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Policy Terms and Conditions IBM

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0% found this document useful (0 votes)
1K views58 pages

Policy Terms and Conditions IBM

Uploaded by

San
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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2024 Group Medical Insurance Cover Policy

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.

Employee, Spouse and Children Policy (ESC Policy)

 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

 The policy coverage is limited to expenses incurred within India.

GENERAL INFORMATION

Insurance Company - HDFC Ergo General Insurance Company Ltd.

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

POLICY DETAILS: EMPLOYEE, SPOUSE AND CHILDREN (ESC) POLICY

 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

Employee’s share in the Premium (ESC Policy)

 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).

Employees who are on LOA (GI, HCAM, US Onsite etc)

 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.

DOMICILIARY EXPENSES ON OUTPATIENT CARE (OPD Benefit)

 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:

Top-up Sum Insured (In INR) OPD Limit (In INR)


1,00,000 15,000
2,00,000 20,000
4,00,000 25,000
6,00,000 25,000
11,00,000 25,000

 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)

In event of any incident identified as a workplace incident and if recommended by IBM

 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.

Additional coverage under family floater (ESC Policy)

 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.

Addition of Dependents (ESC Policy)

 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 Inclusion (only for ESC Policy)

 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.

All such requests must be shared over email to

 [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

 The maximum age up to which a member can be enrolled is 90 years.


 The parents’ coverage for 2023 & 2024 comes with a 2-year lock-in, hence:

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.

Addition of Dependent parents (Parents Policy)

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 Inclusion (Parents Policy)

 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.

Removal of Dependents (Parents Policy)

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.

All such requests must be shared over email to

 [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

 All pre-existing diseases are covered.


 Only investigation, tests and diagnosis which requires Hospitalisation is covered. In case there is an active
treatment of the disease following the investigation, tests and diagnosis, the expenses of investigation, tests
and diagnosis will be covered.
 Pre-hospitalization expenses incurred 30 days prior to hospitalization and post-hospitalization expenses
incurred up to 60 days after hospitalization relating to the illness is covered to the extent of insurance
coverage available, 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. All pre-hospitalization claims should be
submitted only with / after the main hospitalization claim is submitted. Reimbursement of these expenses
(both pre and post hospitalization) is possible only on production of complete and detailed bills and
documents relating to the same along with a signed claim form.
 Co-payment Applicable on Hospitalization 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 HOSPITALISATION BENEFIT

 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:

1. Expenses incurred for pre and post hospitalization treatment.


2. Expenses incurred for the treatment of any of the following diseases:
 Asthma
 Bronchitis
 Chronic Nephritis and Nephritic Syndrome
 Diarrhea and all types of Dysenteries including Gastroenteritis.
 Diabetes Mellitus and Insidious
 Epilepsy
 Hypertension
 Influenza, Cough, and Cold
 All Psychiatric and Psychosomatic disorders
 Pyrexia of unknown origins for less than ten days
 Tonsillitis and Upper Respiratory Tract infections including Laryngitis.
 Pharyngitis
 Arthritis, Gout, and Rheumatism
 Note: When treatment such as Dialysis, Chemotherapy, Radiotherapy, Eye Surgery, Lithotripsy (Kidney
stone removal), D&C and Tonsillectomy are taken in the Hospital/Nursing Home and the insured is
discharged the same day, the treatment will be taken under the Hospitalization Benefit Section.
 This benefit is within the overall inpatient cover i.e., there is no additional sum insured OR sub limit
applicable on this benefit.

 Co-payment Applicable on Domiciliary Hospitalization 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.

MEDICAL ADVANCEMENT COVERAGE:

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.

Modern Treatment Methods and Advancements in Technologies


 Uterine Artery Embolization and HIFU
 Balloon Sinuplasty
 Deep Brain Stimulation
 Oral Chemotherapy
 Immunotherapy - Monoclonal Antibody to be given as injection
 Intra Vitreal Injections
 Robotic Surgeries
 Stereotactic Radio Surgeries
 Bronchical Thermoplasty
 Vaporisation of the Prostrate (Green laser treatment holmium laser treatment)
 IONM (Intra Operative Neuro Monitoring)
 Stem Cell Therapy

IN PATIENT TREATMENT FOR PSYCHIATRIC AND BEHAVIOURAL CONDITIONS

 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:

Top-up SI Maternity Limit


1,00,000 65,000
2,00,000 70,000
4,00,000 75,000
6,00,000 80,000
11,00,000 1,00,000

 Hospitalization for maternity benefit can be availed up to 4 children.


 The insurance plan also provides for pre and postnatal expenses as a part of the maternity benefit. The
benefit will include consultations, prescribed medications, and prescribed investigations up to a maximum of
INR 10,000 per maternity event. This benefit is a sub limit of the maternity benefit.
 Pre Natal expenses prior to hospitalization and post hospitalization expenses incurred up to 60 days after
maternity are covered to the extent of maternity sublimit of INR 10,000.
 The pre-natal claims should be submitted only with / after the main claim. Reimbursement of these expenses
(both pre- and post-natal) is possible only on production of complete and detailed bills and documents
relating to the same along with a signed claim form.
 In case of any active treatment given to the new-born baby, the expenses will be treated as child expenses
(immunization expenses excluded).
 The benefit also covers pre-natal and post-natal expenses for medically terminated pregnancies.
 Sterility treatment /IVF treatment /Other fertility treatments are also now covered under the policy up to the
maternity sub-limit and can be availed twice in an employment tenure.
 Surrogacy coverage up-to Maternity Limit of NR 60,000/-

Co-payment Applicable on Maternity Expenses

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.

Infertility treatment benefit

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

The expenses out of scope of the infertility coverage are as below:

a. OPD treatments with regards to infertility treatment


b. Pre & Post expenses of infertility treatment taken
c. Expenses for diagnosis & screening
d. Any expense for donor screening or compensation.

Catract Surgery Benefits

a. Cataract is covered under Day care procedures.


b. Expenses related to multifocal lenses and toric lenses will not be admissible under this coverage as these lenses
are used only for replacement of the spectacles, and any procedure for avoiding usage of spectacles will fall under
cosmetic clause of policy terms and conditions.
c. However, claims (cashless/ reimbursement) for Multifocal lens will be allowed if insured is under 45 years of age.

HEALTH SCREENING BENEFIT

I. Health screening benefit is available to eligible members on an annual basis unless otherwise specified.

II. Biometric Screening

 Combination of Onsite & offsite mode will be used.


