Policy Terms and Conditions IBM
Policy Terms and Conditions IBM
OBJECTIVE
To provide employees and their immediate dependents an opportunity to avail insurance coverage for hospitalization
and Domiciliary hospitalization expenses incurred on account of their medical needs.
All IBM India regular employees (full time and part time), Fixed Time Hires (FTH) and their immediate
dependents (spouse and up to 4 children).
The Primary Insured’s male and female children aged between 0 days and 24 years irrespective of gender
can be enrolled as long as they are unmarried, still financially dependent on him/her and have not
established their own independent households. However, the policy covers a differently abled dependent
child with 40% or more disability, subject to the employee submitting the disability certificate given by
competent authority.
The policy also supports coverage of members who identify under the third gender.
Regular (full time and part time) employees who are covered under the Employee State Insurance Coverage
(ESIC) Act will also be covered under this policy.
If an employee opts out of this policy, none of the benefits in this policy shall apply. However, the employee
shall continue to be eligible for benefits required under law for a sum insured of INR 200,000.
In case of demise of an employee, the dependents (only enrolled spouse and children) shall remain covered
under base coverage until 3 months of the date of demise of the employee.
Parents Policy
IBM India regular employees and FTH employees (tenure >1 year) can insure their dependent parents by
paying the premium applicable. Please note parents-in-law cannot be covered in the policy.
The maximum age up to which parents can be insured is 90 years. However, parents above 90 years of age
can be covered under the 2024 policy if they have been covered under the IBM India Parents policy on a
continuous basis in the preceding policy years.
No member can be covered twice in the policy even if he/she is a dependent of more than one employee. If
two or more siblings working with IBM India are found to have enrolled their parents for more than once
under the policy, it will be considered as BCG violation and strict action will be taken.
The parents’ coverage for 2023 & 2024 comes with a 2-year lock-in and hence: Employees who have
enrolled their parents in 2023 policy will have a continued coverage for parents under 2024 policy, with same
sum insured or can enhance their sum insured in 2024. Opting out of the parental plan or reducing the sum
insured is not allowed. Aside, switching between plans i.e., individual to floater and vice-versa is not
admissible.
Employees joining on or after Jan 1, 2024, and enrolling both parents can avail a common floater coverage
for both parents or an individual coverage for each parent. The premium applicable under floater coverage
will depend on the age band of the elder parent and the sum insured selected, while the premium applicable
under the individual coverage will depend on each parent's age band and the respective sum insured
selected for each.
Employees joining on or after Jan 1, 2024, and enrolling only one parent can avail the individual coverage
basis the individual policy premium rater. The premium applicable will be basis the parents’ age band and
the coverage selected.
The premium rates will be the same under the 2024 policy, hence staying constant even if the age band of
parent(s) changes. The total premium payable may change with the impact of applicable taxes or if
employee is enhancing parental cover in 2024.
The premium paid by employees joining on or after Jan 2, 2024, will be pro-rated from their date of joining
until the end of policy year, i.e., December 31, 2024
SCOPE
GENERAL INFORMATION
HDFC Ergo General Insurance Company Ltd will be the insurer for the Group Medical Insurance Policy of IBM India
for the calendar year 2024.
TPA (Third Party Administrator) - Medi Assist India TPA Pvt Ltd
Medi Assist India TPA Pvt Ltd will be the Third-Party Administrator (TPA) and will facilitate administration of IBM
India Group Medical Insurance policy for the calendar year 2024.
REGULAR EMPLOYEES
All IBM India regular employees are covered under this policy for the base sum insured of INR 400,000.
Employees have an option of increasing the sum insured by opting for additional cover/top-up, the premium
for which is entirely payable by the employee.
Owing to the 2 years lock-in on top-up for 2023 & 2024, additional coverage selections made in 2023 will
hold good/continue for 2024. If employees have not opted for top-up cover in 2023, they cannot avail the
same in 2024. However, employees joining IBM on or after Jan 1, 2024, shall avail/opt top-up cover within 30
days of their joining.
W e have introduced flexibility option of allowing employees who have enrolled for top-up plan in 2023 to
enhance their sum insured in 2024. Opting out or opting in of the top-up plan or reducing the sum insured is
not allowed in 2024.
This is a family floater plan, provided for the nuclear family (nuclear family is defined as employee, spouse
and up to 4 dependent children) i.e., there is no restriction on the amount available for each member as long
as the family does not exceed the limit of INR 400,000 or the enhanced cover in case additional cover is
opted.
Health insurance benefits have also been extended to the same gender domestic partners of LGBT
employees. Employee may enrol their partner during the renewal/enrolment window as spouse.
All existing employees as of December 31, 2023, may avail coverage from January 1, 2024, by default.
Spouse & Children - insured as of December 31, 2023, may avail coverage from January 1, 2024.
Validation and Enrolment/updation of dependents’ details (spouse and children) of existing employees will be
possible on or before January 31, 2024.
New employee may avail coverage from their date of joining in IBM India.
New employees can enrol their dependents, enhance the family floater cover, enrol parent/s and opt for
parent coverage or opt out within 30 days of joining (including the date of joining, i.e., date of joining +
29 days).
New dependents are to be insured within 30 days (date of below mentioned event + 29 days) of
eligibility.
o From date of marriage
o From date of birth of a baby
o From date of legal adoption of a child
Employees who wish to renew / enrol may log in to the Medi Assist portal
(https://portal.mediassist.in/Home.aspx) using their User ID and password to subscribe. Alternatively,
employees can also log in to Medi Assist mobile app to enrol. Please scroll down to learn how to complete
online enrolment.
It is the responsibility of the employee to declare correct and accurate information regarding the name and
date of birth as declared in Medi Assist Website. If any information provided by an employee is found to be
incorrect or false, this would result in BCG violation.
No member can be covered twice in the policy even if he/she is a dependent of more than one employee.
Claims submitted for dependents whose name has not been enrolled on the website will not be processed by
Medi Assist. Further, the claim will not be paid if such a claim is in any manner fraudulent or supported by
any fraudulent means or devices whether by the insured person or by any other person acting on his behalf.
The ESC policy provides protection to employee’s spouse and children for up to 3 months in case of loss of
the employee’s life, with a portability option with same benefits under a retail policy. The spouse and children
so covered for additional 3 months shall be covered under the base coverage, and premium refunds
pertaining to top-up sum insured and parents’ coverage, in case of no claim submitted under these 2
coverages’, shall be made on a pro-rata basis
The premium for the base sum insured is shared between the employee and IBM.
If an employee avails of the insurance coverage, there would be a deduction of INR 2,324.58 (1,969.99 +
GST 354.60) per annum from a regular employee’s salary and a deduction of INR 1,190.19 (INR 1008.63 +
GST 181.55) per annum from a fixed term hire employee’s salary in the month of March 2024.
For new hire employee, premium amount will be prorated depending upon the Date of Joining (DOJ) of the
employee.
Unless an employee chooses to opt out of the policy, the premium, for this coverage will be deducted from
the employee’s salary in the month of March 2024 for employees who were on the rolls of the company as
on December 31st, 2023, of the previous year.
For new employees the premium will be deducted in the succeeding month after completing 30 days from
enrolment start date/their date of joining.
This premium is eligible for deduction from the taxable income within the defined limits under Section 80 D of
the Income Tax Act.
This premium deduction does not require a declaration in the investment module of India Tax
declaration/Tax benefits & Form-16, as the deduction will happen automatically from the employee’s salary.
Premium amounts for primary coverage and enhanced coverage for employee and nuclear family will be
deducted from the employee's payroll without any prior intimation. The deduction will be done within 90 days
of the employee having enrolled his/her dependents on the Medi Assist website.
Employees on assignment outside India (LOA in India payroll) will have to pay the insurance premium co-
share though they and their families are out of the country unless and until they have opted out during
enrolment window period of the annual policy year (by default all active employees of IBM India will be
covered for base coverage of 4 Lakhs at the beginning of the new policy year to ensure no employee and
their declared dependents miss out on the coverage).
All such employees on assignment (LOA in India payroll) and did not opt out of GMC 2024 policy, need to
make a direct transfer/payment of applicable premium co-share to IBM India. (Basis the email or details
shared by Indian payroll team)
Employees who have opted for top-up coverage in 2023, cannot opt out from 2024 policy or avoid paying
premium co-share in 2024 policy.
Employees who have enrolled their parents in 2023, cannot opt out from 2024 parent’s policy or avoid paying
premium in 2024 policy.
Only employees who are enrolled for the basic coverage (INR 4 Lakhs) in 2023 can opt-out in 2024 for
themselves and immediate dependents.
Once the employee opts out of the scheme, they and their immediate family are not eligible for any benefits
as specified in this policy.
The employees who have opted out of the 2023 policy, they may re-join the policy in 2024 for base
coverage, as midterm inclusion is not allowed.
The employee can log in to Medi Assist website (https://portal.mediassist.in/Home.aspx) or logon to the
Medi Assist mobile app to opt out.
In case employee opts out, employee would only be eligible for hospitalization benefits on account of accident during
the course of employment and or treatment of occupational diseases, as required under applicable law for a sum
insured of INR 200,000.
Opting out of the ESC Policy
In case, an employee does not wish to be part of the ESC policy, he/she has an option to opt out of the
policy within 30 days of enrolment start date. Once an employee has opted for the ESC policy, he/she will
not be able to opt out of the policy mid-year.
The employee can log in to Medi Assist website (https://portal.mediassist.in/Home.aspx) or logon to the
Medi Assist mobile app to opt out.
Once the employee opts out of the scheme, they and their immediate family are not eligible for any benefits
as specified in this policy.
The employee would only be eligible for hospitalization benefits on account of accident during the course of
employment and for treatment of occupational diseases, as required under applicable law.
The employee who has opted out of the policy 2023, they may re-join the policy only in 2024, as midterm
inclusion is not allowed.
In case employee opts out, the employee would only be eligible for hospitalization benefits on account of
accident during the course of employment and for treatment of occupational diseases, as required under
applicable law for a sum insured of INR 200,000.
No Corporate buffer.
No Maternity coverage.
No cover for cancer screening.
No domiciliary expenses.
Enhancement of Sum Insured is not allowed.
No Co-pay applicable on the opt out policy.
No family coverage.
Employees can opt for parental coverage under voluntary parental policy, as per the terms and conditions of
the Voluntary parental plan.
Employee opted out in 2023 policy will have an option to opt in for 2024 policy.
No Midterm inclusion is allowed during a policy period.
This benefit is extended only for ESC policy and not applicable for Parents Policy.
This benefit would be available only for specialist consultations (allopathic consultation) and investigations
prescribed by a specialist and not for the treatment taken. Please note that routine health check-ups do not
fall under the category of domiciliary benefit and such claims will not be admitted by the insurer.
The employee has an option to enhance the OPD sub-limit up to INR 25,000 by selecting additional top-up.
The sub-limit can be enhanced with selection of top-up coverage, applicable as below:
The balance under this benefit/sub-limit cannot be carried forward to subsequent year(s). There is no
minimum amount for claim.
The OPD benefit has a sub-limit of INR 10,000 under the basic sum insured of the ESC policy and FTH
policy.
