Employee Insurance Benefits First American India .Employee Insurance Benefits First American India

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  • Employee Insurance Benefits

    First American India Policy Period 01st Jul 2016 30th Jun 2017





    Medical Benefit

    Coverage Details

    Cashless Process


    Claims Process

    Claims Document List

    Benefits Extensions Definitions

    Prudent Utilization of Benefit

    Help desk at First American

    General Exclusions

    GMC Contact Details


    Policy covers financial assistance in the event of hospitalization of covered member

    Hospitalization of member is considered in Insurance when there is treatment for

    1. Diagnosed Ailment

    2. Requiring Active line of treatment treatment which can be done only in hospital not

    on out patient basis. This is determined by the TPA doctor based on set medical protocols for various ailments and procedure.

    3. For at least 24 hours

    Exception to the conditions are

    - Day care procedures procedure taking less than 24 hours due to advancement in

    medical technology (dialysis , cataract)

    - Pre and Post hospitalization (30 & 60 days) on settlement of the main hospital bill.

    Hospitalization may be required as per treating doctor based on the presenting signs and

    symptoms, but only post complete diagnosis, admissibility of treatment would be established.

    Hospitalization for Diagnosis only , where no active line of treatment or self inflicted or elective

    surgery for betterment etc. are common rejections.


    Benefit Design Group Medical Plan


    Medical Benefit GMC Coverage Details Policy Parameter

    Insurer Oriental Insurance Co

    TPA Good Health TPA

    Policy Start Date 1st July 2016

    Policy End Date 30th Jun 2017

    Coverage Type Family Floater

    Dependent Coverage 1 + 5 - Employee + (Spouse + 2 Dependent Children + 2 Parents / 2 Parents IL) as per company

    policy conditions.

    Sum Insured INR 300,000

    Co Pay 10% of Co payment applicable for all parents / parents IL claims.

    Benefits / Extensions Coverage

    Standard Hospitalization Yes

    TPA services Yes

    Pre existing diseases Yes

    Waiver on 1st year exclusion Yes

    Waiver on 1st 30 days excl. Yes

    Maternity benefits Yes

    Pre & Post Natal Expenses Yes

    Well Baby Expenses Not covered

    Benefits / Extensions Coverage

    Baby cover day 1 Yes

    Room rent eligibility Yes

    OPD No

    Day Care Yes

    Domiciliary Hospitalization No

    Dental & Vision Restricted (only in case

    of accident)

    Pre-Post Hospitalization Exp. Yes

    Ailment Capping No*

    * Except Cataract, Maternity & Dental


    Medical Benefit Dependent Coverage

    Maximum no of Members insured in a family 1 + 5

    Employee Yes

    Spouse Yes

    Children Yes (for the first 2 living Children)

    Parents Yes

    Parents-in-Law Yes

    Employee can choose enroll parents / parents In law

    Siblings No

    Others No

    Please note all existing depended coverage can be done at inception of policy or 30 days from date of joining. This includes

    Spouse, children and Parents / In laws

    Mid Term enrollment of existing Dependents Disallowed

    Mid Term enrollment of New Joinees (New employees +their


    Allowed provided intimation to HR within 30 days from the

    date of event

    Mid term enrollment of new dependents (Spouse/Children) Allowed provided intimation to HR within 30 days from the

    date of event

    No Individual should be covered as dependent of more than one employee


    Maternity Benefits

    These benefits are admissible in case of hospitalization in India.

    Covers first two living children only. Those who already have two or more living children will not be eligible for this benefit.

    Expenses incurred in connection with voluntary medical termination of pregnancy during the first 12 weeks from the date of conception are not


    Well baby charges or cost incurred at hospital where there is no treatment was administered to the new born are not covered under the policy.

