-law can be included?

A. Yes. The insured employee may opt to cover either of his/her own dependent parents or dependent
parents-in-law subject to maximum of two in numbers but no inter/intra changing between parents and
parents-in-law will be allowed.

Q. Is there any age limit for persons to be covered under the policy?
A. All serving/ retired employees and their dependent family members up to 80 years can be covered
under the policy.

Q. What is the maximum benefit available under the policy?

A. The policy would provide benefit up to Rs. 5 lakh on floater basis in a policy year per family unit of
an insured employee.

Q. What is Family Floater policy?

A. Family Floater is one that takes care of hospitalization expenses of insured members of your entire
family. This sum insured, which can be utilized by any/all insured persons in any proportion or amount
subject to maximum limit as fixed for insured employee family unit under the policy.

Q. Can the sum insured be increased or decreased during the policy period?
A. The sum insured selected at inception of policy is final and cannot be revised either
upward/downward in the midterm of the policy.

Q. Is there any sub limits on room rent ?

A. Yes. As per policy terms and conditions, per day room rent shall be restricted to 1% of sum insured
per day or the actual amount whichever is less in case of normal room.

Q. Is there any restriction on ICU Charges?

A. As per policy terms and conditions, ICU charges per day shall be restricted to 2% of sum insured
per day or the actual amount whichever is less.

Q. What is ailment sublimit? What is the sublimit for different ailments applicable under the pol-
icy?
A. Ailment sublimit is the restriction in terms of treatment cost applicable to specific common illness.
Under this policy sublimit shall be applicable for the following:

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 Cataract/Hernia/Hystectomy: Restricted to actual Expenses incurred or 25% of Sum Insured

whichever is less.
 Major Surgeries: Actual expense incurred or 70% of the sum insured whichever is less .
 Pre & Post hospitaliastion- Actual expenses incurred or 10% of the sum insured which ever is
less.
 Maternity -Restricted to Rs.30,000 for Normal and Rs.50,000 for Caesarean.
 Ambulance charges –Actual expense incurred; subject to a maximum of INR 2,500/- in a poli-
cy year.

Q. What does the health insurance policy not cover?

A. There would be certain standard exclusions such as cost of spectacles, contact lenses and hearing
aids not being covered, dental t r e a t m e n t / s u r g e r y ( u n l e s s r e q u i r i n g h o s p i t a l i z a t
i o n ) n o t b e i n g c o v e r e d , Vaccination and Inoculation other than for animal bite. convalescence,
general debility, Circumcision, Cosmetic surgery, Plastic surgery, Psychiatric and psychosomatic
disorders Injury arising out of drug/alcohol abuse congenital external defects, venereal disease,
intentional self-injury, use of intoxicating drugs/alcohol, HIV/AIDS, expenses for diagnosis, x-ray or
laboratory tests not consistent with the disease requiring hospitalization, experimental or unproven
treatment, All external equipment, Expenses on vitamins and tonics unless forming part of treatment for
injury or diseases as certified by the attending physician, War, act of foreign enemy, ionizing radiation and
nuclear weapon, Naturopathy acupressure, acupuncture, magnetic therapies, experimental and unproven treatments/
therapies. treatment.

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, elastocrepe bandages, external orthopaedic pads, sub
cutaneous insulin pump, Diabetic foot wear, Glucometer / Thermometer, alpha / water bed and similar
related items etc., and also any medical equipment, which is subsequently used at home etc.
Genetic disorders and Stem Cell implantation/surgery.
Change of treatment from one system of medicine to another unless recommended by the Consultant /
hospital under whom the treatment is taken.
Treatment for Age related Macular Degeneration (ARMD), treatment such as Rotational Field
Quantum magnetic Resonance (RFQMR), Enhanced External Counter Pulsation (EECP), etc.
All non-medical expenses including convenience items for personal comfort such as charges for
telephone, television, ayah, private nursing/barber or beauty services, diet charges, baby food,
cosmetics, tissue paper, diapers, sanitary pads, toiletry items and similar incidental expenses.
Any kind of Service charges, Surcharges, Admission Fees/Registration Charges, Luxury Tax and
similar charges levied by the hospital
For detailed exclusions, please refer to policy document.

