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INDEX

1. GENERAL . ii 2. RULES iii 3. ENROLLMENT . vii 4. ANNUAL LIMITS viii 5. EXCLUSIONS .. ix

6. DOS AND DONTS ..... x 7. PROCEDURE FOR QUERY / ENROLLMENT / COLLECTION OF AUTHORISATION LETTER .. xi

GENERAL
1. This scheme will be termed Medical Benefit Scheme hence after referred to as M.B.S. 2. It will cover permanent employees of TATA MOTORS, Pune who are not covered under E.S.I.S./Apprenticeship Act. 3. It will be effective from 1st April, 2003. 4. This cancels all previous schemes. 5. THIS SCEHEME DOES NOT GUARANTEE 100% REIMBURSEMENT OF MEDICAL EXPENSES. 6. The rules laid down for reimbursement of claims should be strictly followed. 7. The Company reserves the right to add, delete, change, and modify any part or whole of this scheme including procedures and rules, at its discretion any time it feels necessary.

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RULES
1. Enrollment of yourself and your dependent family members will be the first step necessary for getting reimbursement of your medical claims through Medical Benefit Scheme. Details of enrollment are mentioned on page no. vii 2. There is an approved Panel of Consultants but there is no panel for General Practitioners, Dentists & Radiologists (X-Ray specialists). 3. TREATMENT FOR COMMON/ MINOR AILMETS may be taken from a General Practitioner. He /she however, must have any of the qualifications mentioned below. Allopathy : M.B.B.S., L.C.P.S., M.R.C.S.L.R.C.P. Ayurvedic : B.A.M.S., G.F.A.M., D.A.S.F., M.F.A.M., D.S.A.C., M.A.Sc., M.D. (AYU), AYURVED VISHARAD. Homeopathy: L.C.E.H., D.H.M.S., M.H.M.B.S., B.H.M.S., MD. Dental : M.D.S., B.D.S., L.D.S. Approval for reimbursement of treatment taken from a practitioner with any other qualification will be at the discretion of the company. 4. Medicines given by General Practitioner from his own stock are not reimbursable. Medicines prescribed by the General Practitioner / Consultant will be reimbursed as per the M.B.S. rules. 5. Treatment given by a Panel Consultant in his / her own specialty only will be reimbursed as per rules. 6. Treatment taken from a Non-Panel Consultant will be reimbursed through the Medical Benefit Scheme, only if the same is taken in a Multi specialty hospital where that Consultant happens to be on that Hospitals Panel. 7. Claim should be supported by proper ORIGINAL receipts, photocopies of prescriptions and reports. Receipts should be printed, with Doctors name and qualifications. Scribbled receipt on any piece of paper with or without rubber stamp will not be accepted. Investigation reports, once submitted cannot be returned. If therefore, these are required for future use, please submit photocopies of the same with the medical claim. 8. Claim should be submitted in the standard form. These forms are available in all factory dispensaries. THESE FORMS ARE NOT ABVAILABLE IN MEDICAL BENEFIT SCAHEME CELL. Completed claim should be dropped in the Medical Claim Box only.

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9. Claim form should be filledin completely, legibly and correctly, THE PERSSONAL NUMBER ESPECIALLY SHOULD BE WRITTEN CORRECTLY. 10. Claims must be submitted within one month of completion of treatment. In case of continuous treatment, part claim should be submitted. However, claims for medical expenses during a particular financial year must be submitted in that particular year. 11. There is no panel of X-Ray specialists. However, X-Ray must be obtained from a qualified X-Ray specialist having qualifications as M.D. (Radiology). 12. There is a separate panel of experts in Ultrasound (Sonography). Kindly tell your doctor that the investigation of ultrasound (ULTRASONOGRAPHY) has to be carried out from one of the Panel Ultrasound Experts only. 13. All pathological investigations have to be carried out at a Panel Pathologist / Panel Laboratory. 14. All treatment connected with the pregnancy or any gynecological problem must be taken from a Gynecologist on the Panel. Any such treatment from a general practitioner or a Gynecologist not on the panel (even including the diagnosis of pregnancy) will not be reimbursed. 15. Claims under Maternity Benefit for first two living issues only will be reimbursed to be employee. No maternity claim will be reimbursed after two living issues to any employee. 16. Claims for abortions / miscarriage / MTP will be reimbursed on a total number of two occasions only before the second issue. Claims for MTP after the second issue will be reimbursed only if the MTP is accompanied with Tubectomy /Vasectomy operation within one month. 17. The company will reimburse the medical expenses as per existing rules for the operation of rejoining of the vas / rejoining of fallopian tubes in the rare event of an employee / spouse who a has undergone vasectomy / tubectomy, loses subsequently all his / her children in an unforeseen mishap. 18. In case of hospitalization, when the expenses are anticipated to be more than Rs. 300/- the employee can avail himself / herself of a direct payment facility. This facility is also available for certain modern, expensive Investigations / Procedures like MRI / CAT SCAN. It is not available for routine investigations. 19. Costly vaccines that are included in the list of WHOs (World Health Organization) Immunization Schedule will be reimbursed from hospitalization Budget.

