Summary of Group Mediclaim Policy 2025-26

SUMMARY OF

 GROUP MEDICLAIM POLICY 2025-26

(Uploaded by LIC on Retired Employees Portal) 

The Group Mediclaim Scheme provides pre-authorization for cashless/reimbursement of hospitalization expenses to all classes of employees/retired employees of the Corporation and their dependents through a Group Mediclaim Policy. Policy is being serviced by The New India Assurance Company Limited. Scheme offers compulsory family floater sum insured of Rs. 10 Lakh & 15 Lakh. Employees have also availed benefit of optional increased Total Sum Insured (on floater basis) for Rs. 12 Lakh, 15 Lakh, 20 Lakh, 25 Lakh, 30 Lakh, 40 Lakh, 50 Lakh and 75 Lakh.

Pre-Hospitalization medical expenses up to 30 days period and Post-Hospitalization medical expenses up to 60 days period are covered. However, In case of Renal Failure and/or Organ Transplantation and/or Cancer related ailment/ treatment, limit of 30/60 days for pre/post hospitalization medical expenses is not applicable. Claimant can claim pre & post hospitalization medical expenses related to the above mentioned ailments beyond 30/60 days.

• 3.
  The TPAs assigned to service various LIC zones for the policy period 01.04.2025 to 31.03.2026 are as following:

  • (i)
    Western Zone & Central Office TPA: MD India Healthcare Services (TPA) Pvt. Ltd.
  • (ii)
    Central Zone TPA: Health India Insurance TPA Services Pvt. Ltd

    sheela.pednekar@healthindiatpa.com
    The All India Network Hospital can be seen by login into the website	www.healthindiatpa.com

  • (iii)
    Northern Zone TPA: Good Health Insurance TPA Ltd.
  • (iv)
    North Central Zone TPA: Medi Assist India TPA Pvt. Ltd.
  • (v)
    East Central Zone TPA: Health India Insurance TPA Services Pvt. Ltd.

(vi) Eastern Zone TPA: Heritage Health TPA Pvt. Ltd.

(vii) South Central Zone TPA: Medi Assist India TPA Pvt. Ltd.

(viii) Southern Zone TPA: MD India Healthcare Services (TPA) Pvt. Ltd.

Room rent, Boarding, Nursing (including Injection/Drugs and Intra venous Fluid administration Expenses), DMO/RMO/CMO/RMP charges of the hospital, not exceeding 1.5% of Total Sum Insured (Basic + Additional) per day, subject to maximum amount of Rs. 7500/­(for Class A cities), Rs. 7000/- (for Class B cities) & Rs. 5000/- (for Other cities) per day. However, the maximum Room Rent Limit in Class A Cities for members who are covered for Total Floater Sum Insured of Rs. 40,00,000/- or Rs. 50,00,000/- or Rs. 75,00,000/- shall be Rs. 10,000/- per day and for Mumbai (MMR), New Delhi, Faridabad, Ghaziabad, Gurgaon, Chennai, Kolkata maximum room rent limit is Rs. 12,000/- per day. GST on room rent will be in addition to Room-rent capping.

Classification of Cities for Room Rent Charges

At the time of hospitalization, if the Insured Person chooses higher room category than eligible room category as per the terms and conditions of the policy, proportionate deduction will be applicable on Associate Medical Expenses. It shall be effected in the same proportion as the eligible rate per day bears to the actual rate per day of Room Rent.

Pulse Oxymeter expenses are covered. There is NO Capping/Ceiling on ICU/ICCU expenses.

Following Diagnostic Tests without hospitalization shall be covered subject to the following:

Reimbursement of expenses is allowed only for the above tests and no equivalent diagnostic test will be considered for this purpose. The maximum reimbursable amount under this benefit shall be Rs. 85,000/- for the family, during the policy year. The above amounts shall be within the overall Sum Insured limit. For claiming reimbursement under this, the tests should have been recommended by an MD DOCTOR or A DOCTOR WITH EQUIVALENT QUALIFICATION and supported by documents and certification evidencing present complaints necessitating the tests to be carried out. However, if the Test is recommended by prescription from a Govt. Hospital then the above condition can be waived.