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Q. What is OPD treatment? Is OPD treatment covered under this policy?
A. OPD treatment is where the insured person visits a clinic / hospital or associated facility like a con-
sultation room for diagnosis and treatment based on the advice of a Medical Practitioner. The Insured is
not admitted as a day care or in-patient. OPD treatment is not covered under this policy.

Q. What is Corporate Buffer?

A. This is a special provision made under the policy under which additional amount of rupees one
hundred lakh which floats on all employees of all state PSUs covered under either under a single/
multiple group health policies on a first cum first serve basis. This provision has been provided to meet
the contingency of additional admissible hospitalization expenses of insured member exceeding his
sum insured in a policy year.

The above amount shall be available to cover additional admissible expenses up to Rs. 5 lakh beyond
employees’ maximum sum insured in respect of eleven specified critical illnesses of an insured family
unit in a policy year. The amount will be made available to insured member on recommendation of the
Welfare society on a first-cum-first serve basis till exhaustion of the above corpus.

This aggregate corporate buffer amount is final and shall float over all insured members covered either
under a single/ multiple group policies issued to PSUs in a year. The above amount shall be available to
cover additional admissible expenses up to Rs. 5 lakh beyond employees’ maximum sum insured in
respect of eleven specified critical illnesses of an insured family unit in a policy year. The amount will
be made available to insured member on recommendation of the Welfare society on a first-cum-first
serve basis till exhaustion of the above corpus.

Q. What are the eleven critical illnesses under Corporate Buffer provision?
A. Following eleven illness/diseases are eligible for sanction of additional amount from Corporate
Buffer:

Cancer of specified severity, First heart attack of specified severity, Coronary Artery Surgery(CABG)
Open Chest CABG, heart valve replacement, Coma of specified severity, Kidney Failure, Stroke
resulting in permanent symptoms, Major Organ/Bone Marrow Transplant, Multiple Sclerosis, Major
Neurone Disease with Permanent Symptoms, Permanent paralysis of Limbs.

Q. What happens if the Sum Insured/ corporate buffer is exhausted?

A. Once the sum insured of an insured family unit is exhausted in a policy year, cover for that insured
family unit will cease till expiry of the policy period. Similarly, buffer provision of the policy will cease
on exhaustion of buffer amount in a policy year.

Q. What is the procedure for availing buffer provision of the policy?

A. After getting the request from hospital / insured member, the welfare society will process the same
and recommend to policy issuing office of the insurance company for release of additional amount
from the available corporate buffer fund which would be sanctioned by the insurance company within
two working days from the date of receipt of request by them.

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Q. What are documents required to be submitted for availing buffer amount?
A. The insured claimant needs to submit the request to welfare society for sanction of additional
amount beyond his sum insured by the insurance company. The application needs to be supported by
documentary evidences from the treating hospital with regard to details of illness/disease and additional
cost involved thereof.

Q. Is Maternity Expenses covered under this policy?

A. Yes, policy covers maternity expense of insured female employee right from day one. As per the
policy terms & condition the maximum benefits for maternity will be allowed for first two children up
to INR 30,000 for normal delivery & up to INR 50,000 for caesarean section. Please note that materni-
ty benefit will be covered only if she herself is an employee.

Q. Is Baby Well-Care charges covered under this policy?

A. Baby Well-Care charges for a new born baby are covered under the Policy within the maternity ben-
efit sum insured limit of the female employee.

Q. Does this Policy Cover expenses related to medical complications for the Baby? Are there any
limits?
A. Policy covers medical complications of the baby post-delivery right from day one within the Plan
sum insured.

Q. What is Waiting Period? Is there any Waiting Period for claims under this policy?
A. Generally, there will be a 30 days waiting period starting from the policy inception date, however,
this waiting period under the policy is waived..

Q. What is pre-existing condition in health insurance policy? Is pre-existing condition covered

under this policy?
A. Pre-existing condition is a medical condition/disease that existed before you obtained health insur-
ance policy. Generally the insurance companies do not cover such pre-existing conditions, within
12/24/48 months prior to the first inception of policy. However, the Pre-existing conditions under the
policy are waived.

