CITRUS INFORMATICS INDIA PVT LTD

GROUP MEDICLAIM POLICY

03RD JULY 2023 – 02ND JULY 2024
 ABOUT FIRST POLICY
ABOUT SBI GENERAL INSURANCE
COMPANY LTD
GMC COVERAGES

TABLE OF COVERAGE EXPLAINED

CASHLESS PROCESS
CONTENT NETWORK HOSPITALS
S REIMBURSEMENT PROCESS &
DOCUMENTS
GENERAL EXCLUSIONS
CONTACTS
FIRST POLICY- AN OVERVIEW
WE HELP YOU BUY. WE DO NOT SELL.

FIRST POLICY, is a process driven, ISO CERTIFIED composite insurance broking

company, licensed by the IRDA and established in 2002. We have the distinction of being
one among the FIRST BATCH OF 11 insurance broking companies in India. We use the
expertise of our core team and believe in ensuring that the policies are designed to
MAXIMIZE COVERAGE WHILE MINIMIZING RISK.
We have recently acquired AMICUS INSURE, a major broking firm in Mumbai and the
combined knowledge and size of the merged entity will enable us to leverage better terms
for our customers.
We are also a part of world’s largest broking network UNISONSTEADFAST, with
20,000 Employees which handles premiums in excess of US$ 25 bn across more than 130
geographies, 550 Network Partners Worldwide. This helps us to bring you the best-in-
class insurance solutions from around the world. We have recently won GREAT PLACE
TO WORK (GPW) certification too.
SBI GENERAL IS ONE OF THE FASTEST GROWING PRIVATE GENERAL INSURANCE COMPANIES, WITH THE
STRONG PARENTAGE OF SBI, THEY HAVE A VISION IS TO BECOME THE MOST TRUSTED GENERAL INSURER.
ESTABLISHED IN 2009, WITH 17 BRANCHES IN 2011, THEY HAVE EXPANDED TO OVER 137 BRANCHES PAN-
INDIA AND A CUSTOMER BASE OF OVER 10 CRORE CUSTOMERS. THEY HAVE BEEN AWARDED ‘INSURER OF
THE YEAR’ IN THE NON-LIFE CATEGORY AT FICCI INSURANCE INDUSTRY AWARDS, FOR TWO CONSECUTIVE
YEARS IN 2020 & 2021.
 GMC
COVERAGES / DETAILS
SPECIFICS
INSURER SBI GENERAL INSURANCE
COMPANY LTD

TPA INHOUSE
GMC
FIRST POLICY INSURANCE
INTERMEDIARY
BROKERS PVT LTD
COVERAGES
POLICY PERIOD 03RD JULY 2023 – 02ND JULY 2024

…1… TYPE FLOATER

LIVES EMPLOYEE + DEPENDENTS ​

DEFINITION (SPOUSE+ 3 DEPENDENT CHILDREN +
PARENTS/PARENTS IN LAWS)​

SUM INSURED 4 LAKHS

 GMC
COVERAGES / DETAILS
SPECIFICS
MID TERM SUM
Not Allowed
INSURED CHANGES
 Pre-existing diseases
 Waiver on 1st , 2nd & 4th year waiting period
STANDARD WAIVERS  Waiver on 1st 30 days
 Maternity waiting period
GMC
ROOM RENT / ICU 1% / Actuals
CHARGES
COVERAG AMBULANCE
CHARGE
Rs.1500/- per family

ES DISEASE SUB LIMITS No Limit

PRE AND POST
30 And 60 days
HOSPITALIZATION
…2.. DAY CARE Diseases covered as per insurer List – Pls refer
PROCEDURES attachment
Normal – 35 K
MATERNITY C-Section – 50 K
BABY DAY 1 COVER Covered within family sum insured
 GMC
COVERAGES / DETAILS
SPECIFICS
PRE-POST NATAL Covered Rs.5000/- within maternity benefit
EXPENSES
AYUSH Rs.20,000/- in Govt & NABH approved hospitals

