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Group Mediclaim Insurance Policy

Version 1.3

November 1, 2017
Wipro – For Internal Circulation only
Compensation & Benefits team

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1. Objective / Philosophy of the Policy
Group Mediclaim policy provides for reimbursement of hospitalization expenses for illness,
disease or injury sustained by employee, spouse and children.

Expenses for hospitalization are payable only if a 24-hour hospitalization has been taken (except
for select day care procedures, which do not require a 24-hour hospitalization). Under the
scheme, the typical expense heads covered are the following: room/boarding expenses as
provided by the hospital or nursing home; nursing expenses; surgeon, anesthetist, medical
practitioner, consultant, specialist fees; anesthesia, blood, oxygen, operation theater charges,
surgical appliance, medicines and drugs, diagnostic material and X-Ray; dialysis, chemotherapy,
radiotherapy, cost of pace maker, artificial limbs and cost of organs and similar expenses.

2. Coverage
All India based employees and long-term assignees (on India payroll) of Technologies, India BU
and WC are covered under the policy.

3. Salient Features
There are two plans called as ‘Base’ and ‘Top-up’. The Floater Sum Insured available under the
plans are given below. Wipro will offer all employees the base sum insured based on their
respective bands.
Table 1
Grade BASE Sum Insured (INR)
B3 and below 200,000
C1, C2 300,000
D1, D2 400,000
E 500,000

Table 2
Additional TOP-UP Sum Insured Options (INR)

200,000
400,000
600,000
800,000
1,000,000

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From the policy year 2017-18 onwards, an employee can increase her/his sum insured by
opting for any slab in the top-up plan during the enrolment window. Once an employee opts
for top-up, s/he will not be able to opt out from top-up / reduce the top-up amount for three
policy years, irrespective of the change in premiums. Post completion of three years, employee
can reduce the top-up amount or opt out from top-up, provided there is no claim in the third
year. However, once an employee opts for a slab in top-up, s/he will be allowed to choose any
available, higher top-up amount every year during the enrolment window.
Table 3
Policy Details
Policy Holder Wipro Limited
Policy Duration November 1, 2017 to October 31, 2018
Insurer United India Insurance Co. Ltd.
Third Party Administrator (TPA) Medi Assist India Pvt. Ltd.

Members Coverage and special conditions (if any)


Employee Covered
Spouse Covered. Incase employee’s spouse is also a full-time Wipro
employee, then employee should login to My Wipro > My Data >
Family Details > Spouse details and enter spouse’s Employee ID.
Then, an auto-generated e-mail will get triggered to the spouse re-
confirming this. To avoid premium deduction for both employees,
we will have to cover one of the employee as primary and the other
as spouse (secondary member).
Children Covered. No restriction on number of children. Children covered up
to the age of 25 or till employed or till marriage, whichever is earlier.

Table 4
Policy Benefits
Benefits Base Plan Top-up Plan
Standard Hospitalization Covered
Pre & Post Hospitalization Relevant expenses Covered (30 days & 60 days respectively) Refer
expenses maternity benefit for maternity related pre and post limits
Pre-existing diseases (including
internal and external congenital Covered
diseases)
Waiting periods (First 30-days,
First Year, First Two Years and Waived off
First Four Years)
Up to INR 2,000 per claim for Up to INR 3,000 per claim for
Ambulance services
emergencies only emergencies only
Normal & Caesarian Delivery (first 2 Normal & Caesarian Delivery (first 2
Maternity instances of live birth for the instances of live birth for the
mother): INR 40,000. Pre-& Post mother): INR 50,000. Pre-& Post

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Natal, OPD expenses up to Natal, OPD expenses up to
INR 5,000 within the maternity INR 5,000 within the maternity
limit. limit.
Within the maternity limit for normal expenses. Complications which
New born baby cover from day 1 require an admission can be processed under the balance floater sum
insured.
Covered (Only selected procedures like dialysis, chemotherapy,
radiotherapy and other such specified treatments taken in the hospital /
Day care procedures
nursing home where the insured member is discharged on the same day.
Refer policy terms and conditions for details.)
Up to INR 10,000 for surgical Up to INR 15,000 for surgical
treatment per family. Out of this, treatment per family. Out of this,
the sublimit for Root Canal the sublimit for Root Canal
treatment is INR 3,000 per tooth treatment is INR 5,000 per tooth
inclusive of cost of the crown. inclusive of cost of the crown.
(Cosmetic treatment like filling, (Cosmetic treatment like filling,
capping, polishing, dentures, capping, polishing, dentures,
scaling, cleaning and treatment of scaling, cleaning and treatment of
Dental
similar nature are not payable. similar nature are not payable.
Detailed prescription, nature of Detailed prescription, nature of
treatment, procedures done, pre- treatment, procedures done, pre-
numbered receipts are a must for numbered receipts are a must for
dental treatment claims. In dental treatment claims. In
addition, X-ray reports may be addition, X-ray reports may be
asked for justification of asked for justification of
admissibility of claim.) admissibility of claim.)
In-vitro fertilization Up to INR 40,000 Up to INR 50,000
Covered for a maximum of first 10 cases throughout the year with a limit
Emergency Air Ambulance of INR 100,000 per case in absence of multi-specialty hospital in a radius of
50 kms for named ailments only (subject to approval of insurer).
Covered up to INR 5,000 per employee. Expenses related to external aids
Mobility Extension used for mobility (like walker, crutches) upon the prescription of the
treating doctor and admissibility of the main claim.
Lasik Treatment Covered, if required for correction of power of 6.0D or above
Morbid obesity treatment Covered only if it is life threatening and not for cosmetic purposes
Ayurvedic hospitalization is covered for treatment taken in a registered
Ayurveda
with a justified admission. (Refer section 4.4 for details)
Mental Ailment In-patient treatment of mental ailment. Only established ailments covered.
Oral chemotherapy – restricted to
Not covered Covered
cancer treatment only
Hormone therapy – restricted to
cancer treatment under
Not covered Covered
hospitalization including pre &
post only
HIV Covered up to sum insured for employee, spouse and children

