Employee Benefits Manual

KOTAK MAHINDRA BANK LTD &

CLIENT
GROUP COMPANIES
 Group Mediclaim Policy

What does Mediclaim Policy cover?

The benefit a Mediclaim Policy will offer is coverage against any Medical Contingency
requiring the member to be hospitalized. In case of hospitalization only (i.e.
hospitalization for more than 24 hours ) , the insurance company will pay the insured
person the reasonable amount of expenses incurred towards treatment up to the Sum
Insured limits and subject to the insurance policy guidelines.

Non Medical expenses like Administration Charges , Registration Charges, Telephone

charges / fax charges; food charges if not part of room rent for patient and food charges
for relatives / attendant etc. are not payable.

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Group Mediclaim Policy Details

Policy Parameter
 Policy Start & End Date
 Insurer
Third Party Administrator (TPA)
 Geographical Limits
31st March 2018 to 30th March 2019
National Insurance Co. Ltd
Mediassist Insurance TPA Pvt. Ltd.
India (Covers treatment in India only) admissible claims there of shall be payable in Indian currency.

Covered Members Description Special Conditions if any

 Family Scope Family Floater 1 + 5 Uniform Sum Insured of INR 4 Lac per family

 Employee Covered Till the time the employees are working in the company

 Spouse Covered No Age Limit

 Child Covered 2 Children only (Up to 25 Yrs.)

Up to 85 Years for the new joinees

 Parents Covered **Parent In Laws** (FatherIn Law & Mother In Law are not covered in policy)

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Benefit Structure

Policy Benefits
 Standard Hospitalization Covered
 Cashless Facility Available
 Pre and Post Hospitalization Expenses 30 days pre and 60 days post hospitalization expenses will be covered
 Pre-Existing Diseases Covered
 30 days waiting period Waived Off
 1/2/4 years waiting period for named illnesses Waived Off
INR 30,000/- for Normal and INR 50,000/- for Caesarian delivery (No Co-Pay
 Maternity Benefit
Applicable)
 9 months waiting period Waived Off
From Day One Under Family Floater Sum Insured Subject to declaration within
15 days from date of birth & availability of scope for addition under the policy.
(In case baby’s name is not finalized employee can declare the name of baby
 Baby Cover
with mothers name for e.g. if mothers name is ABC baby’s name has to be
declared as Baby of ABC within 15 days from date of birth to
hr.helpdesk@kotak.com)
The Mediclaim coverage for dependents of the deceased employee will
 In the event of death of employee
continue throughout the policy year.
 For employees who have completed 5 years in the system
An additional Vintage Buffer of INR 2 lakhs per family post utilization of basic
and will complete 5 years in the due course of the policy year
Sum Insured.
on the date of admission of the hospitalization.

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Benefit Structure
Policy Benefits
 Co-Payment
 Room Rental Restriction
 Treatment for Morbid Obesity
 Internal Congenital Disease
 Lasik Surgery
 Infertility / Sub Fertility
 Mortuary Charges
 Ambulance Charges
 Day Care Procedures
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30% Co-Payment on all claims except for Maternity
INR 3,000 per day for Normal Rooms and INR 6,000 per day for ICU. (Inclusive
of Nursing Charges).
Covered as per the Policy terms & condition
Covered as per the Policy terms & condition
Covered as per policy terms and condition (in the event the power is (-) 7 or (+)
7 and above
Covered up to Maternity sublimit of Normal delivery
Covered as per the Policy terms & condition
Covered Up To INR 2,000 Per Claim
This benefit is available only for shifting patient from residence to hospital &
only if patient is admitted to ICU or emergency ward or from one hospital to
another hospital& subject to availability of Sum Insured.
Covered as per Insurer’s List
New Initiative – Voluntary Top -Up

Sum Insured Premium (Excl. GST)

INR 1 Lac INR 3,000/-
INR 2 Lac INR 5,800/-
INR 3 Lac INR 8,000/-
INR 4 Lac INR 10,000/-