 Onsite here means IBM Campus and Offsite means identified network hospitals / diagnostic centres.
 Employees who are not able to participate in the onsite biometric screening camps have a choice to get the
screening done at identified network diagnostic centres/hospitals and file a reimbursement claim.
 BMI, BP, Random blood glucose, total cholesterol, Hb%, peak flow test, manual short HRA from wellness
checkpoint will be offered for all employees through onsite biometrics screening camps.

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.

VI. Co-payment Applicable: There is no Co pay applicable on 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.

A. Risk factor screening:

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

One time HIV Screening


Test individuals at increased risk or upon request by patient. May repeat based on risk
(Rapid HIV Test by Blood
factors.
or Saliva)
Test the following individuals:

 Persons born in geographic regions with HBsAg prevalence of ≥2%


One time Hepatitis B  Unvaccinated persons whose parents were persons not vaccinated as infants
Screening whose parents were born in geographic regions with HBsAg prevalence of ≥8%
 Injection-drug users
 Men who have sex with men
 Persons with elevated ALT/AST of unknown etiology
 Persons with medical conditions that require immunosuppressive therapy
 Infants born to HBsAg-positive mothers
 Household contacts and sex partners of HBV-infected persons
 Persons who are the source of blood or body fluid exposures that might warrant
post exposure prophylaxis (e.g., needle stick injury to a health care worker)
 Persons infected with HIV

HCV-testing is recommended for those who:


 Currently inject drugs
 Ever injected drugs, including those who injected once or a few times many
years ago
 Have certain medical conditions, including persons:
a) who received clotting factor concentrates produced before 1987
b) who were ever on long-term haemodialysis?
c) with persistently abnormal alanine aminotransferase levels (ALT)
d) who have HIV infection?
 W ere prior recipients of transfusions or organ transplants, including persons
One time Hepatitis C who:
Screening a) were notified that they received blood from a donor who later tested positive for
HCV infection
b) received a transfusion of blood, blood components or an organ transplant before
July 1992
 HCV- testing based on a recognized exposure is recommended for:
a) Healthcare, emergency medical, and public safety workers after needle sticks,
sharps, or mucosal exposures to HCV-positive blood
b) Children born to HCV-positive women

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.

F. CANCER SCREENING TESTS

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

H. Periodic Check-up Guidelines for Children (Paediatrics)

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

Ages 3-18 Every year

I. Risk factor screening for children:

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

J. Physical Exam for children

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.

5. Retain the scanned/photocopies of all the documents for your reference.

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

7. The medical team at Medi Assist processes the claim:

1. In case of approval, the amount is reimbursed via NEFT


2. In case your claim is denied, the denial letter is sent to your registered e-mail quoting the reason for denial
of your claim.

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.

Expenses towards Appliances:

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.

CRITICAL ILLNESS BUFFER


 This benefit is extended only to the employee, spouse, and dependent children. This benefit is not applicable
to the Parents Policy.
 IBM shall extend support of an additional INR 700,000 per policy year for the treatment of the following
critical illnesses.
 The Critical Illness Buffer can only be used once the family floater amount and the additional coverage if any
taken by the employee have been exhausted and only for the following diseases:

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

Care Procedures coverage

Day Care Procedures will include following Day Care Surgeries & Day Care Treatments:
Day Procedure Description
Stapedotomy
Stapedectomy
Revision of a stapedectomy

Other operations on the auditory ossicles

Microsurgical operations on the middle ear Myringoplasty (Type -I Tympanoplasty)


Tympanoplasty (closure of an eardrum perforation/reconstruction of
the auditory ossicles)
Revision of a tympanoplasty
Other microsurgical operations on the middle ear under general
/spinal anaesthesia

Myringotomy

Removal of a tympanic drain


Incision of the mastoid process and middle ear
Mastoidectomy
Other operations on the middle &
Reconstruction of the middle ear
internal ear
Other excisions of the middle and inner ear
Fenestration of the inner ear
Revision of a fenestration of the inner ear
Incision (opening) and destruction (elimination) of the inner ear
Other operations on the middle and inner ear under general /spinal
anaesthesia

Excision and destruction of diseased tissue of the nose


Operations on the nose & the nasal Operations on the turbinate’s (nasal concha)
sinuses Other operations on the nose
Nasal sinus aspiration

Operations on the eyes Incision of tear glands


Other operations on the tear ducts
Incision of diseased eyelids
Excision and destruction of diseased tissue of the eyelid
Operations on the canthus and epicanthus
Corrective surgery for entropion and ectropion
Corrective surgery for blepharoptosis
Removal of a foreign body from the conjunctiva
Removal of a foreign body from the cornea
Incision of the cornea
Operations for pterygium
Other operations on the cornea
Removal of a foreign body from the lens of the eye
Removal of a foreign body from the posterior chamber of the eye
Removal of a foreign body from the orbit and eyeball
Operation of cataract
Retinal detachment
Vitrectomy and Trabeculectomy

Incision of a pilonidal sinus


Other incisions of the skin and subcutaneous tissues
Surgical wound toilet (wound debridement) and removal of diseased
tissue of the skin and subcutaneous tissues
Local excision of diseased tissue of the skin and subcutaneous
tissues
Other excisions of the skin and subcutaneous tissues
Simple restoration of surface continuity of the skin and subcutaneous
Operations on the skin & subcutaneous tissues
tissues Free skin transplantation, donor site
Free skin transplantation, recipient site
Revision of skin plasty
Other restoration and reconstruction of the skin and subcutaneous
tissues
Chemosurgery to the skin
Destruction of diseased tissue in the skin and subcutaneous tissues
Incision and drainage of abscess Destruction of diseased tissue in the
skin and subcutaneous tissues

Incision, excision and destruction of diseased tissue of the tongue


Partial glossectomy
Operations on the tongue Glossectomy
Reconstruction of the tongue
Other operations on the tongue

Incision and lancing of a salivary gland and a salivary duct


Operations on the salivary glands &
Excision of diseased tissue of a salivary gland and a salivary duct
salivary ducts
Resection of a salivary gland
Reconstruction of a salivary gland and a salivary duct
Other operations on the salivary glands and salivary ducts