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Stem cell and cyber knife
Covered up to 50% of the sum insured
treatment
Cochlear implant Limited up to the default sum insured as per the employee grade
Donor medical expenses Covered only if the recipient is a member in the policy and if the donor is a
(excluding organ cost) non-member of the policy.
Up to INR 25,000 for employees
Keratoconus treatment Not covered
only
Room rent/ICU charge limit across
all cities per day (No Limit for INR 2,700 INR 4,000
Band E employees)
Nursing charges (to be billed
25% of room rent limit
separately)
No Proportionate deduction on
Yes (only difference in room charges need to be borne by the employee)
opting for higher room rent.
Co-pay on all claims 10%
Co-pay on day care procedures 10%
Co-pay on maternity claims 10%
Co-pay for employees dying in
No
harness
Ailment capping Yes. Refer section 4.5 Yes. Refer section 4.6

4. Terms and Conditions applicable to both plans


4.1 Policy covers hospitalization expenses. Expenses prior to and after hospitalization are also
covered. Further details of coverage are given below:
Expenses on hospitalization for a minimum period of 24 hours are admissible. However, this time
limit is not applied to specific treatments as detailed later in the policy.

Note: Procedures/treatments usually done in outpatient department are not payable under the
policy even if converted as an in-patient in the hospital for more than 24 hours or carried out in
Day Care Centers.

A. Room, Boarding and Nursing expenses as provided by the Hospital/Nursing Home. This
also includes nursing care, RMO charges, IV Fluids/Blood transfusion/injection
administration charges and similar expenses.

B. Surgeon, Anesthetist, Medical Practitioner, Consultants, Specialists Fees

C. Anesthetic, Blood, Oxygen, Operation Theatre Charges, surgical appliances, Medicines &
Drugs, Dialysis, Chemotherapy, Radiotherapy, Cost of Artificial Limbs, Cost of prosthetic
devices implanted during surgical procedure like pacemaker, orthopedic implants, infra
cardiac valve replacements, vascular stents, relevant laboratory/ diagnostic tests, X Ray
and other medical expenses related to the treatment.

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D. Coverage for dependents in case of employee’s death to continue till the end of the policy.
E. No deductions in case of death during hospitalization
F. Admission less than 24 hours’ hospitalization without active line of treatment in life
threatening situations (only for employees, when at work)

Note: No payment shall be made under 4.1B other than as part of the hospitalization bill.

4.2 DOMICILIARY HOSPITALIZATION as defined below in clause 5.7 below for a period
exceeding three days and subject however that domiciliary hospitalization benefits shall not
cover:
i) Expenses incurred for pre and post hospital treatment and
ii) Expenses incurred for treatment for any of the following diseases: -
1) Asthma
2) Bronchitis
3) Chronic Nephritis and Nephritic Syndrome
4) Diarrhea and all type of Dysenteries including Gastroenteritis
5) Diabetes Mellitus and Insipidus
6) Epilepsy
7) Hypertension
8) Influenza, Cough and Cold
9) All Psychiatric or Psychosomatic Disorders
10) Pyrexia of unknown Origin for less than 10 days
11) Tonsillitis and Upper Respiratory Tract infection including Laryngitis and pharyngitis
12) Arthritis, Gout and Rheumatism
Liability of the company under this clause is restricted as stated in the Schedule attached
hereto.

4.3 Expenses on Hospitalization upon written advice of a Medical Practitioner, for minimum
period of 24 consecutive hours are admissible. However, this time limit is not applied to
specific treatments as mentioned below:
Table 5
1 Hemo dialysis 8 Surgical treatment of anal fistulas
2 Parenteral Chemotherapy 9 Dilation and Curettage (D&C)

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3 Radiotherapy 10 Surgical treatment of hemorrhoids (piles surgery)
4 Eye surgery 11 Operation on a testicular hydrocele
5 Dental surgery 12 Treatment of a varicocele and a hydrocele
6 Lithotripsy 13 Tonsillectomy with adenoidectomy
7 Myringoplasty 14 Coronary angioplasty
15 Tonsillectomy 20 Varicose Vein Ligation
16 Tympanoplasty 21 Sclerotherapy
17 Herniotomy / Hernioplasty 22 Sinusitis
18 Paracentesis (myringotomy) 23 Hysterectomy
19 Coronary angiography 24 Fracture/dislocation excluding hairline fracture

This condition will also not apply in case of stay in hospital of less than 24 hours provided
a. The treatment is undertaken under General or Local Anesthesia in a hospital/day care
center in less than 24 hours because of technological advancement and
b. Which would have otherwise required a hospitalization of more than 24 hours.

Note: Procedures/treatments usually done in out-patient department are not payable under
the policy even if converted as an in-patient in the hospital for more than 24 hours or carried
out in Day Care Centers.

4.4 For Ayurvedic Treatment, hospitalization expenses are admissible only when the
treatment has undergone in a Government Hospital or in any Institute recognized by the
Government and/or accredited by Quality Council of India/National Accreditation Board of
Health.