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20. Following Multi-specialty Hospitals in Pune have offered a concessional Schedule of charges for TATA Motors - Pune. Whenever a TATA Motors patient is admitted in theses Hospitals under care of a Consultant who is on the Panel of that hospital (who may not be in the panel of TATA Motors) an Authorization letter can be issued in his/ her name. For administrative convenience, it is necessary that Authorization letter is collected from MBS office by the concerned employee before admission / discharge of patient.

List of Multi- specialty Hospitals


Grant Medical Foundation (Ruby Hall), Pune Inlaks and Budhrani Hospital, Pune Sanjeevan Hospital, Karve Road, Pune MMF - Ratna Memorial Hospital , Pune MMF - Joshi Hospital, Pune Deenanath Mangeshkar Hospital, Pune Sahyadri Hospital, Karve Road, Pune Jehangir Hospital, Pune Lokmanya Hospital, Chinchwad Lokmanya Hospital, Nigdi Niramaya Hospital, Chinchwad Aditya Birla Hospital, Thergaon Sant Dnyaneshwar Hospital, Bhosari Moraya Hospital, Chinchwad

21. Company will undertake to pay the full amount of hospital bill up to a limit of Rs 10,000/- only. The amount so paid will be treated as an advance to the employee and NOT as reimbursement. In those cases where it is expected that the total expenditure will exceed this amount, the employee or the consultant concerned should contact the Medical Department of the Company and appraise it of the situation. 22. Reimbursement granted by the Company to employee for medical treatment is subject to Income-Tax rules and deduction for such Income-Tax if any, will be done by the Company as per existing rules of the Income-Tax Act. 23. On payment of the bill, Company will adjust the amount paid against various items as per MBS rules and accordingly settle the bill for the employee. The excess if any, over the settled amount will be recovered from the employees salary directly, in suitable installments, determined by the Company from time to time. ANY PAYMENT / RECOVERY WILL BE MADE THROUGH SALARY SLIP ONLY. 24. Apart from the hospital bill, for any additional medical expenditure incurred by the employee DURING the hospitalization, a separate claim should be submitted. It should be accompanied by a photo copy of the Discharge Card. 25. Dental / Psychiatric / Allergic treatment will be considered for reimbursement under the respective heads up to the limits laid down only. They will not be considered under the category of Hospitalization / Domiciliary. 26. There are certain Diagnostic Centres who also have offered concessional rates for Investigations carried out in their Centres. Following is the list of such Centres v

where investigations will be carried out on Tata Motors employees (who are enrolled in the Companys MBS) at concessinal rates as indicated.

LIST OF DIAGNOSTIC CENTRES


Omega Scan Centre, Poona Hospital Complex, Pune Poona Diagnostic Services, Poona Hospital Complex, Pune Nissan, Sancheti Hospital campus, Pune Apollo Scan Centre, Jehangir Hospital, Pune Anushka Scan- KEM Hospital Campus, Pune Medivision (Gyro), Near Saras baug, Pune P H Medical Centre, Pune Satara Road Niramaya Hospital, Chinchwad Ruby Hall Clinic, Pune Lokmanya Hospital, Nigdi MEGAVISION Scans, Nigdi Vision Scan, Yerawada Inlaks & Budhrani Hospital, Koregaon park, Pune Medinova Diagnostic centre, Pune

27. OUTSIDE PUNE, where Panel of consultants is not available; the following rates would prevail for reimbursement of HOSPITALISATION treatment. Attending Doctor 1. Post Graduate degree in the Specialty like M.D. / M.S. 2. Post Graduate diploma in the Speciality like DGO / DCH 3. M.B.B.S., L.C.P.S. B.A.M.S. and Other qualification accepted by the Company for the General Practitioners. 4. All other categories PLEASE NOTE.
1. These apply only to hospitalization treatment taken outside Pune where the Panel

Eligible amount for reimbursement 100% as per the rules.

60% as per the rules.

50% as per the rules.

Nil

does not exist.


2. The percentage shown will apply to ALL rates including Room charges, Special

Services, Surgeons fees, Delivery charges, Consultation charges etc.


3. Outside Pune, wherever Doctors with post graduate qualification are available, the

hospitalization treatment, investigations, etc. will be reimbursed if the treatment is taken from them only.