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

Transoral incision and drainage of a pharyngeal abscess


Operations on the tonsils & adenoids Tonsillectomy without adenoidectomy
Tonsillectomy with adenoidectomy
Excision and destruction of a lingual tonsil
Other operations on the tonsils and adenoids under general /spinal
anaesthesia
Incision on bone, septic and aseptic
Closed reduction on fracture, luxation or epiphyseolysis with
osteosynthesis
Suture and other operations on tendons and tendon sheath
Reduction of dislocation under GA
Arthroscopic knee aspiration
Aspiration of hematoma
Trauma surgery and orthopaedics Excision of dupuytren's contracture
Carpal tunnel decompression
Surgery for ligament tear
Surgery for meniscus tear
Surgery for hemoarthrosis/pyoarthrosis
Removal of fracture pins/nails
Removal of metal wire
Joint Aspiration - Diagnostic / therapeutic

Incision of the breast


Operations on the breast Operations on the nipple
Excision of breast lump /Fibro adenoma

Incision and excision of tissue in the perianal region


Surgical treatment of anal fistulas
Surgical treatment of haemorrhoids
Division of the anal sphincter (sphincterotomy)
Operations on the digestive tract
Other operations on the anus
Ultrasound guided aspirations
Sclerotherapy etc.
Ultrasound guided aspirations
Sclerotherapy etc.
Therapeutic Ascitic Tapping
Endoscopic ligation /banding
Dilatation of digestive tract strictures
Endoscopic ultrasonography and biopsy
Replacement of Gastrostomy tube
Endoscopic decompression of colon
Nissen fundoplication for Hiatus Hernia /Gastro esophageal reflux
Disease
Endoscopic Gastrostomy
Laparoscopic procedures eg colecystectomy, appendicectomy etc.
Endoscopic Drainage of Pseudopancreatic cyst
Hernia Repair (Herniotomy / hernioraphhy / hernioplasty)
Therapeutic ERCP

Incision of the ovary


Insufflation of the Fallopian tubes
Other operations on the Fallopian tube
Dilatation of the cervical canal
Conisation of the uterine cervix
Other operations on the uterine cervix
Incision of the uterus (hysterotomy)
Operations on the female sexual organs Therapeutic curettage
Culdotomy
Incision of the vagina
Local excision and destruction of diseased tissue of the vagina and
the pouch of Douglas
Incision of the vulva
Operations on Bartholin’s glands (cyst)
Endoscopic polypectomy
Myomectomy, hysterscopic or laparoscopic biopsy or removal

Incision of the prostate


Transurethral excision and destruction of prostate tissue
Transurethral and percutaneous destruction of prostate tissue
Open surgical excision and destruction of prostate tissue
Operations on the prostate & seminal
Radical prostatovesiculectomy
vesicles
Other excision and destruction of prostate tissue
Operations on the seminal vesicles
Incision and excision of periprostatic tissue
Other operations on the prostate

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

Incision of the testes


Excision and destruction of diseased tissue of the testes
Unilateral orchidectomy
Bilateral orchidectomy
Orchidopexy
Operations on the testes
Abdominal exploration in cryptorchidism
Surgical repositioning of an abdominal testis
Reconstruction of the testis
Implantation, exchange and removal of a testicular prosthesis
Other operations on the testis under general /spinal anaesthesia

Surgical treatment of a varicocele and a hydrocele of the spermatic


cord
Excision in the area of the epididymis
Operations on the spermatic cord, Epididymectomy
epididymis and ductus deferens Reconstruction of the spermatic cord
Reconstruction of the ductus deferens and epididymis
Other operations on the spermatic cord, epididymis and ductus
deferens

Operations on the foreskin


Local excision and destruction of diseased tissue of the penis
Operations on the penis Amputation of the penis
Plastic reconstruction of the penis
Other operations on the penis

Cystoscopical removal of stones


PCNS (Percutaneous nephrostomy)
Operations on the urinary system PCNL (Percutanous Nephro-Lithotomy)
Tran urethral resection of bladder tumour
Suprapubic cytostomy

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

True cut Biopsy


Endoscopic Foreign Body Removal
Vaccination / Inoculation - Post Dog bite or Snake bite
Endoscopic placement/removal of stents
Tumour embolization
Aspiration of an internal abscess under ultrasound guidance
Procedures of Heart and Blood vessels
Coronary Angioplasty (PTCA)
Insertion of filter in inferior vena cava
TIPS procedure for portal hypertension
Blood transfusion for recipient
OTHER Procedures
Therapeutic Phlebotomy
Pericardiocentesis
Insertion of gel foam in artery or vein
Carotid angioplasty
Renal angioplasty
Procedures of Respiratory System
Brochoscopic treatment of bleeding lesion
Brochoscopic treatment of fistula /stenting
Bronchoalveolar lavage & biopsy
Direct Laryngoscopy with biopsy
Therapeutic Pleural Tapping

Lengthening of thigh tendons


General Treatment Close reduction of Fracture Cases
Repair of knee joint

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)

GENDER REALIGNMENT COVERAGE

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

VALUE ADDED SERVICES

HDFC Ergo Insurance is providing a host of value-added services as listed below exclusive for IBMers

Master Health Check-up, diagnostics, and consultation at defined Network Centres


 You can get discounts up to 20% for a master health check-up for yourself and your immediate family
(enrolled in the IBM medical insurance policy). You can also avail discounts on diagnostics and Discounts on
consultation at defined Network Centres. The discounts will differ from one network centre to another.
 To avail the benefit, please reach out to HDFC Ergo on the toll-free number 1800 102 0333 or write to
[email protected]. The HDFC Ergo team will help you locate the nearest network centre.
 Please show your Medi Assist Health id card (E-card) with HDFC Ergo logo or IBM Id card to avail these
benefits at the network centre. In case you have any concerns, do escalate by calling on the Toll-free
number and an HDFC Ergo team member will address it on priority.

Discounts on Apollo Pharmacies

 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:

1. Please carry employee id card and show it before billing.


2. Use below code for availing discount.

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.

Medical Second Opinion

 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:

Patient Patient’s Location where second Patient Contact


Department Ailment
Name opinion is required No.
e.g., South Delhi, North Delhi, Gurgaon e.g., Medicine, Surgery, Neuro,
etc. Cardiac etc.

 The suggestion shall be received by you within 3 days.


 You may then choose from the options provided and schedule a visit for second opinion; the consultation
expense will be borne by you.

FIXED TIME HIRES (FTH)

With tenure above 12 months

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:

Username: employee ID@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 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.

With tenure less than or equal to 12 months

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.

Fixed Time Hire: Co-share of premium (ESC policy)

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 Interns Policy

The IBM interns under IBM Interns policy are covered for the base coverage of INR 4 Lakhs, under Niti Aayog
program.