GMC CORPORATE BUFFER NA

TREATMENT FOR
COVERAGES REFRACTIVE ERROR
Covered with refractive error +/- 7.5

AGE BAND 1 day – 80 yrs

…3..
TORIC LENS ​ 30,000/- per eye

DOMICILIARY
Covered Rs.20,000/- ​
HOSPITALIZATION ​
 GMC COVERAGES /
DETAILS
SPECIFICS

HOMEOPATHIC MEDICINE & Covered up to Rs.15,000/-

UNANI TREATMENT
GENETIC DISORDER​​ Covered up to 1 Lakhs

GMC HIV/AIDS/MENTAL ILLNESS ​ Covered up to Rs 40,000/-​​

1. New joiners – allowed

COVERAGES
2. Midterm add/ del of
(Spouse/Children)- In case of newborn
MID TERM ADDITIONS baby & Newly married spouse –
…4.. Allowed

3. Midterm add/ del of Dependents of

existing employees – Not Allowed
 MODERN TREATMENTS DETAILS – EXAMPLES
 Uterine Artery Embolization and HIFU - 50% of SI
 Balloon Sinuplasty - 50% of SI
 Deep Brain stimulation - 50% of SI
 Oral chemotherapy - 50% of SI
 Immunotherapy­Monoclonal - 50% of SI
GMC  Intravitreal injections - 50% of SI
 Robotic surgeries - 50% of SI

COVERAGES  Stereotactic Radio Surgeries - 50% of SI

 Bronchial Thermoplasty - 50% of SI
 Vaporisation of the prostrate (Green laser treatment or holmium laser treatment) -
…5… 50% of SI

 IONM - (lntra Operative Neuro Monitoring) – 50 % of SI

 Stem Cell Therapy: Hematopoietic stem cells for bone marrow transplant for
hematological - 50% of SI
 DETAILS

 Cochlear Implant Procedure

 Femtolaser

50 % OF CO  Retrograde intra renal surgery

GMC PAY
 Quantum magnetic resonance therapy

COVERAGES

…6..  Holter monitoring

LIST OF
 Inguinal and abdominal Hernia
GMC COVERAGES EXPLAINED
TERMS EXPLANATION
PRE & POST If the Insured member is Hospitalized and the claim is payable, the
Insurer will also then reimburse the Insured Member’s Pre and post
HOSPITALIZATION hospitalization Expenses for up to 30 days prior and 60 days post his
EXPENSES / her Hospitalization.

This Covers the cost of delivery – Normal or caesarean – of the first

two children for the insured member up to the limit specified. Those
who already have two or more living children will not be eligible for
this benefit. However, their 3rd or 4th child can be included in the
MATERNITY BENEFITS GMC policy. Also, expenses incurred in connection with voluntary
medical termination of pregnancy are not covered, unless the
doctor has advised based on tests and reports.

ROOM RENT / ICU It is the limit up to which your insurance company will bear the
room rent/ICU charges.
AMBULANCE This is for transportation by a licensed ambulance service to the
nearest Hospital in case of an Emergency only.
CHARGE
DISEASE SUB LIMITS Sub limits are basically a fixed value for a particular disease /
treatment within the sum insured. The remaining has to be borne
by the patient. For ex: Cataract could be capped at 20,000. The rest
of the amount will have to be borne by insured.

DAY CARE Such medical procedures, which do not require you to stay in the
hospital for more than 24 hours are day care procedures. Pls refer
PROCEDURES the list to know the procedures covered by your insurer
GMC STD COVERAGES

 GMC covers Hospitalization expenses including pre & post

Hospitalization expenses and day care procedures as applicable for
treatment within India and within the policy period.

 There should be Hospitalization for a minimum period of 24 hours for

the claim to be admissible

 However, Day care treatments like Dialysis, Chemotherapy, Eye surgery,

kidney stone removal, etc as per insurer list is covered.

 Please keep extra cash for consumables and other deductibles as per the
policy conditions or for a security deposit if requested by hospital to be
adjusted against the deductibles at time of discharge

 Please refer the next slide for exclusions

GMC – GENERAL EXCLUSIONS – AN INDICATIVE LIST

 Hospitalization due to intentional self-injury, use of intoxicating drugs/ alcohol etc.

 Injury or disease directly or indirectly caused by or arising from War or War-like

situations or caused directly or indirectly by nuclear weapons

 HIV and AIDS, Venereal diseases

 Circumcision unless necessary for treatment of disease

 Any non-medical expenses like consumables, registration / admission fees,

cafeteria charges, diet charges, extra room, telephone charges etc.