Please note that OUT STATION TRAETMENT (treatment taken out of Pune region) of enrolled Parents / Brothers / Sisters will not be considered for reimbursement UNDER ANY CIRCUMSTANCES. vi

ENROLLMENT
NO REIMBURSEMENT IS POSSIBLE PRIOR TO ENROLLMENT UNDER ANY CIRCUMSTANCES ELIGIBILITY
Family Member
Employee- Self

Premium Per Year


Nil

Coverage Condition
He/she should be permanent employee of TATA Motors Pune and out of purview of the ESIS / Apprenticeship Act. Nil All children must be covered immediately after their birth. Delay in the enrollment of the child will result in the recovery of the PREMIUM from the year of his / her birth date or employees enrollment whichever is later. Sons / Daughters should be below 25 years of age, unemployed, unmarried & dependent on employee. Proof of BIRTH DATE is essential

Effective Date
From the date signing the YELLOW CARD by employee. -do-

Legally married spouse (one only) Children from legally married & enrolled spouse only

Nil

-do-

1 st Child 2 nd Child 3 rd Child 4th Child 5th Child 6th Child Father / Mother

Nil Nil Nil Rs 120/Rs 150/Rs 150/Rs 100/per Member

-do-

Brother/ Sister

Rs150/- per Member

Child for whom the premium is deducted will not stop, unless his / her name is deleted from the MBS Coverage subject to Medical Report by Panel Physician in case of Father and Panel Physician and Panel Gynaecologist in case of Mother and acceptance by Medical Committee. Should be dependent on the employee and should be staying with the employee in Pune. Under taking to this effect by the employee is necessary -doHe/She Should be below age of 20 years, Unmarried, Unemployed. Proof of Birth Date is essential.

-do-

-doFrom the effective date of acceptance, communicated to the employee

-do-

YELLOW CARD
KINDLY NOTE THAT THE ENROLLMENT OF SELF OR DEPENDENTS IN THE COMPUTER IS NOT POSSIBLE UNLESS THE YEELLOW CARD IS SIGNED AND DATED PERSONALLY BY THE EMPLOYEE.

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ANNUAL LIMITS
Category Hospitalization Type Of Treatment Treatment taken in hospital as indoor patient and costly special investigations other than Psychiatric, Dental and Allergic disorder
Reimbursement Percentage As Per Rules

Annual Limit Per Year Rs.15,000 /- per member for Self /Spouse/ Enrolled children Rs. 18,000/per Enrolled Father/ Mother Rs 10,000 for enrolled Brother/ Sister Rs. 20,000/- Per Family Rs. 3000/- per member per year for Allopathy. Rs 2000 per member per year for Ayurvdic / Homeopathy. This is part of Domiciliary budget Rs 3000/

100%

Domiciliary

Treatment taken as an outdoor patient including the treatment during pregnancy.

100%

Psychiatric

Dental

Allergic disorders

Treatment taken for Psychiatric illnesses either as indoor or out door patient Treatment taken for Dental disorders either as indoor or out door patient Treatment taken for allergic disorders either as indoor or out door patient

100%

Rs. 900/- per Member

100%

Rs. 3000/- per Member

100%

Rs. 800/- per Member

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EXCLUSIONS
Claims for the treatment of the following conditions are NOT REIMBURSABLE under the scheme under any circumstances. The Companys decision in cases of dispute in this area will be final and binding on the employee. 1. Beauty treatment by plastic surgery. 2. Treatment taken for obesity, intentional self injury, attempt at suicide, general debility, vitamin deficiency, nutritional anemias, over-dose of drugs, venereal diseases (VD) and complications/ sequels occurring there of conditions/ complications/ squeal arising from consumption of liquor, wine and such intoxicating drinks or drugs, routine health check ups pre- employment medical checkup. 3. Expenses on spectacles contact lenses etc. (however, charges for consultation of an Ophthalmologist on Panel for the purpose of prescribing corrective lenses will be reimbursed). 4. Treatment by Yogasanas, Naturopathy, Hydrotherapy, Magneto therapy, Acupuncture, Acupressure, Electro-physical therapy and such allied disciplines, as determined by the Company from time to time. 5. Massage treatment. 6. Treatment taken from Nutritional experts. 7. Any extra charges for imported medicines (such as Cargo charges, freight and insurance charges etc.). The actual cost of medicines will be reimbursed according to MBS rules, provided the medicines are not available in India. 8. General health tonics, food tonics, appetizers, advertises health products and all such medicines used as house hold remedies, which are available across the counter without a doctors prescription (whether a prescription is submitted or not). The plea that the tonics have been prescribed by the doctor will not be accepted for reimbursement. 9. Ambulance or other transport charges. 10. Any treatment taken for growing and / or falling hair for baldness. 11. IQ test 12. Orthodontic treatment on any indication even though it is advised by a qualified Dentist for any relevant cause. 13. Any treatment for disorders of sexual potency. 14. Over staying for personal reasons in the hospital after the concerned consultant advice for discharge from the hospital 15. Expenses for treatment taken from Non- Panel Doctors/ Deleted doctors and treatment taken in their hospital will be reimbursed. 16. Expenses for out station treatment for Father/ mother/ brother /Sister will not be reimbursed.

