TCS India Policy – Health Insurance

VERSION 24.0
  2008

This is a controlled document. Unauthorised access, copying and replication are

prohibited.

This document must not be copied in whole or in parts by any means, without
the written authorisation of the Global Head – Human Resources, TCS.

Document Release Notice

This policy on India - Health Insurance, Version 24.0 is published for use in Tata Consultancy Services
(TCS) with ef fect from 01 April 2021.

This document is subject to TCS Document Control Procedure.

Sof tcopy of the latest version of this document is available in MyHR in Knowmax.

This document was revised/updated on 13 May 2021.

Approved By: Sathya Narayana Mehta (Head - Policy and Talent Transformation)

Authorised By: Milind Lakkad ( Global Head – Human Resources)

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Contents
Introduction - Health Insurance Scheme ................................................................................... 5
Applicability.......................................................................................................................... 5
Provisions............................................................................................................................ 5
1. Benefits/ Entitlements and Coverage: ..................................................................... 5
2. Enrollments under HIS:......................................................................................... 9
3. Deletion f rom HIS ...............................................................................................11
4. Premium:...........................................................................................................12
Claim Procedure..................................................................................................................13
Reimbursement of Claims .....................................................................................................14
Cashless Facility..................................................................................................................14
Types of Cashless Hospitalisation ..........................................................................................15
Domiciliary Hospitalisation.....................................................................................................15
Dental Treatment .................................................................................................................15
Terms & Conditions..............................................................................................................16
Defined Benefits ..................................................................................................................17
1. Maternity Benefits ...............................................................................................17
2. Cataract Treatment .............................................................................................18
3. Joint Replacement ..............................................................................................18
4. Hysterectomy Expenses ......................................................................................18
5. Cancer Care: .....................................................................................................18
6. Treatment of Multiple Sclerosis .............................................................................18
7. Cochlear Implants...............................................................................................18
8. Treatment for Obstructive Sleep Apnea..................................................................18
10. Treatment of obesity or conditions arising thereof (including morbid obesity)................19
11. Stem Cell Therapy ..............................................................................................19
12. DIVYAANG Benef it .............................................................................................19
13. Sex / Gender Reassignment Surgery (SRS) ...........................................................19
14. Insanity/ Anxiety / Mental Illness ...........................................................................19
15. Treatment outside India .......................................................................................19
16. Alternative System of Medicines ...........................................................................20
17. Continuous Period of Medical care ........................................................................20
Exclusions under Hospitalization and Domiciliary ......................................................................21
Appendix A: Coverage and Scenarios related to enrolment ..................................................24
Appendix B: Schedule of Indemnities and % of Sum Insured ................................................29
1. Sum assured in case of Permanent Total Disablement .............................................29

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 2. Sum assured in case of Permanent Partial Disablement ...........................................29
Appendix C: Commonly used terminologies ........................................................................31
1. Domiciliary Treatment .........................................................................................31
2. Hospitalisation....................................................................................................31
3. Hospital/Nursing Home: .......................................................................................31
4. Inpatient Care: ...................................................................................................32
5. Day Care Centre:................................................................................................32
6. Medically Necessary Treatment: ...........................................................................33
7. Reasonable Charges:..........................................................................................33
8. Unproven/Experimental treatment: ........................................................................33
9. Alternative treatments:.........................................................................................33
10. Active Line of Treatment: .....................................................................................33
11. Congenital Anomaly: ...........................................................................................33
12. Internal Congenital Anomaly:................................................................................34
13. External Congenital Anomaly:...............................................................................34
14. Pre-hospitalisation Medical Expenses: ...................................................................34
15. Post-hospitalisation Medical Expenses:..................................................................34
16. Medical expenses:..............................................................................................34
17. Medical Advice: ..................................................................................................34
18. Room Category: .................................................................................................35
Appendix D: List of Day Care Procedures where Hospitalisation benefits are applicable ........36
Revision List......................................................................................................................40

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Introduction - Health Insurance Scheme

For TCS, the health and wellbeing of all employees and their f amily is paramount. Hence, TCS provides
them with easy access to best-in-class medical f acilities through a comprehensive Health Insurance
Scheme (HIS).

‘Family’ in this context implies spouse, children, parents and parents-in-law only. TCS has tied up with
the Insurance Company to offer a comprehensive HIS to its employees. Insurance Company has in turn
appointed a Third Party Administrator (TPA) to f acilitate the claim processing, settlements and
hospitalisation process for the employees and their beneficiaries.

TCS reviews the scheme and its provisions f rom time to time. Hence, the scheme is subject to a
revision, which may result in a corresponding change in the entitlements, the extent of coverage, the
premium amount payable, beneficiaries who can be covered, etc.
Note: Period to be considered for payment of premium and coverage to employees and their declared
beneficiaries is the financial year from April to March.

Applicability

This policy is applicable to:

­ Full Time Employees of TCS India and TCS eServe International (HIS coverage will continue till the
time of employment).

­ ACE Interns, Global Interns & BPOS

This policy is not applicable to:

­ Business Associates, Academic Interns & Contract Consultants

Provisions

1. Benefits/ Entitlements and Coverage:

Health Plans

(i) There are various Health Plans under HIS namely Gold, Gold Plus, Platinum and Platinum Plus, and
employees and their enrolled beneficiaries are eligible for Domiciliary and Hospitalisation covers as per
the def ault plan applicable to them (based on their grade).

(ii) The benef its, in accordance with the applicable plan, are extended on payment of applicable
premium as per the scheme.

(iii) Employees can view the coverage, premium and plan details via the path below:
Ultimatix  Employee Services  Employee Self Service  Global ESS  Benefits and Taxes
 Health Insurance Scheme  Beneficiary Details

(iv) At the beginning of the enrolment period, employees will continue to be tagged to their default plan
or their previously upgraded plan.
a. Employees tagged to their default plan will have the option to upgrade to two more levels up
to maximum of Platinum plan, if not upgraded previously.

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 b. Employees who had upgraded their HIS plan previously, can move up by one more level up to
maximum of Platinum plan.

c. The HIS plan upgrade details are broadly summarized as below:

Upgrade Permitted
HIS Health Plan Gold Plus Platinum Platinum Plus
ESIC Plan Gold Plan Plan Plan Plan
ESIC Plan Def ault Plan Yes Yes - -
Gold Plan - Def ault Plan Yes Yes -
Gold Plus Plan - - Def ault Plan Yes -
Platinum Plan - - - - -
Platinum Plus Plan - - - - Def ault Plan

Example

An employee with default ‘Gold’ Plan can upgrade to either ‘Gold Plus’ or ‘Platinum Plan’.

An employee with default ‘Gold Plus’ Plan can upgrade to maximum of Platinum Plan.