Q. How can an employee enroll for the policy?

A. Serving/ retired employees of the State PSUs, who are members of the Welfare Society and who opt
to join the scheme voluntarily and pay required amount towards premium in time through their
respective PSU employer would be enrolled for coverage. The employee need to provide details of
his/her dependent family members details along with his family members photographs in the required
format designed for the purpose duly signed and mentioning the names of the member at the backside
of the photograph for inclusion for coverage.

Q. Whether disclosure of existing health policies by employee is required?

A. Yes.

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Q. Whether an employee holding existing health policy can join this policy?
A. Employee may avail the cover at his option.

Q. In case the employee is covered under both individual as well as group health polices, then
how his claim will be settled?
A. The insured claimant would have the option to prefer claim on policy of his choice in case of
multiple policies covering him. For e.g, if insured has two policies of one having sum insured of Rs. 3
Lakh and the other having Rs. 5lakh Sum Insured and his total claim towards medical expense is Rs.5
Lakh and the insured has a choice to claim either on Rs. 5 Lakhs policy or he can claim first Rs. 3
Lakhs from the earlier policy and balance Rs. 2 Lakh from the subsequent policy.

Q.What are the modes of payment of premium?

A. Total amount i.e. premium plus applicable service tax collected from its’ employees who opt to be
covered under the group health policy(ies) shall be remitted by PSUs/ Welfare society, as the case may
be, to the designated office of the insurance company by cheque/ECS/NEFT/. However, the payment of
premium by NEFT is recommended.

Q. If my health cover is not renewed in time, will I be covered ?

A. Required premium for renewal of policy are to be paid to the Company on or before expiry date of
the policy. Coverage will not be available to employees for the period unless required premium is
received by the insurance company. The policy will lapse if the premium is not received by the
Company within due date. Employee and it’s family members will be excluded from coverage of the
policy in case of default of premium payment by him. Employees/ PSUs/Welfare society at their own
interest should arrange to make payment of renewal premium before due date in order to have
continuity of coverage.

Q. What is cashless facility?

A. Insurance companies have tie-up arrangements with several hospitals all over the country as part of
their network. Under a health insurance policy offering cashless facility, a policyholder can take
treatment in any of the network hospitals without having to pay the hospital bills as the payment is
made to the hospital directly by the Third Party Administrator, on behalf of the insurance company.
However, expenses beyond the limits or sub-limits allowed by the insurance policy or expenses not
covered under the policy have to be settled by you directly with the hospital. Cashless facility, however,
is not available if you take treatment in a hospital that is not in the network.

Q. What is a health Identity Card?

A. A health photo Identity Card will be given to you by servicing TPA. It will consist of the name of
your PSU, your employee / Society Membership ID, a Unique identification number, policy period and
TPA’s address and contact details. The Health card will help in availing cashless facilities in TPA
network hospitals.

Q. What will the validity of the card?

A. Initially one year which may be extended subsequently.

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Q.What is my recourse, if ID card is not given to me? Will I be able to avail cashless facilities
without the same?
A. Please inform your welfare officer who in turn will inform United India TPA to send you another
card. Cash less cannot be availed without the health ID card.

Q. What is the procedure of applying for a new health ID card in case of loss?
A. Alongwith ID card a welcome letter will be given to you with your login ID and password. This will
help you to go on to serving TPA website and download E-card which work similar to the health ID
card.

Q. In case of hospitalisation, who should intimate the TPA?

A. In case of hospitalisation in TPA network hospital, the insured is required to submit the health ID
card at the time of admission in the hospital and the hospital authorities will inform the TPA. In other
cases, the insured member will inform TPA within the time specified in the policy.