These expenses incurred without hospitalization are payable per insured only once for respective diagnostic tests during the policy period. However, for MRI, CT Scan, Sonography & Biopsy tests, the same are allowed twice during the policy period, per Insured person, if done for a different organ/body part.

The insured persons under the Policy consist of the following and located all over India.

• a.
  In-service employees of the Corporation
• b.
  Spouse, Dependent children (as defined below) and Independent children of in-service employees/retired employees. Cover to Independent Children shall cease on attending age of 45 years (l.b.d.) or up to date of death of both parents covered under the policy, whichever is earlier.
• c.
  Retired Employees of the corporation.
• d.
  Dependent Parents & Parents-in-law of in-service employee.
• e.
  Continuation of Coverage to dependent parents/parents-in-law after retirement of in-service employees.
• f.
  Spouse and dependent children of deceased employees (Both in-service & retired)
• g.
  Regular part timers for family floater cover of Rs. 1,00,000/- only.
• h.
  Persons engaged under Board approved Policy on Fixed Term Engagements on contractual basis and their eligible family members.

Dependent children means:

• a.
  Legitimate children including legally adopted children.
• b.
  Male children who have not completed 21 years of age or he has completed 21 years of age prosecuting whole time studies in recognized educational institution & he has not completed 25 years of age.
• c.
  Unmarried female children or those who are widowed or divorced, and residing with and dependent on the employee. However, after the marriage of unmarried female children or remarriage of widowed/divorced female children, the cover shall remain valid for 3 months or policy expiry date, whichever is earlier.
• d.
  Mentally Retarded children fully dependent on the employee / retired employee
• e.
  Physically handicapped children fully dependent on the employee/ retired employee
• f.
  Dependent children not completed 25 years (l.b.d.) of age studying abroad during their visit to India.

DEPENDENT MEANS: Financially dependent on the employee / retired employee and their income not more than Rs. 13,950/- per month.

• 1)
  Fees paid in cash will be reimbursed on submission of numbered bills upto a limit of: Surgeon/Consultant/Specialist: Rs. 30,000/­Assistant Surgeon: Rs 12,000/-

  Anesthetist: Rs 20,000/-.

• 2)
  Cataract shall be limited to Actual OR maximum of Rs. 70,000/- (inclusive of all charges,excluding service tax) for each eye, whichever is less. The above limit of Cataract is uniform all over India.
• 3)
  Expenses incurred for Ayurvedic/Homeopathic/Unani Treatment are admissible provided the treatment for illness/disease and accidental injuries, is taken in a Government hospital or in any institute recognized by Government and/or accredited by Quality Council Of India / National Accreditation Board on Health, excluding centers for spas, massage and health rejuvenation procedures. Further, Steam Bath, Shirodhara, PANCHAKARMA and similar ayurvedic treatments are NOT payable. However, the maximum reimbursement will be 25% of sum insured during the policy period.
• 4)
  Ambulance Charges: Actual, subject to maximum of Rs. 5000/- per trip per Hospitalization. In cases where the patient has to be shifted from one Hospital to another Hospital for better medical facilities, the ambulance charges would also be covered. The ambulance charges shall therefore be covered for the actual amount subject to a maximum of Rs. 5000/- for each such trip. For a Patient hospitalized due to cardiac ailment and has to be transported in a Cardiac Equipped Ambulance, the above limit is extended to Rs. 10,000/- for going to hospital only. In case of death only, ambulance charges subject to maximum Rs.5000/- can be claimed for shifting dead body from hospital to home or hospital to cemetery. Reimbursement of ambulance charges is subject to submission of proper bill. (Please note, a Trip means one side journey)
• 5)
  Lasik Laser treatment: The maximum amount payable is Rs. 35,000/- per eye for keratotomy of Insured having (-4) and above refractive error, and for therapeutic reasons like recurrent corneal erosions, nebular opacities and non healing ulcers.
• 6)
  Age Related Macular Degeneration (ARMD) and/or treatment for retinal disease by intravitreal/intraocular injection/intervention admissible only upto Rs. 100,000/- per member per eye per year.
• 7)
  Robotic surgery for Malignant Cancer/Cancer, Brain, Heart and Spine only are payable. However, if insured undergoes Robotic surgery for other ailment, cover under the policy shall be limited only to the applicable conventional charges.
• 8)
  Cochlear Implant – Hospitalization expenses for cochlear implantation surgery (including cost of implant) is payable up to a sublimit of Rs 10,00,000/- per member with first  Rs 1,50,000/­to be borne by Insured member.
• 9)
  Treatment related to Psychiatric and Psychosomatic disorder- Only Hospitalization expenses are covered for treatment of psychiatric and psychosomatic diseases up to Sub limit of Rs 50,000/­per member per year. Pre and Post Hospitalization expenses including expenses incurred for counseling/consultation are not covered.