(v) An employee will not be allowed to downgrade his/her plan throughout the tenure, under any
circumstances Also, there shall be no change to the plan during the course of the year.

Note:

(i) Employees in the ‘Platinum Plus’ plan have no upgrade options, since this is the highest plan offered.

(ii) Employees who are covered under ESIC (Employees' State Insurance Corporation) are eligible for
a floater cover of Rs 5 lacs per family per annum under TCS HIS plan. Such employees may avail
benefits under ESIC or TCS HIS. For more details, you may connect with your respective HR Business
Partner (HR BP).

Coverage

(i) Domiciliary Cover

This is a provision to enable employees and their beneficiaries to cover the cost of any domiciliary
treatment (including dental treatments).

(ii) Base Cover:

This is a provision to cover the cost incurred on hospitalisation treatments up to a specified limit.

Note: The Domiciliary and Base cover limit is defined for each insured person per annum. Hence,
unused sum of one beneficiary cannot be used towards treatment of other beneficiaries.

(iii) Floater Cover:

This benef it covers the hospitalisation expenses incurred over and above the basic hospitalisation
cover limit. All employees are covered under the Floater Cover and will continue to be covered
throughout their tenure in TCS. This cover is also extended to all beneficiaries enrolled under HIS.

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 Note: The Floater Cover is a family floater i.e. the coverage is defined on a per family basis. Hence,
in case a part of the Floater Cover is utilised by any beneficiary, the remaining balance can be
utilised by the same/other beneficiary, if there is a need.

(iv) Personal Accident Insurance:

This is applicable only to active employees at no additional cost.

Benef its are applicable in case of Accidental injury leading to Permanent Total Disablement (PTD)
or Permanent Partial Disablement (PPD).It is also applicable in case of Permanent Total
Disablement (PTD) arising out any disease / ailment / illness.

Event Amount Limit (In Rs.)

Permanent Minimum of Rs. 11 lakhs or 6 times of employee’s annual

Total Disability compensation whichever is higher subject to maximum of Rs. 20 Crore

Permanent 6 times employee’s annual compensation subject to a maximum of Rs.

Partial 20 Crore (This is based on a percentage defined under Appendix B:
Disability Schedule of Indemnities and % of Sum Insured

(v) Critical Illness – Leave Without Pay (LWP) Benefit Cover:

a. This is a weekly benefit provided for a maximum period of 52 weeks only, to employees who are
on LWP f or Medical reasons and have raised a hospitalization claim for the same. This is applicable
in the below scenarios :

a.1. When they are suf fering f rom tertiary / critical illness as def ined below (Refer List of
Tertiary/ Critical illness),

List of Tertiary/ Critical illness:

Cancer Nephritis of any etiology plus bacterial renal failure requiring kidney transplantation and
dialysis, Cerebral or vascular strokes, Open and closed heart surgery, Malignant diseases
conf irmed by histopathological reports, Viral encephalitis, Brain surgery, Liver cirrhosis
associated with hepatitis B\C, Compound\multiple fracture of femur, Intra cranial injury, Coma,
Spinal injury resulting in Paraplegia, Cerebral haemorrhage, Third degree burns, Major organ
transplant and Multiple Sclerosis.

a.2. When they suffer any bodily injury caused due to accidents / occupational hazards arising
out of and in course of employment.

b.In both the above scenarios, the amount payable as Weekly Benefit is as given under:

Computed based on 66% of employee’s monthly compensation / number of weeks in a month

(OR)
Rs. 40,000/- per week payable on monthly basis, whichever is lower.

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 Note:

(i) Employees need not apply for this benefit, but will be payable by default post the verification
of the HIS claim raised and Leave Without Pay (LWP) application in Ultimatix.

(ii) This benefit can be availed only once by the employee, during his/her tenure with the
organization.

d. The amount is credited in the salary account of the employee by the end of every month. This
amount will be calculated on a prorata basis.

Other Benefits

(i) Hospitalisation Cash Benefit (applicable only for the employee and not for beneficiaries):

a. This is applicable only in case the employee is hospitalised f or more than 5 consecutive
days.

b. Starting f rom the 6th day, he/she will be eligible for Hospital Cash @ Rs.1, 000/- per day
until the time he/she gets discharged.

c. Employee need not apply for this benefit but will be payable by default post the verification
of necessary documents.

d. This is applicable only if hospitalisation expenses are payable and length of stay is justified
with necessary documentary evidences.

(ii) Trauma Care Support (applicable only for the employee and not for beneficiaries):

a. In case the employee is hospitalised owing to a Personal Accident and post discharge from the
hospital continues to be on leave for recuperation, the trauma care expenses would be payable
f rom the day the employee exhausts all the available paid leaves and if he/she continues to be
on LWP.

b. Employee will be eligible f or Trauma care expenses of Rs.5, 000 per week upto a max of Rs.60,
000 and is applicable only if Base and Floater covers are not fully exhausted.

c. Employee need not apply for these benefits but will be payable by default post the verification
of the necessary documents.

Note: Wherever, both Trauma Care and LWP Financial Assistance is applicable, only one
benefit will be extended (whichever is more beneficial to the employee)

(iii) Ambulance expenses:

Air Ambulance

a. These expenses are payable upto a limit of Rs. 1,00,000 per event and Rs. 20,00,000 during
the Financial Year. Air Ambulance is payable subject to the below conditions:

b. Medical condition of the patient is very critical and requires emergency Hospitalization for
survival.

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 c. When the patient is based out of a remote location and / or Other modes of transport are
inadvisable as per the treating doctor.

d. Transportation by Air Ambulance is to the nearest Healthcare f acility where patient can be
treated.

Road Ambulance

a. These expenses are payable upto a limit of Rs. 2,000 per family during the Financial Year.

b. Road Ambulance is payable to shift the insured person to the nearest Healthcare facility and/or
f rom one Healthcare facility to another for better treatment/diagnosis.

(iv) Cancer Benefit:

a. The employee and declared beneficiaries will be eligible for a monetary benefit of Rs 25, 000/-
over and above the sum insured.

b. This request is reviewed post a hospitalisation claim.

c. The benef it can be availed only once during the entire tenure with the organization.

2. Enrollments under HIS:

(i) New Joinees will be covered by their default health plan and will have the option to upgrade to
two more levels, up to maximum of Platinum plan, if needed, only during subsequent enrolment
period.

(ii) Employees can cover Spouse, Children and Parents/Parents-in-law within 90 days from date of
joining/date of marriage/child/children’s date of birth, as appropriate..

Note:

(i) The 90-days timeframe to update beneficiaries may not be applicable during the last quarter of the
financial year as the HIS beneficiary addition link will remain closed post March payroll freeze.

