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Hospitalization Mediclaim

Claim Lodgment Procedure

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SSC Portal & Medi-Buddy Link

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MEDICLAIM POLICY

Mediclaim is a health insurance to cover medical costs incurred by an employee. Our health insurance policy is a contract between an
Oriental Insurance Co. Ltd. and L&T in which the insurance company agrees to provide health insurance cover to its employees at a
premium fixed by the insurance company. The policy is for a period of one year and can be renewed every year after paying the
premium. The Insurance Company offers cashless as well reimbursement facilities through a Third Party Administrator (TPA) & for
current policy period (1ST OCT 2017 – 30TH SEPT 2018) TPA is Dedicated Healthcare Systems (India) Pvt. Ltd. (DHS).

DHS is now merged with MediAssist Insurance TPA Private Limited.

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Insurance Policy Conditions

 Expenses incurred for any disease or illness for which treatment is taken in a hospital and the Hospitalization period
should be more than 24 Hrs. (except Hospitalization for Surgeries for Diseases of Eyes like Cataract, Glaucoma, etc.,
Hospitalization for Dialysis, Chemotherapy, Radiotherapy & D & C).
 Expenses incurred during 30 days pre and 60 days (30 days for Maternity claims) post are also paid.
 Employee, Spouse and 2 Dependent children (up to age of 25 yrs. of age) are covered in S & E cadre employees.
 In Covenanted Employees (M1A & Above & Equivalent cadres), Employee + Any 3 dependents (out of Spouse, 2 Dependent
children up to age of 25 yrs. of age & 2 Dependent parents i.e. mother & Father up to age of 90 yrs. of age). That means any
4 persons including Employee can avail the Mediclaim facility within 1 policy year.
 Change in dependent during the policy period is not allowed.
 Hospitalization
 Maternity, which is included in the overall limit. 9 months waiting period is waived off. Benefit to include Abortion,
Mis-carriage, Voluntary Termination (WITHIN 12 WEEKS) of pregnancy even when taken on OPD basis.
 Pre-Post natal expenses is covered within maternity limit.
 In maternity first two deliveries are only payable.
 Children up to age of 25 years or marriage whichever is earlier are covered.
 New born baby is covered from day one as follows:
- Any expenses incurred for baby during the maternity stay of mother in hospital is payable only up to up balance
to maternity limit of mother.

- Any expenses incurred for baby for Hospitalization due to re-admission (other than during the maternity stay of mother in
Hospital) is payable up to available policy limit or balance family sum insured.

 Territorial limit includes Nepal, Bangladesh & Bhutan (Only reimbursement mode & settlement in INR only).
 Notice of claim / Intimation is not required.
 All pre-existing diseases stands covered.
 Waiver of 30 days/12 months exclusion and waiting period.
 Non-medical charges such as admission, registration, ambulance hire, documentation charges, surcharge, service charge and
cost of recording (CD) is covered.
 Attendant/Ayah charges when prescribed for post hospitalization period.
 Dental treatment on OPD basis limited to Rs. 3,000/- per family.
 Eye treatment on OPD basis limited to Rs. 3,000/- per family.
 Expenses during and / or forming part of hospital stay for HIV test, vaccination, waterbed, inhaler/nebulizer/specialty
instrument, services is covered.
 Out-patient treatment (OPD) is not covered, except treatment of Animal bites, treatment including diagnostics arising out of
Accident. Expenses incurred for investigation or treatment irrelevant to the diseases diagnosed during hospitalisation or
primary reasons for admission. Private nursing charges, Referral fee to family doctors, out station consultants / Surgeons fees
etc.
 Expenses incurred in voluntary medical termination of pregnancy during the first 12 weeks from the date of conception are
not covered.
 In case of Ayurvedic treatment, Hospitalisation expenses are admissible only when the treatment is taken as in-patient, in a
Government Hospital/ Medical College Hospital.
 Non-medical charges such as admission, registration, documentation charges, surcharges, service charge, and cost of recording
(CD) are covered. Any charges which form part of hospital bill including diet are payable. Ambulance services – Rs.3000/-
shall be reimbursable in case patient has to be shifted from residence to hospital in case of admission in Emergency Ward /
I.C.U. or from one Hospital / Nursing home to another Hospital / Nursing Home by registered ambulance only for better
medical facilities.
 Cataract Surgery with standard imported foldable lens, subject to a maximum limit of Rs.30,000/- for each eye.
 Claim file has to be lodged to insurance company within 30 days from the date of discharge. Also any Deficiency or
Queries has to be submitted within 7 days from the date of the Query letter.
 NEFT mode of payment for claims reimbursement.
 Family planning operation performed in hospitals is covered with Sub Limit of Rs. 10,000/- within maternity limit.
The following diseases is covered (on case to case basis & subject to the policy terms) as per the actual limit of the policy.