OPD benefits cover all specialist consultations. Specialist means Doctors having a diploma or a post graduate
degree in a clinical subject after MBBS. The coverage is subject to terms, conditions, and exclusions of the
policy. Some of the common clinical diploma and post graduate degrees / qualifications are MD, MS, DM,
MCH, DGO, DNB, DCH, DPM, D Ortho, DLO, FRCS, MRCP, FRCSC & FRCAS. Some common specialists
include:
o Cardiologist
o ENT Specialist
o Neurologist
o Oncologist
o Gastroenterologist
o Paediatrician
o Gynaecologist & obstetrics
o Orthopaedics
o Nephrologists
o Urologist
o Ophthalmologist
o Endocrinologist
o Psychiatric/ Behavioural consultation by a Psychiatrist (MD Psychiatry, or similar degree) is covered.
(Psychologist consultation not covered)
o Medically prescribed physiotherapy referred by specialists (as mentioned in the section) is also
covered with applicable co-pay.
Any investigation prescribed by a specialist would be admissible under the OPD benefit, i.e., blood tests, X
ray, ECG, MRI, CT scans etc.
Under OPD benefits all screening tests prescribed by General Physician (MBBS) and chronic screenings are
now covered.
Maternity and infertility related expenses including pre- and post-natal expenses are not covered under the
OPD benefits of the policy.
The Policy also covers home care cover inclusion for chemo & dialysis cases through accredited providers
only.
Non-Allopathic/Non-Specialists consultation; investigation/Medicines & consumables/Routine Health Checks
ups and other regular investigation without any specific illness are not covered / will not be payable even if it
is prescribed by a specialist allopathic doctor.
Co-payment Applicable under the OPD benefit
o A co-payment of 50% on the admissible claim amount shall apply on each and every claim by the
employee and dependents (Spouse and children)
Special provision under Domiciliary Outpatient care (OPD Benefit)
The co-payment (50%) applicable under the benefit shall be waived for the claim and
100% of the eligible expenses under consultation, investigation and treatment / medication would be
covered up to the sum insured (INR 10,000) under the benefit,
All other terms, conditions under the benefit would remain unchanged.
Owing to 2-year lock-in on additional coverage in top-up option for 2023 & 2024, an employee who has
selected additional coverage in 2023 shall continue to have the same coverage in 2024 and cannot opt-out
of the policy in 2024. However, employee who have opted top up in 2023 has an option to enhanced top up
coverage in 2024. Employees who have not availed top-up in 2023 will not be provided an option to opt for
Top up policy in 2024.
An employee joining on or after Jan 1, 2024, and availing the policy has the option of buying additional
coverage for his/her family in excess of INR 400,000 and can opt for INR 100,000, INR 200,000, INR
400,000, INR 600,000 or INR 11,00,000 (a total sum insured of maximum of INR 15,00,000 for family).
The incremental premium incurred due to additional coverage will be deducted from the employee’s salary.
There would be an additional goods and services tax levied on the insurance premium. Please refer Medi
Assist portal for rate chart of premiums applicable (https://portal.mediassist.in/Home.aspx).
The members who have enrolled in 2023 policy will be rolled over to the 2024 policy. Employees are
required to review the member details and/or add new members (recently married spouse, newly born or
adopted child)
Employees who wish to enrol may log in to the Medi Assist portal (https://portal.mediassist.in/Home.aspx)
using their User ID and password to subscribe. Alternatively, can also log in to Medi Assist mobile app to
enrol. Please scroll down to learn how to complete online enrolment.
Any ailment diagnosed / treated during coverage/enrolment window period under the lower sum insured will
continue to have the lower sum insured as the maximum cover (for that ailment and all related ailments).
This is applicable when the sum insured has been increased during enrolment period by an employee joining
IBM India in 2024.
Coverage at any point for any person under the ESC policy will not exceed INR 15 Lacs even if both
employee and the spouse are employees of IBM (dual coverage is not allowed). The policy sub-limits for
maternity, domiciliary expenses, etc would apply.
Existing employees availing the policy can add dependents at the time of renewal of the insurance policy
once a year and on or before January 31, 2024. They have to log in to the Medi Assist website
(https://portal.mediassist.in/Home.aspx) or Medi Assist mobile app and add dependent details. Coverage will
be effective from the starting date of the new policy.
New employees availing the policy can add dependent details within 30 days of joining (date of joining + 29
days) by logging on to the Medi Assist website (https://portal.mediassist.in/Home.aspx) or Medi Assist mobile
app. Coverage will be effective from the date of joining.
Newly married employees availing the policy can add spouse details by logging on to the Medi Assist
website (https://portal.mediassist.in/Home.aspx) or Medi Assist mobile app within 30 days of the date of
marriage (date of marriage + 29 days). Coverage will be effective for the spouse from the date of marriage.
Employees availing the policy who have a new-born child can add him/her within 30 days of the date of birth
(date of birth + 29 days) by logging on to the Medi Assist website (https://portal.mediassist.in/Home.aspx) or
Medi Assist mobile app. Coverage will be effective for the new born child from the date of birth.
Employees availing the policy who have adopted a child can add him/her within 30 days of the date of legal
adoption (date of legal adoption + 29 days) by logging on to the Medi Assist website
(https://portal.mediassist.in/Home.aspx) or Medi Assist mobile app. Coverage will be effective from the date
of adoption.
Mid Term Inclusions will be allowed only as an exception for employees availing the policy who missed
adding their dependents like newly married spouse, new-born child and adopted child details due to some
valid reasons. Some of the reasons for which midterm inclusion can be allowed are:
a) New addition in family (spouse or child) while employee was on international assignment and looking for
enrolment soon after his/her return to home country India (within 30 days of assignment end date / return
date)
b) New hires who could not access his/her IBM India mails / network to refer welcome emailer with details / join
Start@IBM session / due to any other technical issues / laptop delivery / operating from the client location
since their date of joining.
c) Employee was on LOA/ any other approved long leave for the complete enrolment window period. (30 days
from the policy start date or from marriage/childbirth/ adoption event date whichever is applicable)
All such requests for Midterm Inclusions for spouse /children, employee need to have approvals from the
People Manager (as per Blue pages) and would need to submit proof of marriage or birth certificate or any
other applicable documents over email to the [email protected] for BOM Team to review /approve and
take it up for insurer concurrence. The coverage date will be effective from the date of inclusion once
approved and endorsed by the insurer.
Employees returning from LOA can have their dependents enrolled under the policy by putting forth the
request for the same internally in IBM by reaching their People manager (as per Blue pages), and Team
benefits ([email protected]) seeking relevant approvals. The date of coverage inception for the members
will be the date of return of the employee from LOA. The request must be made to [email protected]
or [email protected], within 30 days from their day of return.
There is no mid-term enhancement of sum insured under both the policies viz., Employee, Spouse &
Children (ESC policy) / Voluntary Topup policy or Parents policy
Removal of Dependents (ESC Policy)
Dependents cannot be removed during a policy period except under the following circumstances:
Divorce
Death of a dependent
Resignation of the employee
The company at its sole discretion can ask for supporting documents for addition or removal of dependents
from the coverage.
[email protected],
[email protected]
With relevant proofs / documents (soft copy) within 30 days of the incident date.
Benefits Covered under ESC Policy: For details, please refer to the relevant section.
Inpatient Hospitalization.
30 days pre-hospitalization.
60 days post-hospitalization.
Day care procedures covered - specified list.
Waiver of Pre-existing disease exclusion.
No 30 days and two/one year waiting period.
No room rent or type restriction.
Co-payment - 10% for employee and 20% for dependents. In case of death of an employee the co-pay
would be waived for the claim.
Congenital internal diseases are covered.
Congenital external diseases are covered.
Gender realignment surgery coverage (refer to the WPATH Protocol document).
Health insurance benefits have also been extended to the same gender domestic partners of LGBT
employees. Employee may enrol their partner during the renewal/enrolment window as spouse.
HIV cover added to the main policy in both OP & IP
Inpatient Behavioural and Psychiatric treatments are covered within the overall Hospitalization limit.
Exclusions under this benefit are:
a) De-addiction program
b) Admission for primary purpose of confinement.
Complications from family planning devices where Hospitalization is required (eg: Impacted IUCD)
Expenses incurred towards resuscitation / revival in death cases, even when treatment is given in a hospital
or ambulance will be consider under the base sum insured.
Hospitalization expenses for suicide cases or attempted suicide cases (coverages as per Mental health act
2017).
Ambulance Limit at INR 1,500 per hospitalization-covers charges from the place of incidence to the hospital.
Orthopaedic appliances up to 5% of the eligible hospitalization expenses or actuals whichever is lower -
Coverage for assistive aids: Expenses for crutches, wheelchairs, artificial limbs & other assistive aids
(Defined assistive aids as indicated and prescribed by doctor post-surgery would be covered. However, aids
/ equipment for durable and long terms use at home would be excluded.
Oral chemotherapy drug/tablet coverage within the base sum insured/ top-up coverage.
Laser treatment for correction of eye due to refractive error greater than or equal to 7.5 Degree is covered.
The procedure would be covered even if the refractive error is less than 7.5 Degree if the surgery is
performed for therapeutic reasons like erosions, non-healing ulcers, recurrent corneal erosions, nebular
opacities, etc.
Domiciliary Hospitalization Benefit
Coverages for ARMD without any sub-limit
Maternity benefits
Sterility treatment /IVF treatment /Other fertility treatments coverage under Maternity benefit
Infertility to be covered twice in an employment tenure. Surrogacy coverage up-to Maternity Limit
Domiciliary expenses on outpatient care
Cancer screening tests, based on health screening and risk factor screening.
Critical Illness Buffer
Additional sum insured Benefits (Top-up)
Value Added Services
PARENTS POLICY
1. Employees who have enrolled their parents in 2023 shall have their parents covered in 2024 under the same
coverage. Employees who have not covered their parents in 2023 will not have the option to cover their
parents in 2024.
2. Employees joining on or after Jan 1, 2024, and enrolling both parents can avail a common floater coverage
for both the parents, or an individual coverage for each parent. The premium applicable under floater
coverage will depend on the age band of the elder parent and the sum insured selected, while the premium
applicable under the individual coverage will depend on each parent's age band and the respective sum
insured selected for each.
Employees joining on or after Jan 1, 2024, and enrolling only one parent can avail the individual coverage
basis the individual policy premium rater. The premium applicable will be basis the parents’ age band and
the coverage selected.
Basis the 2-year lock-in, the premium (without tax) against the sum insured selected in 2023 will remain the
same in 2024 as well. However, the premium may vary in case of change in tax rates or if employee is
enhancing parental cover in 2024.
Employees availing the policy can choose to cover their dependent parents for a sum insured of either INR
100,000, INR 200,000, INR 300,000, or INR 500,000.
Please note parents-in-laws cannot be covered in the policy.
The premium for covering parents will be deducted from the employee's salary. There would be an additional
goods and services tax levied on the insurance premium. For new hire, this amount will be prorated
depending upon the Date of Joining (DOJ) of employee. This amount will be eligible for deduction from
taxable income within the defined limits under Section 80 D of the Income Tax Act. This premium deduction
doesn’t require declaration in the investment module of India Tax declaration/Tax benefits & Form-16 as the
deduction will happen automatically from the employee’s salary.
The Parent Policy also attracts an additional Third-Party Administrator (TPA) charge of INR 92.50 per parent
per year and an additional goods and services tax on the same which will also be deducted from the
employee’s salary. Please refer Medi Assist portal for rate chart of premiums applicable
(https://portal.mediassist.in/Home.aspx).