(ii) All employees who join TCS in the last quarter of the financial year/New additions on account of
life changing events are advised to enroll their beneficiaries soon after joining/immediately after life
changing event, in order to avail the HIS coverage effective from the date of joining/birth/marriage.

(iii) The path to add/delete beneficiaries is as follows:

Ultimatix  Employee Services  Employee Self Service  Global ESS  Benefits and Taxes
 Health Insurance Scheme  Beneficiary Details

Note:

(i) Addition of beneficiaries in Ultimatix  Employee Services  Employee Self Services 

Global ESS  My Profile  Family Details or any other link apart from HIS Beneficiary link is not
adequate for coverage of beneficiaries under HIS. There is a separate link viz.‘India HIS Beneficiary
details’ under GESS to enrol the beneficiaries.

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 (ii) Similarly, overseas employees have to specifically enroll their beneficiaries under TCS India Health
Insurance Scheme. New beneficiaries enrolled under overseas health insurance policy would not be
automatically rolled over to India Insurance on return to India/end of deputation.

(iii) Enrolments under India HIS should be completed as per specified timelines and under the path
mentioned above.

(iv) Employees have no restriction on maintaining dual coverage for spouse and beneficiaries under
India HIS and overseas Insurance.

(iv) For employees who want to add their Spouse on marriage:

a. They should first update their marital status and date of marriage under My Profile via Ultimatix
 Employee Services  Employee Self Services  Global ESS  My Profile  About 
Basic Details.

b . Subsequent to this, they are required to update thespouse’s contact details and thedependent
f lag as (Y) underUltimatix  Employee Services  Employee Self Services  Global ESS 
My Profile My Contacts,

c. The option to add the Spouse/Parents-in-Law will be available under the ‘HIS Beneficiary details’
link, only after completion of the above steps mentioned.

d. Details f or spouse should be added/updated within 90 days f rom date of marriage / joining.
However, if the employee does not enrol his spouse within 90 days f rom date of Marriage, he/she
can add them during the subsequent window period in the next financial year.

(v) All employees have the option to cover parents OR parents-in-law OR a combination of each upto
a maximum of two, i.e. they can cover 1 Parent and 1 Parent-in-law. If he/she chooses not to include
parents / parents in law within the permitted enrollment period, he/she can add them only during the
subsequent enrolment window.

For any new addition of parents / parents–in- law as benef iciaries, pre-existing ailments or
disease/ailments/conditions other than those defined under ‘List of Tertiary/ Critical illness’ will not be
covered in the first year of enrolment.

Note: This will not be applicable to beneficiaries added within 90 days from date of joining or marriage.

(vi) While deleting the benef iciaries, the employee will have to select the appropriate reason for
deletion.

a. If the employees delete their parents / parents-in-law details, they will not be able to re-enroll them
f or the next 3 years, from the date of deletion.

b. Also, once re-enrolled, the employee will not be able to delete them for the next 3 years, except in
case of their unfortunate demise.

Note: Any other changes in dependents to be done by employees, owing to marital circumstances, will
follow the system driven process, and the employee is expected to update the marital status in the
GESS portal.

(vii) In case of a lif e changing event (marriage / death of insured beneficiary) if an employee wants to
replace the insured beneficiaries (parents / parents-in-law), , it should be done only in the beginning of

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the next f inancial year or during the subsequent enrolment window, as the coverage will be ef fective
f rom next financial year..

(viii) Expiry of personal/official insurance coverage of parents/parents-in-law exiting their own business
will not be considered as an acceptable situation warranting an addition of parents/parents-in-law in the
scheme, as employees can cover their parents/parents-in-law even if they are working or if they have
any personal/official mediclaim/insurance policy.

(ix) Children cannot be enrolled, if they are employed/married/more than 25 years of age. For existing
enrollments, employees should delete such records, else these records will be purged at the start of
the next f inancial year.

(x) In case of addition of a new born child, employee will have the option to enrol the child within 90
days from date of birth. An unnamed child can be enrolled as ‘baby of <mother’s / father’s name>’. After
the baby is named, the employee can edit/update the child’s actual name within the 90 day window
f rom date of birth.

(xi) Any other relative (such as brothers, sisters of the employee/Spouse, grandparents, sister/brother-
in-law, etc.) whether beneficiaries or otherwise cannot be covered by the HIS under any situation.

(xii) Retired employees may choose to continue the HIS cover post retirement,on payment of applicable
premium. The revised retirement benefits would be applicable from the subsequent financial year. For
the year of the retirement, the current benef its will apply. Coverage can continue f or the f amily post
death of the retired employee, upon payment of the applicable premium.

(xiii) Retired employees would be tagged to the same health plan that they were tagged to at the time
of retirement.

(xiv) Employees are required to declare and update details of relatives in GESS to avoid dual
enrollments in the policy.

(xv) An employee whose spouse is also a TCSer should ensure that; both of them do not enrol each
other and the same benef iciaries (parents/children) f or HIS coverage. Such dual coverage is not
permitted under any circumstances.

(xvi) The benef its under HIS can only be availed after the beneficiaries are enrolled in the system. The
exception to this will be in case of cashless hospitalisation of the new born child soon af ter birth. (If
cashless is availed for new born child soon af ter birth, then employee should ensure that the child is
enrolled within 90 days from date of birth, failing which, the cashless expenses can be recovered from
the employee). Modifications made under GESS in Ultimatix in the ‘HIS Benef iciary Details’ link will
ref lect in the TCS Health Insurance Portal within a maximum duration of 15 to 20 days.

Refer to Appendix A: Coverage and Scenarios related to enrolment for further details

3. Deletion from HIS

(i) Employee continues to be covered year on year throughout his or her tenure in TCS. The cover ends
only when the employee separates from TCS.

(ii) Benef iciaries who are covered will continue to remain covered throughout the employee’s tenure in
TCS, unless :

a. the employee explicitly deletes them

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 Note : However, if the employee deletes their parents / in-law details, they will not be able to
re-enroll them for the next 3 years from the date of deletion.

b. the employee separates f rom TCS. In this case, the date of release/ date of intimation of
separation, whichever is later, is considered as the last day of coverage f or the employee and
the enrolled beneficiaries.

Note:

(i) TCS reserves the rights to recover the amount if an employee has availed HIS Benefits for
self or for enrolled beneficiaries, post release from TCS. The same may be adjusted or
recovered in through the Full and Final Settlement (FFS) process of the employee.

(ii) Hospitalisation or domiciliary claims, if any, need to be raised in the system on or before the
last working day in the company. No claims will be accepted after release from the company.