• The Top –Up cover is an independent cover where in the premium including the GST component will have to be completely borne by the
employees.
• The Top-Up policy will trigger on exhaustion of the base cover. (Base cover will include Vintage Buffer for eligible employees).
• All the terms and conditions – will be similar to the base cover including co-pay and sub-limits.
• In the event the employee who has participated in the Top-up and moves out of the organization – he / she will be eligible for a pro-rated
refund of the premium only in the event the said cover is un-utilised.
• Post closure of the window – no employees will be allowed to enroll for the top – up. Mid Term enrollment not allowed.
• New Joinees will have an option to enroll mid-term – along with the enrollment for base policy. The premium for the mid – term joinees will be
charged on a pro-rated basis.
• Portability option is available when employees move out of the organization: The policy will be converted into retail insurance plan – post
paying appropriate premium quoted by the insurer. (For the availing the said benefit the employees may reach out to the contact details
mentioned towards the end of the presentation 45 days prior to the date of separation from the organisation failing which portability may not
be possible)

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Enrollment Process
The enrollment in the Top-Up policy will be done simultaneously with the Base policy enrollment.

This will lead you to Your GMC Base

Login using your Portal will prompt for Once you confirm
profile completion policy, will be listed in
credentials received a password reset at the profile
page – please enter
from Benefit Me - first login – Please completion, you will the first section; In the
your details to second section, you
Portal reset the password. land on the
complete profile can see the Voluntary
dashboard section
updation Top-Up policy Tab

Once you have
Confirm enrollment by
clicking on “Confirm updated the details,
please save using the
Enrollment” button
‘Save’ button
Here the details of the Click on the “Enroll
Now” button next to
family is available &
the options of Edit & the GMC base
policy.
Confirm is available.

If the Top-Up cover is

Once the enrollment in
your base policy is
completed, the portal
will prompt for
enrollment in the Top-
Up Policy.
The options of various
sum insureds with be
available with
premiums. The same
can be selected and
confirmed.
not required, please
select the “Not Confirm enrollment by
Interested” option and clicking on “Confirm
confirm, failing which Enrollment” button
the default top up
cover may get applied

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Dependent Enrollment for New Joinees

All New Joinees are requested to declare their dependents along with their own declaration at the time of joining.

1. All New Joinees must ensure that their Date of Birth (DOB) are declared at the time of joining as without the same Insurance Enrolment is not
processed.

Note: *There will be no mid year enrolments allowed during the year except:

(a) Marital Status Change

(b) Birth of a child, provided there is scope available to cover the New Born.

*Intimation should be provided to respective HR department on specific mail id’s suggested within 15 days from the date of marriage and birth
accordingly..

Marsh open the

enrollment window for
new Joinees for
Provide required addition/modification of
details of your
data. Post Closure of
dependents to the HR.
Window period sends
the data to the insurer
for endorsements
Insurer updates their E-Cards uploaded
TPA updates the active
data, endorses on TPA’s website
member database and
member and sends the within 20 working
issues the e-cards
detail to the TPA days.

E Card Received by
Employees
Error in the data E Card OK
printed on card
Employee
Use Card for
Notify HR/JLT with verifies details
Cashless
revised details on the E card
Hospitalisation

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Planned Hospitalisation

Contact Mediassist & inform about the nature of

PLANNED HOSPITALIZATION PROCEDURE hospitalization & your ID No. (Contract details
START provided towards the end of the presentation.)

Network Hospital faxes Request to Get the Admission Request Note form filled 72 Hours
Mediassist on prior to the admission which Network hospital will get
Fax No. 1800-425-9559 signed from the treating doctor / hospital and insured.
Request will be subsequently sent by Hospital to
Mediassist on Toll Free No. MediAssist.
1800-419-9392

Mediassist doctors will examine the Pre-Authorization

Request form & decide on cashless availability, as per
the policy guidelines.

Authorization Letter (AL) / Denial Letter / Addition

Requirement Letter issued depending on plan ,benefit
& balance sum available to the hospital.