(N.B: Company’s Liability in respect of all claims admitted during the period of insurance shall
not exceed the Sum Insured per person as mentioned in the schedule)

4.5 The following ailments are capped with the below mentioned sub-limits (specific to A-
type & B-type city). These sub-limits are inclusive of all hospitalization and implant charges,
irrespective of the room category. (All Wipro office locations are considered as Class A and
rest of the locations are considered as Class B.)
Note: The below sub-limits are inclusive of pre and post-hospitalization expenses
Table 6

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A-class B-class
Surgery
Ailments Description city limit city limit
Type
(INR) (INR)
Cataract (including
Eye surgery Clouding of vision, common in elderly people 27,000 22.000
lens)
Inflammation and infection of
Throat
Tonsillectomy tonsils/adenoids, glands between mouth, 29,000 17,000
surgery
nose and throat
Abnormal connection between two organs,
General generally between the rectum and
Fistula High 35,000 30,000
surgery vagina/rectum and urinary bladder, resulting
due to injury/surgery
General
Fistula Low Same as above 30,000 25,000
surgery
Repair of a fissure (a crack or a tear in the
General lining of an organ), sphincterectomy is the
Fissurectomy 25,000 20,000
surgery correction of a tear on a sphincter (muscle that
helps in contraction of an organ)
Hemorrhoidectomy Surgical removal of a hemorrhoid (protrusion
General
(Excluding staples & of the mucous lining of rectum due to 32,000 25,000
surgery
tackers) constipation)
Thyroidectomy - General Partial surgical removal of a thyroid gland
40,000 35,000
HEMI surgery (usually done when suffering from cancer)
Thyroidectomy - General
Total surgical removal of a thyroid gland 50,000 45,000
TOTAL surgery
A procedure done by inserting a fiber optic
Arthroscopy Orthopedics tube into the joints to study the nature of 35,000 30,000
condition causing inflammation
Arthroscopic Done to treat cartilage tears (cartilage is tissue
Orthopedics 103,000 50,000
surgery lining the joints)
Removal of hydrocele (collection of fluid
Hydroceletomy –
Urology around testes), one side. Related to the male 25,000 20,000
Unilateral
reproductory organ
Removal of hydrocele (collection of fluid
Hydroceletomy –
Urology around testes), both sides. Related to the male 35,000 30,000
bilateral
reproductory organ
An x-ray test done to find out the flow of blood
Coronary
into and out of one's heart (basically to study
Angiogram Cardiology 20,000 15,000
the nature of blood vessels). CT Angiogram not
(including dye)
payable
Hernia repair –
General Correction of hernia (protrusion of internal
Open (including 35,000 35,000
surgery organs through weak abdominal muscles)
mesh)
Hernia repair - General Correction of hernia (protrusion of internal
60,000 50,000
laparoscopic surgery organs through weak abdominal muscles)
Appendicectomy – General Removal of appendix by cutting open the
35,000 30,000
open Surgery abdomen
Removal of appendix by laparoscopy
Appendicectomy - General (insertion of a laparoscope and removal of
57,000 45,000
laparoscopic surgery appendix bit by bit, requires just a small
incision on the abdomen)

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Cholecystectomy – General Removal of gall bladder upon finding stone
45,000 40,000
open Surgery formation (by cutting open the abdomen)
Cholecystectomy – Removal of gall bladder upon finding stone
laparoscopic General
formation (by minimal invasion - using 55,000 45,000
surgery
laparoscope)
Hysterectomy – Removal of uterus due to any complications
Gynecology 50,000 45,000
vaginal /open (by cutting open the abdomen)
Hysterectomy – Removal of uterus due to any complications
Gynecology 60,000 55,000
laparoscopic (by laparoscopy)

4.6 The following ailments are capped with the below mentioned sub-limits in the Top-up plan.
These sub limits are inclusive of all hospitalization and implant charges, irrespective of the room
category. The A and B type city classification does not apply to these limits.
Table 7
Capped Ailment limits as per the Top-up Top-up limits(INR)
selected 200,000 400,000 600,000 800,000 1,000,000
Appendicectomy - laparoscopic 62,700 68,970 75,867 83,454 91,799
Appendicectomy – open 38,500 42,350 46,585 51,244 56,368
Arthroscopic surgery 113,300 124,630 137,093 150,802 165,883
Cataract 29,700 32,670 35,937 39,531 43,484
Cholecystectomy - laparoscopic 60,500 66,550 73,205 80,526 88,578
Coronary Angiogram (CT Angiogram not 22,000 24,200 26,620 29,282 32,210
payable)
Fissurectomy 27,500 30,250 33,275 36,603 40,263
Fistulectomy – High 38,500 42,350 46,585 51,244 56,368
Fistulectomy – Low 33,000 36,300 39,930 43,923 48,315
Haemorrhoidectomy 35,200 38,720 42,592 46,851 51,536
Hernia repair - laparoscopic 66,000 72,600 79,860 87,846 96,631
Hernia repair - open 38,500 42,350 46,585 51,244 56,368
Hydrocelectomy - Bilateral 38,500 42,350 46,585 51,244 56,368
Hydrocelectomy - Unilateral 27,500 30,250 33,275 36,603 40,263
Hysterectomy - Laparoscopic 66,000 72,600 79,860 87,846 96,631
Hysterectomy - Open 55,000 60,500 66,550 73,205 80,526
Thyroidectomy 55,000 60,500 66,550 73,205 80,526
Tonsillectomy 31,900 35,090 38,599 42,459 46,705

4.7 MEDICAL EXPENSES INCURRED UNDER TWO POLICY PERIODS


If the claim event falls within two policy periods, the claims shall be paid taking into
consideration the available sum insured in the two policy periods, including the deductibles
for each policy period. Such eligible claim amount to be payable to the insured shall be
reduced to the extent of premium to be received for the renewal/due date of premium of
health insurance policy, if not received earlier.

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4.8 SPECIAL CONDITIONS
If employee is married at the time of inception of the policy and separated / divorced during
the top up recovery of first 3 months, in such a scenario, GMC top up contributed would not be
reimbursed, however any remaining contribution will be rectified as per the no. of units. This
would be applicable to GMC base monthly contribution as well.