4. Premium:
(i) The total Premium amount is split between Base Cover and Floater Cover Premium as per the
applicable plan.

a. Base Cover Premium towards basic hospitalisation and domiciliary cover f or employee,
spouse and 3 children is borne by TCS. Premium f or parents / parents-in-law / remaining
children, if enrolled, will be borne by employee, as applicable. Such premium f or parents’
category will be based on the age of the beneficiary.

b. Floater Cover Premium is partially borne by the employee and partially by TCS.

(ii) In case the employee opts to upgrade to a higher plan, the additional premium between the
existing default plan and the new plan will be borne by the employee.
For complete details on benefits and premium refer to Global GESS via the path:

Ultimatix  Applications  Employee Services  Employee Self Service  Global ESS 

Benefits & Taxes  Health Insurance Scheme  Beneficiary Details

(iii) Base Premium f or Parents/Parents-in-law will be prorated f or new joinees and f or employees
getting married during the financial year.

(iv) Premium that is paid f or employee and beneficiaries is f or the entire f inancial year. There will
be no ref und / stoppage of premium recovery in any scenario including the following:

- Employee separates anytime during the financial year

- Death of an insured person

- Marriage/Divorce

- Deletion on account of dual enrollment

- Children no longer eligible for coverage

- Birth of a child

- Beginning or cessation of the employment of the insured beneficiary

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 - Cessation of Insurance cover as provided by the employer of the insured beneficiary

Note:

(i) The premium, as applicable and payable by the employee, is deducted through the employee’s
payroll.

(ii) GST is applicable to all the premium amounts.

(iii) Premium paid by the employee qualifies for tax benefits as per relevant applicable taxation laws in
the country.

(v) For Employees proceeding on Leave Without Pay (LWP):

a. The employee and beneficiaries who are covered (as of LWP start date) will continue to be
covered f or the entire duration of the LWP. The applicable premium f or LWP period will be
deducted af ter the employee reports back to work and the payroll processing starts. In case,
the employee f ails to report back to work then the applicable premium will be recovered through
their FFS.

b. In case the employee resigns while on LWP or prior to reporting back, HIS coverage will
continue till the date of resignation. Outstanding premium if any, will be recovered through their
f ull and final settlement.

Claim Procedure

1. With a view to ensure a hassle f ree experience, employees are required to provide prior intimation
to the TPA (at least 72 hours in advance), in case of a planned hospitalization (except in case of an
emergency).
2. This is applicable f or both cashless and reimbursement mode. Such intimation must be provided
through our Health Insurance portal accessible via the below path

Ultimatix  Employee Services  Health & Wellness  TCS Health Insurance Portal  Cashless
 Intimate e-Cashless.
(OR) through the MediBuddy Mobile App which can be downloaded on Android and iOS devices.

3. GIPSA (General Insurers' Public Sector Association) is an association of Insurance companies that
has negotiated rates and packages at GIPSA specific hospitals (Ref er Health Insurance portal to get
details of hospitals governed under GIPSA). These negotiated/package rates are known as PPN
(Pref erred Partner Network) rates.

4. Treatments availed at GIPSA governed hospitals will be covered upto the GIPSA rates or rates
def ined in this policy, whichever is lesser.

5. In any given scenario, the GIPSA hospitals should not charge an amount higher than the GIPSA
def ined rates for hospitalization. This is irrespective of the Sum Insured / room eligibility of the employee
as per TCS Health Insurance policy. In case, an employee notices any discrepancy, the same can be
highlighted to [email protected]. Reimbursement f rom these hospitals will be restricted to
GIPSA rates f or applicable procedures. 10% deduction would be applicable on admissible amount in
case of availing reimbusement from a network hospital.

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Reimbursement of Claims

(i) Employees must opt f or hospitals which are part of the network list and avail the cashless facility.
Prior intimation of at least 72 hours is mandatory to avail cashless facility, except in case of emergencies
/ accidents. The list of network hospitals can be accessed through the Health Insurance Portal or
through MediBuddy Mobile App. 10% deduction on the admissible amount will apply in case of requests
f or reimbursements f or hospitalisation in a network hospital, without prior initimation to avail the
cashless facility.

(ii) In case of Hospitalization in a non-network hospital, an advance notice of Hospitalization is

mandatory (except in case of emergencies / accidents). Only in case, advance intimation of at least 72
hours is not provided, 10% deduction on the admissible amount will apply.

(iii) Employees can pre-intimate hospitalisation details either through the Health Insurance portal on
Ultimatix or through Medibuddy Mobile App.

(iv) Employees can register their Domiciliary or Hospitalisation claims through the TCS Health Insurance
Portal. To access the TCS Health Insurance Portal, employee needs to log in Ultimatix and access the
below link:

Ultimatix  Employee Services  Health & Wellness  TCS Health Insurance Portal

(v) Claim guidelines updated on the TCS Health Insurance portal should be ref erred to before
submission of a claim.

(vi) All reimbursement claims should be raised against the appropriate heads of Domiciliary or
Hospitalisation in the portal within 90 days from the date of incurring the expense (in case of domiciliary
claims) or within 90 days from the date of discharge (in case of hospitalisation claims).

(vii) Claim documents must be submitted within 24 hours f rom the date of registration of claims. The
Submission date should be accordingly mentioned in the claim form.

(viii) All claims to be entered through TCS Health Insurance Portal only. No claims will be accepted
manually.

(ix) Employees should upload and retain scanned or photo copies of all the documents, so that the
same can be produced if/ when required.

(x) Insurer reserves the right to reject claims raised af ter the mentioned timeline. Concerns related to
claims processing should be raised within 30 days from date of approval/rejection of the claim. No
queries raised beyond this period will be taken up.

(xi) Insurance company or TPA is not liable to return the submitted claim documents under any
circumstances. This is applicable even for the claims, which are rejected by the Insurance Company.

Cashless Facility

The Insurance Company/TPA has empanelled specific hospitals through which a cashless facility can
be provided to the employee and the enrolled beneficiaries. i.e. the patient can undergo treatment at
the hospital without making a direct payment to the hospital. The payment (up to the entitlement limit)
is made f rom the Insurance Company to the Hospital through the TPA.

10% deduction on the bill amount will apply in case of requests for reimbursements and/or cases where
the employee opts for hospitals outside the network list.

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For more details, please refer the cashless procedure available on TCS Health Insurance Portal.

Types of Cashless Hospitalisation

(i) Planned Cashless Hospitalisation:

a..The insured person seeks cashless hospitalisation through planned admission (that is, with prior
intimation to the insurance company and approval).

b. In such cases, it is mandatory to intimate the TPA about the details of the hospitalization at least
72 hours in advance. This will enable the TPA to ensure a smooth and hassle f ree admission process
f or the patient. Process to be followed for the same is updated on the Health Insurance portal.