 Cost of spectacles, contact lenses, hearing aids etc.

 Any cosmetic or plastic surgery except for correction of injury

 Hospitalization for diagnostic tests only – observation and diagnosis

 Infertility treatment

 Voluntary termination of pregnancy (MTP) unless advised by doctor for medical

reasons

 Dental Treatment & surgery except for correction of injury

CLAIMS PROCEDURE - CASHLESS

 Cashless hospitalization helps the insured to avail of hospital facilities without

having to worry about paying hospital bills. The insurance company
coordinates directly with their list of Networked hospitals to settle the claim as
per the specified conditions mentioned before in the policy.

 Please ensure you refer the Network list (attached) of your insurer to avail
this facility

 Please keep extra cash for consumables and other deductibles as per the policy
conditions at the time of discharge or for a security deposit at the beginning to
be adjusted at discharge

PLEASE REFER THE ATTACHED EXCEL SHEETS FOR THE

LIST OF NETWORKED HOSPITALS
 CASHLESS AT NETWORK
HOSPITALS
 Keep your Id card number ready
 On reaching the hospital, approach the insurance desk of the hospital with below docs
* Patient Insurance card , Address proof ( Aadhar card) , photo – Sometimes requested
* Main member address proof(Aadhar card), Pan Card, Photo
 Hospital will coordinate with the TPA of your insurer for necessary approvals
 Hospital applies for pre-authorization to the TPA within 24 hrs of admission TPA verifies applicability of the claim to be registered and issue
preauthorization
 The usual TAT is 4 Hours
 After Approval from TPA , the insured gets treated on a cashless basis
 At the time of discharge, the Hospital sends complete set of claims documents for processing to the TPA
 The TAT specified is again 4 hours.
 Please give an extra hour incase the TPA is facing approval volumes. Hence it is always advisable to start the discharge procedure in the first half
of the day for a more hassle-free process.
 Keep some cash ready at the discharge time as you may have to pay for consumables that aren’t covered by your policy
 Basis approval, the insured have to pay all non-medical expenses like refreshments, consumables, admission charges etc

 If submitting pre-post claim, submit the copy of the discharge summary

 CLAIMS REIMBURSEMENT PROCEDURE & DOCUMENTS

IN CASE YOU CHOOSE A NON-NETWORK

HOSPITAL

 In case of non network hospital, you will have to clear the bills

 Please ensure that you collect all necessary documents such as –

discharge summary, investigation reports etc. with seal and sign for

submitting your claim – refer the document list

 Submission of hospitalization claim - You must submit the final

claim with all relevant documents within 30 days

 Please refer the claim reimbursement process for your Insurer in the

attached list of documents

REIMBURSEMENT DOCS FOR NON-
NETWORK HOSPITALS
 Duly filled claim form with claimant signature and treating doctor sign and hospital seal in Part B of claim form
 Copy of members Insurance id card
 Govt id proof of employee and patient
 Pan card if the claim amount is more than 1 lakh
 For NEFT transfer for claim settlement, a copy of cancelled cheque / Copy of the account passbook front page in which bank name,
Bank branch name, A/C holder name, A/C no., IFSC code should be very clear (Account has to be that of the main member)
 Original detailed discharge summary - with seal and sign
 Attending doctors' bills, prescription, receipts and certificate regarding diagnosis – with seal and sign
 Original hospital main bill - Consolidated and detailed breakup with all separate pharmacy and other bills with seal and sign from the
hospital along with Paid Receipt
 Original investigation reports – Lab, scan and other reports
 Follow up advice or letter for line of treatment after discharge from hospital, from doctor
 Incase of surgical packages – detailed breakup of the Package
 FIR copy incase of hospitalization due to accident/Attending doctors' certificate in case MLC/FIR not done
 If submitting pre-post claim, submit the copy of the discharge summary
 The documents and other requirements for Pre / Post remain the same as above
 Contact Persons for your queries

First Policy Insurance

Lakshmi K T
For Enrolment cards & [email protected]
MIS Mobile - 7736696404

Ritty Cleetus K
For Claims [email protected]
Mobile - 7736154041
Gina Hari
Escalations [email protected]
Mobile -9820220704

Your insurance partner (SBI)

Kathiravan.M
AM [email protected]