It is the responsibility of the employee to declare correct and accurate information regarding the
name and date of birth in the Medi Assist website. If any information provided by an employee is
found to be incorrect or false, it would result in BCG Violation.
Enrolment and coverage for parents for new hire employees can only be done within 30 days from
employee’s date of joining (date of joining + 29 days).
No member can be covered twice in the policy even if he/she is a dependent of more than one
employee.
The risk inception date for employees existing on or before December 31, 2023, will be January 1, 2024. For
new joiners joining on or after January 1, 2024, the risk inception date will be their date of joining.
Claims submitted for dependents whose name has not been enrolled on the website will not be processed by
the TPA. Further, the claim will not be paid if such claim be in any manner is fraudulent or supported by any
fraudulent means or devise whether by the insured person or by any other person acting on his behalf.
In case of a claim being submitted with only one parent enrolled, addition of the other parent is allowed. In
such scenario the coverage will be changed from the individual coverage to the floater coverage and the
floater premium for the selected coverage will be applicable. The employee may choose to enhance the
sum-insured, however, reduction of sum-insured after a claim is made during the window period, is not
allowed.
Any ailment diagnosed / treated during coverage/enrolment window period under the lower sum insured will
continue to have the lower sum insured as the maximum cover (for that ailment and all related ailments).
This is applicable when the sum insured has been increased during enrolment window period.
Employee’s share in the Premium (Parents Policy)
The premium for insuring the parents will be completely borne by the employee.
Premium for parents however is payable on annual basis only.
Applicable premium amount for coverage of employee's parents will be deducted from the employee's
payroll without any prior intimation.
The deduction will be done within 90 days of the employee having enrolled his/her dependents on the Medi
Assist website.
For onsite employees, the deduction will be done from the onsite payroll and wherever the deduction is not
possible through the onsite payroll, will be communicated to pay either through cheque or online transfer.
The employees (DOJ on or after 1st Jan’24) will have an option under the renewal window, from January 1,
2024, to January 31, 2024, to choose to pay the parent’s premium as a lump sum in March 2024, or as 2
equal instalments in February 2024 and March 2024.
For all existing employees as on Dec 31,2023, the same selections will continue/hold good till end of 2024.
W hile the employees have enrolled for the parental plan will have a lock-in for 2 years, we have introduced
flexibility option of allowing employees who have enrolled for parental plan in 2023 to enhance their sum
insured in 2024 by paying the additional premium required for opting in the enhanced sum insured slab.
Opting out of the parental plan or reducing the sum insured is not allowed.
New employees availing the policy can opt for parent’s coverage within 30 days of joining (date of joining +
29 days) by logging on to the Mediassist Portal (https://portal.mediassist.in/Home.aspx) or Medi Assist
mobile app. Coverage will be effective from the date of joining.
Mid-term addition of parents is not allowed under the policy except for the below listed scenarios:
a) Retirement of parent from a job where he / she was covered.
b) Demise of the bread earning parent where the other parent was covered (employee is required to submit
required documents within 30 days of the demise).
c) Employee returning to India from an offshore assignment (employee is required to submit the enrolment
request within 30 days of their return).
The above additions are basis the terms & conditions, please refer the relevant FAQs for details.
There is no mid-term enhancement of sum insured in respect of existing members under both the policies
viz., Employee, Spouse & Children / Voluntary Topup policy and Parents policy.
All such requests for Midterm Inclusions for parents, employee need to have approval from their People
Manager (as per Blue pages) and would need to submit proof or other applicable documents over email to
the [email protected] for BOM Team to review /approve & take it up for insurer concurrence. The
coverage date will be effective from the date the inclusion once approved and endorsed by the insurer.
Dependents cannot be removed during a policy period except under the following circumstances:
Divorce
Death of a dependent
Resignation of the employee
The Insurance Company at its sole discretion can ask for supporting documents for addition or removal of
dependents from the coverage.
[email protected]
[email protected]
with relevant proofs / documents (soft copy) within 30 days of the incident date.
Benefits Covered under the Parents Policy: For details, please refer to the relevant section.
Hospitalization Expenses
Domiciliary Hospitalization Benefit
Coverage for ARMD with an overall limit of INR 50,000/- per year
Additional Benefits
Value Added Services
HOSPITALISATION EXPENSES
a) A co-payment of 10% on the admissible claim amount shall apply on each and every claim by the employee.
b) A co-payment of 20% on the admissible claim amount shall apply on each and every claim by the
dependents (Spouse, children and parents).
c) The co-payment on admissible claim amount shall not apply in case of death of the employee during
hospitalization.
Domiciliary Hospitalization refers to medical treatment for a period exceeding three days for such
illness/disease/injury which in the normal course would require care and treatment at a hospital/nursing
home but is actually taken whilst confined at home in India under any of the following circumstances namely:
The condition of the patient is such that he/she cannot be moved to the Hospital/Nursing Home, or
Patient cannot be moved to the Hospital/Nursing Home for lack of accommodation therein.
However, the Domiciliary Hospitalization benefits shall NOT cover:
Coverage for Stem Cell, Robotic & Bone Marrow for Cancer cases.
Coverage is offered subject to
(A) The treatment having FDA approval
(B) Medically indicated Robotics surgeries can be covered under the policy
(C) Bone marrow transplant for cancer would cover.
(D) All FDA approved Stem cell therapy would be covered.
Please note Gene therapy is not covered.
This benefit is extended only to the employee, spouse, and dependent children. It is not applicable to the Parents
Policy.
This benefit is unique considering that health insurance products in India typically exclude coverage of
psychiatric conditions.
The benefit shall pay for all eligible expenses incurred of inpatient treatment for any psychiatric and behavioural
condition.
This benefit is within the overall inpatient cover i.e., there is no additional sum insured OR sub limit applicable on
this benefit.
Some exclusions for this benefit are: (1) De addiction programs. (2) Admission for primary purpose of
confinement
Co - payment Applicable Inpatient Psychiatric and Behavioural Expenses.
a) A co-payment of 10% on the admissible claim amount shall apply on each and every claim by the employee.
b) A co-payment of 20% on the admissible claim amount shall apply on each and every claim by the
dependents (Spouse, children).
c) The co-payment on admissible claim amount shall not apply in case of death of the employee during
hospitalization.
MATERNITY BENEFIT
This benefit is extended to the employee, available only to employee and spouse. It is not applicable to the
Parents Policy.
The limit for maternity benefit for employees availing the policy is up to a maximum of INR 60,000 within the
overall inpatient cover. If both Husband & wife are employees of IBM even, then the maximum of INR 60,000
only be applicable for maternity claim.
Maternity limit can be increased up to maximum of INR 100,000/- by opting top-up cover as below:
a) A co-payment of 10% on the admissible claim amount shall apply on each and every claim by the employee
maternity and related claims up to 4 deliveries.
b) A co-payment of 20% on the admissible claim amount shall apply on each and every claim by the
dependents for maternity and related claims up to 4 deliveries.
c) The co-payment on admissible claim amount shall not apply in case of death of the employee during
hospitalization.
The Infertility treatment benefit is extended to the employee and their spouse under the ESC policy, as part of the
Maternity coverage. This implies the treatments (inpatient & day care basis only) under the infertility treatment benefit
are covered under the policy up to the maternity sub-limit.
Sterility treatment /IVF treatment / other fertility treatments from a part of the infertility treatment benefit, while below
is the list of day care procedures covered under the benefit:
a. Ovarian drilling
b. Ovarian cystectomy
c. Therapeutic insufflation of the Fallopian tubes
d. Tuboplasty
e. Therapeutic curettage
f. Endocopic polypectomy
g. Myomectomy
h. Hysterscopic or laparascopic biopsy or removal of uterine fibroid
i. Incision of the scrotum and tunica vaginalis testis
j. Surgical treatment of a varicocele and a hydrocele of the spermatic cord
k. Assisted reproductive procedures like In vitro fertilization (IVF), GIFT, ICSI
I. Health screening benefit is available to eligible members on an annual basis unless otherwise specified.
III. This benefit is extended only under the employee, spouse, and children (ESC) Policy. This benefit is not
applicable to the Parents Policy. This benefit is applicable to employees only except for Sections H, I & J where
children are eligible.
IV. This benefit is within the overall Sum Insured as a sub limit i.e., there is no additional sum insured. Any Claim will
be paid from main sum insured.
V. The benefit can be claimed as a reimbursement. No cashless is available for this benefit.
VII. The benefit would cover tests for specific screening of conditions only and not for diagnostic purposes,
existing medical conditions, treatment, or follow-up treatment.
VIII. Following screening tests are also covered (in addition to biometric screening): Depending on the age / gender
& risk factor(s), screening may be suggested.
Service Frequency
Questions and Counselling by Healthcare Professional on every
Smoking Use Screening
screening visit starting at age 12 or as clinically appropriate
Questions and Counselling by Healthcare Professional on every
Alcohol Abuse Screening
screening visit starting at age 12 or as clinically appropriate
Questions and Counselling by Healthcare Professional on every
Depression Screening
screening visit starting at age 12 or as clinically appropriate
Family History of cancer, premature
cardiovascular disease, and other significant On every screening visit
illness
B. Physical Exam:
Service Recommendation
Height, Weight, Body mass index (BMI), Waist
Measurement on every screening visit
circumference
Blood pressure measurement Measurement on every screening visit
Measurement on every visit (Snellen chart recommended) on
Vision screening
every visit
C. Blood Tests:
Service Recommendation
Total-cholesterol and HDL-cholesterol
Check in men 35 years old and above and women 45 years old
measurement (Full lipid profile including fasting
and above. Start earlier for any adult with any risk factors for
Total-cholesterol, LDL-cholesterol, HDL-
cardiovascular disease. Repeat testing every 5 years if normal or
cholesterol, and Triglyceride measurement is
more frequent if elevated.
also acceptable)
Measure in adults 40 years old and above or earlier if tobacco use,
obesity, family history of diabetes or large for gestational age baby,
Fasting blood glucose measurement hypertension, or dyslipidaemia present. If normal repeat every 5
years; more frequent screening is appropriate based on risk
factors.
D. Other tests
Note: For persons who might have been exposed to HCV within the past 6 months,
testing for HCV RNA or follow-up testing for HCV antibody is recommended.
Screening is recommended for:
Household contacts and other close contacts of patients with active TB
People living with HIV
Tuberculosis screening Current and former workers in workplaces with silica exposure
TB should be considered in people with an untreated fibrotic chest X-ray lesion
In settings where the TB prevalence in the general population is 124/100,000
population or higher
Preferred screening test is dual-energy x-ray absorptiometry (DEXA scan). Screen
Osteoporosis screening women aged 65 or older. Screening in men and in women under age 65 based on risk
factors. Repeat testing should be based on risk factors and findings of previous test.
Service Recommendation
Cervical cancer Preferred screening test is the Papanicolaou (Pap) smear. Screen women ages 21 to 65
screening years, every 3 years.
Breast cancer Preferred screening test is mammography. Screen women ages 50 to 75 years every two
screening years.