(ii) Emergency Cashless Hospitalisation:

The insured person is admitted due to a medical emergency within a very short notice and requires
urgent treatment (i.e. requests needs to be given highest priority and approvals need to be obtained
immediately).

Note: While availing cashless facility, employee/patient may need to pay the deposit amount as per
the hospital policy/requirement. Employee may claim the same as reimbursement on submission of
the original deposit receipt or request hospital to refund the deposit amount once the cashless is
settled by TPA.

Domiciliary Hospitalisation

(i) If the medical condition legitimately requires Hospitalisation but the condition of the patient is so
serious that he/she cannot be moved to the Hospital OR there is no accommodation available in the
Hospital, then treatment may be carried out at home.

Illustration: The condition of a patient with a heart problem may, in the opinion of the attendingphysician
be such that, the patient could not be moved to a hospital without causing harm to his/her health.

(ii) Claims in respect of such medical conditions will be considered under the 'Hospitalisation' category
of HIS, provided the period of treatment is for 3 consecutive days or more.

(iii) Any claim under this head should always be accompanied by a certif icate f rom the attending
specialist or physician which certifies that the treatment given is tantamount to Hospitalisation treatment
(and not domiciliary treatment).

(iv) The f ollowing ailments shall not be covered under the Domiciliary Hospitalisation benefits:

1) Asthma 2) Bronchitis 3) Chronic Nephritis & Nephrotic Syndrome 4) Diarrhoea & all types of
dysenteries including gastro-enteritis 5) Diabetes Mellitus & Insipid us 6) Epilepsy 7) Hypertension
8) Inf luenza, Cough & Cold 9) All Psychiatric & Psychosomatic Disorders 10) Pyrexia of Unknown
Origin 11) Tonsillitis & Upper Respiratory Tract Inf ection including laryngitis & Pharyngitis 12)
Arthritis, Gout & Rheumatism 13) Peritoneal Dialysis

Dental Treatment

(i) The expenses towards dental treatment or surgery does not include any of the cosmetic surgeries
including crowns, dental implants, artif icial dentures, braces, bridges, orthodontics, prognathism,
retrognathism, etc.

TCS Conf idential 15

(ii) Major dental surgeries such as maxillo f acial surgery or any lif e threatening surgeries are covered
under Hospitalisation only if necessitated by accident and/or hospitalisation is for more than 24 hours.
However, cosmetic surgeries and tooth implants are not covered under the scheme.

(iii) Expenses f or extraction, f illings, medicines, consultation f ees, root canal expenses and x-ray
charges are only reimbursed under Domiciliary Dental Coverage.

(iv) Case summary (date wise treatment details) or x-ray f ilms are mandatory to process any dental
claim.

Note:

(i) Employees should refer to the contact matrix before initiating any queries via an email to Corporate
HIS. Refer to Contact Matrix and address for Claim Submission available on the TCS Health
Insurance Portal Homepage

(ii) The 90 days’ timeframe to raise claims may not be applicable during the last quarter of the financial
year as the HIS claim reimbursement link will be closed on 30th April every year. All employees who
have claims in the last quarter of the financial year are advised to raise claims before 30th April. This
includes pre/post hospitalization claims if any and claims incurred at overseas.

(iii)For hospitalisation beginning in March and extending up to April:

Any hospitalisation that starts (date of admission) on or before 31st March and continues beyond that,
including post hospitalisation, will come under the purview of that particular financial year limits only
(Financial Year in which the patient is admitted in the Hospital). For all such hospitalisation claims,
associates are required to raise the claim with an approximate amount (as per the estimation given by
the concerned doctor/hospital).

Terms & Conditions

1. TCS/Insurance Company solely act as f acilitators f or the disbursement/administration of the

insurance benef its. TCS/Insurance Company undertakes no responsibility in the respect of any
eventuality/mishap during the course of the treatment of insured person at any of the hospitals
empanelled by the Insurance Company.

2. TCS understands the sensitivity of personal information and medical records. TCS and the Insurance
Company undertake to secure the confidentiality of all medical records, conditions and treatment of an
insured person from unauthorised disclosure & misuse.

3. The Insurance Company shall not be liable to make any payment under the HIS in respect of any
claim, if such a claim is f ound to be in any manner f raudulent and supported by any fraudulent statement
or device whether by the insured or by any other person on their behalf. TCS/The Insurance Company
views such cases very seriously and stern action will be taken against the employee, which may also
lead to termination of employment with TCS OR debarment f rom applying f or any claims under the
policy for a period of not less than 5 years.

4. The Insurance Company shall not be liable for settlement of claims for any treatment taken from the
de-listed/black-listed Hospitals/Clinic/Medical Professionals. The list of such hospitals is available under
the Health Insurance Portal.

TCS Conf idential 16

Defined Benefits
Def ined Benef its are applicable to all employees including employees at onsite (Def ined limit or
Hospitalisation limit/GIPSA limit whichever is lesser would be considered). The def ined limits are
inclusive of related complications and expenses incurred one month prior & post the hospitalisation.

1. Maternity Benefits

- Maternity expense / treatment shall include the following Medical treatment Expenses:

a. Medical Expenses for a delivery (including complicated deliveries and caesarean

sections) incurred during hospitalisation;

b. The lawf ul medical termination of pregnancy during the Policy Period limited to three
deliveries or terminations or either during the lifetime of the Insured Person;

c. Pre-natal and post-natal Medical Expenses for delivery or termination.

d. Any complications arising during the course of pregnancy and prior / post delivery

- Maternity related expenses including medicine expenses, doctor’s consultation f ees, routine
check-ups and diagnostic tests conducted during the maternity period will not be covered under
domiciliary under HIS.

- The total amount payable for any maternity related hospitalisation resulting in normal delivery/
instrumental delivery (f orceps/ vacuum/etc.) will be limited to INR 75,000/- f or the entire
maternity related hospitalisation episode.

- The total amount payable f or the maternity related hospitalisation resulting in C-section delivery
will be limited to INR 1,00,000/- for the entire maternity related hospitalisation episode.

- The overall limit as mentioned against each of the delivery types is inclusive of pre-
hospitalisation and post hospitalisation expenses, pertaining to one month prior and post-
delivery.

- The above limits on hospitalisation expenses exclude the expenses incurred on the new born
child.

- New born baby expenses –The Hospitalisation expenses of the new born child will be covered
only if the child is suffering from any ailment/illness/disease/condition which requires in-patient
treatment in the Hospital subject to addition of child under HIS within the stipulated period.
Hospitalisation expenses for routine check-up/tests/screening and vaccination charges, etc. of
the baby are not admissible. Well Baby Care expenses (if any) may be considered only within
the Maternity limit of Rs. 75,000/- or Rs. 1,00,000/- depending upon the mode of delivery and
subject to the Insurance company’s review and decision.