Q. What is the procedure to be followed for cashless directly with network hospitals?
A. Cashless facility can be availed servicing TPA network hospitals. The procedure as mentioned below
needs to be followed for availing cashless facility.
 Chose network hospital from updated servicing TPA network list of hospitals on the website.
 Show your health ID card issued by servicing TPA at the time of admission at hospital. Collect
the pre-authorization form from the hospital corporate Desk. Fill-up personal details and the
rest to be filled up by the hospital treating doctor alongwith contact number.
 Hospital will send the fax/email to the servicing TPA.
 TPA will acknowledge receipt of intimation regarding hospitalization to the insured member
through mobile application.
 Servicing TPA shall process the claim as per policy terms & conditions and send an approval
letter to Hospital for treatment of insured member.

Q. What if the there is no help desk in the hospital or there is no one available in the help desk?
A. All TPA network hospitals have help desk to deal with health insurance claims. The insured to
approach Corporate Desk of the hospital with health ID card issued by servicing TPA for cashless
facilities.

Q. If TPA does not respond, or no adequate response is obtained then whom to approach next?
A. TPA network hospitals will directly deal with servicing TPA for claim settlement. The contingency
may arise in case of settlement of re-reimbursement claims. In such cases the claimant may approach
our policy servicing office/ TPA's higher office as per the escalation matrix provided by the servicing
TPA in the information sheet which would be sent by the TPA alongwith health ID Card to the insured
employees.

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Q. If the hospital does not recognize the health card issued by the TPA , what am I supposed to
do?
A. Health ID cards issued by servicing TPA to insured members are unique ID and members’ data in
the health card are captured in the TPA’s software. Insured members should contact servicing TPA
with their employee/member id on all correspondence sent by the hospital to enable them to retrieve all
details of the insured members for extending cash-less facility for treatment availed in net-worked hos-
pitals.

Q. Can a hospital be added under the cashless tie up list during the policy period?
Yes. Adding up hospitals into TPA’s network is a continuous process and the TPAs servicing health
policies in India are negotiating with hospitals and bringing them under their net-work to provide cash-
less facilities to insured members under health policies. List of network hospitals are updated in TPAs’
website regularly. Sometimes hospitals are removed from the list as they deviate from the norms as
agreed or are violating the parameters as confirmed. For an updated list of hospitals do visit the TPA’s
website.

Q. How the claim will be settled in case of a retired employee and/or his family residing in the
interiors of the State of Odisha?
A. In case of remote/interior places where there is no cashless facility, the insured to collect all the
relevant documents in original in respect of hospitalization treatment from the hospital/nursing home
and submit the same to TPA Bhubaneshwar office for reimbursement.

Q. How much time TPA will take to settle reimbursement claim ?

A. Maximum 15 days from the date of receipt of all relevant documents/ clarifications.

Q.How can claimant employee will know the status of his claim?
A. Servicing TPA will update insured claimant on status of claim through mail/mobile applications.
Insured claimant can also know the status of his claim by logging in TPA’s website. SMS intimation
will also be given by servicing TPA to the insured’s mobile number. The insured member may contact
the TPA office/ policy issuing office also for claim updating.

Q.What are the documents required to be submitted by the employee for claim settlement?
A. In case of cashless settlement, TPA will collect the documents from the concerned hospital.
However, in case of reimbursement, documents like discharge summary, prescriptions, bills,
investigation reports etc. should be collected from the concerned hospital and submitted to the TPA’s
Bhubaneswar office for payment .

Q. What if the cashless payment is not received by the hospital on time?

A. In cases of delay in communication of approval to hospital byTPA, the employee may servicing TPA
as per escalation matrix provided in the information sheet. The employee may also contact our policy
servicing office for delay. Contact policy issuing office. The number is 0674-2572735, Mobile-
9437003294.

Q. Where the claim will be settled? Whom to contact in case of delay ?

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A. Claim will be settled by TPA at their Bhubaneshwar office. In case the claim is not settled within
reasonable time, the employee may contact the policy issuing officer i.e United India Insurance, Branch
Office Satya Nagar, BBSR-7.