Screen all adults ages 50 to 75 by:
Colon cancer a) Fecal occult blood testing on 3 consecutive stool samples annually
screening b) Flexible Sigmoidoscopy every 5 years, with fecal occult blood testing every 3 years
c) Or Colonoscopy every 10 years
G. Vaccination
Service Recommendation
Hepatitis B Vaccine All doses + booster dose
Service Recommendation
at the following ages:
3 to 5 days
1 month
2 months
4 months
6 months
Well child visit for ages 0-3
9 months
12 months
15 months
18 months
24 months
30 months
Smoking Use Questions and Counselling by Healthcare Professional) on every screening visit starting at
Screening age 12 or as clinically appropriate
Alcohol Abuse Questions and Counselling by Healthcare Professional on every screening visit starting at
Screening age 12 or as clinically appropriate
Depression Questions and Counselling by Healthcare Professional on every screening visit starting at
Screening age 12 or as clinically appropriate
Service Recommendation
Height, Weight, and Body mass index (BMI), waist
Measurement on every screening visit
circumference
Blood pressure measurement Measurement on every screening visit
Measurement on every visit (Snellen chart recommended)
Vision screening
on every visit
You can submit reimbursement claims for the screening test(s) availed through offsite medium.
The following is the procedure to submit your reimbursement claims for a screening test through the Mediassist
Portal (https://portal.mediassist.in/Home.aspx):
1. Login to the Mediassist Portal Click the Submit claims button from ‘Claims’ tile and select submit hospitalisation
claim.
2. Enter the details of your screening. The form is divided into 3 parts - This would include your Beneficiary Details,
Claim Details, and Declaration of Claim Submission. Add your bank details so that the reimbursement amount can
be transferred to your account. Remember to raise separate claims for separate screenings.
3. Scan and upload your documents to enable Medi Assist to start processing your claims based on the online
submission even before receiving the physical documents. You must mandatorily submit claim form, eligibility
declaration, original bill and receipt, and copy of reports of the tests for the claim to be approved after scrutiny of
these originals. Remember to upload documents such as ID proof and address proof.
4. Once you have duly filled in the form and saved it, please re-check all the details entered. After a claim form is
submitted, you will not be able to make any changes.
6. Kindly take a printout of filled claim form, sign and submit it within 3-4 days from the date of the tests along with all
financial original documents for final settlement of the claim. The following original documents should be submitted to
Medi Assist for each claim:
a. Claim form
b. Eligibility declaration
c. original bill & receipt
d. Copy of reports of the tests
Note:
You can submit an online claim beneficiary only after the closure of enrolment window period of 30 days.
The size of each of document should be less than 5 MB.
It is the responsibility of the employee to declare correct and accurate information regarding the claim and ensure
that the claim submitted is genuine. If any information provided by the employee is found to be manipulated,
incorrect or false this would result in BCG violation.
ADDITIONAL BENEFITS
Ambulance Expenses:
The insurance plan will cover ambulance expenses for all emergency hospitalizations. The limit for the ambulance
charge is INR 1,500. Employees can claim ambulance charges only from the place of incidence/home of the patient
to the hospital and not the return trip. Ambulance usage on the return trip will be at the cost of the employee.
The insurance plan will cover the cost of appliances as a part of orthopaedic treatment. These include but are not
restricted to braces, splints, crutches, wheelchairs, artificial limb etc. These expenses are a part of the hospitalization
benefit and are reimbursable up to a maximum of 5% of the total eligible claim amount or actual expense of the
appliance whichever is lower.
1. Blindness
2. Cancer
3. Coronary artery surgery
4. Heart valve replacement
5. Kidney failure
6. Major organ transplant
7. Multiple sclerosis
8. Myocardial infarction
9. Paralysis
10. Stroke
11. Surgery of Aorta
12. Treatment of any injury arising out of road accidents to employees
13. Coma of specified severity
14. Motor Neuron Disease
15. Complications for a Preterm Baby
16. Defined Life-threatening emergencies related to maternity.
17. Hospitalization arising of Covid which is life threatening/critical condition.
18. Cochlear implants
19. Any other exceptional life-threatening conditions (disease/condition/injury which MUST be the PRIMARY CAUSE
of threat to life of the insured member in a span of one year). The provision to consider exceptional life-threatening
conditions will be as per the below laid out procedure:
Defined Life-threatening emergencies related to maternity will be covered under the critical illness buffer once the
maternity sub limit is exhausted. These defined conditions are:
1. Life threatening PPH (PPH)
2. Post-natal sepsis
3. Life threatening Eclampsia
4. Life threatening issues arising out of perforation & sepsis post MTP.
Procedure:
A team of 3 doctors would be constituted by HDFC Ergo (all doctors working with HDFC Ergo).
IBM India Ltd would suggest a designated doctor from IHS team who would be the SPOC. The concerned
doctor would be contacted by HDFC Ergo team if there’s any requirement or for inputs. IBM team will not
have any role in decision making.
If, any one doctor from HDFC Ergo team agrees the consideration of the exception, the case would be
considered as approved for exception.
If HDFC Ergo doctors team feels the case ambiguous, they may refer the case to appropriate external
consultants for their opinion.
The decision of HDFC Ergo doctors’ team would be final and binding on all
Treatments which are not likely to improve the likely survivability significantly would not be considered.
Palliative treatments would be excluded.
The condition / diagnosis / treatment for which buffer is requested must be otherwise admissible under the
policy terms & conditions.
The treatment must be for a disease / condition / injury which MUST be the PRIMARY CAUSE of threat to
life of the insured member in a span of one year.
Approvals of corporate buffer for any exceptional life-threatening condition would be based on the merits of
the case and not form precedence for any future claims.
Coverage of HIV / AIDS through Critical Illness Buffer: HIV/AIDS is included in the critical illness list for
critical illness buffer.
Apart from the above list of illness, the buffer amount of INR 700,000 can be utilized for the treatment of any
injury arising out of road accidents of employees only.
Co-payment Applicable: The critical illness is linked with the additional coverage taken by the employee. The
eligibility for critical illness buffer will be determined as per the table below.
Additional coverage Amount opted for self and Co-payment Total Sum Insured (Base +
Family (%) Additional)
11 lakhs 0% 15 Lakh
4 lakhs to 6 lakhs 10% 8 to 10 Lakh
1 lakh to 2 lakhs 20% 5 to 6 Lakh
No additional coverage 30% 4 Lakh
Day Care Procedures will include following Day Care Surgeries & Day Care Treatments:
Day Procedure Description
Stapedotomy
Stapedectomy
Revision of a stapedectomy
Myringotomy
External incision and drainage in the region of the mouth, jaw and face
Incision of the hard and soft palate
Excision and destruction of diseased hard and soft palate
Other operations on the mouth & face Incision, excision and destruction in the mouth
Plastic surgery to the floor of the mouth
Palatoplasty
Other operations in the mouth under general/spinal anaesthesia
Operations on the scrotum & tunica Incision of the scrotum and tunica vaginalis testis
vaginalis testis Operation on a testicular hydrocele
Excision and destruction of diseased scrotal tissue
Plastic reconstruction of the scrotum and tunica vaginalis testis
Other operations on the scrotum and tunica vaginalis testis
Lithotripsy
Coronary angiography
Hemodialysis
Radiotherapy for Cancer
Cancer Chemotherapy
Other Operations
Renal biopsy
Bone marrow biopsy
Liver biopsy
Biopsy/Hystersocpy? covered if malignancy is confirmed- capped upto
Rs10,000/-
PT Scan
Excision of cyst/granuloma/lump
Ascitic/Plueral tapping
Varicose veins ligation
Plastic reconstruction of the penis
Other operations on the penis
Non-adjuvant chemotherapy to be considered under day care
treatment
IV Push Chemotherapy
HBI-Hemibody Radiotherapy
Infusional Targeted therapy
SRT-Stereotactic Arc Therapy
Oncology SC administration of Growth Factors
Continuous Infusional Chemotherapy
Infusional Chemotherapy
CCRT-Concurrent Chemo + RT
2D Radiotherapy
3D Conformal Radiotherapy
IGRT- Image Guided Radiotherapy
IMRT - Step & Shoot
Infusional Bisphosphonates
IMRT – DMLC
Rotational Arc Therapy
Tele gamma therapy
FSRT-Fractionated SRT
VMAT-Volumetric Modulated Arc Therapy
SBRT-Stereotactic Body Radiotherapy
Helical Tomotherapy
SRS-Stereotactic Radiosurgery
X-Knife SRS
Gammaknife SRS
TBI-Total Body Radiotherapy
Intraluminal Brachytherapy
Electron Therapy
TSET-Total Electron Skin Therapy
Extracorporeal Irradiation of Blood Products
Telecobalt Therapy
Telecesium Therapy
External mould Brachytherapy
Interstitial Brachytherapy
Intracavity Brachytherapy
3D Brachytherapy
Implant Brachytherapy
Intravesical Brachytherapy
Adjuvant Radiotherapy
Afterloading Catheter Brachytherapy
Conditioning Radiothearpy for BMT
Extracorporeal Irradiation to the Homologous Bone grafts
Radical chemotherapy
Neoadjuvant radiotherapy
LDR Brachytherapy
Palliative Radiotherapy
Radical Radiotherapy
Palliative chemotherapy
Template Brachytherapy
Neoadjuvant chemotherapy
Adjuvant chemotherapy
Induction chemotherapy
Consolidation chemotherapy
Maintenance chemotherapy
HDR Brachytherapy Plastic Surgery
Construction skin pedicle flap
Gluteal pressure ulcer-Excision
Muscle-skin graft, leg
Removal of bone for graft
Muscle-skin graft duct fistula
Removal cartilage graft
Myocutaneous flap
Fibro myocutaneous flap
Breast reconstruction surgery after mastectomy
Sling operation for facial palsy
Split Skin Grafting under RA
Wolfe skin graft
Plastic surgery to the floor of the mouth under GA
1. Thyroplasty Type II
2. Uvulo Palato Pharyngo Plasty
3. Vocal Cord lateralisation Procedure
4. AV fistula – wrist
5. URSL with stenting
6. URSL with lithotripsy
7. Cystoscopy & Biopsy
8. Kidney endoscopy and biopsy
9. Epidural steroid injection
10. VP shunt
11. Laser Ablation of Barrett’s oesophagus
24 Enhanced Day care List
12. EUS + submucosal resection
13. Infected sebaceous cyst
14. Colonoscopy
15. Unilateral
16. POP application
17. Partial removal of metatarsal
18. Remove of tissue expander
19. Intra articular steroid injection
20. Mediastinal lymph node biopsy
21. EUA + biopsy multiple fistula in ano
22. D&C
23. MIRENA insertion
24. Hymenectomy (imperforate Hymen)
The IBM India GMC policy also covers Gender Realignment expenses under the WPATH protocol. The coverages
under this benefit are as below:
Treatment Type Covered Covered Under
Male to Female
Inpatient or Day-care
Breasts/Chest - Augmentation mammoplasty
Yes benefits as per policy
(implants/lipofilling)
conditions
Inpatient or Day-care
Genital surgery - penectomy, orchiectomy, vagioplasty,
Yes benefits as per policy
clitoroplasty, vulvoplasty
conditions
Facial feminization, liposuction, lipofilling, voice surgery, Inpatient or Day-care
thyroid cartilage reduction, gluteal augmentation Yes benefits as per policy
(implants/lipofilling), hair reconstruction. conditions
Surgery - change of
primary or secondary Female to Male
sex characteristics Inpatient or Day-care
Breasts/Chest - Subcutaneous Mastectomy, creation of
Yes benefits as per policy
male chest
conditions
Genital surgery - Hysterectomy/ovariectomy,
reconstruction of fixed part of urethra, combined with Inpatient or Day-care
Metoidioplasty or Phalloplasty (employing a pedicled or Yes benefits as per policy
free vascularized flap), vaginectomy, scrotoplasty, conditions
implantation of erection and/or testicular prostheses
Inpatient or Day-care
Liposuction, lipofilling, voice surgery, pectoral implants Yes benefits as per policy
conditions
Electrolysis No
Hair removal Laser Treatment No
Waxing No
If part of pre and post
hospitalization duration
expenses as per policy
Hormone therapy Yes conditions
OR part of domiciliary
expenses, as per
policy conditions
Either If part of pre and
post hospitalization
Voice and
duration expenses
communication Yes
OR part of domiciliary
therapy
expenses, as per
policy conditions
Either If part of pre and
post hospitalization
duration expenses
Psychotherapy Yes OR part of domiciliary
expenses, as per
policy conditions
HDFC Ergo Insurance is providing a host of value-added services as listed below exclusive for IBMers
There is 11.5% discount offered to IBMers on medicines, 5% discount on purchase of non-pharma (FMCG)
item and 15% discount on Apollo private labels products from Apollo Pharmacies. This discount is not
available at pharmacies located in the Apollo Hospitals and Apollo Clinics.