- The overall limit for maternity benefits is valid even in case of multiple Child birth (twins/triplets)
or complications related to maternity.

- An employee can avail Maternity benefits for the birth of first three children only, irrespective of
whether earlier maternity benefits where claimed through this policy.

- Surgical intervention f or treatment of Inf ertility and / or IVF, irrespective of the gender of the
benef iciary is admissible subject to a maximum limit of Rs 1,00,000.

TCS Conf idential 17

 - Only 2 episodes of treatments towards Infertility / IVF procedures may be claimed throughout
the employee’s tenure.

- Non-surgical intervention (Intra Uterine Insemination) or. Medical Management f or treatment

f or infertility is admissible under Domiciliary limit.

- Sterility/ family planning treatments are not admissible.

2. Cataract Treatment

- An upper limit on Hospitalisation expenses (including Floater Cover) has been def ined at Rs
30,000 towards correction of cataract in a single eye. This is inclusive of all the expenses
incurred towards correction of cataract including the lens charges and pre and post
hospitalisation expenses, (if any) pertaining to one month prior and post hospitalisation.

3. Joint Replacement

- The upper limit f or Single Joint Replacement is Rs. 2,50,000 and Rs. 4,00,000 f or Bilateral Joint
Replacement. The limits are inclusive of pre and post hospitalisation expenses, (if any)
pertaining to one month prior and post hospitalisation.

- There should be a minimum gap of one month between two single joint replacements.

4. Hysterectomy Expenses

- The upper limit for Hysterectomy expenses including pre and post hospitalisation expenses, if
any pertaining to one month prior and post hospitalisation has been capped at Rs. 75,000 per
benef iciary in a policy year.

- Hysterectomy includes Hysterectomy with or without Salpingo-oopherectomy.

5. Cancer Care:

- Conventional/Parenteral chemotherapy or Radiotherapy is covered under the purview of the

policy.

- Other therapies including Oral/Targeted/Hormonal Chemotherapy are also covered subject to

a maximum limit of the Base Sum insured per year per Family.

6. Treatment of Multiple Sclerosis

- OPD/Daycare Medical expenses incurred f or the treatment of Multiple Sclerosis f or the

Employee are payable subject to maximum limit of Rs 2,50,000 per annum.

7. Cochlear Implants

- Hospitalisation expenses f or Cochlear implantation are payable subject to 50% of actual

expenses or 50% of the Base sum insured plus Floater sum insured whichever is less.

8. Treatment for Obstructive Sleep Apnea

- These expenses will be payable upto 50% of the actual expenses. However, this medical
condition has to be confirmed by Polysomnography test and should be certified by the treating
doctor that the employee needs to use CPAP or BiPAP machine.

TCS Conf idential 18

 - Repair, Replacement and Maintenance charges f or the Instruments are not admissible under
the policy.

9. These expenses will be payable only if the employee is using a CPAP or BiPAP machine and only
once during his / her tenure with the organisation

10. Treatment of obesity or conditions arising thereof (including morbid obesity)

- These expenses are covered under the purview of the policy.

- Bariatric surgery f or treatment f or Morbid Obesity where BMI is more than 35 with severe
medical conditions or BMI of more than 40 are admitted.

- This is applicable for Employees only and not for other beneficiaries.

11. Stem Cell Therapy

- The treatment with Stem cell Therapy is applicable for employees only and is payable upto a
maximum limit of 50% of the Base Sum Insured per employee.

- This provision is available only to those employees where the treating Doctor has certified that
the Stem Cell Therapy is recommended f or treatment of an illness other than Hematologic
Cancer.

12. DIVYAANG Benefit

- This benef it is provided to differently abled Children of the employees and is payable upto Rs
10,000/- per annum per child.

- Employee can claim this amount by raising a request under the Hospitalization category.

13. Sex / Gender Reassignment Surgery (SRS)

­ Surgical procedures for Sex / gender reassignment are payable up to a maximum of 50% of the
total expenses, capped at Rs. 2,00,000 per employee.

14. Insanity/ Anxiety / Mental Illness

­ Treatment f or Insanity / anxiety / mental Illness is payable under the Domiciliary limit. In case
of hospitalization with an ‘Active line of treatment’, medical expenses for treatment of certain
psychiatric and Psychosomatic Disorders or Mental Illness are payable upto Rs. 2,00,000 per
f amily. This benefit is extended to all beneficiaries. Hospitalization purely for
rehabilitation/observation ordiagnostic purpose is not payable.

15. Treatment outside India

- Hospitalisation treatment taken outside India by insured persons who travel out of India on
of ficial work is covered under the Basic HIS Policy. The hospitalisation expenses incurred
outside India may be claimed by employees. Refer to Provisions - Benefits / Entitlements
and Coverage section for Base Cover limit.

- the expenses on domiciliary treatment incurred outside India will not be covered under the HIS
scheme.

TCS Conf idential 19

 - In case the employee is covered by Overseas Mediclaim Policy (OMP), benefits should be first
availed against the OMP and only then claimed under the HIS subject to maximum limit per
insured person per annum.

- In case the employee is not covered by an OMP, the employee may claim benefits under the
Basic HIS policy.

- The process f or raising claims for treatment taken outside India will be the same as f ollowed
f or hospitalisations in India.

- In case of expenses which are incurred outside India and for which the settlement under OMP
is pending, employees should raise the claim f or an amount upto the Base Cover limit under
India HIS within 90 days from the date of discharge/before the year-end deadlineand thereafter
submit the documents once they have the bills to support the same or when the settlement is
complete. Relaxation of additional 60 days will be given only for document submission in such
scenarios.

- The claim amount should be in equivalent Indian Rupees only and a settlement will be done in
equivalent Indian Rupees only.

- It is recommended to have the claim documents and bills in English language.

16. Alternative System of Medicines

- Expenses incurred for Ayurvedic/Homeopathic/Unani treatment are payable up to a maximum

limit of 25% of the Basic Sum Insured provided the treatment f or illness/disease/injury, is
administered by a Registered practioner and taken in a Government recognized
hospital/institute and /or accredited by Quality Council Of India / National Accreditation Board
on Health. Only the cost of medicines is reimbursed & not the expenses incurred on special
diets, such as fruit juices, milk, ghee, etc.

- Siddha, Panchakarma, Patanjali, Acupuncture, Hypnosis, Health Spa, Naturopathy, Herbal /

rehabilitation treatments, health rejuvenation procedures& related expenses are not payable.

- Expenses payable for each family for the above methods of treatment will be limited to 10% of
the f loater sum insured for the family.