Q. Under what circumstances, my claim may get denied?

A. A claim may be denied under few of the following circumstances:
If the disease for which a claim is put forward, falls under the permanent exclusions of the policy.
If the treatment is taken as an Out Patient other than accidental claims.
If hospitalization expense is mainly involving investigation charges and there is no active line of treat-
ment given to the patient.
If hospitalization was for a duration less than 24 hours (unless listed under day care)
If hospitalization is not required for treating the medical condition and the treatment could have been
administered as an outpatient.

Q. Do I have to pay to hospital even when I avail cashless treatment?

A. Insurance policy covers medical expenses that are reasonable and necessary. However, non-medical
expenses (NME) shall not be payable under most health insurance policies.
You may have to pay in situations if you have availed a room that is higher than the room category you
are eligible as per your policy in which case you would have to bear differential room rent cost.

Q. How do I get update on the cashless claim status?

A. You can check the status of your claim by visiting TPA’s web site through your web or mobile
browser.

Q. Do I need to provide any other proof to Hospital at the time of availing Cashless?
A. You will be required to provide an authenticated photo id proof in addition to the Medi Assist ID
card. The photo ID could be in the form of Passport, Voters ID, Driving License, Employee ID with
Photo, ATM Card with photo, Adhaar Card etc.

Q. Can I change the hospital during course of treatment?

A. Yes, provided the further course of treatment is taken at a hospital with proper discharge on the ad-
vice of the Hospital.

Q. How do I get reimbursement of my hospital expenses if cashless is not availed?

A. When you have availed treatment in a Network hospital by paying full bill amount or accessed a
hospital which is not in TPA network, you can submit original bills for such expenses to servicing TPA
for processing the payment on reimbursement basis as per policy terms and conditions.

Q. How do I intimate claim?

You can intimate a claim by writing to servicing TPA, by calling toll free number / dedicated telephone
number of the TPA or by accessing web site through mobile application.

Q. I have paid the hospital bills, what should I do now to get back the money? Will I get back all
the money that I paid?

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A. You will have to submit a reimbursement claim with servicing TPA by submitting all documents in
original. Your reimbursement claim shall be processed by TPA as per your policy terms & conditions.
Non-medical expense or NME if any shall not be paid.

Q. Where do I submit reimbursement claim documents?

A. You can submit your claim documents to TPA’s Bhubaneswar office.
Please refer and follow the process elucidated below to claim your hospitalization expenses:-
Fill in the reimbursement form. Submit the filled form along with the hard copy of the documents with-
in 30 days of discharge from hospital/nursing home. The documents that you need to submit for a hos-
pitalization reimbursement claim are:
• Original hospital final bill
 Pre-Numbered / Printed Receipts for payments made to the hospital
• Complete break-up of the hospital bill
• Original Detailed Discharge Summary
• All Investigation reports
• All medicine bills with relevant prescriptions
• Operation Theatre Notes in the event of a surgery performed
• Sticker for the Implant, if any, used during surgery
• A copy of the Invoice for the implant, if any, used during surgery performed
• Original duly completed and signed claim form
• Duly completed and signed Medical Practitioner’s Form
• Copy of our ID card or current policy copy and previous years’ policy copies if any
• Company Employee ID card if you and your family are insured through your employer

Q. Can I submit photo copies of the documents?

A. All original documents are required to be submitted in original as photo copies are not accepted.

Q. How do I get update on the status of reimbursement claim?

A. You can check the status of your claim by visiting track.medibuddy.in through your web or mobile
browser, click on any option followed by the date of hospitalization.

Q. How many days do I have to send my bills for reimbursement?

A. All the bills along with the claim form have to be submitted to TPA within 15 days from date of dis-
charge from hospital.

Q. How do I get the claim amount?

A. Claim amount would get credited to your account within 15 days from the date TPA receives com-
plete claim documents/ clarifications.

Q. Do I get back my original reports in case required for further treatment or in case of critical
illness or for follow-up?
A. Original reports can be returned to you only with the concurrence of the insurance company.

Q. Do I need to pay any money at the time of discharge?

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A. In case of Non Network Hospitals – You will have to make all payments yourself and then forward
the claim (all the hospital documents and signed claim form in original) to TPA in order to get claim
reimbursed from Insurance Company.