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Emergency Hospitalisation

Member gets admitted in the hospital

START Member / Hospital applies for pre- TPA verifies applicability of the claim to
in case of emergency by showing his
authorization to the TPA within 48 be registered and issue pre-
E-Card & Id proof issued by Gov.of
hours of admission authorization
India. Treatment starts.

Yes

Hospital sends complete set of claims Member gets treated and discharged
documents for processing to the TPA after paying all non entitled benefits Pre-authorization
on cashless@mediassistindia.com like refreshments, etc. given by the TPA

No

Claims Processing by TPA & Insurer

Member Pays and Takes Discharge

Release of payments to the hospital

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Reimbursement Process

Employee intimates about the Employee submits all the

original documents to the TPA will check for the
hospitalization by mentioning Employee
claim cell team within 15 eligibility and admissibility of
ID Patient’s Name ,Med-ID Hospital Name
days from the date of the claim as per policy terms
START ,Date of Admission and Ailment name on
discharge.
claimintimation@mediassistindia.com
and Kotak.claims@marsh.com within 48
hrs. from the time of admission.

No
TPA Will Send denial letter
to the employee. Is Claim
payable?

Yes Yes
TPA will process the claim within 21
working days, claim amount will be TPA will check
transferred to respective entities account.. whether all the
documents are
in order

No

Employee submits the shortfall documents

TPA will ask for the
to TPA within 7 working days from the
additional/missing
receipt of intimation
documents

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Documents Required

 Claim form duly filled and signed by the claimant.

 Original Discharge Summary
 Hospital bills in original (with bill no; signed and stamped by the hospital) with all charges itemized and the original receipts
 Attending doctors’ bills and receipts (if separate from hospital bill) and certificate regarding diagnosis.
 Original reports of Bills and Receipts for Medicines, Investigations along with Doctors prescription in Original and Laboratory
 All original payment receipts must be taken from the hospital including invoices for implants and stickers in case of lenses
 Follow-up advice or letter for line of treatment after discharge from hospital, from Doctor.
 Break up details of Pharmacy items, Materials, Investigations even though it is there in the main bill
 In case the hospital is not registered, please get a letter on the Hospital letterhead mentioning the number of beds and availability
of doctors and nurses round the clock.
 In non-network hospitalization, please get the hospital and doctor’s registration number in Hospital letterhead and get the same
signed and stamped by the hospital or submit the Form C copy.
 Claim documents need to be submitted within 15 days from the date of discharge. In case of pre & post hospitalization claim
documents need to be submitted within 7 days from the date of completion of 60 days or treatment whichever is earlier.

Note: There may be additional documents other than the above mentioned list, required by the TPA, based on specific treatments.
All the documents should be in original only.

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Documents required for Specified Ailment’s

 Additional Documents Required For Cataract Claims

 IOL Sticker [Intra Ocular Lens Sticker] along with original purchase invoice of lens used in surgery
 A-scan report.

 Additional Documents Required For Specific Claims

 Angioplasty –Sticker and purchase Invoice of stent, CAG report required
 Bypass Surgery (Coronary artery bypass graft) –CAG report required
 Knee Replacement / joint Replacement –Sticker and purchase Invoice of Implant

 Additional Documents Required For Accident Claims

 Attested copy of First Information Report (FIR) from police or Medico-Legal Case certificate (MLC) from hospital
 Treating doctor’s certificate stating whether patient was under influence of alcohol/other narcotics substance during the accident

 Additional Documents Required For Chemotherapy / Radiotherapy / Dialysis Claims

 Doctor’s letter stating number of sittings and frequency of each sitting
 Note: there may be additional documents other than the above mentioned list, required by the TPA, based on specific
treatments.

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FAQ’s

What is Medical Insurance?

Medical Insurance is a purely hospitalization policy which provides coverage to you as an employee and also covers your family
(spouse, two dependent children and parents) towards treatment in case of a medical emergency, as per policy terms and conditions.

What is family floater?

Under the family floater, the insurance cover will be available to all members of the family unit. The sum insured is available for
utilization by any member of the family. It is however subject to the overall family sum insured for all members put together.

What is Pre Existing Disease Coverage?