17. Continuous Period of Medical care

- “Period of Medical care” shall be deemed to mean the period commencing on the f irst day on
which an insured person is under the care of a Medical Practitioner f or the treatment of any
particular medical condition while the policy is in force and terminating on the expiry of 45 days
f rom the day the insured person resumes normal work or activities. In case the insured person
is hospitalised twice during the Period of Medical Care for the same ailment/medical condition,
any claims for treatment availed during this period can be claimed as one request.

- In case the medical condition/treatment had commenced prior to the date of insurance, for the
purpose of reimbursement, the medical condition shall be deemed to commence from the first
day of coverage.

Illustration : If the date of cover is with effect from 01 June and the insured person has been
undergoing treatment for a medical condition prior to 01 June, all the expenses relating to the
medical condition will be covered w.e.f. 01 June.

TCS Conf idential 20

 - A certif icate from the attending Medical Practitioner will have to be submitted certifying that the
member had recovered from the medical condition and is fit to resume normal work or activities
and stating the date thereof.
For details on treatments and expenses related to it refer to Appendix C: Commonly
used terminologies

Exclusions under Hospitalization and Domiciliary

(i) There are certain exclusions in HIS due to which NO benef its are payable. This list of exclusions
(enumerated below) is only indicative and not exhaustive.

a. Expenses towards Health Check-ups, correction of eye sight, cost of spectacles, contact lens,
cost of braces, cost of scaling of teeth, hearing aid, Nebulizer, beauty treatment, external
congenital defects/diseases/anomalies i.e. the defects/conditions/anomalies which are visible
at the time of birth; and anaemia, etc. are not covered by this policy.

b. Lasik/Laser surgery and advanced surface ablation surgery are not covered under domiciliary
or Hospitalisation.

c. Vaccination, Inoculation, Baby Check-up charges (MMR/BCG/Polio/Anti Typhoid) Circumcision

(other than on medical grounds), Strictures, Change of Lif e (beauty treatment of any
description) cosmetic or aesthetic treatment, Hair Loss/Alopecia and its treatment, Weight Loss/
Height Gain treatment, Acne/ Pimples Treatment, , Plastic Surgery other than as may be
necessitated due to accidental injuries.

d. Convalescence (which expression shall also cover general debility “run down” condition and
general “over haul”) or Rest Cure, Rehabilitation, Venereal Disease, , Intentional self -injury,
Intemperance or disease or condition or accident arising out of the use of intoxicating drugs or
liquor or alcohol or any disease directly or indirectly due to any one or more of them. Use of
tobacco leading to cancer.

e. Health routine check-up examination / Master Check-up unless necessary positive existence
f or treatment of any medical condition.

f. Expenses incurred at Hospital or Nursing Home primarily for evaluation / diagnostic purposes
which is not f ollowed by ’Active line of treatment’ for the ailment during the hospitalised period.
Refer to the definition of ’Active line of treatment’ in the section on Hospitalisation
under Appendix C.

g. Weakness related treatments are not payable.

h. Extra amount paid directly by the associate to consultant / surgeon etc. over and above
hospitalisation expenses (wherein consultant / surgeon charges are already included in the hospital
bill) will not be reimbursed.

i. Injury, disease or illness directly or indirectly due to or arising f rom ionising radiation or
contamination by radioactivity f rom any nuclear f uel or f rom any nuclear waste or f rom the
combustion of nuclear f uel (solely f or the purpose of this exclusion, combustion shall include any
self -sustaining process of nuclear f ission), War, Invasion, Act of Foreign Enemy, Hostilities or
Warlike Operation (whether war be declared or not), Riot or Civil Commotion or Breach of Law or
hunting.

TCS Conf idential 21

 j. Bodily injury / sickness / disablement due to wilf ul or deliberate exposure to danger (except to
save a human lif e), intentional self -inflicted injuries, attempted suicide and arising out of non-
adherence to any medical advice or bodily injury sustained as a result of participating in any criminal
act, Breach of Law, injury sustained whilst or as a result of participating in any hazardous sport or
hunting. Steeple chasing, Polo or winter sports or riding or driving in races, employment in Military,
Naval or Air Services or engaging in Aviation or Ballooning or entering into, travelling in or leaving
any aircraf t or balloon, unless specifically included in any other policy of the company.

k. Nutritional Supplements, Expenses on vitamins and tonics, etc. unless forming part of treatment
f or injury or disease as certified by the attending physician.

l. Genetic disorders like Colour Blindness, Sickle Cell anaemia, Haemophilia, Down Syndrome,
etc. and stem cell implantation or associated surgeries.

m. Treatment of obesity or conditions arising thereof (excluding morbid obesity) and any other
weight control program services or supplies etc. even if associated with thyroid problem.

n. Instruments, CAPD procedure and all related expenses, for treatment of Dialysis, external
equipment or prosthetic devices , ambulatory devices like walker, crutches, Belts, collars, Caps,
Splints, Slings, Stockings, diabetic foot wear etc.

o. Experimental and unproven treatment, not recognized by the Indian Medical Council.

p. Treatment of Age related Macular Degeneration (AMRD), Rotational Frequency Quantum

Magnetic Resonance therapy (RFQMR), External Enhanced Counter Pulsation (EECP) therapy
etc.

q. Robotic surgeries, Cyberknife surgeries are not payable unless there is no other alternative
available.

r. Procedures and treatments usually done in outpatient department are not payable under the
policy even if converted to day-care surgery/procedure or as in- patient in the Hospital for more
than 24 hours. Example: administration of Intravitreal/intravenous injections, Remicade,
Herceptin, Zoledronic, Rituximab, Avastin Injections and any other preventive injections or
vaccinations, etc.

s. Non-Medical expenses such as Telephone, Television, Ayah, Private Nursing, diet charges,
baby food, cosmetics, tissue paper, diapers, sanitary pads, toiletry items and similar expenses
as listed under IRDA guidelines.

t. Maternity and maternity related expenses are not payable f or more than f irst three living
children.

u. Expenses incurred towards abortion, voluntary termination of pregnancy and related

complications are not payable.

v. Check up and diagnostic tests done during maternity period.

w. Diagnostic, X-ray or Laboratory examination not consistent with or incidental to the diagnosis
of positive existence and treatment of any ailment, sickness or injury for which confinement at
a hospital or nursing home is required.

TCS Conf idential 22

 (ii) This exclusion shall not apply to injury resulting f rom an accident to a f ully licensed standard
type of aircraft operated by a recognised airline on a f ully regular scheduled air route in which
the insured person is travelling as a bonafide passenger.