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 o Stem Cell Implantation/ Surgery, Cyber knife Treatment and Oral Chemotherapy
o Robotics Treatment
o Air Ambulance charges
o EECP
o Ophthalmic procedures related to Injection Lucentis/avastin (Intravitreal injections)
o Peritoneal dialysis
o Genetic Disorders
o Advance/Unproven Medical/Surgical treatments
o Biodegradable Stent
o Second Opinion Cost
o Post Hospitalization Expenses for Physiotherapy (up to 4 months from Date of Discharge)
o Mobility Extension for Medical Reasons
o No deductions in case of death during Hospitalization
o No Active Line of Treatment in case of life threatening situations
o Bariatric Surgery

Some exclusion in Insurance Policy

 Diagnostic Test and routine Health checkup.

 Cost of Spectacles, lenses, Hearing Aids, Dental Treatment, Surgery for correction of eye sight.
 General Debility, Rest Cure, Sterility, Birth Defect (Congenital Ailments).
 Convalescence, general debility, ‘run down’ condition or rest cure, congenital external diseases or defects or anomalies,
sterility, any fertility, sub-fertility or assisted conception procedure, venereal diseases, intentional self-injury/suicide, all
psychiatric and psychosomatic disorders and diseases / accident due to and or use, misuse or abuse of drugs / alcohol or use
of intoxicating substances or such abuse or addiction etc.
 All expenses arising out of any condition directly or indirectly caused by, or associated with Human T-cell Lymphotropic
Virus Type III (HTLD - III) or Lymphadenopathy Associated Virus (LAV) or the Mutants Derivative or Variations Deficiency
Syndrome or any Syndrome or condition of similar kind commonly referred to as AIDS, HIV and its complications including
sexually transmitted diseases.
 Expenses incurred at Hospital or Nursing Home primarily for evaluation / diagnostic purposes which is not followed by active
treatment for the ailment during the hospitalised period.
 Expenses incurred for investigation or treatment irrelevant to the diseases diagnosed during hospitalisation or primary reasons
for admission. Private nursing charges, Referral fee to family doctors, out station consultants / Surgeons fees etc.
 External and or durable Medical / Non-medical equipment of any kind used for diagnosis and or treatment including CPAP,
CAPD, Infusion pump etc., Ambulatory devices i.e. walker , Crutches, Belts ,Collars ,Caps , splints, slings,
Braces, Stockings etc. of any kind, Diabetic foot wear, Glucometer / Thermometer and similar related items etc. and also any
medical equipment which is subsequently used at home etc.
 All non-medical expenses including Personal comfort and convenience items or services such as telephone, television, Aya /
barber or beauty services, diet charges, baby food, cosmetics, napkins , toiletry items etc., guest services and similar incidental
expenses or services etc.
 Any treatment required arising from Insured’s participation in any hazardous activity including but not limited to scuba diving,
motor racing, rock or mountain climbing etc. unless specifically agreed by the Insurance Company.
 Outpatient Diagnostic, Medical or Surgical procedures or treatments, non-prescribed drugs and medical supplies, Hormone
replacement therapy, Sex change or treatment which results from or is in any way related to sex change.
 Massages, Steam bathing, Shirodhara and alike treatment under Ayurvedic treatment.
 Any treatment received in convalescent home, convalescent hospital, health hydro, nature care clinic or similar establishments.
 Treatment of obesity or condition arising there from (including morbid obesity) and any other weight control programme,
services or supplies etc.
 Expenses on vitamins and tonics etc. unless forming part of treatment for injury or disease as certified by the attending
physician
 Any dental treatment or surgery which is corrective, cosmetic or of aesthetic procedure, filling of cavity, root canal including
wear and tear etc. unless arising from disease or injury and which requires hospitalisation for treatment.
 Circumcision (unless necessary for treatment of a disease not excluded hereunder or as may be necessitated due to any
accident), vaccination, inoculation or change of life or cosmetic or of aesthetic treatment of any description, plastic surgery
other than as may be necessitated due to an accident or as a part of any illness.
 Injury or disease directly or indirectly caused by or arising from or attributable to War, Invasion, Act of Foreign Enemy, War
like operations (whether war be declared or not) or by nuclear weapons / materials.
 Any stay in the hospital for any domestic reason or where no active regular treatment is given by the specialist
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Accommodation or Room Tariff & charges for Hospitalization:

Employees are required to adhere to the ‘Type of Room’ as applicable to their cadre, Subject to the ‘Maximum Limit of Room Tariff’,
since reimbursements will be made as per eligibility. Limits have been revised w.e.f 1st Jan 2014.

FOR L & T EMPLOYEES

Tier II Cities Tier III Cities

Tier I Cities
Ahmednagar,
Pune, Bangalore, Jamshedpur, Mysore,
Cadre & Grade Type of Room Delhi, Mumbai,
Hyderabad, Surat, Vizag, Coimbatore
Kolkata, Chennai
Baroda, Kochi,
(in Rs.)
Ahmedabad (in Rs.) (in Rs.)

S&E Economy class Room 3500/- 3000/- 2500/-

Tier 1 & 2 Twin sharing Room 3000/- to 4000/- 2750/- to 3500/- 3000/-
Tier 3 Single Occupancy 6500/- 5000/- 4500/-
Tier 4 & above Deluxe Room At actuals /- At actuals At actuals
EMC Members Suite At actuals At actuals At actuals

If employee is availing the Higher Room category irrespective of eligible room rent limit, all ‘over and above’ charges will be
deducted proportionately related to room rent, while settling the claims. In surgical case, Professional, Nursing and OT charges
will be deducted proportionately and in medical cases, Professional and Nursing charges will be deducted proportionately.

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Submission of Reimbursement Mediclaim form in SSC Website:

On Home page as shown in the given below screen shot we are having Employee Benefits icon, kindly click on same for lodging
Employee reimbursement claims

Quick Links

On Home page as shown in the given below screen shot we are having Employee Benefits icon, kindly click on same for lodging
Employee reimbursement claims.

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Select ‘Claim Type’ as “MEDICLAIM” & then click on “Add Claim”.

Click on ‘Submission’.

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 Please fill in the details.

Click on ‘Save as Draft’.

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Click on ‘Sent as Intimation’.

Click on ‘Submission’.

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Fill in the details.

Click on ‘Save as Draft’.

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Click on ‘Next’.

If saved, then, you need to update expenses. Please click on claim number from the summary and go in the last saved page.

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Click on ‘Next’ and update expenses.

Update expenses incurred and fill in the break ups. Amount should not be in decimal value.

Example: In case, if the total room expense is Rs. 8000/- for 7 days. Then, if spilt up and rounded off,
the value will be 8000÷7 = 1143. But, when we enter it, then it will be reflected as 1143*7=8001.

In such cases, please enter only single entry for the whole amount & update room charges as 8000*1
and mention it in remarks.

Click on ‘Save as Draft’.

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After saving the data, amount will be reflected in total expense.

Please click on ‘Submit’.

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Click on ‘Print’ and send the form attached with original claim documents to the mentioned address.

Claim print form looks like this:

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Please Note:
For time being, save all the details to be filled in claim, in an excel sheet and copy & paste immediately to save the data
successfully.

Otherwise, the session will get expired and screen will not move further if clicked on ‘Back’ & below screen will be displayed.