    Benefit Details

    For Normal Delivery INR 30,000/- within the Floater Sum Insured

    For C Section / Cesarean Delivery INR 50,000/- within the Floater Sum Insured

    Restriction on no of children Maximum of 2 Children

    9 Months waiting period Waived off

    Baby wellness charges Not covered

    Pre-Post Natal Expenses Not covered

    Baby Day One Cover

    All new born babies are eligible to be covered form date of birth. In unfortunate event of baby requiring inpatient

    hospital care , the policy extends the coverage

    Subject to declaration to HR / Insurer with in 30 days from the date of the event

    the baby gets covered within the available family floater sum insured for the policy year

    Well baby charges are not covered the charges / treatment cost spent towards baby check up , vaccination,

    inoculations etc


    Medical Benefit Standard Coverage

    Room and boarding

    Doctors fees

    Intensive Care Unit

    Nursing expenses

    Surgical fees, operating theatre, anesthesia and oxygen and their administration

    Physical therapy

    Drugs and medicines consumed on the premises

    Hospital miscellaneous services (such as laboratory, x-ray, diagnostic tests)

    Dressing, ordinary splints and plaster casts

    Costs of prosthetic devices if implanted during a surgical procedure

    Radiotherapy and chemotherapy

    A) The expenses are payable provided they are incurred in India and within the policy period. Expenses will be reimbursed to

    the covered member depending on the level of cover that he/she is entitled to.

    B) Expenses on Hospitalization for minimum period of 24 hours are admissible. However this time limit will not apply for

    specific treatments i.e. Dialysis, Chemotherapy, Radiotherapy, Lithotripsy (kidney stone removal), Tonsillectomy, D & C

    taken in the Hospital/Nursing home and the insured is discharged on the same day of the treatment will be considered to be

    taken under Hospitalization Benefit, however under pre authorization (cashless) only.

    C) Anesthesia, Blood, oxygen, OT charges, Surgical appliances, Medicines, drugs, Diagnostic Material & X-ray, Dialysis,

    Chemotherapy, Radiotherapy, cost of pacemaker, artificial limbs and cost of stent and implant.


    Benefits For

    FAI Definition

    Pre existing diseases

    Covered Any Pre-Existing ailments such as diabetes, hypertension, etc or related ailments for which care, treatment or advice

    was recommended by or received from a Doctor or which was first manifested prior to the commencement date of the

    Insured Persons first Health Insurance policy with the Insurer

    First 30 day waiting




    Any Illness diagnosed or diagnosable within 30 days of the effective date of the Policy Period if this is the first Health

    Policy taken by the Policyholder with the Insurer. If the Policyholder renews the Health Policy with the Insurer and

    increases the Limit of Indemnity, then this exclusion shall apply in relation to the amount by which the Limit of Indemnity

    has been increased

    First Year Waiting



    Applicable During the first year of the operation of the policy the expenses on treatment of diseases such as Cataract, Benign

    Prostatic Hypertrophy, Hysterectomy for Menorrhagia or Fibromyoma, Hernia, Hydrocele, Congenital Internal Diseases,

    Fistula in anus, Piles, Sinusitis and related disorders are not payable. If these diseases are pre- existing at the time of

    proposal they will not be covered even during subsequent period or renewal too

    Baby Cover Day 1

    Covered This policy is extended to cover the new born child of an employee covered under the Policy from the time of birth till 90

    days. Not withstanding this extension, the Insured shall be required to cover the newly born children after 90 days as

    additional member as mentioned elsewhere under this Policy.


    Covered The Insurer will pay Rs.2000/- for Emergency ambulance and other road transportation by a licensed ambulance

    service to the nearest Hospital where Emergency Health Services can be rendered. Coverage is only provided in the

    event of an Emergency.

    Dental & Vision



    Applicable Treatment cost for root canal, tooth fillings, scaling of teeth and Optical care cost of eye glasses besides cosmetic

    treatment, frames, contact lenses & hearing aid cost would not be paid / covered/

    Day Care

    Covered Day Care Procedure means the course of medical treatment or a surgical procedure listed in the Schedule which is

    undertaken under general or local anesthesia in a Hospital by a Doctor in not less than 2 hours and not more than 24

    hours. Generally 8 aliments (i.e. Dialysis, Chemotherapy, Radiotherapy, Cataract surgery, Lithotripsy (kidney stone

    removal), Tonsillectomy, D & C)

    Benefit Extensions Definitions





    Once in 15 days

    FAI would share New Joiners and Deletions with Oriental,


    In 2 working days

    Marsh would compute the