4.9 CRITICAL ILLNESS COVER


The Policy covers critical Illness for a Sum Insured of INR 200,000 only for Employees.
a. The Benefit under this clause is in addition to the Floater Sum Insured applicable to the
Employee.
b. The cover is not applicable to the Employee’s Spouse or Children.
c. The insured must survive at least three months after commencement date of insurance and
30 days after the diagnosis of the ailment for the cover to be become payable by the insurer.

Critical illness means any of the below listed ailments:


I. CANCER OF SPECIFIED SEVERITY
A malignant tumor characterized by the uncontrolled growth and spread of malignant
cells and with invasion of normal tissue and destruction of normal tissues. This
diagnosis must be supported by histological evidence of malignancy & confirmed by
a pathologist. The term cancer includes leukemia, lymphoma and sarcoma.
The following are excluded:
A. Tumors showing the malignant changes of carcinoma in situ & tumors which are
histologically described as pre-malignant or non-invasive, including but not limited to:
Carcinoma in situ of breasts, Cervical dysplasia CIN1, CIN -2 & CIN-3.
B. Any skin cancer other than invasive malignant melanoma.
C. All tumors of the prostate unless histologically classified as having a Gleason score
greater than 6 or having progressed to at least clinical TNM classification
T2N0M0.........
D. Papillary micro - carcinoma of the thyroid less than 1 cm in diameter
E. Chronic lymphocytic leukemia less than RAI stage 3
F. Micro carcinoma of the bladder
G. All tumors in the presence of HIV infection.

II. FIRST HEART ATTACK of specified severity


The first occurrence of an acute myocardial infarction which means the death of a portion
of the heart muscle because of inadequate blood supply to the relevant area.

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The diagnosis for this will be evidenced by all the following criteria:

a) A history of typical clinical symptoms consistent with the diagnosis of Acute Myocardial
Infarction (for example: typical chest pain)
b) New characteristic electrocardiogram changes
c) Elevation of infarction specific enzymes, Troponins or other specific biochemical
markers.

The following are excluded:


(1) Non-ST-segment elevation myocardial infarction (NSTEMI) with elevation of Troponin
I or T;
(2) Other acute Coronary Syndromes
(3) Any type of angina pectoris

III. CORONARY ARTERY SURGERY (CABG) Open Chest CABG


The actual undergoing of open chest surgery for the correction of one or more coronary
arteries, which is/are narrowed or blocked, by coronary artery bypass graft (CABG).
The diagnosis must be supported by a coronary angiography and the realization of surgery
must be confirmed by a specialist medical practitioner.

Excluded are:
A. Angioplasty and/or any other intra-arterial procedures
B. Any key-hole or laser surgery.

IV. HEART VALVE REPLACEMENT


The actual undergoing of open-heart valve surgery to replace or repair one or more
heart valves, because of defects in, abnormalities of, or disease-affected cardiac
valve(s). The diagnosis of the valve abnormality must be supported by an echo
cardiograph and the realization of surgery should be confirmed by a specialist medical
practitioner.

Exclusions:
A. Catheter based techniques including but not limited to, balloon
valvotomy/valvuloplasty are excluded.

V. COMA OF SPECIFIED SEVERITY


A state of unconsciousness with no reaction or response to external stimuli or
internal needs. This diagnosis must be supported by evidence of all the following:
1. No response to external stimuli continuously for at least 96 hours

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2. Life support measures are necessary to sustain life and
3. Permanent neurological deficit which must be assessed at least 30 days after the
onset of the coma.

Exclusions:
A. The condition should be confirmed by a specialist medical practitioner. Coma resulting
directly from alcohol or drug abuse is excluded.

VI. KIDNEY FAILURE


End stage renal disease presenting as chronic irreversible failure of both kidneys to
function, because of which either regular renal dialysis (hemodialysis or peritoneal
dialysis) is instituted or renal transplantation is carried out. Diagnosis must be confirmed
by a specialist medical practitioner.

VII. STROKE RESULTING IN PERMANENT SYMPTOMS


Any cerebrovascular incident producing permanent neurological sequelae. This includes
infarction of brain tissue, thrombosis in an intra-cranial vessel, hemorrhage and
embolization from an extracranial source. Diagnosis should be confirmed by a specialist
medical practitioner and evidenced by typical clinical symptoms as well as typical findings
in CT Scan or MRI of the brain.
Evidence of permanent neurological deficit lasting for at least 3 months must be
produced.

The following are excluded:


1. Transient ischemic attacks (TIA)
2. Traumatic injury of the brain
3. Vascular disease affecting only the eye or optic nerve or vestibular functions.

VIII. MAJOR ORGAN / BONE MARROW TRANSPLANT


The actual undergoing of a transplant of one of the following human organs: heart, lung,
liver, kidney, pancreas, that resulted from irreversible end-stage failure of the relevant
organ, or human bone marrow using hematopoietic stem cells. The undergoing of a
transplant must be confirmed by a specialist medical practitioner.

The following are excluded:


1. Other stem-cell transplants
2. Where only islets of Langerhans are transplanted

IX. MULTIPLE SCLEROSIS

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The definite occurrence of multiple sclerosis. The diagnosis must be supported by all the
following:
a) Investigations including typical MRI and CSF findings, which unequivocally confirm the
diagnosis to be multiple sclerosis;
b) There must be current clinical impairment of motor or sensory function, which must
have persisted for a continuous period of at least 6 months, and
c) Well documented clinical history of exacerbations and remissions of said symptoms
or neurological deficits with at least two clinically documented episodes at least one
month apart.

Exclusions:
1. Other causes of neurological damage such as SLE and HIV are excluded.

X. MOTOR NEURONE DISEASE WITH PERMANENT SYMPTOMS


Motor neuron disease diagnosed by a specialist medical practitioner as spinal muscular
atrophy, progressive bulbar palsy, amyotrophic lateral sclerosis or primary lateral
sclerosis. There must be progressive degeneration of corticospinal tracts and anterior
horn cells or bulbar efferent neurons. There must be current significant and permanent
functional neurological impairment with objective evidence of motor dysfunction that
has persisted for a continuous period of at least 3 months.