Pre-Existing disease coverage is offered to all members without any waiting period. This helps the member get a complete coverage for
all medical emergencies, including ailments that may have been there before the start of this policy.

What is Waiver of 30 days waiting period for non accidental claims?

Here in customized policy there is No 30 days waiting period for enrolled members for filing any claim due to illness.

Is Maternity Benefit Covered under the Policy?

Yes, it is covered. The maternity Benefit ensures that female members of the group are covered for medical expenses relating to first two
delivery. This benefit will ensure that delivery related expenses up to an amount of INR 30,000/- for Normal and INR 50,000/-for
Caesarian delivery will be borne by the insurance company. This benefit will be available to all female members i.e female employees
and spouses of all male employees. No Co-Pay will be applicable on Maternity Claims.

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FAQ’s

What is Pre & Post Hospitalization Benefit ?

Relevant medical expenses incurred during a period upto 30 days prior to 60 days after hospitalization will be considered as part of claim
and therefore settled as per policy guidelines. Pre-Post expenses are not payable in case of Maternity claims.

What expenditures will generally be covered under the Pre Hospitalization Clause ?
Expenses incurred for Laboratory Test, Pathological Test, Doctor Fees for Consultation and such similar over heads usually incurred for 30
days prior to the date of hospitalization will be covered under the Pre Hospitalization Clause.

What expenditures will generally be covered under the Post Hospitalization Clause ?
Expenses incurred for Laboratory Test, Pathological Test, Doctor Fees for Consultation and such similar over heads usually incurred for 60
days from date of discharge will be covered under the Post Hospitalization Clause.

What is the Room Rent Limit per day ?

INR 3,000/- for Normal Rooms & INR 6,000/- For ICU Rooms per day.
In the event a member chooses to avail a Hospital room of higher class than eligible as per the cap applicable, all incremental expense on
hospitalization resulting out of choosing a higher class of room will be deducted proportionately from claim payable.

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,
Govt. Hospital or otherwise.

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FAQ’s

Is dental treatment covered under the policy ?

Dental treatment or surgery is covered only in case of accidental injuries and not otherwise.

Are congenital diseases covered under the Policy ?

Congenital Diseases means the abnormalities of structure or function which are pre sent at birth. They may or may not be inherited. Yes,
Internal Congenital is covered but external congenital are not covered under the Policy.

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, Tonsillectomy etc. taken in the Hospital / Nursing Home.

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 Third Party Administrator (TPA) Network. However , you do have the right
to choose any other hospital also, subject to the Hospital meeting the following criteria as mentioned below:
It should have at least 15 in patient beds; and fully qualified doctor(s) and nursing staff should be in-charge round the clock.
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.

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FAQ’s

Will my stay be covered under Mediclaim, if I have been admitted under doctors instructions but there has been no proper line of
treatment ?
No. Hospitalization not accompanied with active line of treatment is not covered under Mediclaim Insurance.

What if the cost exceeds the sum insured ?

In such a situation you will be liable to pay the incremental amount , over and above the Sum Insured limit , as per policy terms and
conditions. The TPA will inform the hospital about your balance sum insured and the hospital will recover the amount over and above the
balance sum insured from you. Only in the event the employee has availed the Top – UP Sum Insured – he / she will be eligible to
claim from the Top- UP policy over and above the base Sum Insured. For. E.g.
• Payable Amount = INR 7 Lacs
• 30% on Payable Amount which is INR 7 Lacs = INR 2,10,000
• Final Amount Payable = INR 4,90,000
• Base Policy will cover = INR 4,00,000
• Top Up Policy will cover = INR 90,000

* All Policy T&C in the Top – Up policy will be as per the base policy including the Co-Pay and the Sub-Limits.

Is there any limit for reimbursement of expenses incurred in a laboratory or diagnostic center 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 reimbursed up to the sum insured amount or sub-limit.

Are all pregnancy related expenses covered ?

Voluntary medical termination of pregnancy is not covered under mediclaim. Only cases of abortions where mothers life is under threat and
doctor has advised an abortion during the first 12 weeks from the date of conception is covered in the mediclaim policy.
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FAQ’s

How do you define dependency and in whose case is it applicable ?

