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Help Document on

Mediclaim Policy

&

Claim Lodgment

Procedure

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Contents Introduction

Mediclaim Policy……………………………………….…………………3

Policy Terms & Conditions……………………………….………………3

Exclusion in the Mediclaim policy..………………………………………4

Accommodation or Room Tariff & charges……………...………………5

Procedure for printing ID card……………………………………………6

Procedure for availing Cashless facilities………………………………...11

Procedure for Reimbursement of Hospitalization Claim…………………14

Submission of Reimbursement Mediclaim form in SSC Website...……...16

Contact Details……..………………………………………………….…30

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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 2012 – 30TH

SEPT 2013) TPA is

Dedicated Healthcare Systems (India) Pvt. Ltd. (DHS)

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, and 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.

Hospitalization - Limit is max up to Rs.1 Lakh for S&E Cadre employees and Rs.3 Lakhs for Covenanted

employees (per policy period & per family).

Maternity limit is up to Rs.25000/- for S&E cadre employees and up to Rs.50000/- for covenanted employees

which is included in the overall limit mentioned above.

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.

All pre-existing diseases stands covered.

Genetic Disorders & stem cell implantation / surgery are not 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.

In maternity first two deliveries are only payable.

Sterilization expenses not payable in case of normal deliveries.

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, subject to a maximum limit of Rs.30,000/- for each eye.

Claim file has to be lodged to insurance company within 7 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.

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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 like 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.

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

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 Oct 2010

FOR L & T EMPLOYEES & L&T INFOTECH EMPLOYEES

Cadre & Grade Type of Room

Tier I Cities

Delhi, Mumbai,

Kolkata,

Chennai

Tier II Cities

Pune, Bangalore,

Hyderabad, Surat,

Baroda, Kochi,

Ahmedabad

Tier III Cities

Ahmednagar,

Jamshedpur,

Mysore, Vizag,

Coimbatore

S & E, A-5-0 to B-3-4 Economy class Room 2500/- 2000/- 1500/-

M1 A to C Twin sharing Room 2500/- to 3000/- 2250/- to 2500/- 2000/-

M2 A to C, 31, 32 Twin sharing Room 2500/- to 3000/- 2250/- to 2500/- 2000/-

M3 A to C, 33,20,21,22,23 Single Room 5000/- 4000/- 3500/-

M4 A & Above, 11, 12, 13 Deluxe Room At actuals At actuals At actuals

FOR L & T FIANANCE EMPLOYEES

Cadre & Grade Type of Room

Tier I Cities

Delhi, Mumbai,

Kolkata, Chennai

Tier II Cities

Pune, Bangalore,

Hyderabad, Surat,

Baroda, Kochi,

Ahmedabad

Tier III Cities

Ahmednagar,

Jamshedpur,

Mysore, Vizag,

Coimbatore

S & E Economy class Room 2500/- 2000/- 1500/-

M6 A & B Twin sharing Room 2500/- to 3000/- 2250/- to 2500/- 2000/-

M5 A & B Twin sharing Room 2500/- to 3000/- 2250/- to 2500/- 2000/-

M4 A & B Twin sharing Room 2500/- to 3000/- 2250/- to 2500/- 2000/-

M3 A & B Single Room 5000/- 4000/- 3500/-

M2 A, M1 B & Above Deluxe Room At actuals At actuals At actuals

FOR L & T GENERAL INSURANCE CO. EMPLOYEES

Cadre & Grade Type of Room

Tier I Cities Delhi,

Mumbai, Kolkata,

Chennai

Tier II Cities

Pune, Bangalore,

Hyderabad, Surat,

Baroda, Kochi,

Ahmedabad

Tier III Cities

Ahmednagar,

Jamshedpur,

Mysore, Vizag,

Coimbatore

4 C Economy class Room 2500/- 2000/- 1500/-

4 A & B Twin sharing Room 2500/- to 3000/- 2250/- to 2500/- 2000/-

3 A & B Twin sharing Room 2500/- to 3000/- 2250/- to 2500/- 2000/-

2 C Twin sharing Room 2500/- to 3000/- 2250/- to 2500/- 2000/-

2 A & B Single Room 5000/- 4000/- 3500/-

1 C & B & Above Deluxe Room At actuals At actuals At actuals

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FOR L & T INFRASTRUCTURE EMPLOYEES

Cadre & Grade Type of Room

Tier I Cities Delhi,

Mumbai, Kolkata,

Chennai

Tier II Cities Pune,

Bangalore,

Hyderabad, Surat,

Baroda, Kochi,

Ahmedabad

Tier III Cities

Ahmednagar,

Jamshedpur,

Mysore, Vizag,

Coimbatore

JB1C Economy class Room 2500/- 2000/- 1500/-

JB1 A & B Twin sharing Room 2500/- to 3000/- 2250/- to 2500/- 2000/-

JB2 A & B & C Twin sharing Room 2500/- to 3000/- 2250/- to 2500/- 2000/-

JB3 A & B & C Single Room 5000/- 4000/- 3500/-

JB4 A & B & C Deluxe Room At actuals At actuals At actuals

Procedure for printing ID card is as under:

STEP 1:

First visit DHS site by internet address www.dhs-india.com

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STEP 2:

Then double click on "Login Cardholders".

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STEP 3:

Go to “Log in Employee Number”

Enter your Employee number as LT with your P. S. No. without any gap in both the fields.