Process:
PRG_ID/Code PRG_NAME
2197 IBM INDIA
Important:
According to the “Drugs Price Control Order” (DPCO) the pricing structure of certain drugs would be regulated by the
Government of India.
All pharmacies and chemists have to mandatorily comply to this rule of not extending discounts on DPCO drugs.
Hence Apollo Pharmacy will not be able to extend any discount on DPCO drugs. Discounts on rest of the products
remains unchanged.
HDFC Ergo insurance may suggest doctors to IBMers should they seek a medical second opinion. The
service will be managed on a case-to-case basis
You will be required to share the required information in the below table with Team Benefits:
IBM India FTH employees with a tenure of more than 12 months can avail similar benefits as of regular employees.
The employees can enrol their dependents (spouse, children and parents) / opt-out of the policy within 30 days of
policy inception. The new employees can also opt for additional coverage within 30 days of their date of joining (date
of joining + 29 days). Please note that the top-up selections and parents’ enrolments made in 2023 will be carried
forward for 2024 as the top-up policy and the parent’s policy in 2023 will have a 2-year lock-in. Employees who have
not opted for top-up and/or parents’ coverage in 2023 shall not avail the same in 2024.
To enrol dependents, FTH employees are required to log in to https://portal.mediassist.in/Home.aspx. The login
credentials for the initial login on the Mediassist Portal will be as follows:
For example, if your employee id is 123456, your username would be 123456@IBM and if your date of birth is 30-
November-2014, your initial password would be 30112014123456. Please change your password after you log in for
the first time.
Please note, FTH employees can now enroll through the Medi Assist app as well. To know more about the same,
please refer to the FAQs section.
Please refer to the relevant sections in previous pages for the complete information of benefits listed below -
1. Employee, Spouse and Children coverage - Base coverage of INR 4 lacs (ESC policy)
2. Voluntary Opt-out option under ESC policy
3. Voluntary topup coverage enhancement option
4. Voluntary parents’ coverage option
5. Hospitalization expenses
6. Domiciliary hospitalization benefit
7. In patient treatment for psychiatric and behavioural conditions
8. Domiciliary expenses on outpatient care
9. Maternity benefits
10. Health screening benefits
11. Additional benefits
12. Critical illness buffer
13. Value added services.
All FTH employees will be automatically enrolled under the base coverage. If you do not wish to participate in the
program, you can opt-out by logging in to https://portal.mediassist.in/Home.aspx within the renewal window starting
January 1, 2024, closing January 31, 2024, or 30 days from date of joining (date of joining + 29 days), as applicable.
The FTH employees with tenure less than or equal to 12 months are covered under ESC policy for base coverage of
Rs. 4 Lakhs.
The FTH employees need to enrol their dependents (spouse and children only) or opt-out if they do not wish to
participate in the policy within 30 days of policy inception.
Similarly, new hire FTH employees can enrol their dependents / opt-out of the policy within 30 days from their date of
joining (date of joining + 29 days).
To enrol dependents, the FTH employees are required to log in to https://portal.mediassist.in/Home.aspx. The login
credentials for the initial login on the Medi Assist Portal will be as follows:
Username@IBM
Password: Date of birth followed by employee ID (eg.: ddmmyyyyEmployeeID)
For example, if your employee id is 123456, your username would be 123456@IBM and if your date of birth is 30-
November-2014, your initial password would be 30112014123456. Please change your password after you log in for
the first time.
Please note, FTH employees can now enrol through the Medi Assist app as well. To know more about the same,
please refer to the FAQs section.
The fixed term hires with tenure of less than or equal to 12 months have the following benefits:
1. Employee, Spouse and Children coverage - Base coverage of INR 4 lacs (ESC policy)
2. Voluntary Opt out option under ESC policy
3. Hospitalization expenses
4. Domiciliary hospitalization benefit
5. In patient treatment for psychiatric and behavioural conditions
6. Domiciliary expenses on outpatient care
7. Maternity benefits
8. Health screening benefits
9. Additional benefits
10. Critical illness buffer
11. Value added services.
Please refer to the relevant sections in the previous pages for the benefits listed above.
All FTH employees will be automatically enrolled under the ESC policy. If you do not wish to participate in the
program, you can opt-out by logging in to https://portal.mediassist.in/Home.aspx.
The premium for the base sum insured (Rs. 4 Lakhs) is shared between the FTH employee and IBM.
If an FTH employee avails the insurance coverage, there would be a deduction of INR 1008.63/- (excluding the
goods and services tax; currently at 18%) per annum from his/her salary.
For new hire FTH employee, joining post inception of the policy, this amount will be pro-rated depending upon their
Date of Joining (DOJ).
Unless an employee chooses to opt out of the policy, the premium co-share for this coverage will be automatically
deducted for all FTH employees who were on the rolls of the company as on December 31, 2023.
For new FTH employees the premium will be deducted in the succeeding month after completing 30 days from their
DOJ (date of joining + 29 days).
Note: FTH tenure is considered as per the offer letter start date and end date.
The IBM interns under IBM Interns policy are covered for the base coverage of INR 4 Lakhs, under Niti Aayog
program.
Please refer to the relevant sections in the previous pages for the benefits listed above.
All interns (age group 15 to 18 years) will be automatically enrolled under the policy. The policy coverage will be for
the tenure of the internship.
The Insurer will not make any payment for any claim in respect of any Insured Person directly or indirectly for,
caused by, arising from or in any way attributable to any of the following unless expressly stated to the contrary in
this Policy:
i. Invasion, act of foreign enemy, civil war, public defence, rebellion, revolution, insurrection, military or usurped acts,
chemical and biological weapons
ii. Any Insured Person committing or attempting to commit a criminal or illegal act, while sane or insane.
iii. Any Insured Person’s participation or involvement in naval, military or air force operation, racing, diving, aviation,
scuba diving, parachuting, hang gliding, rock or mountain climbing.
iv. The abuse or the consequences of the abuse of intoxicants or hallucinogenic substances such as drugs and
alcohol, including smoking cessation programs and the treatment of nicotine addiction or any other substance abuse
treatment or services, or supplies.
v. Obesity or morbid obesity or any weight control program, where obesity means a condition in which the Body
Mass Index (BMI) is above 29 and morbid obesity means a condition where the BMI is above 37.
vi. Alzheimer’s disease: general debility or exhaustion (“run down condition”); stem cell implantation or surgery which
is not approved by FDA; or growth hormone therapy; sleep apnea, gene therapy, Parkinson’s Disease for parents
vii. Venereal disease, sexually transmitted disease, or illness; (except HIV, which is covered in both OP & IP)
viii. Vicarious pregnancy, birth control, contraceptive supplies or services and complications arising therefrom.
ix. Dental treatment and surgery of any kind, unless requiring Hospitalization.
x. Treatment and supplies for analysis and adjustments of spinal subluxation, diagnosis and treatment by
manipulation of the skeletal structure or for muscle stimulation by any means (except treatment of fractures and
dislocations of the extremities).
xi. Circumcision (if not required as a part of treatment of a disease or due to injury).
xii. Laser treatment for correction of eye due to refractive error less than 7.5; if the procedure is performed only to get
rid of spectacles or contact lenses the claim is not payable; if the Lasik Surgery is performed for therapeutic reasons
like erosions, non-healing ulcers, recurrent corneal erosions, nebular opacities, etc it is payable.
xiii. Aesthetic or change of life treatments of any description such as treatments to do or undo changes in
appearance or carried out in childhood or at any other times driven by cultural habits, fashion or the like or any
procedures which improve physical appearance.
xiv. Plastic surgery or cosmetic surgery unless necessary as a part of medically necessary treatment certified by the
attending Medical Practitioner for reconstruction following an Accident or Illness.
xv. Experimental, investigational, or unproven treatment, devices and pharmacological regimens, or measures
primarily for diagnostic, X ray or laboratory examinations or other diagnostic studies which are not consistent with or
incidental to the diagnosis and treatment of the positive existence or presence of any Illness for which confinement is
required at a hospital.
xvi. Convalescence, cure, rest cure, sanatorium treatment, rehabilitation measures, private duty nursing, respite
care, long term nursing care or custodial care.
xvii. Any non-allopathic treatment, except Ayurveda treatment Benefit. Expenses incurred on treatment taken under
Ayurveda, subject to amounts specified in the Schedule of Benefits.
xviii. All preventive care, vaccination including inoculation and immunizations, any physical, psychiatric, or
psychological examinations or testing during these examinations; enteral feedings (infusion formulas via a tube into
the upper gastrointestinal tract) and other nutritional and electrolyte supplements, unless certified to be required by
the attending Medical Practitioner as a direct consequence of an otherwise covered claim.
xix. Charges related to a hospital stay not expressly mentioned as being covered, including but not limited to charges
for admission, discharge, administration, registration, documentation, and filing.
xx. Items of personal comfort and convenience including but not limited to television, telephone, foodstuffs,
cosmetics, hygiene articles, body care products and bath additives, barber or beauty services, guest services as well
as similar incidental services and supplies, and vitamins and tonics unless vitamins and tonics are certified to be
required by the attending Medical Practitioner as a direct consequence of an otherwise covered claim.
xxi. Treatment rendered by a Medical Practitioner which is outside his discipline or the discipline for which he is
licensed; referral fees or out station consultations; treatments rendered by a Medical Practitioner who shares the
same residence as an Insured Person or who is a member of an Insured Person's family, however proven material
costs are eligible for reimbursement in accordance with the applicable cover.
xxii. The provision or fitting of hearing aids, spectacles or contact lenses including optometric therapy, any treatment
and associated expenses for alopecia, baldness, wigs, or toupees, medical supplies including elastic stockings,
diabetic test strips, and similar products.
xxiii. Any treatment or part of a treatment that is not of a reasonable cost, not medically necessary; non-prescription
drugs or treatments.
xxiv. Artificial limbs, crutches or any other external appliance and/or device used for diagnosis or treatment.
xxv. Immunization.
xxvi. Treatment for C3R (CORNEAL COLLAGEN CROSSLINKING WITH RIBOFLAVIN) and INTACS are not
payable. Treatment related to ROP (retinopathy of prematurity) and RFL (Retrolental Fibroplasia) is not payable.
xxvii. Quantum Magnetic Resonance Therapy or RFQMR (Cytotron) treatments are not admissible under the policy.
xxviii. Parkinson’s Disease for parents are not admissible under the policy
Some common scenarios where claim is not payable under the policy.