Dependency means a person is financially dependent on the primacy insured i.e. they are not engaged in any kind of profession of
earning their livelihood or are gainfully employed. They should be dependent on the Employee.

Is dependency applicable in spouse also ?

No dependency for spouse is not relevant under this policy.

What happens if my family status change during the policy ?

If the family status changes (by reason of marriage / child birth), the employee needs to share the details to the respective HR – w.r.t. the
new dependent within 15 days from the date of marriage or child birth, as applicable.

Will the policy cover my third child in case of twins ?

Second delivery of Twins or Triplets coverage where maternity limit increases by 25k and all such children are covered under Sum
Insured. (This is a new improvement in the policy benefit)

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FAQ’s
Is 24 hours hospitalization mandatory for filing a claim in the Mediclaim Policy ?
Yes, only expenses on hospitalization for minimum period of 24 hours are admissible. However this time limit will not apply for specific
treatments i.e. Dialysis, Chemotherapy, Radiotherapy, Eye surgery (Cataract only) Lithotripsy (kidney stone removal), Tonsillectomy taken in
the Hospital/ Nursing home and the insured is discharged on the same day of the treatment will be considered to be taken under Hospitalisation
Benefit.

What us meant by a Networked / Empanelled Hospital ?

The hospitals which have tie up with the TPA servicing the Mediclaim policy is called a network / empaneled hospital. An exhaustive list of
Network Hospitals is available on TPA Portal.

What is the Admission Request Note (ARN) ?

This is a Request for Cashless Hospitalzation. ARN is available at the network hospital and has to be duly filled up, signed and stamped by
the treating Doctor. There after the hospital will fax it to Mediassist on the number given in the previous slide. Members are requested to inform
Mediassist & Marsh SPOC that he / she is availing cashless benefit for further assistance.

How to fill and Admission Request Note ?

Part A : To be filled in by the Treating Doctor. Information required are : The ID. No. as printed on the Card, Sign and Symptoms of the
present aliment, duration of the aliment, diagnosis, pre-existing conditions if any, proposed line of treatment, approximate date of admission,
approximate duration of stay and approximate cost of hospitalization.

Part B : To be filled in by the Claimant – consent of the claimant to the Terms and Conditions of Mediassist; authorising Mediassist to obtain
details of treatment / collect documents and also authorise Mediassist to pay the hospital bill and reimburse itself / receive the amount of claim
receivable from the insurance company. If the claim is rejected, undertake to pay Mediassist / Insure the amount paid by them to the hospital.

What is an authorisation letter ?

Authorization Letter is the Communication Ascertaining the Admissibility or Acceptance of the Cashless Service.The same is issued by
Mediassist subject to admissibility of the claim and availability of balance sum insured for the member.

How do I know whether my Claim has been admitted for Cashless or not?
Authorization Letter or Denial Letter will be faxed / mailed directly to the Hospitalby TPA – Medi assist. For an update member can contact
Mediassist or Marsh Representative for further assistance.

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Exclusions – Highlights
Injury or Disease directly or indirectly caused by or arising from or attributable to War, Invasion, Acts of Foreign Enemy Warlike operations
(whether war be declared or not) and Injury or disease directly or indirectly caused or contributed to by nuclear weapons/materials.

Circumcision unless necessary for treatment of a disease not excluded hereunder or as may be necessitated due to an accident ,
vaccination or inoculation or change of life or cosmetic or aesthetic treatment of any description, plastic surgery other than as may be
necessitated due to an accident or as a part of any illness.

Surgery for correction of eye sight, cost of spectacles, contact lenses , hearing aids etc.

Dental treatment or surgery -corrective, cosmetic or aesthetic procedure, filling of cavity, root canal, wear and tear unless arising due to
an accident and requiring hospitalisation.

Convalescence, Generaldebility “Run-down” condition or test cure, congenital external disease or defects or anomalies, sterility, infertility /
sub-infertility or assisted conception procedures, venereal disease, intentional self-injury, suicide, all psychiatric and psychosomatic
disorder / diseases, accidents due to misuse or abuse of drugs / alcohol or use of in-toxicating substances.