For example if your Employee number is 20000954 then

Your Login ID - LT20000954

Password - LT20000954

Then Click on "I agree"

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STEP 4:

For very First login Screen for Change Password will appear. Change your password to proceed further.

However please remember it forever.

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STEP 5:

Go to “Members Home”

Screen will show your personal details.

Click on “ready to print” (right hand bottom corner)

Your card will be displayed and you can take a print of the same. Cards will not be printed for dependants.

Therefore in case of dependent’s claims please tell the hospital that DHS will honor the cashless arrangement on

the basis of your card. Ecards for current year with new DHS I.D. No. are been already updated on DHS website.

Note that your last year DHS cards & the Password stands deleted w.e.f. 1st Oct 2011.

Check Claim

Status

Check Policy terms &

conditions

Click here to take a

printout of DHS E-CARD

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Procedure for availing Cashless facilities

Cashless Hospitalization can be availed only at DHS network hospitals. To check whether the hospital is in network or not,

please refer the guide book provided along with cards. Alternatively the list can also be viewed in website www.dhs-

india.com as follows

Choose the city

Choose the

state

Choose the City in the pop

up screen

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Once the city is selected the list of that city appears. If further bifurcation is required on the basis of area in the city then

the same can also be selected.

Alternatively if a particular hospital required is to be located , then press CNTRL+F and enter part or full name of the

hospital as shown below

Write the name of the

hospital you want in

the particular city.

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In case of planned Hospitalization

1) DHS Identity card should be presented at the hospital while approaching for the cashless facility.

2) Please approach the hospital well in advance for getting the approval from DHS before the admission of the patient.

3) The Hospital will submit a Cashless request form duly filled in to DHS. This Cashless request form will have to be

signed by the treating doctor and must be stamped by the hospital

4) DHS will issue a Letter of Guarantee directly to the hospital, specifying the amount that can be expended by the

hospital.

5) The employee can make an enquiry with the hospital as to whether the sanction is received before the patient gets

admitted himself into the hospital.

6) The entire procedure will take a minimum of 6 – 8 hours.

7) 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.

8) Kindly note that the letter of guarantee is valid for a period of fifteen days from the date of its issue. An application

will have to be made to DHS for renewal of letter of guarantee, if admission is postponed beyond fifteen days.

Hospitals may take some deposits for non-payable expenses.

In case of Emergency Hospitalization

DHS Identity card is E-Card print out should be presented at the hospital while approaching for the cashless

facility.

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.

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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 7 days from the date of discharge & the claims for

reimbursement of post Hospitalization expenses has to submit within 70 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)

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

prescriptions.

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

item.

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Diagnostic test reports in original 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.

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

Certificate from the attending medical practitioner / surgeon that the patient is fully cured. Bills of surgical

appliances, if purchased.

In case of Accidental/fracture case, the Medico Legal Case (MLC) 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.

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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

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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 “MEDICLIAM” & then click on “New Claim” to submit the claim intimation followed by the Oriental

Hospitalization claim form for reimbursement.

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Please go through the SOP / Help Manual

To fill new claim details & intimation click on New Claim

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Mediclaim Intimation form to be filled & then click on ‘Save’.

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After saving the ‘Mediclaim Intimation’ form, click on the check box of declaration & then click on “Submit Intimation”

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As soon as you click on “Submit Intimation” the below mentioned pop up will be displayed which states that now the

Hospitalsation claim form need to be submitted. Click on “OK”

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As soon as you will click on “OK” then the “Claim History” page will appear. & then to fill the Hospitalsation claim form click on the

link available on ‘Claim number’

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Now click on the link available on “Mediclaim Submission – Not created”

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On this “Mediclaim Submission” you need to fill the Hospitalsation details.

Some details will be directly picked up from the Claim Intimation form.

On this page you need to fill the mandatory field marked by * – Date of Detection, Expenses Incurred etc.

Kindly fill the amount in the “Expenses Incurred” field only & let the “Claim Amount” field as blank.

Then Click on “SAVE”

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After click on “Save”, the 2nd part of the claim form will appear which include - Schedule of Expenses : Click to update Expenses

Incurred – Once you click on this link the small window will appear as shown in 2nd snap shot. Make sure that the “Total Amount”

& “expenses incurred“ both has to be same. Note that any medicinal bill amounts you can put in point no. 2

Then click on “Save & close”

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Now click on – “Document check list – Click for Check List”

Once you click on this link the small window will appear as shown in 2nd snap shot. Click on the check box

Then click on “Save & close”

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Once the Claim forms entirely filled then click on the check box under Declaration.

Then click on “Submit Claim”

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As soon as you click on “Submit Claim” the below shown pop will appear stating that you need to click on the print icon

to take a print of claim form & then dually signed claim form with other original claim document need to be send to SSC –

Mediclaim dept. Address of SSC-Pune is available in Dialogue box,

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Click on “Settlement History” to check the payment details which shown in 2nd snap shot.

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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 on Mob. No. 9987008927 or

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

For cashless claims, to send the Preauthorization Admission request Form from

hospital to DHS, the Fax no. 022-22874235, 022-2795999 & to confirm whether

Fax has been received By DHS or not you can contact DHS on

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Toll Free No. 18002090201, DHS Mumbai Office No. – 022-67354300, 022-66275900 / 914 /

932.

Please help us to serve you better.

Larsen & Toubro Limited

Shared Services center

EBC – Mediclaim Hospitalization

ICC Devi Gaurav Tech Park, 2nd Floor,

Old Mumbai Pune Highway,

Pimpari,

Pune: 411018