Any Hospitalization for infusion of only oral medication and intramuscular injection throughout the course of
hospitalization then the claim would not be admissible even if there is admission for more than 24 hours.
Any Hospitalization for less than 24 hours other than specified in the day care list would not be admissible
under the policy.
Any OPD treatment or treatment possible at home or treatment done at home would not be considered
under the hospitalization benefits or inpatient benefits of the policy terms and conditions.
Any OPD consultation or tests related to maternity or infertility would not be covered under the OPD benefits
of the policy terms and conditions. (Procedure, investigation, test, consultation which are done to check or
increase the chances of pregnancy will be considered under the infertility treatment.)
Expenses related to any procedure or medicines would not be covered under the OPD benefits of the policy.
Parents are not eligible for availing the OPD benefits of the policy.
Expenses related to treatment of Parkinson’s disease are not covered for parents under the policy.
Expenses related to any day care surgery/procedures which are not listed in day care list of the policy would
not be covered under the policy.
Any cosmetic procedure or cosmetic treatment or any procedure which enhances the physical appearance
will not be admissible under the policy.
RFQMR is not payable under the policy
Any Dental treatment which does not require hospitalization would not be admissible under the policy
irrespective of etiology/Cause.
Any expenses related to the doctor treating out of his discipline then the same would not be considered
under the policy.
Ayurvedic treatment other than the govt prescribed procedures would not be admissible under the policy.
Ayurvedic treatment on outpatient basis, Admission for routine Panchakarma without diagnosis etiology and
treatment plan are not admissible under the policy.
Ayurvedic Treatment taken at SPA, Resort and non-registered hospital are not admissible under the policy.
CAPD expenses are not admissible under the policy however CAPD device cost can be admissible.
Hormonal Therapy is not admissible under the policy.
Treatment for Morbid obesity and complication or any treatment like Liposuction which would enhance the
physical appearance is not admissible under the policy.
Expenses related to cosmetic treatment would not be admissible under the policy.
Asymptomatic covid claims are not payable under the hospitalization/inpatient benefits of the policy terms
and conditions.
Claim would not be payable if insufficient documents are submitted.
Family planning procedures are not covered under the policy.
Voluntary termination of pregnancy, faetal Reduction (in case of twins and triplets etc), abortion within 12
weeks of pregnancy are not covered under the policy.
Laser treatment for eye correction having refractive error lesser than +/-7.5 are not covered under the policy
Implantable contact lens, toric lens and multifocal lens are not payable under the policy.
Pre and post hospitalization expenses not related to the diagnosis of the main claim would not be admissible
under the policy.
Regular Health check-up are not admissible under the policy terms and conditions even if it is prescribed by
a specialist.
Any misrepresented claim would not be admissible under the policy.
Note: Above scenarios are only common scenarios of rejections and for complete details regarding the claim
admissibility or rejection please refer the complete W3 document.
NOTE: All types of non-medical expenses other than the insurer agreed expenses incurred during the course of
hospitalization are not covered and have to be paid to the hospital before discharge
Log-in to “https://portal.mediassist.in/Home.aspx”.
Enter your Medi Assist Username and Password.
Click on any of the tabs reflecting in the homepage and “Talk to Us” tab will be reflecting, then click on the
"Talk to Us” tab and get instant resolution to your queries.
The user can chat with our Chat Bot.
End chat - Close the tab to end the chat.
Q. Who can be covered under the policy and for what amount?
A. You and your nominated dependents (spouse and children*) are eligible under a family floater cover of INR
400,000 unless you have opted out of the policy. If you wish to enhance the coverage beyond the family floater of
INR 400,000 (up to INR 1,500,000 in total by opting in the voluntary TOP UP sum insured), the incremental premium
has to be borne by you**.
You have the option of covering your parents under the parents' policy, but the premium, TPA charges and the
goods and services tax would have to be borne by you. Please note parents-in-law cannot be covered in the policy.
Q. What are the services available to me through HDFC Ergo /Medi Assist India TPA Private Limited?
A. The following services are available to employees:
Premium amount due wrt insurance coverage will be prorated depending upon the Date of Joining (DOJ) of the
employee. Parents-in-law cannot be covered in the policy.
Claims submitted for dependents whose name has not been enrolled in the website will not be processed by TPA.
Employees who have a newborn child can add them within 30 days of the date of birth. Coverage will be effective for
the newborn child from the date of birth.
Mid Term Inclusions (after 30 days period) will be allowed only as an exception for employees who missed adding
the spouse details and newborn child details due to some valid reasons stated under MTI section above.
Any request for Midterm Inclusions for spouse and children has to have approvals from the People Manager (as per
blue pages) along with the BOM Manager. The employee would need to submit proof of marriage or birth certificate
whichever is applicable. The coverage date will be effective from the date the inclusion is endorsed by the insurer.
There is no midterm enhancement of sum insured in respect of existing members under both the policies viz.,
Employee, Spouse & Children and Parents.
Claims submitted for dependents whose name has not been enrolled in the website will not be processed by the
TPA.
Also, in case of demise of a family member, please share the death certificate with date of death and send it to
[email protected] for them to delete the same from enrolment records.
Q. 'I am a newly hired employee. My wife has a pre-existing health condition. How is this handled/covered?'
A. Your wife's condition will be covered; there is no 9-month (waiver) period.
Step 3: It’s mandatory to change your password, before you can access any details.
Please call the support team at 080-46855351 if you face any difficulties in logging in or accessing the portal.
Note: The password is set to default at the beginning of each policy year and can be changed later by the employee
as per their convenience.
1. Go to Enrolment form.
2. Enter Bank details under the "Update Bank Details" section.
3. Click “Submit” at the bottom of the page.
FTH employees with tenure of more than 12 months can also enrol their parents under the Parents Policy, in addition
to their dependents (spouse and up to 4 children).
FTH employees with tenure of less than or equal to 12 months can enrol themselves along with their spouse, and up
to four children till the age of 24 years. However, the policy has no age cap for a child suffering from any physical
disability subject to the employee submitting the disability certificate given by competent authority.
Q. What are the sum insured options available under the policy?
A. For FTH employees with tenure of less than or equal to 12 months, the base sum insured of INR 4 lacs is
available only and with no option for opting in any voluntary plans. This coverage is a floater coverage, which means,
the same sum insured will be shared by the enrolled spouse and children.
For FTH employees with tenure of more than 12 months, the base sum insured of INR 4 lacs is available. The
employee may choose to enhance the coverage up to INR 10 lacs with enhancement options of INR 1 lac, INR 2
lacs, INR 4 lacs, INR 6 lacs and INR 11 lacs. This coverage is a floater coverage, which means, the same sum
insured will be shared by the enrolled spouse and children. Also, the employee has option to cover both their
parents. The sum insured options available for Parents Policy are INR 1 lac, INR 2 lacs, INR 3 lacs and INR 5 lacs.
Note: The e ID card is the sole property of Medi Assist India TPA Private Limited and must be returned upon request
or in the event of separation from the Company's services.
Complete the online enrolment process by adding self and dependent details by visiting Mediassist portal
(https://portal.mediassist.in/Home.aspx) or Medi Assist App (Refer to steps for online enrolment).
It is advisable to take a print of the ID cards after completing the enrolment. These ID cards will be useful at the time
of hospitalization.
Q. Can I increase my coverage (Top-up & Parents) in 2024 by paying extra premium?
A. In 2024, an employee who is already part of the voluntary plan (Top UP and Parental Plan) in 2023 gets an option
to increase/maintain his/her sum insured during 2024 enrolment window period (1st Jan – 31st Jan 2024). Opting for a
higher coverage will only be possible during the 2024 enrolment window period and not during the mid of the policy
year. However, reduction in sum insured slab or opting out under 2024 top up/parents’ policy is not allowed.
Q. After quitting IBM, can I continue availing the benefits of this policy by paying extra premium?
A. Once you leave IBM yourself and your enrolled dependents coverage under the group policy would cease / STOP
effective your Last Working Day with IBM India. However, You can directly get in touch with HDFC Ergo
([email protected]) 60 days prior to your last working day at IBM India, explore the portability option and if
satisfied can avail the benefits of portability for yourself and your enrolled family members (spouse and children
only). You may choose to buy a retail policy with HDFC Ergo Health, but it would be subject to underwriting with the
insurer portability guidelines and retail policy will be effective post separation from IBM.
Q. Whom do I contact to know about the products offered by HDFC Ergo and avail the portability benefit?
A. You can write to [email protected] with following details:
Someone from HDFC Ergo shall reach out to you basis the above details provided to discuss the plan details.
You may choose to get in touch with HDFC Ergo 60 days before your last working day at IBM India.
Q. I did not enrol my parents during the 2023 enrolment window/within 30 days of my date of joining. How do
I enrol my parents in the mid of the policy?
A. Mid-term addition of parents is not allowed under the policy. However, you may request for the mid-term addition
under below scenarios:
Q. Will I be insured in the policy even If I have not got my electronic id card?
A. You and your nominated dependents will be insured from the day you join IBM/date of renewal of policy,
whichever is later, provided you complete the online enrolment at https://portal.mediassist.in/Home.aspx or on
Medi Assist mobile app within the specified timeline.
Employees, who have resigned from IBM, are required to respond to Shortfall raised by Medi Assist within 5
working days failing which the claim will be rejected and prorated premium refund will be advised in FFS.
In case, there is no claim made (processed & amount settled) by you for self and nuclear family, pro-rata premium
paid for coverage and/or additional coverage will be refunded back to you for the period the coverage cease to exist.
In case of any claim is made (Processed & amount settled) for any one/all of the insured person, there will not be any
refund of premium.
If an employee has availed the health screening benefit and undergone the comprehensive risk screening tests (all
tests / screenings / vaccinations (including for Hepatitis B) under Sections A to J in the policy under Part II: Health
screening benefit (beyond the Biometric screening), there will be no refund of premium under the ESC policy.
In case, there is no claim made (Processed & amount settled) for the parent, prorate premium paid for the concerned
parent will be refunded back to you for the period the coverage cease to exist. In case of any claim is made
(Processed & amount settled), there will not be any refund of premium.
In case of demise of one of the parents under the parents’ policy floater coverage, the existing parent will continue to
be under the floater coverage for the policy year and no refund will be initiated.
In case of demise of both the parents under the parents’ policy floater coverage, refund will be prorated (if
applicable). In case a claim is reported for either parent, no refund will be made.
Q. I enrolled one of my parents under the policy and have submit a claim. Now I need to increase the
coverage amount. How can I do that?
A. In case your dependent parent is covered in GMC 2023 policy they will continue to be covered for the same
credentials under 2024 policy (by default). However, you have an option to increase/maintain his/her sum insured
during 2024 enrolment window period (1st Jan – 31st Jan 2024). The reduction of coverage amounts or removal of
the parent from the policy is not allowed. It should also be noted that any ailment diagnosed / treated during
coverage/enrolment window period under the lower sum insured will continue to have the lower sum insured as the
maximum cover (for that ailment and all related ailments). This is applicable when the sum insured has been
increased during enrolment period by an employee joining IBM India in 2024 or enhancement of coverage by
existing employee.
Q. I have enrolled myself, spouse and children under the ESC policy. I need to increase my sum-insured/top-
up. How do I do that?