All expenses arising out of any condition directly or indirectly caused to or associated with Human T-Cell Lymphotrophic, Virus Type III
(HTLB- III) or Lymphadenopathy Associated Virus (LAV) or the Mutants Derivative or variations Deficiency Syndromeorany Syndrome or
condition or a similar kind commonly referred to as AIDS, complications of AIDS and other sexually transmitted diseases (STD).

Expenses incurred primarily for evaluation / diagnostic purposes not followed by active treatment during hospitalization.

Expenses on Vitamins and Tonics unless forming part of treatment for injury or disease as certified by the attending physician.
Treatment arising from or traceable to pregnancy/childbirth including caesarean section , miscarriage , abortion or complication thereof
including changes in chronic conditions arising out of pregnancy.

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Exclusions – Highlights

Naturopathy, un proven procedure / treatment, experimental or alternative medicine / treatment including acupuncture, acupressure, magneto-
therapy etc.

Expenses on irrelevant investigations / treatment, private nursing charges, referral fee to family physician, outstation Doctor / Surgeon /
Consultants Fees etc.

Genetic Disorder / Surgery

External / Durable medical / Non-Medical equipment of any kind used for diagnosis / treatment including CPAP, CAPD, Infusion Pump etc.,
ambulatory devices like walker / crutches / belts / collars / Caps / Splints / Slings / Braces / Stockings / Diabetic Foot-Wear / Glucometer /
Thermometer and similar related items and any medical equipment which could be used at home subsequently.

Non- medical expenses including personal comfort / convenience items / Services such as telephone /Television /Aya /Barber /Beauty Services/
Diet Charges/ Baby Food/ Cosmetics/ Napkins/ Toiletries/ Guest Services etc.

Change of treatment from one pathy to another unless being agreed/ allowed and recommended by the consultant under whom treatment is
taken.

Treatment for obesity or condition arising there from any other weight control program/ services/ supplies.

Arising from any hazardous activity including scuba diving, motor racing, parachuting, hand gliding, rock or mountain climbing etc. unless
agreed by Insurer.

Treatment received in convalescent home / hospital, health hydro / nature care clinic and similar establishments.
Stay in Hospital for domestic reason where no active regular treatment is given by specialist.

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Exclusions – Highlights

Out-patient diagnostic / medical / surgical procedures / treatments, non-prescribed drugs/ medical supplies/ hormone replacement therapy,
Sex change or any treatment related to this.

Massages/ Steam bath/ Surodhara and a like Ayurvedic treatment.

Any kind of service charges / surcharges / admission fees / registration charges etc. levied by the Hospital.

Doctor’s home visit charges / attendant, nursing charges during pre and post hospitalization period.

Treatment which the Insured was on before hospitalization and required to be on after discharge for the ailment / disease / injury different
from the one for which hospitalization was necessary.

Note:This is an illustrative List of Exclusions, detail policy exclusions are always as per contract between Kotak Group & Insurance Co.
Payment: All medical / surgical treatments under this policy shall have to be taken in India and admissible claims there of shall be payable
in Indian currency.

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Contact Co-ordinates
Dedicated Toll Free No for Kotak Group Employees-1800-419-9392

First - Point of Contact –Not Resolved in 1 hour for Cashless hospitalization

Responsibility Claims Managers ( Cashless & Reimbursement)

Mobile No 91-7506351375 / 91-7506351376
EMAIL ID claimcell1@kotak.com/ claimcell2@kotak.com
Second - Point of Contact –Not Resolved in 1 hour for Cashless hospitalization

Responsibility Claims Sr. Manager ( Cashless & Reimbursement)

Mobile No 91-7506351377

EMAIL ID kotak@mediassistindia.com

Final Escalation Point of Contact –Beyond 3 hours for Cashless Hospitalization

Responsibility Manager Client Support

Mobile No 8879765310

EMAIL ID Kotak.claims@marsh.com

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