Q. What is Domiciliary Hospitalization Expenses and is it covered under this policy?

A. Medical Treatment for a period exceeding 3 days for such illness/disease/ injury which in the nor-
mal course would require care and treatment at the Hospital /Nursing Home but actually taken whilst
confined at Home in India under any of the following circumstances:
Condition of the patient is such that he/she cannot be moved to the hospital /nursing home
Or
The patient cannot be moved to the hospital/nursing home for lack of accommodation therein.
Domiciliary expenses are not covered in this policy. Please refer to the policy document.

Q. What is Congenital Anomaly? Is Congenital Anomaly covered as part of this policy?

A. Congenital Anomaly refers to a condition(s) which is present since birth, and which is abnormal
with reference to form, structure or position.

There are two types of Congenital Anomalies

Internal Congenital Anomaly: which is not in the visible and accessible parts of the body is called
Internal Congenital Anomaly

External Congenital Anomaly: which is in the visible and accessible parts of the body is called Ex-
ternal Congenital Anomaly .
Treatment of Internal Congenital Anomaly is covered in this policy, whereas treatment of external con-
genital anomaly is not covered in this policy.

Q. What are alternative treatments ?

A. Alternative Treatments are forms of treatment other than treatment ‘Allopathy’ or ‘modern
medicine’ and includes Ayurveda, Unani, Siddha, Homeopathy. For Ayurvedic/Homeopathic/Unani
Treatment. Hospitalization expenses are admissible only when the treatment is taken as in patient in a
Government Hospital/Medical College.Hospital.

Q. What is the time period for ANY ONE ILLNESS:

A. Any one illness means continuous period of illness and it includes relapse within 45 days from the date of
discharge from the Hospital / Nursing Home from where treatment has been taken. Occurrence of same illness
after a lapse of 45 days as stated above will be considered as fresh illness for the purpose of this policy.

Q. Is Lasik surgery covered under my policy?

A. Lasik surgery is not covered under your policy.

Q. Is Genetic disorder treatment covered?

A. Treatment to genetic disorder is not covered under the policy terms and conditions.

Q. Is family planning covered in the policy?

A. Family planning is not covered under the policy.

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Q. Is weight loss program covered?
A. Weight loss program is not admissible under the policy terms and conditions.

Q. What is payable as per policy for any cosmetic treatment?

A. Any cosmetic treatment is not covered under the policy terms and conditions.
Q. Are physiotherapy treatments covered?
A. Physiotherapy treatments shall be covered if deemed necessary by the treating doctor. This can be
part of pre or post hospitalization expenses taken under Domiciliary Treatment.
Q. What are pre & post hospitalization expenses & for how many days can they be claimed?
Pre Hospitalization expenses are the medical expenses incurred 30 days prior to date of admission of
the insured person/patient. This implies that pre hospitalization should be followed by hospitalization
more than 24 hours with active line of treatment.
Post Hospitalization expenses are the medical expenses incurred immediately after the insured person /
patient is discharged from the hospital. Such medical expenses are incurred for the same condition for
which the insured person’s/patient’s hospitalization was required and the inpatient hospitalization claim
for such hospitalization is admissible by the insurance company till 60 days from Date of discharge.

Q. Is Dental implant covered?

A. Dental treatment or surgery of any kind which is done in a dental clinic and those that are cosmetic
in nature are not payable.
Q. Is filling tooth cavity covered?
A. We wish to bring to your notice that tooth cavity filling is not covered under the policy terms and
conditions.

Q. Is scaling and polishing of teeth payable?

A.No, scaling and polishing of teeth is not covered under the policy terms and conditions.
.
Q. Is planned termination of pregnancy due to personal reasons covered?
A. Termination of pregnancy due to personal reason shall not be covered.

Q. Is doctor advised medical termination of pregnancy owing to a complication payable?

A. Termination of pregnancy due to complications and recommended by expert is covered under the
policy however final decision on the admissibility of the claim will be done after scrutiny of documents.