10) Maternity Expenses Benefit:

• a.
  Normal Delivery: The maximum benefit allowable will be maximum upto Rs. 1,00,000/-
• b.
  Caesarian Section Delivery: The maximum benefit allowable will be maximum upto Rs. 1,50,000/-.

These limits are linked with child birth. Medical expenses due to any complication developed during gestation period shall be paid separately as per terms and conditions of the policy. These benefits are admissible only if the expenses are incurred in Hospital/ Nursing Home as in­patients in India.

• 11)
  Physiotherapy as a part of the Pre & Post hospitalization period is payable upto a limit of INR 50,000/- per person per year. Physiotherapy treatment taken at clinic or at specialized physiotherapy treatment centre is only payable. Treatment for Physiotherapy at home not payable. Physiotherapy treatment at home is payable only when the patient is permanently or temporarily disabled (Partial & Total). However, such disability should be certified by the consultant doctor under whom patient is treated. Temporary Disability for Physiotherapy to be availed at home – Can be defined as: Impairment of mental or physical faculties that may impede the affected person from functioning normally only so far as he or she is under treatment; with a minimum of 15 days of treatment certified by the treating doctor. The pre & post hospitalization period limit of 30/60 days shall not be applicable for patients who are totally and permanently disabled/paralyzed.

Limitation of 24 hours hospitalization is NOT applicable for surgeries/procedures defined in the policy. Surgeries/Procedures not defined but agreed by Company/TPA which require less than 24 hours hospitalization due to advancement in Medical Technology or life threatening situations managed as emergency care in hospital even if does not fall under active line of treatment are also covered.

In case of hospitalization, where cashless facility is not availed, it is suggested to intimate the concerned TPA with particulars relating to policy, name of insured person in respect of whom claim is to be made, nature of illness/injury and name and address of the attending Medical Practitioner/Hospital/Nursing Home immediately after admission in the hospital for smooth settlement of claims. Final claim along with hospital receipted original Bills/Cash memos, claim form and documents as listed in the claim form below should be submitted not later than 20 days of discharge from the hospital. The insured may also be required to give the Company/TPA such additional information and assistance as the Company/TPA may require in dealing with the claim.

Members who are diagnosed with a defined Qualifying Medical Conditions, are entitled to an independent review of their Medical Records by a World Leading Medical Center that specializes in the medical condition with which the Member has been diagnosed from MDindia Healthcare Networx Pvt Ltd (herein after called MDIndia Networx)

Facility of Tele-consultation for covered members under Group Mediclaim Scheme has been introduced. This facility of 24x7 online consultations from anywhere in India is being provided through MediBuddy (MB) Application.

One medical examiner for emergency purpose at premises of Central Office and each Zonal Office have been made available by insurer through respective TPAs from 11:00 am to 04:00 pm on working days.

This facility is available only for Employees and Retired Employees, NOT for dependent/independent family members.