XI. PERMANENT PARALYSIS OF LIMBS


Total and irreversible loss of use of two or more limbs because of injury or disease of
the brain or spinal cord. A specialist medical practitioner must believe the paralysis will
be permanent with no hope of recovery and must be present for more than 3 months.

PROVISIONS
1) The Company shall compensate the Insured person only once in respect of any one or
more of the covered diseases under the policy.
2) Should a benefit be paid in terms of this policy on behalf of an Insured Person the
coverage for that person terminates under this policy and such person shall not be
entitled to be covered by this policy or its renewal thereof.

4.10 LOSS OF PAY COVER


a) The Policy covers Loss of Pay to Employees only
b) The Benefit under this clause is in addition to the Floater Sum Insured applicable to the
Employee.

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c) The coverage is for illnesses / diseases only. Accidents and Maternity are excluded from this
cover.
d) The cover under the clause commences from the day when, ‘Loss of Pay’ starts after
exhausting all leaves to the Employees Credit.
e) The cover ceases from the date on which the Hospital / Nursing Home / Treating Doctor
Certifies that the Employee is fit for resumption of duty or the date on which the Employee
resumes duty, whichever is earlier.
f) The Employee needs to produce a ‘LOP certificate’ from the Employer.
g) For a claim to be admissible under this clause a claim must be admissible under the
hospitalization claim.
h) The weekly compensation is payable for a maximum period of 52 Weeks.
i) The cover is not applicable to the Employee’s Spouse or Children.
j) The limits for employees of Azim Premji Foundation, Azim Premji University, Azim Premji
Educational Trust, Azim Premji Foundation for Development, Wipro Kawasaki Precision Mach
Ltd., Premji Invest or any such entity / subsidiary of the Wipro Group, shall be based on the
grades equivalent to or nearest to that of the grades of employees of Wipro Limited.
k) The weekly compensation payable is given below
Table 8
Employee Band Loss of Pay Benefit per week (INR)
Band B3 and below 5,000
Band C1 and above 10,000

4.11 Premium deduction conditions if both employee and spouse are employed with Wipro
a. Premium will be deducted from employee at a higher band, if both employee and spouse
are part of this policy
b. Premium will be deducted from either one of the employees, if both employee and
spouse are part of this policy and are in the same band.
c. If one employee is in BPS and the spouse in WT/WI, at the same/different band, premium
will be deducted from the employee in WT.

4.12 New hires / New Incumbents / Intercompany transfers / Onsite return


a. New hires / intercompany transfers / Onsite return employees will have the option to
choose Top-up plans within the first 30 days of joining / returning. Failure to select an
option, will result in auto-enrollment into the Base plan with default band-wise sum
insured.
b. A block of three years would be observed from the year of enrollment into the policy.
New hires can change plans (opt out of / reduce Top-up) only upon completion of three
policy years / atleast 2 renewal cycles. For example: if an employee joins in March 2015,
he will have to choose a Top-up plan within 30 days of joining. He will be able to opt out

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of / reduce Top-up sum insured only after atleast two renewal cycles (based on the year
the plan opens for new enrollments). In this case, he will be part of the 2014-15 policy
and 2015-16 and 2016-17 as per choice made while joining/enrolment. He can only
increase the top-up sum insured to any higher top-up slab during the renewal cycles for
2 years. But reduction / opt out of top-up sum insured will only be allowed post being in
the plan for atleast three policy cycles. In this case, he can reduce / opt out of top up
sum insured in 2017-18 renewal cycle provided there is no claim in the third year (2016-
17).

c. New incumbents - spouse and child details need to be added within the 30 days of date
of marriage or date of birth, respectively.

4.13 Resignation cases / Exiting employees


a. Employee who makes a claim (partial cover or full cover), and then exits in the same
policy cycle, will have to pay the premium for the remaining months in the policy year
through the full and final settlement.
b. All exiting employees must raise any pending claims before their last working date.

4.14 Adoption cases


The adopted child can be covered from the date of adoption and the claims will be honored with
effect from the adoption date. However, the adopted child should be enrolled through myWipro
> My Data within 30 days from the date of adoption to be eligible for any claim reimbursement

4.15 Long term onsite assignees opt out option


Employees who have been on long term onsite assignment for three years or more can choose
to opt out of the policy. However, the opt out option will only be available if the employee has
had no claims in the last three years.
In the above scenario, the organization will not be liable if there is an untoward incident when
the employee / his family travels on a personal trip to India.

Remember to declare your marital status and family members at myWipro > My Data at the
time of a life changing event like marriage, child birth etc. The same applies for intercompany
transfers also.

4.16 The Policy will carry a 10% co-pay from the employee for admissible claim amount.

4.17 Root Canal Treatment claims

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RCT (Root Canal Treatment) Flap surgery/Surgical Extraction should be claimed under insurance in the
first instance. Once insurance is settled, unpaid value can be claimed under MAS by producing the
insurance settlement letter. Co-pay amount will not be payable through MAS.

5. Process for Claim Submission


5.1 Claim documents
In the event of a claim, you would be required to furnish the following for or in support of a
claim:
i. Duly completed claim form
ii. Bills, receipts and discharge certificate/card from the Hospital
iii. Bills from Chemists supported by proper prescription.
iv. Test reports and payment receipts.