Q. Is Alcoholic Cirrhosis of liver treatment payable?

A. No, treatment of Cirrhosis due to alcohol is not covered under the policy.

Q. Is terrorism risk covered?

A. No.

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Q. What is the minimum duration for Inpatient Hospitalization?
A. 24 hours duration is mandatory for Inpatient Hospitalization along with active line of treatment, un-
less it is a Day Care Procedure as listed by the insurer which does not require 24 hours admission.

Q. What is a Day Care Procedure?

A. Day Care Procedure means the course of medical treatment / surgical procedure in specialized Day
Care Centre which enables the insured person to be discharged on the same day. The requirement of
minimum number of beds will be waived, provided other conditions of a Hospital are met. Please refer
to the list of Day Care Procedures for which 24 hours hospitalization condition is waived.
Q. What are the ailments covered in day care?
Only expenses on hospitalization for minimum period of 24 hours are admissible. However, this time
limit is not applied to specific treatments defined under day care list i.e., dialysis, chemotherapy, radio
therapy, eye surgery, lithotripsy (kidney stone removal), tonsillectomy etc. taken in the hospital/nursing
home and the insured is discharged on the same day. In these cases the treatment will be considered as
taken under Hospitalization benefit.

Q. What happens when an employee/member has joined & there is a hospitalization during the
period when the cards are yet to be received?
A. Employees/ members are covered from the date of joining; they can obtain e-card which can be used
in case of hospitalization. Alternatively, payment can be done by the employee/ member and reim-
bursement can be taken.
Q. What expenses are payable as a part of pre hospitalization and post hospitalization expenses?
A. Consultation charges, prescribed medicines, prescribed investigations, physiotherapy (associated
with hospitalization only) etc.

Q. I have to undergo a transplant surgery? Is the claim payable?

A. Expenses related to donor screening, treatment, including surgery to remove organs from the donor
in case of a transplant surgery is covered within the plan sum insured selected by you. However the
cost of the organ will not be payable.

Q. I have to get some investigations done as advised by my Doctor! How do I claim them?
A. Investigation during 30 days pre-hospitalization, whilst hospitalized & 60 days post hospitalization
may be covered as far as the same is recommended by treating doctor & is deemed medically necessary.

Q. What are the tax benefits I get if I opt for Health Insurance?
Ans. Health insurance comes with attractive tax benefits as an added incentive. There is an
exclusive section of the Income Tax Act which provides tax benefits for health insurance, which is
Section 80D.

Service the gateway to Growth Page 13

Regional office, Bhubaneswar
FOR FURTHER DETAILS CONTACT OUR SERVICING OFFICE :
(I) UNITED INDIA INSURANCE CO LTD
A) SERVICING OFFICE:
Mr. CHITTA RANJAN SAMANTARAY
SENIOR BRANCH MANAGER
BRANCH OFFICE,
10 SATYA NAGAR, BHUBANESWAR 751007
Cell No : +91 9437003294
Email ID: corpcellmumbai@gmail.com
OTHER CONTACT POINTS
B) REGIONAL OFFICE TEAM:
Mr. PITAMBER BEHERA
MANAGER, HEATH DEPT.
MOB : +91 9437136936
Email ID: pitamberbehera@uiic.co.in
Mr. P.K.PATNAIK
CHIEF REGIONAL MANAGER
TEL: 0674-2391738
Email ID: pkpatnaik@uiic.co.in
II) THIRD PARTY ADMINISTRATORS:
A)Medi Assist India TPA Pvt. Ltd
Mr. Joyti Ranjan Behera
Team Leader
Plot No. 656 ( 2nd. Floor), Sahid Nagar
Bhubaneswar 751007
Tel. No. 0674- 2549314
Cell No. +91 9438409998
Email: joytiranjanb@mediassis$ndia.com
Rajendra Kumar Khuntia
Branch Head
Dept. - Operation
Premier Court( 4th. Floor),
No.:4 Chandni Chowk Street,
Kolkatta 700 072
Tel. NO. 033- 40534614/ 40534615
Mobile No.: + 91 8585056760
Eamil id: rajendrakk@mediassistindia.com>
Website : www.mediassistindia.com
B) Second TPA details will be shared
_____________
Service the gateway to Growth Page 14