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DOS AND DONTS DOS


Do these for speedy and correct settlement of your Medical claim and avoid monetary loss. 1. READ THE BOOK CAREFULLY YOURSELF AND ALSO EXPLAIN THE RULES TO YOUR FAMILY MEMBERS. 2. Take treatment from a General Practitioner who is qualified as per the qualifications approved by the Company (Page iii) 3. When required take treatment from a Panel Consultant in his/ her own specialty only by referring to this booklet. MENTIN TO THE CONSULTANT THAT YOU ARE A TATA MOTORS EMPLOYEE AT THE BEGINNING OF THE CONSULTAION. 4. Fill up the claim form completely & correctly, especially the PERSONAL NUMBER & your signature. 5. Take hospitalization treatment in any hospital (excluding the deleted hospitals & those hospitals belonging to Consultants who are not included in the Companys Panel of Consultants) but ensure that the treatment is from the Panel Consultant / Consultant in the panel of recognized hospital. 6. Attach all relevant ORIGINAL receipts, photo copies or certified copies of prescriptions, reports to the claim. Receipts/bills should indicate break-up under various items. 7. Diagnosis must be mentioned on the prescriptions or receipts submitted along with the medical claim. Prescriptions in case of continuous treatment should be renewed from the concerned Doctor at least once in SIX months. 8. Retain Employees Counterfoil with you and present the same for any future reference. 9. Refer any query within three months of claim submission. 10. Always drop your completed claim form in the Medical Claim Box only. 11. Enroll all your family members as per the MBS Rules as early as possible. Retrospective reimbursement prior to enrollment is simply not possible. 12. Submit claim immediately on completion of the treatment for illness. 13. Submit part claim in case of long period of illness. 14. ALWAYS CONSULT YOUR COMPANY MEDICAL OFFICERS FOR NONEMERGENCY HOSPITALISATION / OPERATION. THIS MAY SAVE YOU CONSIDERABLE AMOUT OF MONEY. 15. TELL YOUR GENERAL PRACTITIONER TO PRESCRIBE MEDICINES (in his own pathy) AND NOT SUPPLY THEM FROM HIS DISPENSARY. Tell your General practitioner to give you prescription for medicines. These medicines should be purchases from the Chemists shop 16. Refer Notice Boards in Company on 25th of every month for CIRCULARS from Medical Department.

DONTS
Avoid these to prevent delay in the settlement of your medical claims. 1. DO NOT APPROACH MEDICAL CELL BEYOND RECOMMENDED VISITING HOURS. This Delays Processing Of Your Own Claims. 2. Do not attach duplicates, photo copies, etc. of RECEIPTS. 3. DO NOT KEEP THE COUNTERSLIP BLANK. 4. Do not hand over your claim in person. 5. Do not take medicines from General Practitioners own stock. 6. Do not wait to submit the claim till the last date. 7. Do not take the treatment from non-qualified doctors to avoid: i. Complication of the disease. ii. Increase in your expenses. iii. Non-reimbursement of the claims. 8. Do not submit your medical claim form without putting your PERSONAL NUMBER.

PROCEDURE FOR QUERY / ENROLLMENT / COLLECTION OF AUTHORISATION LETTER


01. Any query should be referred to Medical Cell within three months BEYOND WHICH NO QUERY WILL BE ENTERTAINED. 02. Queries will not be entertained on phone. 03. In case of dispute, employee may submit his / her grievance to the MBS Committee through Medical Benefit Cell. 04. The Committees decision will be final and binding on the employee in all areas of disputes. TIMINGS FOR QUERIES & ENROLLMENT ARE AS FOLLOWS: Pimpri Works Chinchwad Works Car Plant : 2.00 p.m. to 4.00 p.m. Except Sunday : 2.00 p.m. to 4.00 p. m. Tuesday only : 2.00 p.m. to 4.00 p.m. Friday, Sunday & Tuesday

Timings for Collection of Authorization Letter 8.30 a.m. to 5.00 p.m. Pimpri Works Chinchwad Works Car Plant : Medical Cell C 6 First Floor : Chinchwad Dispensary : Car Plant Dispensary

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