MEDICLAIMBENEFITS

1. Is the 24 hours rule applicable for all ailments?

Yes, the 24 hours hospitalization is a must. However, this time limit is not applied to specific
treatments which do not necessarily require 24 hours due to technological advancement in
treatment. Some of these treatments include Dialysis, Chemotherapy, Radiotherapy, Eye
Surgery, and Tonsillectomy taken in the Hospital/Nursing Home.
2. Are there any special criteria for seeking admission/ treatment in the hospitals/ nursing
homes?
It is generally recommended that you choose a Hospital on the TPA Network. However, you do
have the right to choose any other hospital also, subject to the Hospital meeting one of the
following minimum criteria as under:

It should be registered with the relevant governmental and regulatory authorities. The
registration number should be printed on discharge summary and / or receipt of the
Hospital.

OR
It should have at least 15 inpatient beds.
Fully qualified doctor(s) should be in charge round the clock.
Fully Operational OT.
Nursing Staff Round the clock.
Further, it necessarily should not be blacklisted with the TPA.
3. Does pre-existing disease cover mean that all diseases and medical procedures are
covered?
Pre-existing disease benefit helps the member get a complete coverage for all medical
emergencies, including ailments that may have been there before the start of this policy.
However, it does not cover congenital external disease / illness / defect & genetic complications.
4. What expenditures will generally be covered under the Pre Hospitalization Clause?
Medical expenses incurred for Laboratory Test, Pathological Test and such similar overheads are
usually incurred prior to hospitalization and will be covered under the pre hospitalization clause.
Pre Hospitalization expenses are payable only if it is followed by at least 24 hrs hospitalization
within 30 days of expense and there should be an active line of treatment given based on the
investigation.
5. What expenditures will generally be covered under the Post Hospitalization Clause?
Medical expenses incurred for the treatment subsequent to release from hospitalization and other
such similar overheads will be covered under the post hospitalization clause. Post Hospitalization
expenses are covered up to 60 days from the date of discharge.

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6. Is there a time limit within which I am expected to submit the pre and post hospitalization
bills?
Yes, you are advised to submit bills with respect to Pre Hospitalization, within 7 days of discharge
from hospital. Post Hospitalization bills must be submitted within 7 days of completion of the
treatment or completion of 60 days post discharge, whichever is earlier.
If the bills are not submitted within the timelines, the insurance company has right to reject the
claim.
7. Is there any limit for reimbursement of expenses incurred in a laboratory or a diagnostic
centre as part of hospitalization?
No. If the expenses form part of the hospitalization process and if the amount is approved and
payable as per the terms and conditions of the policy, then they are reimbursable up to the sum
insured amount.
8. Will my hospitalization be covered under Health Insurance, if I have been admitted under
doctors instructions but no treatment is given?
No. Hospitalization not accompanied with active line of treatment is not covered under Health
Insurance.
9. What is meant by a Networked / Empanelled Hospital?
The hospitals which have a tie up with the TPA servicing the health policy is called a network /
empanelled hospital. An exhaustive list of Network Hospitals is available on the TPA website or
with the concerned Vantage Account Manager.
10. If I avail cashless facility, will the Insurer pay the entire amount or will I be required to bear
part of the bill at the hospital?
All expenses that are covered under the Insurance Policy will be paid for by the Insurer. However,
you will be required to pay for non-admissible expenses, if any, such as Registration charges,
charges incurred on account of person accompanying you, etc.
Further, you will also bear the amount deducted on account of any restriction in the policy like
room rent, co-pay, deductible etc.
11. Can I file more than one claim in a year?
You can claim as many times you are hospitalized during the period of Insurance but the
insurance company's liability in respect of all claims put together shall not exceed the Sum
Insured or any specific restrictions as mentioned in the Policy.
12. Will my coverage be treated as continuous if I take an individual policy?
No, the coverage will not be treated as continuous, once you leave the organization. If you take
an individual policy, it will start as a new policy.

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13. What if I undergo major hospitalization in 2 different hospitals? Will the policy reimburse
expenses incurred?
Yes. The expenses are reimbursed up to the limit of sum insured and if they satisfy the terms and
conditions of the policy and proper documents required for both the hospitalization (Transfer
Summary from previous hospital to the second hospital & Discharge Summary from the second
hospital is must).
14. Is Dental Treatment covered?
Dental treatment or surgery of any kind is covered only if there is hospitalization on account of
accidental cases. Non accidental dental treatment is not covered under this policy unless specific
cover has been taken for the same.
15. Are naturopathy and Ayurvedic expenses covered?
Naturopathy and Ayurvedic expenses are not covered under the policy, irrespective of whether
they were incurred in a network hospital or otherwise.
16. My spouse has been hospitalized for delivery and I will be claiming re-imbursement for the
same. Is there any specific document that I need to take from the hospital?
Apart from all the necessary documents like discharge summary, final bill, consultation papers,
payment receipts etc. in original, you also need to ensure that the GPLA status or obstetric
history is mentioned on the discharge summary. GPLA refers to Gravida Para Living Abortion and
it gives information of previous pregnancies if any. Further, in case of caesarean delivery, the
report of the last USG done before delivery is required along with the indication for doing a
caesarean delivery.
17. Is 24 hours hospitalization necessary for maternity related complications before the
delivery?
Yes. 24 hours hospitalization is necessary as it does not form a part of the day care list of
procedures.
18. My spouse has been hospitalized for maternity related complication in her 5th month of
pregnancy. Will it be covered under my overall sum insured limit?
It will be covered under the maternity sublimit subject to 24 hours justified hospitalization. This
means that the maternity sub limit available for any subsequent hospitalization related to this
pregnancy will be reduced by an amount paid for the complication.
19. Are pre and post hospitalization for maternity related expenses covered?
No. Your company does not cover pre and post natal expenses in the policy.
20. Will miscarriage related expenses be covered under the policy?
Miscarriage will be covered under the policy within the maternity sub limit subject to the claim
fulfilling the other policy requirements.
Please note that voluntary termination of pregnancy forms exclusion under the policy.

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21. I already have twins. My spouse is expecting again. Will I be allowed to claim the maternity
expenses incurred for the delivery of the 3rd child?
No. The Group Health insurance policy only allows maternity related coverage for the first 2
children. Maternity expenses for the 3rd child will not be covered under the policy even if you
haven't claimed earlier for maternity in the existing policy.
22. Will the delivery related expenses be covered in case there are twins born during the
second delivery?
In case twins are born during the second delivery, the policy will pay proportionate expense that
would have been incurred in case of birth of a single baby. However, both the children cannot be
covered under the family floater sum insured as the health insurance allows coverage only for the
first 2 living children.
23. I have a son and my spouse is expecting again. As we do not want to have any more
children, our doctor has suggested that we get a sterilization operation done during the
delivery itself. Will these expenses be payable?
The expenses incurred for sterilization procedures are not payable. If these form part of the
delivery expenses, it would be deducted during settlement of the claim.

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