The Interns policy brings the following benefits:

1. Base coverage of INR 4 lacs (ESC policy)


2. Hospitalization expenses
3. Domiciliary hospitalization benefit
4. In patient treatment for psychiatric and behavioural conditions
5. Domiciliary expenses on outpatient care
6. Health screening benefits
7. Additional benefits
8. Critical illness buffer
9. Value added services

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.

No co-pay is applicable for claims of workplace incidents.

EXCLUSIONS UNDER THE POLICY

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

Virtual Chat option on Medi Buddy portal - Steps

 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.

Frequently Asked Questions (General)


Q. What is a family floater?
A. Family base cover for self, spouse & children. There is no restriction on the size of the individual claim in a year as
long as the family does not exceed the limit of INR 400,000 or the enhanced cover in case you have opted for the
enhanced (Topup) cover.

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.

NOTE: No other dependents can be insured under this health plan.


* up to 4 dependent children are covered up to age of 24. 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
** Premium chart is available on the site https://portal.mediassist.in/Home.aspx

Q. Who is Medi Assist India TPA Private Limited?


A. Medi Assist India TPA Private Limited is your service provider who will facilitate administration of IBM India
Limited Group Health insurance Policy (GHI) on behalf of HDFC Ergo General Insurance company ltd and assist you
in accessing quality health care. It is not an insurance company; it acts as a liaison between IBM and the insurance
company.

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:

 Online Enrolment System: For self and dependents


 Mobile app named Medi Assist
 Electronic id cards: For self and dependents
 Network Hospital: The largest network of hospitals in the country
 Preferred Network Hospital: Discounted package rates on treatments
 Cashless hospitalization facility: For treatment at network hospitals for ailments covered under the Group
Mediclaim Policy
 Claims administration services: Registration of each claim
 Assessment of each claim for eligibility under the plan
 Recovery of missing documents if required
 Submission of claim to the TPA and follow up for speedy reimbursement
 Dedicated Helpline - Both Voice and mail-based services

Q. What is Medi Assist app?


A. Medi Assist is a mobile app introduced by Medi Assist. It empowers you by providing on the go access to
enrolment, ecards, network hospitals, claims and other benefits.

Q. Where can I download Medi Assist app?


A. Download Medi Assist app from your app store - currently available on Android and iOS

Q. How do I log into the app post download?


A. You can log into the app (Medi Assist) with your unique username and password. The login credentials will be
same as provided for online enrolment portal).

Q. What are the benefits of using this app?


A. Medi Assist works as your one stop solution to policy and claim related information on the go. The various benefits
include:

 Enrol your dependents


 Track claims status in real-time
 Locate network hospitals
 Access your ecard and other important forms and guidelines on the fly
 Access claims history and electronic health records

Q. Do I have an option of opt out of the policy?


A. Yes, you can opt out of the policy by submitting your intent in the Medi Assist website before January 31, 2024, or
30 days from the date of joining (date of joining + 29 days), whichever is earlier. The premium will not be deducted
from your salary. In this case, you and your immediate family will not be covered. You will be provided only coverage
for hospitalization on account of accident during the course of employment and treatment of occupational diseases,
to the extent you are entitled to such benefits under any statute or law.

Q. How does the coverage take place for a new joiner?


A. Your coverage will begin from the date you have joined IBM unless you have opted out of the policy. But for your
dependents, you need to visit the website (https://portal.mediassist.in/Home.aspx) or Medi Assist App and complete
your online enrolment procedure by submitting your dependents' details within 30 days from the date of your joining
(date of joining + 29 days). Please use your employeeID@IBM as the username. An initial password has been set up
for you using a combination of your date of birth and your employee id. 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.

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.

Q. Can I and my sibling(s) enrol our parents under our coverage?


A. No parent 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 parent(s) for more than once under the policy, it
will be considered as BCG violation and strict action will be taken.

Q. What if my family/dependent status changes during the year?


A. Newly married employees can add spouse details within 30 days of the date of marriage. Coverage will be
effective for the spouse from the date of marriage.

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 process for parents’ policy.

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.

In case of a divorce/demise in the family, please inform Team Benefits/India/Contr/IBM [email protected] as


soon as possible.

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.

Q. How do I complete Online Enrolment procedure?


A. Here are the steps given below for enrolling:

Step 1: Click on the link https://portal.mediassist.in/Home.aspx

Step 2: Enter your User ID and Password


Please use your employeeID@IBM as the username. An initial default password has been set up for you using a
combination of your date of birth and your employee id. 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. (ddmmyyyy followed by empid)

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.

i. It is mandatory to review and update Self and dependent details:

1. Go to “Your Health Policy” box on the home page.


2. Click on “Enrolment”.
3. To add or edit any details please click the “Add” button or “Edit” button (as required and applicable)
highlighted against each member and update the details.
4. To add dependents, click on the “Add+” button on the top right corner of the section.
5. Click “Submit” at the bottom of the page.

ii. Update bank detail to be used for claim reimbursement.

1. Go to Enrolment form.
2. Enter Bank details under the "Update Bank Details" section.
3. Click “Submit” at the bottom of the page.

Frequently Asked Questions (FTH Category)


Q. Which dependents can be covered under the FTH policies?
A. All FTH employees will automatically be enrolled under the ESC policy upon their joining / inception of the policy.
They can enrol their dependents (spouse and up to 4 children) on the MediAssist Portal.

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.

It should be noted that the policy does not cover parents-in-law.

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.

Q. What does it mean that there was a 2-year lock-in in 2023?


A. The employees who have enrolled for the top-up/parental plan will have a lock-in for 2 years, we have introduced
flexibility option of allowing employees who have enrolled for top-up/parental plan in 2023 to enhance/maintain their
sum insured in 2024. Opting out of the top-up/parental plan or reducing the sum insured is not allowed.

Q. What is an electronic ID card?


A. All employees and the insured members (provided they have not opted out), under this plan, are entitled for an e
ID card. This ID card will identify them for admission into the network hospitals and to allow access to credit facilities
at preferred hospitals around the country. This e ID card is non-transferable.

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.

Q. How do I get an electronic ID card?


A. You can and need to print the electronic ID card online. Follow the below mentioned steps to print the ID card:

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.

Step 1: Log on to https://portal.mediassist.in/Home.aspx or Medi Assist APP


Step 2: Enter your User ID and Password
Step 3: You can download your e-cards anytime from the "E-cards" section of the portal or Medi Assist App

Q. What happens if I lose the ID card?


A. If you lose the ID card, you may print another copy of the card online. Follow the above-mentioned steps to print
copies of the ID Card.