Complete Information on claims process is available at MyWipro > Finance > My medical claim
> Medical Insurance Claim > Plan details > Guidelines_for_Cashless_and_Reimbursement

For any claims, please use the claim form available in myWipro > Finance > My Medical claim >
Medical Insurance Claim > Medibuddy > Claims > Submit a claim. Attach check leaf as a soft
copy. You will need to fill the claim form and drop the supporting documents in HRSS Drop box.
Please write to wipro@mediassistindia.com for claims processing or for any clarification. Please
refer the portal for the detailed checklist ailment wise at www.mediassistindia.com
Claims will take up to 60 days to be processed once all the requisite documents are received by
MediAssist.

5.2 Claim Procedure


Depending on the need and condition of hospitalization, employee can go for 3 forms of
hospitalization:
1. Planned Hospitalization: In the case of a planned admission, doctor must have been
consulted first and would in turn have advised on the probable date of hospitalization. In
such a case, employee must apply for an approval of the estimated hospital expenses
directly with the TPA at least 4-5 days prior to the date of hospitalization. Employee needs
to fill ‘Pre-Authorization form for Cashless Claim’ (Available in Forms section). This would
help you get the best services, room and rate with help of TPA. Below process can be
followed for registering claim in case of a planned hospitalization (Cashless if approved
by TPA):

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TPA issues TPA sends
letter of the
Hospital At the time
credit (for approval to
Intimates of
cashless) hospital
Employee TPA and discharge,
Employee with which
approaches sends Pre- hospital
calls TPA to approval for allows the
hospital Authorizatio sends final
plan partial employee
with n Request bill and
hospitalizati amount as to get
medical ID / with discharge
on per discharged
E-card approximat summary
Eligibility by paying all
e cost of the for approval
and non-medical
treatment to TPA
Coverage to expenses, if
the hospital any

2. Emergency Hospitalization: In case of emergency hospitalization, hospital will take up


your case on a fast track basis with your TPA and is likely to receive approvals within 4
hours during any working day. For cashless treatment, it is mandatory for the hospital
to have an approval from your TPA. In case of delay in receiving the approval or when
you cannot wait for receiving the approval owing to medical urgency you can undertake
the treatment by paying the necessary cash deposit.
If you receive approval from your TPA after paying the cash deposit, you are entitled for
refund of the cash deposit (as per reimbursement process mentioned in point 3 below).

Member / Hospital
Member gets admitted
applies for pre- TPA verifies applicability
in hospital in case of
authorization to TPA of the claim and issues
emergency bu showing
within 24 hrs of pre-authorization
medical E-card / ID
admission

If TPA does not give pre-authorization, employee pays her/himself to the hospital and claims
reimbursement from insurer, through TPA

If TPA gives pre-


authorization, member Claim processed by TPA
Hospital sends complete
gets treated and and insurer and
set of claim documents
discharged after paying payment released to the
for processing to TPA
for all non-entitled hospital
benefits

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3. Reimbursement: In case any hospital does not accept cashless facility, employee can
register the claim as reimbursement. Below mentioned documents for or in support of
a claim need to be submitted within 30 days of hospitalization:

a) Duly completed claim form


b) Bills, receipts and discharge certificate/card from the Hospital
c) Bills from Chemists supported by proper prescription.
d) Test reports and payment receipts.
Complete Information on claims process is available at MyWipro > Finance > My medical claim
> Medical Insurance Claim > Plan details > Guidelines_for_Cashless_and_Reimbursement

a) For any claims, please use the claim form available in myWipro > Finance > My
Medical claim > Medical Insurance Claim > Medibuddy > Claims > Submit a claim.
Attach check leaf as a soft copy.
b) All relevant documents along with the claim form need to be dropped in the nearest
Wividus drop box.
c) Documents must be submitted within 30 days of completion of hospitalization. Any
late submission shall not be considered.
d) MediAssist will process and settle the claim within 60 days of receipt of complete
documents.
e) Claims will take up to 60 days to be processed once all the requisite documents are
received by MediAssist.

6. Contribution
Wipro pays the annual premium on behalf of the employees; the contribution from the
employees towards this premium is collected monthly, by way of deduction through salary. The
contribution would be based on Marital Status of the employee.
Base plan premium will be deducted monthly from the employee’s payroll. Top-up premium is a
one-time premium deducted in 1/2/3 instalments, based on the employee’s selection during the
enrolment window.
Table 9
Base Plan Premiums

Sum Annual Premium Monthly Premium


Band insured
(INR) Single Married Single Married

B3 and below 200,000 2862 6140 238 512

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C1, C2 300,000 3220 6795 268 566

D1, D2 400,000 3516 7332 293 611

E 500,000 3755 7987 313 667

Table 10
Top-up Plan Premiums
Annual Premium
Top-up sum insured (INR)
Single Married

200,000 1389 2979


400,000 1706 3660
600,000 2097 4497
800,000 2576 5526
1,000,000 3165 6790

All premiums mentioned above are including taxes and are subject to change based on the
policy plan, performance and other criteria.

7. Definitions
7.1 A Hospital means any institution established for in-patient care and day care treatment
of illness and/or injuries and which has been registered as a Hospital with the local
authorities under the Clinical establishments (Registration and Regulation) Act, 2010 or
under the enactments specified under the Schedule of Section 56(1) of the said Act OR
complies with all minimum criteria as under:
a) Has qualified nursing staff under its employment round the clock.
b) Has at least 10 in-patient beds in towns having a population of less than 10 lacs and at least
15 inpatients beds in all other places;
c) Has qualified medical practitioner(s) in charge round the clock;
d) Has a fully equipped Operation Theatre of its own where surgical procedures are carried out;
e) Maintains daily records of patients and makes these accessible to the insurance company’s
authorized personnel.

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7.2 Hospitalization means admission in a Hospital/Nursing Home for a minimum period of
24 hours. In-patient care consecutive hours except for specified procedures/treatments,
where such admission could be for a period of less than 24 consecutive hours.

7.3 Any one illness will be deemed to mean continuous period of illness and it includes
relapse within 45 days from the date of last consultation with the Hospital / Nursing Home
where treatment has been taken.

