Standardized Guidelines for Group Health Insurance

Coverage available only to on-roll employees/contract workers. Policy coverage on named

basis and for annual period only.
Policy is on Individual Sum Insured basis and minimum 10 lives are required to initiate the
policy.

Description Coverage
Type of cover Indemnity
Sum Insured Type Individual Basis
Room Rent Limits 2% of Sum Insured
ICU Limit 4% of Sum Insured
Pre/Post Hospitalization days 30 days/60 days
Ambulance INR 1,000/- per person per event
Sum Insured Options 50K,75K,1L,1.5L,2L
Age Limit 60 years
Eligible Member Employee/Worker only
Initial Waiting Period 15 days for all claims except accidental
Hospitalization.
TPA IFFCO-Tokio Inhouse

Policy Exclusions
Pre-existing Diseases are not Covered
First Year Exclusion is not Waived
Maternity Benefit not covered
OPD is not covered
Domiciliary Hospitalization is not covered under the policy
Deletion of employee / Member from Group not allowed during the currency of the policy.
No refund will be allowed under the policy on account of policy cancellation.
 Addition of members Clause under the policy
Day one cover for New Joinee subject to receipt of premium / maintenance of CD balance
& intimation by 15th of succeeding month.
For Employees who are existing members of the group (at inception of the policy) who are
left out at inception of the Policy , such left out employees to be declared within 15 days
of the inception of the Policy.
In case of Non Compliance of above two conditions, the following conditions shall apply:
Midterm additions of Employee
1) Risk premium on pro-rata basis on each inclusion of Employee+ flat administrative
charges INR 250/- on each member + GST shall be leviable
2) Inclusion of such midterm members shall be subject to Waiting period of 1 month for all
claims except for Accidental Claims

Other Terms and Conditions

Descriptive list of Employees and SI should be duly recorded in policy documents.
All benefits as an inpatient in a hospital attached to room will be restricted to the room
which falls within the room rent limits allowed. The enhanced difference in expenses due
to opting rooms with higher room rent than what has been allowed will be borne by the
insured only. Wherever the room rent based tariff for the other expenses is not available,
the payment would be done in the same proportion as per the entitlement of room rent
under the policy excluding medicines, consumables and implants medically prescribed by
the treating doctor under the policy.
In case of package treatment where individual bifurcation of room rent, medicines,
operation theatre expenses, doctor's consultation charges etc. are not available, then the
package charges shall be proportionately linked to the entitled room rent of the insured
person under the Policy

Intimation of claims: Claim to be intimated within 7 days from the date of the Hospitalization.

Submission of Claim Documents: All Claim documents for reimbursement should be

submitted within 30 days from the date of discharge in case of claim for Pre-hospitalisation
and Hospitalisation expenses. For Post Hospitalisation expenses, all claim documents should
be submitted within 15 days of the completion of Post hospitalisation treatment or Post
hospitalisation days limit stated in the Policy whichever is earlier.
Per life premium and Group discounts are as under :

Sum Insured 50,000 75,000 1,00,000 1,50,000 2,00,000

Premium Per 1550 1950 2150 2700 3250

Life (without
GST )

Group Size Maximum Discount

Below 25 No discount
26 - 100 15%
101- 250 20%
251-1000 25%
Needs to be referred to
Above 1000 Underwriters

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