Frequently Asked Questions (ENROLMENT)


Q. How do I know my balance Sum Insured?
A. Please mail Medi Assist at [email protected] with details about your complete name, employee id, Card
number Or Login to Mediassist portal/app using login credentials.
Q. What do I do when I do not receive any revert on enrolment related queries from Medi Assist?
A. Please mail your query to [email protected], you shall receive revert within 48 working hours.

Q. Can I club my group insurance with my personal insurance?


A. This cannot be done as both are different plans with different coverage.

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:

 Employee Name and Employee ID


 Date of Birth
 Location
 Mobile number
 Preferred Date and time to discuss on plan options

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. Are there any timelines to apply for portability?


A. Proposal form should be submitted 60 days prior to the last working day of employment with IBM.

Q. Can I enrol my brother/sister/uncle/ aunt by paying additional premium?


A. No, this cannot be done as family definition is limited to self, spouse and 4 living children.

Q. Can I enrol my parents-in-law in the policy?


A. No, this cannot be done as family definition is limited to immediate parents. If it is identified during the policy term
that parents-in-law were covered, the enrolment will be cancelled immediately.

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:

 Retirement of parent where he / she was covered


1. The employee is required to submit the request to Team Benefits for the parents’ addition within 30 days of
the date of retirement
2. The employee is also required to submit relevant documents to substantiate retirement
 Demise of the bread earning parent where the other parent was covered
1. The employee is required to submit the request to Team Benefits for the parents’ addition within 30 days of
the demise of the bread earning parent
2. The employee is also required to submit the declaration of death, and a declaration that the other parent is
non-working and solely dependent on the employee, and was financially dependent on the other parent
Q. I have declared my parents in 2023, can I remove them from insurance coverage in 2024?
A. No, the parents cannot be removed from the policy in 2024, While the employees who 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/maintain their sum insured in 2024. Opting out of the parental plan or
reducing the sum insured is not allowed.

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.

Q. What do I do if I decide to leave the services of IBM?


A. You need to inform and submit the claim (if any) to Medi Assist before your Last working day. This is very
important because once you are deleted from the policy you will not be eligible to claim reimbursement for any
expenses incurred.

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.

Q. What do I do in case of demise of a family member?


A. 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. Premium will be refunded (only if
applicable) on prorated basis depending upon date of death and post checking the claim status. In case a claim is
reported, no refund will be made.

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.

Frequently Asked Questions (CLAIMS)


Q. Medi Assist Call Centre not giving correct update on my claim status, what should I do?
A. Please write to [email protected] and seek for your claim status, in case there is no revert within 48 hrs,
Please write to [email protected] and [email protected]

Q. What do I do in case of a hospitalization in my family?


A. In case of planned hospitalization, call on the helpline numbers of Medi Assist India TPA Private Limited to
inform them when you or your nominated dependent needs hospitalization. This should be done at least 48 hours
prior to the date of admission.

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.

Emergency Cashless Hospitalization:

Pre - Auth Emergency Contact Numbers for IBM Employees.

Pre Auth-IBM: 04068178558

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. What is an Authorization letter?


A. On approval of preauthorization, an authorization letter will be sent to the hospital (only if it is on HDFC Ergo
network). The letter authorizes the hospital to extend credit for all medical expenses during hospitalization.
Therefore, to use HDFC Ergo cashless hospitalization service it is very important for you to follow the pre-
authorization process.

Q. My Pre-Authorization request has been rejected. What could be the reasons?


A. Pre-Authorization may be declined under the following circumstances 1) Information provided was inadequate 2)
Disease is not covered by policy 3) Sum insured is exhausted.

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.

Q. During my last hospitalization, I was asked for a deposit / advance. Why?


A. Network & non-network hospitals request for deposit, same is adjusted with the final bill.
Q. What do I do in case a network hospital does not accept my Medi Assist Card?
A. In case there is an issue with a network hospital not accepting your card, then please get in touch with the people
mentioned in the escalation matrix (detailed below) or call Medi Assist on 080-46855351 / 8884388455.

Q. What is a Network Provider and how do I identify them?


A. Based on HDFC Ergo’s experience and expertise they have tied up with hospitals across the country so that their
members can avail of cashless hospitalization facility. The list of HDFC Ergo Network Hospitals is available on Medi
Assist website. You may login at Mediassist portal (https://portal.mediassist.in/Home.aspx) or Medi Assist mobile
application to make a GPS based search for the network hospitals within 20km distance of your location.

Q. Does it mean that I cannot get treated in a hospital of my choice?


A. You can get treated in any hospital within the country, but the cashless facility will be available only at the HDFC
Ergo network hospitals. Moreover, the collection of bills and related documents in case of a network hospital will be
done by Medi Assist, whereas in case of a hospital outside of network, you will have to collect all the documents at
the time of discharge and send it to Medi Assist along with a signed claim form.

Important: Please note that any hospital/nursing home you choose has to be registered and/or have minimum 15
beds.

Q. Do I need to pay any money at the time of discharge?


A. In case of Non-Network Hospitals - You will have to make all payments yourself and then forward the claim (all the
hospital documents and signed claim form in original) to Medi Assist in order to get claim reimbursed from Insurance
Company.

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

Q. What is the process of getting rejected cases reviewed?


A. Please mail Medi Assist at [email protected] with details about your rejected claim.

Q. In case my cashless request is rejected, what should I do?


A. If your cashless is rejected due to some reason, please make the payment and submit the bills for reimbursement.
The case will be reviewed as per policy terms & conditions.

Q. How do I submit my claim documents for reimbursement?


A. You can submit your claims online by scanning the original claim documents and uploading it in the Medi
Assist. The claims can be processed on basis of soft copies and physical claim documents are not required to be
shared with Medi Assist.

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:

Medi Assist India TPA Pvt Ltd;


Tower D, Fourth Floor, IBC Knowledge Park,
4/1, Bannerghatta Road,
Bangalore - 560 029

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.

Online Medical Claim Submission tool offers:


1. Anywhere anytime Claim submission
2. Quick upload of claim documents
3. Secure transmission of claim details
4. Transparent and Faster claim processing /settlement
5. Real-time access to claims documents/details
6. Online submission of shortfall documents

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. If my claim is rejected, can I ask Medi Assist to return my claim documents?


A. In case your claim is rejected for some reason; you can request Medi Assist for the original claim documents.
Same will be dispatched to you within 10 working days.

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 is the process of availing critical illness buffer?