7.4 Cashless facility means a facility extended by the insurer to the insured where the
payments, of the costs of treatment undergone by the insured in accordance with the policy
terms and conditions, are directly made to the network provider by the insurer to the
extent pre-authorization approved.
Please note that employee will not be able to avail ‘cashless’ facility till the enrollment
details of the employee, spouse and/or child/children is shared with TPA (Medi Assist India
TPA Pvt. Ltd)- which normally takes of 45 to 60 days from the date of enrollment to be
updated.

7.5 Day Care center means any institution established for day care treatment of illness
and/or injuries or a medical set- up within a hospital and which has been registered with
the local authorities, wherever applicable, and is under the supervision of a registered
and qualified medical practitioner AND must comply with all minimum criteria as under:
a) Has qualified nursing staff under its employment
b) Has qualified Medical Practitioner(s) in charge
c) Has a fully equipped operation theatre of its own where surgical procedures are
carried out
d) Maintains daily records of patients and will make these accessible to the Insurance
Company’s authorized personnel

7.6 Day Care treatment means the medical treatment and/or surgical procedure which is:
a) Undertaken under General or Local Anesthesia in a hospital/day care center in less
than 24 hrs. because of technological advancements and
b) Which would have otherwise required a hospitalization of more than 24 hours.
Treatment normally taken on an out-patient basis is not included in the scope of this definition.

7.7 Domiciliary Hospitalization means medical treatment for an illness/disease/injury which in


the normal course would require care and treatment at a hospital but is taken while confined at
home under any of the following circumstances:
a) The treatment is beyond 3 days.

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b) The condition of the patient is such that he/she is not in a condition to be removed
to a hospital
c) The patient takes treatment at home because of non-availability of room in a
hospital.

7.8 ID card / E-card means the identity card issued to the insured person by the TPA to avail
cashless facility in network hospitals.

7.9 Medically Necessary treatment is defined as any treatment, tests, medication, or stay in
hospital or part of a stay in hospital which
a) Is required for the medical management of the illness or injury suffered by the
insured;
b) Must not exceed the level of care necessary to provide safe, adequate and
appropriate medical care in scope, duration or intensity;
c) Must have been prescribed by a Medical Practitioner;
d) Must conform to the professional standards widely accepted in international
medical practice or by the medical community in India.

7.10 A Medical Practitioner is a person who holds a valid registration from the Medical Council
of any State of India or Medical Council of India or Council for Indian Medicine or for Homeopathy
set up by the Government of India or a State Government and is thereby entitled to practice
medicine within its jurisdiction; and is acting within the scope and jurisdiction of license.
The term Medical Practitioner would include Physician, Specialist and Surgeon. (The Registered
Practitioner should not be the insured or close family members such as parents, in-laws, spouse
and children).

7.11 Network Provider means the hospital/nursing home or health care providers enlisted by
an insurer or by a TPA and insurer together to provide medical services to an insured on
payment by a cashless facility. The list of Network Hospitals is maintained by and available with
the TPA and the same is subject to amendment from time to time.

Preferred Provider Network means a network of hospitals which have agreed to a cashless
packaged pricing for certain procedures for the insured person. The list is available with the
company/TPA and subject to amendment from time to time. Reimbursement of expenses
incurred in PPN for the procedures (as listed under PPN package) shall be subject to the rates
applicable to PPN package pricing.
Complete list of network hospitals is available at myWipro > Finance > My Medical Claim >
Medical Insurance Claim >Proceed to Medibuddy portal > Search network hospitals.

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7.12 Portability - Employees will now have an option to carry forward the health insurance
policy (with standard benefits and date of first inception being the date from which the
employee is being covered under Wipro’s Group Health Insurance Policy) even after leaving
the Company. Employees can write to parentalinsurance.helpdesk@marsh.com to get the
portability options.
Example: In a retail policy from external market, the period during which pre-existing diseases
are not covered is referred to as the waiting period. In a normal scenario, in case an employee
leaves the Company, s/he will be treated as a new customer and will have to wait for 4 years
for getting pre-existing diseases’ coverage in case s/he buys an insurance policy. With the
feature of portability, an employee will be given an option to carry forward the Policy (with
continuity benefits) with the insurer.

7.13 Pre-existing disease - Any condition, ailment or injury or relation condition(s) for which
you had signs or symptoms, and/or were diagnosed, and/or received medical
advice/treatment within 48 months to prior to the first policy issued by the insurer.

7.14 Pre-hospitalization medical expenses - Relevant medical expenses incurred


immediately 30 days before the Insured person is hospitalized provided that:
a) Such Medical expenses are incurred for the same condition for which the Insured
Person’s Hospitalization was required; and
b) The In-patient Hospitalization claim for such Hospitalization is admissible by the Insurance
Company

7.15 Post hospitalization medical expenses - Relevant medical expenses incurred immediately
60 days after the Insured person is discharged from the hospital provided that:
a) Such Medical expenses are incurred for the same condition for which the Insured

Person’s Hospitalization was required; and


b) The In-patient Hospitalization claim for such Hospitalization is admissible by the
Insurance Company.

7.16 Qualified Nurse means a person who holds a valid registration from the Nursing Council of
India or the Nursing Council of any State in India.

7.17 Reasonable and Customary charges mean the charges for services or supplies, which are
the standard charges for the specific provider and consistent with the prevailing charges in the
geographical area for identical or similar services, considering the nature of illness/injury
involved.

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7.18 TPA means a Third Party Administrator who holds a valid License from Insurance Regulatory
and Development Authority to act as a THIRD PARTY ADMINISTRATOR and is engaged by the
Company for the provision of health services as specified in the agreement between the
Company and TPA.