A. During the enrolment window, you may add/delete dependent and choose from the various options under the top-
up table for enhancement of sum-insured. However, any ailment diagnosed / treated during coverage/enrolment
window period under the lower sum insured will continue to have the lower sum insured as the maximum cover (for
that ailment and all related ailments). This is applicable when the sum insured has been increased during enrolment
period by an employee joining IBM India in 2024. Fresh top up option is not available for 2023 existing employee.
Q. The policy mentions constant premium for 2 years (2023-2024). My parents’ age will move to a higher age
bracket in 2023. How do I avail the constant premium for both years?
A. Under the 2023-2024 policies, owing to the 2-year lock-in, the parents’ premium will remain constant for both
policy years. The parents’ premium for individual coverage will be calculated basis their age as on January 1, 2023,
and the sum-insured selected under the policy. The parents’ premium under the floater policy (both parents being
enrolled) will be calculated basis the elder parents’ age and the sum insured selected. It should be noted that the
premium (without tax) will remain constant for both the policy years, however, the total premium may vary in case of
change in the tax rate between 2023 and 2024 or if employee is enhancing parental cover.
Q. I want to avail the option of paying parents’ premium in instalments for 2023 and 2024. How do I avail
that?
A. In case your dependent parent is covered in GMC 2023 policy they will continue to be covered for the same
credentials under 2024 policy (by default). If you have opted for instalment option in 2023 policy the same will be
applicable for 2024 policy.
Additionally, if you are enhancing the enrolled parents sum insured in 2024 policy you will have an option to select
instalment option in 2024.
The employees who did not go for the instalment option under the 2023 parental plan or did not enhance coverage in
2024 enrolment window shall pay the premium as a lump sum in 2024 policy.
Q. In case of demise of one of my parents under the floater coverage, how will the coverage be treated for
the other parent?
A. In case of demise of one parent under the floater coverage for 2023, the other parent will continue to be covered
under the floater coverage for 2023. In case a parent from the floater coverage of 2023 passes away, the surviving
parent will be moved to individual policy in 2024 with the same sum insured as opted under floater plan and the
premium rate for the selected coverage under the individual policy will apply.
No refund will be processed as the other parent will continue to be under the same coverage.
Fill the Pre-Authorization form, available with the Network Hospitals upon showing the Medi Assist ID card or by
mentioning your IBM employee id. This can also be obtained from the Medi Assist helpline or can be downloaded
from the Medi Assist website.
Submit/Fax the Pre-Authorization Form to our toll-free fax numbers at Bangalore 48 hours in advance.
The advance intimation to Medi Assist will help you to avoid payment of advance amount to some hospitals.
Sign the relevant documents including discharge summary before leaving the hospital/getting discharged. If your
hospitalization is authorized, then ensure you pay for non-medical expenses and co-payment charges for the
dependents and parents, if enrolled.
When you have an emergency hospitalization and get admitted into a network hospital, please inform your family
member/relative/friend to contact the billing dept in the hospital with Medi Assist ID or IBM employee id to send
Preauthorization form to Medi Assist. If your hospitalization is authorized, then ensure you pay for non-medical
expenses and co-payment charges for the dependents and parents, if enrolled. Kindly sign the relevant documents
before leaving the hospital/getting discharged.
Cashless claims
Q What is Pre-Authorization?
A. Pre-authorization is a process that necessarily needs to be completed prior to hospitalization. The forms for the
same can be obtained by calling Medi Assist’s Telephone Help Lines or downloaded directly from the Medi Assist
web site https://portal.mediassist.in/Home.aspx (Home Page). The form needs to be filled with the help of the treating
doctor. This form contains details like details of treating physician and hospital*, details of diagnosis*, treatment
proposed*, past history, estimate expenses*, signature of the treating physician*, etc. Medi Assist’s medical team will
then evaluate the same based on medical and policy grounds. The advance intimation to Medi Assist will help you to
avoid payment of advance amount to some hospitals.
* If complete details are not provided in the form, then credit (in the case of a network hospital) or claim eligibility (in
the case of an out of network hospital) cannot be provided.
Q. How to know whether a particular treatment or hospital is covered or not under insurance?
A. For list of network hospitals, please visit https://portal.mediassist.in/Home.aspx. In order to know whether a
particular treatment is covered or not please send a pre-auth. request to Medi Assist.
Important: Please note that any hospital/nursing home you choose has to be registered and/or have minimum 15
beds.
In case of Network Hospitals - Depending upon eligibility, Medi Assist will extend credit for all the medical expenses
billed by the Network hospital for the treatment of your illness only. All non-medical expenses (described above) and
any amount exceeding the credit limit will have to be paid by you to the hospital at the time of discharge. In case if
the patient admitted is a dependent, 80% of the medical expenses will be paid for and you will have to pay the
balance 20% along with all the non-medical expenses (described above) and any amount exceeding the credit limit
will have to be paid by you to the hospital at the time of discharge. The advance intimation to Medi Assist will help
you to avoid payment of advance amount to some hospitals.
Reimbursement claims
However, if there is any inconsistency, the insurer/TPA reserves the right to call for physical documents. In such
scenarios you can courier the documents to Medi Assist. Address for couriering the claim documents is:
Please specify Employee Name, Employee ID and Medi Assist Health card number on the envelope.
Q. Is there an online tool to submit the claims?
A. Yes. There is a user-friendly tool for Online Medical Claim submission through the Mediassist Online Portal
(https://portal.mediassist.in/Home.aspx).
Q. How does the tool for online medical claim submission work?
A. This feature enables you to submit both Hospitalisation and Domiciliary claims online, and upload scanned
images of claim documents for faster claim processing. It will also allow you to maintain a soft copy of the claim
documents submitted and stay updated on the progress with an easy and hassle-free tracking mechanism.
However, you will still be required to submit the hardcopy of financial documents in original along with the claim form
and cancelled cheque to Medi Assist for further processing of the claim.
On successful claim submission, you will receive an immediate acknowledgement and claim reference number on
your registered email id to access the claim details. The claim details can also be accessed on the Medi Buddy app
once the claim is registered.
Q. As per the doctor, admission was mandatory, then why did Medi Assist reject my claim stating as
“Treatment possible on OPD basis“?
A. Claim is processed as per policy terms & conditions, after assessing the claim if it is found that admission was not
required then decision will be considered accordingly.
Q. Hospital says all documents are given, but Medi Assist says documents not provided. What to do in such
case?
A. Please check with Medi Assist what exactly are they asking for, approach the hospital with the specific
requirement or Please write to [email protected] and seek for support.
Q. What do I do in case my original claim documents are misplaced by me? Can I submit photocopies?
A. Claim will not be processed on photocopies as originals are mandatory. Depending upon the nature and amount
of the misplaced bill, deductions will be done. However final decision vests with the insurer.
Q. If both husband and wife are working with IBM and both have enrolled each other as dependents, in that
case if the maternity amount exceeds the limit, then can both claim the maternity amount?
A. Only one member can be covered once in the policy, duplication of dependent coverage is not permissible and
hence maternity claim will be paid to only one employee who will be covered in the policy
Q. What is the maximum number of claims allowed in a year?
A. There is no limit on the number of claims in a year, claim amount will be limited to Sum Insured.
Q. My claim has been settled but I see some deductions. What can these be?
A. Deductions can pertain to non-medical expenses, non-submission of bills, co pay deductions.
Q. If the date of admission is in 2023 and discharge is in 2024, then how will the claim be paid (if
admissible)? (If the admission date is in previous plan period and discharge date is in current plan period)
A. For any claim settlement, the date of admission will decide the policy / policy period under which the claim would
be considered and settled as per policy T&C and available sum insured.
General
Hence Active line of treatment considered when there is 24 hrs of hospitalization with therapeutic treatment or course
of treatment given in the mode of IV‘s and etc., which reduce or cure the basic disease. Therefore, During the course
of hospitalization, if there are only oral medicines with or without IM injections administered along with observations
and evaluations with hospitalization more than 24hrs, then the claim would not be admissible under the policy.
However, Hospitalization primarily for Diagnostic/evaluation purposes without active line of treatment during
hospitalization is covered provided the same diagnostic test/investigation done cannot be carried out in OPD.
Please note, additional 24-day care procedures has per enhanced policy benefit as below,
Annexure – 1
1. Thyroplasty Type II
2. Uvulo Palato Pharyngo Plasty
3. Vocal Cord lateralisation Procedure
4. AV fistula – wrist
5. URSL with stenting
6. URSL with lithotripsy
7. Cystoscopy & Biopsy
8. Kidney endoscopy and biopsy
9. Epidural steroid injection
10. VP shunt
11. Laser Ablation of Barrett’s oesophagus
12. EUS + submucosal resection
13. Infected sebaceous cyst
14. Colonoscopy
15. Unilateral
16. POP application
17. Partial removal of metatarsal
18. Remove of tissue expander
19. Intra articular steroid injection
20. Mediastinal lymph node biopsy
21. EUA + biopsy multiple fistula in ano
22. D&C
23. MIRENA insertion
24 Enhanced Daycare List 24. Hymenectomy (imperforate Hymen)
Please go through the reference document for claims submission published in Medi Assist micro site for IBM
employees (https://portal.mediassist.in/Home.aspx) to minimize errors at the time of filling the form.
NOTE: We will not be able to assess your claim (credit or non-credit) without a signed claim form.
Serial Serial
Items Items
Number Number
BABY CHARGES (UNLESS
1 40 HAIR REMOVAL CREAM
SPECIFIED/INDICATED)
DISPOSABLES RAZORS CHARGES (for site
2 Hand wash 41
preparations)
3 shoe cover 42 EYE PAD
4 Caps 43 EYE SHIELD
5 Cradle Charges 44 CAMERA COVER
6 Comb 45 DVD, CD CHARGES
EAU.DE-COLOGNE / ROOM
7 46 GAUZE SOFT
FRESHENERS
8 foot cover 47 GAUZE
Serial Serial
Items Items
Number Number
9 Gown 48 WARD AND THEATRE BOOKING CHARGES
ARTHROSCOPY AND ENDOSCOPY
10 Slippers 49
INSTRUMENTS
11 tissue papers 50 MICROSCOPE COVER
SURGICAL BLADES, HARMONIC SCALPEL,
12 Toothpaste 51
SHAVER
13 Toothbrush 52 SURGICAL DRILL
14 bad pan 53 EYE KIT
15 face mask 54 EYE DRAPE
16 flixi mask 55 X-RAY FILM
17 hand holder 56 BOYLES APPARATUS CHARGES
18 sputum cup 57 COTTON
19 Disinfectant Lotion 58 COTTON BANDAGE
20 Luxury Tax 59 SURGICAL TAPE
21 HVAC 60 APRON
22 housekeeping charges 61 TORNIQUET
23 air conditioner charges 62 ORTHOBUNDLE, GYNAEC BUNDLE
24 IM IV INJECTION CHARGES 63 ADMISSION/REGISTRATION CHARGES
HOSPITALISATION FOR EVALUATION/
25 CLEAN SHEET 64
DIAGNOSTIC PURPOSE
26 BLANKET/WARMER BLANKET 65 URINE CONTAINER
BLOOD RESERVATION CHARGES AND ANTE
27 ADMISSION KIT 66
NATAL BOOKING CHARGES
28 DIABETIC CHART CHARGES 67 BIPAP MACHINE
DOCUMENTATION CHARGES /
29 68 CPAP/ CAPD EQUIPMENT’S
ADMINISTRATIVE EXPENSES
30 DISCHARGE PROCEDURE CHARGES 69 INFUSION PUMP_ COST
HYDROGEN PEROXIDE\SPIRIT\
31 DAILY CHART CHARGES 70
DISINFECTANTS ETC
ENTRANCE PASS / VISITORS PASS NUTRITION PLANNING CHARGES -
32 71
CHARGES DIETICIAN CHARGES- DIET CHARGES
EXPENSES RELATED TO
33 72 HIV KIT
PRESCRIPTION ON DISCHARGE
34 FILE OPENING CHARGES 73 ANTISEPTIC MOUTHWASH
PATIENT IDENTIFICATION BAND /
35 74 LOZENGES
NAME TAG
INCIDENTAL EXPENSES / MISC.