A. In case of specified critical illnesses, the employee is eligible for the buffer utilization as per limits specified, please
note to avail critical illness buffer, the employee has to exhaust his/her base sum insured coverage of INR 400,000/-
and top-up sum insured if any.

Q. Can my claim reimbursement be credited through direct bank transfer?


A. Yes, if you declare your bank account details on the Medi Assist portal, same will be considered for direct fund
transferred or you can submit cancelled cheque with name captured on the cheque while uploading the claim for
reimbursement.

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. Can I seek treatment at home and later claim it?


A. Please refer to terms and conditions under domiciliary hospitalization (detailed above).

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

Q. What is active line of treatment?


A. Active treatment is Therapeutic substance or course intended to ameliorate the basic disease problem, as
opposed to supportive or palliative treatment.

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.

Q. Can I claim health check-up charges?


A. Yes, it can be claimed under OPD benefit T & C. Please refer policy t&c for more details.

Q. Is there any minimum time limit for stay in the hospital?


A. Yes. Stay in the hospital should be for minimum of 24 hours. However, there are a few specific ailments like
Dialysis, Chemotherapy, Radiotherapy, Eye Surgery, Lithotripsy (Kidney stone removal), D&C, and Tonsillectomy
which can be covered even though the period of hospitalization is less than 24 hours. For details on the same,
please write to [email protected]

Q. Are all day care procedures/surgeries covered under policy?


A. Day-care treatment strictly refers to treatments, surgeries and operations that require hospitalisation below 24hrs
due to advancement in the medical technologies and procedures. Therefore the day care procedure/surgery which is
listed under HDFC Ergo day care list and procedure to be done as an inpatient, then the procedure will be
considered under day-care.

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)

Q. What is a Claim Form?


A. A claim form is an important document which is essential for claim assessment. This form is provided on request
by Medi Assist help desk or can be downloaded from https://portal.mediassist.in/Home.aspx. This form is to be
signed by the member while availing the credit facility or before submission of a claim.

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.

Q. What are considered Non-Medical Expenses?


A. Following are few non-medical expenses which are considered for the claim approval under the policy:

List of Non-Medical Items Payable under the policy

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.

Q. What are details to be included in the discharge summary?


A. This is a very important document; it will mention the Date of Admission and Date of Discharge, Past History,
details of treatment given, and requirement of medication post hospitalization, if any and doctor’s signature. This will
be on the letter head of the hospital.

Q. In how many days are claims to be submitted to Medi Assist?


A. Claim papers are to be submitted to Medi Assist Help desk representative or couriered to Medi Assist within 30
days from the date of discharge. If any further documents (information) are required then Medi Assist will send a
“shortfall of document intimation” through email, and the same should be requested to hospital and submitted back to
Medi Assist for further processing of the claim. In case, one does not submit the document within 3 Shortfall
reminders (sent every 15 days), the case will be closed and the case cannot be processed further.

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.

Q. What if the cost exceeds the level of hospitalization insurance cover?


A. In such a situation you will be liable to pay the differential amount. We will inform the hospital about your eligible
amount, and they will recover the amount over and above the credit amount from you directly.

Q. In a year how many times can I avail treatment in a hospital?


A. There is no limit on the number of times one can take treatment, however insurance company will reimburse
claims up to the sum insured. And subject to policy terms.

Q. What is the definition of a Hospital/Nursing Home?


A. Hospital/Nursing home means any institution in India established for indoor care and treatment of sickness and
injuries and which

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

1. It should have at least 15 inpatient beds


2. Fully equipped operation theatre of its own wherever surgical operations are carried out
3. Fully qualified Nursing staff under its employment round the clock
4. Fully Qualified doctors should be in charge round the clock.
N.B In class C towns, condition of number of beds is reduced to 10.

Q. What does Ayurvedic treatment does not cover?


A. Ayurvedic treatment on Out-Patient basis, will not be payable. An admission for routine panchakarma treatment
without establishing diagnosis is not payable. Most of the ayurvedic procedures require 1 to 2 hrs, which does not
warrant hospitalization. In the absence of previous consultations, confirming Investigation reports admission for
planned panchakarma and related ayurvedic treatment expenses are not payable.

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.

Q. Can I claim for Ayurvedic treatment under the cashless facility?


A. If the hospital is listed in the Insurance empanelled hospital list then the cashless facility can be availed from that
Hospital. Please check for the empanelled hospital list for the same.

Q. What Is covered in Ayurvedic treatment for parents?


A. Ayurvedic treatment benefit is not covered for parents under the policy

Q. Can I claim the hospitalization expenses for abortion / abortive outcomes?


A. Miscarriage / threatened abortions / medically indicated termination of pregnancy are payable.

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.

Also, Termination of pregnancy less than 12 weeks gestation is not payable.

Q. Infertility treatment is covered or not?


A. Sterility treatment /IVF treatment /Other fertility treatments are now covered under the policy up to the maternity
sub-limit and can be availed twice in an employment tenure.
Family planning (tubectomy, vasectomy) treatments are not payable under policy. It will however cover complications
from Family Planning Devices where Hospitalization is required.

Q. Is Infertility treatment benefit covered under the basic sum-insured?


A. The Infertility treatment benefit is a part of the Maternity benefit and is covered under the maternity sub limit.

Q. Are expenses related to diagnosis/screening related to infertility treatment covered?


A. The policy does not cover any expenses made towards diagnosis, observation, screening etc. pertaining to
infertility

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.

Enhanced Maternity benefits if top up is opted:

Top-up SI Maternity Limit


1,00,000 65,000
2,00,000 70,000
4,00,000 75,000
6,00,000 80,000
11,00,000 1,00,000

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.

Q. ARMD, ROP, keratoconus eye complaints is payable under policy?


A. ARMD (Age related Macular Degeneration) with Injections like Avastin / Lucentis / Macugen is covered under the
policy. Injection Remicade infusion is payable under policy. But 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. For ARMD No Sublimit for ESC policy (per year) , and Up to 50k for Parental
policy (per year)
Q. Lasik surgery for Eye correction is covered?
A. Lasik surgery is covered if power exceeds +/-7.5. But surgeries indicated in view of cosmetic /removing contact
lens / spectacles are not payable. Surgeries related to implantable contact lens not payable.

Q. Are expenses related to multifocal and toric lenses covered?


A. Expenses related to multifocal lenses and toric lenses will not be admissible under the coverage as these lenses
are used only for replacement of the spectacles, and any procedure for avoiding usage of spectacles will fall under
cosmetic clause of policy terms and conditions.