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Medi-Buddy Online Portal:

STEP 1: Login Credentials: LT<PS Number>

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In case of Emergency Hospitalization

 DHS Identity card is employee’s E-Card print out should be presented at the hospital while approaching for the cashless facility.
It is not mandatory to submit Dependent E-Card. For dependent, any valid ID proof is sufficient along with employee’s E-
Card.
 The Hospital will submit a Pre-certification request duly filled in to DHS. This pre- certification will have to be signed by the
treating doctor and must be stamped by the hospital.
 DHS will issue a Letter of Guarantee directly to the hospital, specifying the amount that can be expended by the hospital.

 The entire procedure will take a minimum of 3 – 4 hours.

 In case the total Hospitalization expenditure is more than the amount authorized, the hospital will ask for further authorization
from DHS, giving reasons for the increase, at least one hour before the patient is to be discharged.

Procedure for Reimbursement of Hospitalization Claims

Although Cashless Hospitalization facility is available at the DHS network of hospitals, you may sometimes need to use hospitals that
are not on the DHS network. In case you choose to or are required to avail of Hospitalization facilities at a non-network hospital, your
medical expenses can still be claimed through DHS. This is called Reimbursement. Reimbursement claims may be filed in the following
circumstances

1. Hospitalization at a non-network hospital

2. Post-Hospitalization and pre-Hospitalization expenses

3. Denial of preauthorization on application for cashless facility at a network hospital

Employees have to submit main Hospitalization claim within 30 days from the date of discharge & the claims for
reimbursement of post Hospitalization expenses has to submit within 30 days from the date of discharge otherwise due to
late submission claim will be rejected by the Insurance Company. Claim form is to be sent along with covering letter stating
all the details of employee like OD name, Phone number, and email ID.

 Claim Form has to be properly filled in and signed by the Claimant. Claim form is available in SSC website.

 Original Discharge Card / Summary from the hospital /nursing home with the details such as time in and time out, date of
admission/operation/discharge date, diagnosis, previous history of the patient complaints / symptoms at the time of admission,
noting of investigations done in-house, treatment given during Hospitalization and advice after Hospitalization.

 Doctor's consultation reports/history.

 Numbered and signed Hospital and other medical Bills, Receipts in original. (Bills/Receipts on letterhead are not acceptable).

 Original Cash Memos from hospital/ pharmacies supported by proper detailed break-up of hospital bills with original
prescriptions.

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  Item wise and cost wise breakup for charges shown in the bill for all the amounts, which includes more than one item.

 Diagnostic test reports supported by a note from the attending medical practitioner / surgeon justifying such diagnostics.
Surgeon's certificate stating the nature of the operation performed and surgeon's bill and receipt. Lab Reports not insisted if
forming part of main hospital bill. (Photo copies will be required to submitted with claim file).

 Attending doctor's / Consultant's / specialists / anesthetist's original bill and receipt, and certificate regarding diagnosis.

 Certificate from the attending medical practitioner / surgeon that the patient is fully cured. Original Bills of surgical appliances,
if purchased.

 In case of Accidental/fracture case, the Medico Legal Case (MLC/FIR) paper and letter from hospital / treating Doctor stating
details of accident, alcohol or any intoxicating drugs history.

 Complete obstetric history in case of pregnancy / delivery.

 Intra Ocular lens (IOL) sticker showing serial number in case of Cataract Operation. If lens are expensive then invoice of lens
from hospital.

 All Bills and prescriptions must have the name of patient and Doctor. All documents are to be attached date wise along with
the Claim form.

 Indoor case papers/Day-To-Day treatment charts, when asked by the TPA.

You are requested to make use of the above procedure & help us to process your Hospitalization claim faster through DHS.

We request you to avail Cashless facility to the maximum extent possible.

For any queries & follow up you can lodge Query through SSC Helpdesk.

For cashless claims & to get the Status of the claims under reimbursement you may contact DHS Helpdesk –

Mr. Narayan Pandit on Mob. No. 9987008927 or

Tel No.020-67344444 /443 & on Email id insurance-ssc@larsentoubro.com

Medi-Buddy Link: https://portal.medibuddy.in

Please help us to serve you better.

Larsen & Toubro Limited

SSC MEDICAL TEAM

ICC Devi Gaurav Tech Park,

Pimpri, Pune 411018.

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