36 75 MOUTH PAINT
CHARGES (NOT EXPLAINED)
37 PULSE OXYMETER CHARGES 76 VACCINATION CHARGES
38 SCRUB SOLUTION ISTERILLIU 77 ALCOHOL SWABS
39 Glucometer & Strips 78 URINE BAG
Before a hospitalization, it is absolutely essential to follow the preauthorization procedure which will help Medi Assist
to determine if the event will be covered under the policy. We understand that it would not be possible for you to
remember the above-mentioned exclusions and hence the pre-authorization procedure will also help in determining
the same.
Q. Will I be covered for pre-hospitalization and post hospitalization expenses?
A. Yes, you will be covered for pre-hospitalization expenses incurred 30 days prior to hospitalization and post
hospitalization expenses incurred up to 60 days after hospitalization relating to the illness for which you have been
hospitalized, provided that the ailment is covered under the policy. This is applicable for all eligible treatments other
than maternity. NO CREDIT WILL BE OFFERED FOR THESE EXPENSES. Reimbursement of these expenses is
possible only on production of complete and detailed bills and documents relating to the same along with a signed
claim form.
Q. What expenses are payable as a part of pre-hospitalization and post hospitalization expenses?
A. Consultation charges prescribed medicines and prescribed investigations which are in line with the main
hospitalisation diagnosis.
Employees, who have resigned from IBM, are required to respond to Shortfall raised by Medi Assist within 5 working
days failing which the claim will be rejected and prorated premium refund will be advised in FFS.
a. has been registered as a hospital or Nursing Home with the local authorities and is under the supervision of a
registered and qualified medical practitioner
b. Should comply with minimum criteria as under
Admissions at Non-registered hospitals, treatment availed in SPAs and resorts will not be payable.
Any procedure which are not a listed procedure as per the Govt Ayush guidelines would not be covered under the
policy.
Hospitalization only for MTP not followed by any surgical intervention, is possible on OPD, hence not payable.
Voluntary termination of pregnancy/ multi-fetal pregnancy reductions (e.g.: triplet to twin)/and complication due to
contraceptive failure are not payable under policy.
Q. What is the maternity limit and whether any complication related to maternity pre or post to Delivery is
covered under Maternity limit or General Sum Insured?
A. Maternity limit is INR 60,000 which is part of Sum insured.
Any expenses arising due to complication of maternity and directly or indirectly related to maternity would be
admissible under Maternity sub limit of INR 60,000 only.
Q. Does the Infertility treatment benefit cover OPD charges & pre/post expenses?
A. The benefit covers charges for inpatient treatment, and specified day care procedures (specified in day care list in
the previous pages) only. Expenses towards OPD charges and pre/post expenses are out of scope of the benefit.
However, claims (cashless/ reimbursement) for Multifocal lens will be allowed if insured is under 45 years of age.
The claim is admissible if the hospitalization was primarily for the purpose of investigation & evaluation (there should
be requirement of hospitalisation for conducting investigation. Expense for any Investigation which are possible
under OPD basis would not be payable)
Effective 1st Jan 2023, any screening (even prescribed by General Physician - MBBS) will be covered under the OPD
plan with 50% co-pay.
Q. What do you mean by pre and post-natal expenses? Will it be covered under policy?
A. From the date of conception to delivery the expenses related to scanning’s/ consultations are payable under pre-
natal, after the delivery consultation expenses related to Mother will be paid up to 60 days under post-natal benefit.
Pre-natal and post-natal benefit will be payable up to INR 10000/- under maternity sub limit.
In case of medically terminated pregnancy cover pre and post-natal expenses are covered. (Only if Medical
termination of pregnancy main claim is settled with us)
Q. As a Medical Advancement treatment can I claim for Stem Cell, Robotic & Bone Marrow for Cancer cases?
A. Coverage is offered subject to;
a) The treatment having FDA approval
b) Indications exist (specifically for Robotic surgeries - Robotic radical prostatectomy, Robotic Onco Surgery, Robotic
Cardiac Surgery will be covered. However non-indicated procedures like Myomectomy etc would not be covered. In
such cases usual charges of Laparoscopic surgery package charges would be payable)
c) Bone marrow transplant for cancer would cover.
Any expenses related to routine screening, lab test, scan etc. which is not under the pre and post hospitalization
clause would not be admissible under the policy terms and conditions.
Specialist consultations and investigations advised by specialist will be payable under the policy with 50%
co-pay on actual up to 10,000 INR per family. Specialist includes
MD, MS, DM, MCH, DGO, DNB, DCH, DPM, D Ortho, DLO, FRCS, MRCP, FRCSC & FRCAS
Psychiatric / mental illness / suicidal treatment will be covered under OPD as per terms and conditions of the
benefit.
Dental/ non-medically prescribed physiotherapy/ maternity related expenses are not payable under
domiciliary benefit.
Q. What are the expenses which can be claimed related to a case of Autism?
A. Autism related expenses can be claimed under OPD benefit for possible coverage.
Specialist (Neurologists) consultation, investigation, speech therapy and occupational therapies are covered under
OPD benefits with applicable co-pay for Autism related expenses.
Q. What expenses are covered in Dog bite/Snake bite cases under policy?
A. Dogbite/Snake bite expenses like investigations and medicines or any related procedures done are covered under
daycare/IP benefit if supportive day care/IP summary given as per policy.
Additionally, based on the claim type, the employee will be required to submit the following documents:
Please go through the reference document for claims submission published in Medi Assist site for IBM employees
(https://portal.mediassist.in/Home.aspx) to minimize errors at the time of filling the form.
Q. Any procedure done under day care which are not listed in the policy wordings is covered or not?
A. No, the procedures which are listed in the day care list of the policy are only covered.
Q. Any medication or injection administered under day care other than chemotherapy for cancer treatment
and complications are covered or not?
A. The policy will not cover any injection or any medicines other than chemotherapy drugs which is infused under the
day care procedure. The expenses related to hormonal therapy / biological agents /zoledronic acid etc and other
injections which are administered under day care are not payable as per policy terms and conditions. Further, for any
cancer related treatment, we shall cover only the expense related to chemotherapy/radiotherapy under pre-post
hospitalization /day care procedure (as may be applicable). If any day care treatment is converted to hospitalization
for more than 24 hours without proper justification, the same is not payable as per policy terms and conditions.
Q. Are the expenses related to Ayurveda/Homeopathy/naturopathy under pre and post hospitalization
expenses, if the main claim is settled for allopathic treatment?
A. No, the expenses related to Ayurveda/Homeopathy/naturopathy are not payable under pre and post
hospitalization expenses if the main claim is settled for allopathic treatment.
Pre and post hospitalization expenses would be admissible only if the main claim is settled and the system of
medicine should be the same.
For e.g., If the main claim is settled for Ayurveda treatment and the post hospitalization expenses are of allopathic
treatment then the same would not be admissible. However, expense related to Ayurveda would be admissible under
pre and post hospitalization expenses if the main claim is settled for Ayurveda treatment.
You do not need to wait at the hospital’s insurance desk for long hours
You can obtain a provisional pre-authorization from the comfort of your home or office
You can choose your preferred room type at the hospital
Information regarding out-of-pocket expenses and/or co-pay can be known well in advance
a. You can download the Medi Assist app. Go to the app and click the eCashless tile to initiate a request
b. You can go to https://portal.mediassist.in/Home.aspx and click the eCashless tile to initiate the request.
c. You can also open Medi Assist on your mobile browser and select the eCashless option
d. You can logon to the Medi Assist portal https://portal.mediassist.in/Home.aspx and opt for the eCashless option
e. Use your MAID & DOB or your Medi Assist credentials to log in
Yes. You have an option to upload multiple files when initiating the eCashless request on Medi Assist. Max
file size is 2 Mb.
The ailment for which hospitalization is being sought by you is not covered under your insurance policy
You have exhausted the eligible medical insurance cover/sum insured for the year
Note: In case of insufficient information, Medi Assist will inform you about the additional information you should
provide on Medi Assist before the provisional pre-authorization is approved. In case you fail to provide this
information, pre-authorization can be denied.
10. Can out-patients/health check-ups and emergency admissions avail the eCashless facility?
No, eCashless can be availed only for planned hospitalization. However, in cases where your doctor in the outpatient
department recommends you to be treated as an inpatient, you can avail the eCashless facility from Mediassist
portal or app.
Additional information requested by provider - This appears when the hospital requires some more information from
you on the eCashless.
Additional information requested by Medi Assist - This appears when Medi Assist requires some more information
from you on the eCashless.
Denied - This appears when your eCashless request has been declined.
Approved - This appears when your eCashless request has been approved.
12. How will I come to know of my out-of-pocket expense (based on co-pay and policy conditions) while
initiating the eCashless request?
When you opt for eCashless, based on your recommended treatment, the hospital sends intimation to Medi Assist
regarding the expected expenses for the treatment. Once this is received, Medi Assist applies your policy terms and
conditions (also available on Mediassist portal) in order to calculate the provisionally approved amount and co-pay
for the treatment. This gives you complete visibility into the expected cost of the treatment.
13. Can eCashless request be cancelled if I couldn’t turn up on the date of admission (DOA) or due to any
other unanticipated reasons?
Yes. eCashless can be cancelled in case you do not get admitted to the hospital on the said date. However, your
provisional pre-authorization is still valid for 2 weeks. This means that, if you want to get admitted to the hospital
within two weeks of the said date, you can still use the provisional pre-authorization and passcode provided to you
by Medi Assist. If you would like to get admitted after 2 weeks, you are expected to request eCashless again. If you
wish to cancel your request, please mail [email protected]
You can also connect at the following tollfree number given below:
If you are not satisfied by the response received from the above, please follow the below mentioned escalation
matrix ONLY if your queries are not replied by above mentioned contact points.
Escalation Level 1
Escalation Level 2
If you are not satisfied by the response received from Escalation Level 1
Please call the CRM assigned to your location or nearest location to discuss and write to
[email protected] and copy to [email protected]
Prashant Kumar Suman 7353145000
For IBM support, please write to [email protected] for any additional support, please mark a copy/write to
Nishanth R ([email protected]) Mobile: 9738182750
Escalation Level 3
In-case not satisfied with response /non-response from Escalation level 2, please write to [email protected]
For any additional/emergency support, please mark a copy/write to Parimala Dintakurthi ([email protected])
Turnaround Time: 2 working days
Note: Please write to each escalation level separately according to the timelines. Do not mark a combined
mail to all the escalation points.
Equal Opportunity:
W3 link - https://w3.ibm.com/hr/web/in/benefits/health/hb01-hip01/
POLICY MANAGEMENT
Change Management
The policies are owned by India Compensation & Benefits Leader. All changes made to the policy should be
approved by the policy owner.