However, claims (cashless/ reimbursement) for Multifocal lens will be allowed if insured is under 45 years of age.

Q. Hospitalization for Investigations and evaluation is covered or not?


A. As per policy, admission into hospital for medically necessary treatment as an inpatient is payable.

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)

Q. Under Domiciliary OPD benefit general check-ups are covered or not?


A. General check-ups / routine health check investigations, dental consultations are not payable under Domiciliary
OPD benefit.

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 expenses are not payable under OPD benefit?


A. Expenses not payable under OPD benefit are:

a. Dental treatment related medical expenses


b. Maternity / infertility / miscarriage / pre conception related investigation / consultations
c. Vaccination expenses / doctor visits for vaccination consultations
d. Routine check-ups / health check-ups
e. Procedure charges except road traffic accidental injuries
f. Non allopathic treatments / medical expenses
g. Pharmacy / medicines / consumables & disposables
h. Bills without respective consultation letters / prescriptions
i. Consultation Bills other than specialist
j. Consultation fees details mentioned on letter head / bills which are not in pre-printed bill formats

Q. Maternity consultations are payable under OPD benefit?


A. Not payable. Please refer Pre-natal and post-natal benefit.

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. Chemotherapy, dialysis is payable or not?


A. Payable under day care benefit. Employee has to submit Chemo / dialysis bills along with Chemotherapy chart or
Dialysis chart (which explains treatment summary along treatment dates).

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.

Q. Is CAPD expenses covered under the policy?


A. Expenses related to CAPD (continuous ambulatory peritoneal dialysis) Including related medicines and CAPD
device used for CAPD are payable.

Q. Can I claim for oral chemo drugs under hospitalization policy?


A. Yes, Oral chemotherapy drugs can be claimed under the hospitalization policy however there would be no pre
and post hospitalization expenses coverage for the same.

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.

Q. Are there any Specific criteria under domiciliary outpatient benefits/OPD?

 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. Will the screening tests be payable under OPD benefit?


A. OPD benefit covers all and any screenings tests (including acute and chronic) prescribed by a General
Physician. (Consultation Expenses of General physician are not payable)

Q. Is inpatient admission for administering Inj. Remicade payable?


A. As per policy Inj. Remicade administration / IV infusion is payable under hospitalization policy.

Q. RFQMR is payable or not?


A. Rotational Field Quantum Magnetic Resonance is not payable as per policy terms.

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. Emergency/ER related expenses covered under the policy?


A. Emergency cases/ER related expenses are covered in OPD benefit though if it is non specialist consultation as
well.

Q. Is All Laser treatment covered under policy?


A. Expenses related to Laser treatment Other than correction of eyesight is covered with specific indication of use of
laser in place of conventional procedures by treating doctor.
Also Laser procedures approved by FDA only covered under policy.

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.

Q. How to claim robotic charges for any surgery?


A. As per policy medically indicated robotic surgery is payable for all procedures provided if same is FDA approved.
(If any specific medical indication for choosing robotic procedure over conventional procedure other than cancer is
given to us by treating doctor, then we would consider robotic expenses otherwise we would restrict up to
conventional charges only as per policy).

Q. Medical Termination of pregnancy (MTP) covered under policy?


A. 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.
Also Termination of pregnancy less than 12 weeks gestation is not payable.

Q. What are the mandatory documents required for claim submission?


A. Checklist for employee reference:

1. HDFC Ergo claim form duly filled and signed


2. Photocopy of Ecard
3. Original medicine bills and Doctor’s payment receipts with corresponding prescriptions. Doctor name and
specialization should be visible in prescriptions / consultation letters.
4. Lab reports
Note: Employees do not need to submit original Xray films, ultrasound films, scans, etc. However, the employee may
be asked to submit original lab reports/scans for further investigation, if required.

Additionally, based on the claim type, the employee will be required to submit the following documents:

S.No. Activity Details


Mandatory documents for claim
Claim Type submission Checklist For employee
reference
1. Treating Doctor specialization details
(provided on prescription / letter head),
1 OPD / domiciliary claims diagnosis along with doctor sign and seal
on claim form / prescriptions for all OPD
claims
1. Requisition letter (Doctor's prescription
on advising specific test)
2. Original bill with details of procedure
2 Cancer Screening Tests expenses
3. Investigation report (photocopy attested
by the doctor)
4. Investigation bill in original
1. Photocopy of detailed discharge
summary / day care summary with
signature & seal from hospital where
treatment is taken
2. Original consolidated hospital main bill
with break ups of each item duly signed by
insured
3. Original payment receipt of the hospital
bills
3 Inpatient / Day care claims
4. Original lab investigation bills with
original payment receipts (if any)
5. Original invoice bills for implants (ex:
stents / IOL /mesh etc) with original
payment receipts along with stickers
6. In case of maternity, a certificate from
treating doctor stating obstetric history with
GPLA (Gravida, Para Living & Abortion)
details
1. Original payment receipt of the hospital
bills
2. Original lab investigation bills with
4 Pre and Post Hospitalization Claim original payment receipts (if any)
3. Photocopy of discharge summary of the
main claim with signature & seal from
hospital where treatment is taken
Documents for ID proof –
i. Pan Card
ii. If Pan Card is not available, please
submit any of the documents mentioned
below stating reason for not having Pan
Card.
a) Passport
b) Voter’s Identity Card
c) Driving License
d) Personal Identification and Certification
of the employees for your identity.
e) Letter issued by Unique identification
Authority of India containing details of
name address and Aadhar
f) Number
g) Job Card issued by NREGA duly signed
by an officer of the State Government
KYC/ AML documents if claim amount exceeds > 1 lakh;
5 one ID proof ad one address proof has to be given Documents for address proof
mandatorily I. Electricity Bill not older than 6 months
from the date of Insurance Contract
II. Telephone Bill pertaining to any kind of
telephone connection like mobile, landline,
wireless etc. Provided it is not older than 6
months from the date of claim submission
III. Ration Card
IV. Valid lease agreement along with rent
receipts which is not more than 3 months
old as a residence proof
V. Saving Bank Passbook with details of
permanent/ present residence address
(updated up to 1 month prior to claim
submission document)
VI. Statement of saving bank account with
details of present/ present address
(updated up to 1 month prior to claim
submission document)
1. Photocopy of mandatory documents
(including additional documents specified in
Contribution clause (If an employee is claiming from more S. No. 2) along with settlement note from
than one insurer, the total claim expense is shared by the other TPA / Insurer
6 insurers proportionately. Each insurer contributes towards 2. Employee declaration on claimed
the claim payment in proportion to the sum insured limited amount from HDFC Ergo and settled
opted.) amount from other insurer along with
balance cash paid receipts

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. BPAP, CPAP is payable or not?