7.19 Delisted Hospitals are hospitals which are not covered under the policy due to various
reasons. The treatments covered in these hospitals will not be covered by the insurer. List of
these hospitals is available at myWipro > Finance > My Medical Claim > Medical Insurance Claim
> Proceed to medibuddy portal > Plan details > Delisted hospitals

8. Exclusions under Mediclaim


The company shall not be liable to make any payment under this policy in respect of any expenses
whatsoever incurred by any Insured Person regarding or in respect of:
a) Injury / 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).
b) Circumcision unless necessary for treatment of a disease not excluded hereunder or as may
be necessitated due to an accident.
c) Vaccination and inoculation of any kind unless it is post animal bite.
d) Change of life or cosmetic or aesthetic treatment of any description such as correction of
eyesight, etc. e) Cost of spectacles and contact lenses, hearing aids.
f) Dental treatment or surgery of any kind unless necessitated by accident and requiring
hospitalization.
g) Convalescence, general debility; run-down condition or rest cure, obesity treatment and its
complications including morbid obesity, Congenital external disease/ defects or anomalies,
treatment relating to all psychiatric and psychosomatic disorders, infertility, sterility,
Venereal disease, intentional self-injury and use of intoxication drugs / alcohol.
h) All expenses arising out of any condition directly or indirectly caused to or associated with
Human T-Cell Lymph Tropic Virus Type III (HTLB - III) or lymphadenopathy Associated Virus
(LAV) or the Mutants Derivative or Variation Deficiency Syndrome or any syndrome or
condition of a similar kind commonly referred to as AIDS.
i) Charges incurred at Hospital or Nursing Home primarily for diagnosis x-ray or Laboratory
examinations or other diagnostic studies not consistent with or incidental to the diagnosis
and treatment of positive existence or presence of any ailment, sickness or injury, for which
confinement is required at a Hospital / Nursing Home.
j) Expenses on vitamins and tonics unless forming part of treatment for injury or diseases as
certified by the attending physician.
k) Injury or disease directly or indirectly caused by or contributed to by nuclear weapon /
materials or contributed to by or arising from ionizing radiation or contamination by

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radioactivity by any nuclear fuel or from any nuclear waste or from the combustion of
nuclear fuel.
l) Treatment arising from or traceable to pregnancy, childbirth, miscarriage, abortion or
complications of any of these including caesarean section, except abdominal operations for
extra uterine pregnancy (Ectopic Pregnancy) which is provided by submission of Ultra
Sonographic report and certification by Gynecologist that it is life threatening one, if left
untreated.
m) Naturopathy Treatment, acupressure, acupuncture, magnetic therapies, experimental and
unproven treatments/ therapies. Treatment related like Hysterolaparscopy, ovarian drilling,
endometriosis, chocolate cyst, diagnostic d and C, experimental and unproven treatments/
therapies are not covered. Treatment including drug experimental therapy, which is not
based on established medical practice in India, is treatment experimental or unproven.
n) Treatment for Age Related Macular Degeneration (ARMD), treatments such as Rotational
Field Quantum Magnetic Resonance (RFQMR), Enhanced External Counter Pulsation (EECP),
etc.
o) Family planning surgeries are not covered.
p) Change of treatment from one system of medicine to another unless recommended by the
consultant/ hospital under whom the treatment is taken.
q) All non-medical expenses including convenience items for personal comfort such as charges
for telephone, television, ayah, private nursing/ barber or beauty services, diet charges,
baby food, cosmetics, tissue paper, diapers, sanitary pads, toiletry items and similar
incidental expenses.
r) Any kind of Service charges, Surcharges, Admission Fees/ Registration Charges, Luxury Tax
and similar charges levied by the hospital.
s) All non-medical expenses. The list of non-medical expenses is available in the FAQs on
https://www.medibuddy.in/insuredFaqs.

9. Conditions common to all


9.1 Incontestability and Duty of Disclosure:
The policy shall be null and void and no benefit shall be payable in the event of untrue or incorrect
statements, misrepresentation, wrong description or on non-disclosure in any material in the
proposal form, personal statement, declaration and connected documents, or any material
information having been withheld, or a claim being fraudulent or any fraudulent means or
devices being used by the Insured or any one acting on his behalf to obtain any benefit under this
policy.

9.2 Observance of terms and conditions:

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The due observance and fulfillment of the terms, conditions and endorsement of this policy in so
far as they relate to anything to be done or complied with by the Insured, shall be a condition
precedent to any liability of the Company to make any payment under this policy.

9.3 Fraudulent claims:


If any claim is in any respect fraudulent, or if any false statement, or declaration is made or
used in support thereof, or if any fraudulent means or devices are used by the Insured or
anyone acting on his behalf to obtain any benefit under this policy, or if a claim is made and
rejected and no court action or suit is commenced within twelve months after such rejection
or, in case of arbitration taking place as provided therein, within twelve (12) calendar months
after the Arbitrator or Arbitrators have made their award, all benefits under this policy shall
be forfeited.

9.4 Cause of Action/ Currency for payments:


No Claims shall be payable under this policy unless the hospitalization takes place in India. All
claims shall be payable in India in Indian Rupees only.

10.Contacts
For registering and resolving any issues related to the policy, please raise a helpline ticket with
HRSS.
Table 12
Primary mail ID for all
wipro@mediassistindia.com Operating from Wipro Wividus office
queries
Dedicated Toll-free line 1800-419-1164 24 / 7 * 365 days Call support

11.Amendment History
Version Amendment date Author Approved by Nature of change
1.0 Nov 1, 2015 C&B C&B Head Original version
1.1 Nov 1, 2016 C&B C&B Head Policy renewal
1.2 Nov 1, 2017 C&B C&B Head Policy renewal
1.3 Apr 10, 2018 C&B C&B Head Change in 45-day window to 30 days for new
hires/members enrolment;

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