A. Yes. BPAP and CPAP are admissible under the inpatient benefits of the policy.
Q. I’ve got settlement for maternity claim under my Spouse’s insurance policy from a different
corporate/insurance company. Now I would like to claim for Well baby expenses and pre and post-natal
expenses under IBM health insurance policy?
A. Yes. Claim pertaining to well-baby expenses up to INR 10,000 is admissible within the sublimit of maternity. Pre-
and post-natal can be also be payable up to INR 10,000 sublimit of Maternity.

Q. Congenital external ailments are payable under policy?


A. Cover for congenital external diseases irrespective of age is payable under policy. These expenses would be
covered under the general sum insured and the same would not be covered under the critical illness buffer of the
policy.

Q. Can I claim expenses related to genetic disorder?


A. Yes, expenses related to genetic disorder are admissible under the policy (the requirement of hospitalization
should be established).

Q. Is Genetic test covered under policy?


A. If treatment was dependent on test results of Gene testing in case of cancer, then same is covered but Genetic
testing for academic purpose or to know chances of cancer in offspring is not payable. Gene therapy is not covered.

Q. Hospitalization for CT scan or MRI scans is covered under policy?


A. As per policy admission for investigations & evaluation which requires Hospitalisation is payable.

Q. Why should I submit cash paid receipts?


A. As per original policy cash paid receipt along with original bills are mandatory requirements for claim process.
(cash paid receipts should contain receipt number /TIN number with the hospital name on the top and hospital seal
and signature on the below. Details of expenses mentioned on the hospital letter head or doctors’ letterhead are not
acceptable.)

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. Which claims form to be used for claiming Annual Health screening?


A. OPD claim form to be used which is available in Medi Assist portal.

Q. Is there any co-payment applicable on the Annual health screening claim?


A. No, Co-payment is not applicable for Annual health check screening.

Q. Will availing the Health Screening benefit be treated as a claim?


A. Yes, it is a benefit offered as part of the policy and same will be treated as a claim if availed.

Q. Is the Health Screening claim part of Sum Insured?


A. Yes, the claim would be considered part of the General Sum Insured.

Q. What is the process of availing the Annual Health Screening benefit?


A. Combination of Onsite & offsite mode will be used. Onsite here means IBM Campus and Offsite means identified
network hospitals / diagnostic centres. Employees who are not able to participate in the onsite biometric screening
camps have a choice to get the screening done at identified network diagnostic centres /hospitals and file a
reimbursement claim.
Q. Is the annual health screening benefit applicable for employee & Parents policy?
A. The annual health screening benefit is applicable for only employee policy.

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.

Q. Are expenses related to hospitalization only for physiotherapy payable?


A. Hospitalization only for physiotherapy will not be considered as an active line of treatment and the same would not
be admissible under the policy terms and conditions. However Medically prescribed physiotherapy charges is
payable under OPD benefit with co-pay of 50%, if specialist consultation prescribing physiotherapy given; definition
of a specialist is as stated in the OPD section of the policy.

Frequently Asked Questions (ECASHLESS PROCESS)


1. What is eCashless?
eCashless is an offering by Medi Assist which helps you avoid wait time at the hospital’s insurance desk on the day
of admission to obtain pre-authorization. With eCashless, you obtain a provisional pre-authorization at the comfort of
your home or office well ahead of your admission. This helps you plan your hospitalization better.

2. What are the advantages of eCashless?


eCashless has several advantages over regular cashless hospitalization. Following are a few of these advantages.

 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

All these mean better ways of planning your hospitalization.

3. Where can I avail the eCashless facility?


You can avail the eCashless facility at any of your insurer specific network hospitals.

4. When should I initiate the eCashless request?


eCashless is an offering available for planned surgeries/procedures, where you are aware of the day of admission in
advance. Hence, you should initiate the eCashless request at least 48hrs prior to the day of admission.

5. How can I initiate the eCashless request?


You can initiate an eCashless request using the following ways:

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

6. What are the documents I should submit for eCashless?


While initiating eCashless, you are requested to upload Doctor Consultation letter and Latest investigations reports.

7. Can I upload multiple files using Medi Assist?

 Yes. You have an option to upload multiple files when initiating the eCashless request on Medi Assist. Max
file size is 2 Mb.

8. What are the documents I should carry on the day of admission?


On the day of admission, you must carry the following documents:

 Secure passcode / OTP


 Medi Assist e-Card
 Photocopy of ID card of patient
 Medical advice for hospitalization or previous consultation documents
 All investigation reports (including X-ray/CT/MRI/USG/HPE)
 Any other document, relevant to the treatment of the insured

9. What are the circumstances under which pre-authorization can be denied?


Pre-authorization requests may be typically denied under the following circumstances:

 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.

11. How will I be updated / informed on the status of my ECashless request?


You can track the progress of your eCashless request on your Medi Assist app. You will also receive SMS
notifications from Medi Assist from time to time. You may see any of the following status messages -

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]

Frequently Asked Questions (MISCELLANEOUS)


Q. What are the Help Line Numbers?
A. For IBM employees can call on the chargeable number 8884388455/080-46855351.
While travelling abroad, you can reach out to Medi Assist on the ISD Helpline number: 00 91 80 67617555

You can also connect at the following tollfree number given below:

For Pre-Auth Emergency Contact Number for IBM Employees is:

Pre Auth-IBM: 04068178558

Q. Can I email my queries to Medi Assist India TPA Private Limited?


A. Yes, there is a dedicated email id for IBM. Please send your queries to [email protected]

Q. What is the escalation matrix followed in Medi Assist?


A. Below mentioned are the contact numbers and mail ids for any Queries.

Online Claim Submission


Generic queries

1. Please call on the chargeable number 8884388455/080-46855351.


2. Please write to [email protected] on any unanswered Queries by call centre for more than 2 working days.

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

Please write to [email protected]


Turnaround Time: 1 working day

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

Turnaround Time: 2 working days.

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:

GMC 2024 enrolment guidelines document


https://w3.ibm.com/w3publisher/ibm-india-benefits/latest-updates-2024/69b980c0-9a75-11ee-8020-
89159242b582

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.

Violations and Exceptions


All violations are to be brought to the attention of India Benefits Leader. Exceptions if any, if not specified, will be
approved by India Benefits Leader.

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