(iii) Following services are considered as non-medical items and will not be reimbursed.

a. Registration/Admission Fees

b. Telephone charges.

c. Visitor’s charges, attendant’s charges.

d. Service charges, surcharge and/or any other Charges like Medico Legal Charges
(MLC), Medical Record Charges etc.

e. Diet charges, which are not part of the administered treatment. Non-medical expenses
such as Equipment, Television, Ayah, Private Nursing, baby food, cosmetics, tissue
paper, diapers, sanitary pads, toiletry items and similar expenses.
Note: This list of non-medical items (enumerated below) is only indicative and not exhaustive.

TCS Conf idential 23

 Appendix A: Coverage and Scenarios related to enrolment

Coverage for family members is subject to the following conditions. The term ‘family’ is
inclusive of people from the lesbian, gay, bisexual, transgender and queer (LGBTQ)
community:

Family Member Condition

Spouse ­ Should be legally married to the employee.

­ This also includes same sex partners irrespective of their marital

status.

­ In case employed in another organisation, the employee may claim

HIS benef its subject to the following:

i. In case the Spouse does not get medical benef its/insurance

cover f rom that organisation, he/she may claim benefits under
this scheme.

ii. In case medical benefits/insurance cover is provided by that

organisation, he/she must f irst recover the expenses f rom that
organisation to every extent possible. Af ter the sum insured is
exhausted from HIS of the other organisation, the employee may
claim f or the remaining amount under TCS HIS.

An employee whose spouse is also a TCSer should ensure that;

both of them do not enrol each other and the same benef iciaries
(parents/children) f or HIS coverage. Such enrolment is considered
as dual coverage which is not permitted under any circumstances.

Children ­ Includes Legally adopted Children

­ Includes Children of the Spouse from previous marriage

­ Children should be unmarried. Married Children or those who get

married subsequently cease to be eligible f or coverage f rom the
date of marriage.

­ Children should be less than 25 years of age.

­ Should not be gainfully employed for wages or profit in any service,

business or profession.

­ Children are covered on an “ALL OR NONE” basis. ‘ALL OR NONE”

means that in case the employee has more than three children, TCS
will pay the entire premium for the f irst three children provided the
employee covers the remaining children and pays the cost of
premium for the remaining children. In case the employee does not

TCS Conf idential 24

 Family Member Condition

cover the remaining children, TCS will also not cover the first three
children.

Parents/Parents- ­ All employees have the option to cover Parents OR Parents-in-law

in-law OR a combination of each upto a maximum of two, i.e. they can
cover 1 Parent and 1 Parent-in-law.

Note:

(i) As applicable in the case of Spouse, enrollment of the same set of beneficiaries by an
employee and any other relative, who is also a TCSer, will also be considered as dual coverage
under HIS and is not permitted under any circumstances.

(ii)In case of TCSer spouse, who may need to be enrolled post separation from TCS, employee
should enrol these records under GESS enrolments link within 15 calendar days from date of
separation and/or contact [email protected] further advice.

(iii) In case of multiple Child birth, all Children need to be considered separately under
dependent coverage. Premium of first 3 children will be borne by TCS.

Scenarios related to enrolment

New
Joinee/
Existing Scenarios Process for Enrolment
Employee

New Employee is single Employee will be automatically covered f or self w.e.f the date
Joinee on the date of joining of joining.
and continues to
remain single during Employee has a provision to enrol Parents and Children (in
the financial year. case, employee is a single parent).

There would be no option to enrol Spouse, Parents-in-law.

Parents and/or children should be enrolled within first 90 days

f rom date of joining TCS to get benefit of the cover w.e.f from
date of joining. If he/she chooses not to include the details of
parents within the permitted enrollment period, he/she can add
them only during the subsequent enrolment period. For any
new addition of parents / parents–in- law as beneficiaries, pre-
existing ailments or disease/ailments/conditions other than
those defined under ‘List of Tertiary/ Critical illness’ will not be
covered in the f irst year of enrolment. However this will not be
applicable to benef iciaries added within 90 days f rom date of
joining or marriage. If children are not enrolled within 90 days

TCS Conf idential 25

 New
Joinee/
Existing Scenarios Process for Enrolment
Employee

f rom date of joining, he/she can add them during the

subsequent window period.

Employee is single For Self, Parents and Children

on date of joining and
gets married Employee will be automatically covered f or self w.e.f the date
subsequently during of joining.
the financial year
Employee has a provision to enrol Parents and/or Children (in
case, employee is a single parent).

Parents and/or children should be enrolled within first 90 days

f rom date of joining to get benefit of the cover w.e.f from date of
joining. If not enrolled within 90 days then details of Parents can
be enrolled during the subsequent enrolment period. For any
new addition of parents / parents–in- law as beneficiaries, pre-
existing ailments or disease/ailments/conditions other than
those defined under ‘List of Tertiary/ Critical illness’ will not be
covered in the f irst year of enrolment. However this will not be
applicable to benef iciaries added within 90 days f rom date of
joining or marriage.

If the employee does not enroll his children within 90 days from
date of joining, he/she can add them during the subsequent
window period.

Spouse, Parents-in-law and Children of spouse (f rom earlier

marriage) should be enrolled within f irst 90 days f rom date of
joining. On marriage, Spouse/Parents-in-law should be
enrolled within first 90 days from date of marriage to get benefit
of the cover w.e.f from date of marriage with the employee.

Parents-in-law can be enrolled only if employee’s parents are

not already enrolled.

If parents-in-law are not enrolled within the f irst 90 days from

date of marriage, they can be enrolled during the subsequent
enrolment period. For any new addition of parents / parents–in-
law as benef iciaries, pre-existing ailments or
disease/ailments/conditions other than those def ined under
‘List of Tertiary/ Critical illness’ will not be covered in the f irst
year of enrolment. However this will not be applicable to
benef iciaries added within 90 days f rom date of joining or
marriage. If spouse and children are not enrolled within 90 days
f rom date of marriage, he/she can add them during the
subsequent window period.

TCS Conf idential 26

 New
Joinee/
Existing Scenarios Process for Enrolment
Employee

New Employee is married Employee will be automatically covered w.e.f the date of joining.
Joinee on date of joining
Employee has a provision to enrol spouse, parents OR parents-
in-law and children.

Spouse, parents OR parents-in-law and children should be

enrolled within first 90 days from date of joining to get benefit of
the cover w.e.f from date of joining.

If parents/ parents-in-law are not enrolled within f irst 90 days

f rom date of joining, then they can be enrolled only during the
subsequent enrolment period. For any new addition of parents
/ parents–in- law as benef iciaries, pre-existing ailments or
disease/ailments/conditions other than those def ined under
‘List of Tertiary/ Critical illness’ will not be covered in the f irst
year of enrolment. However this will not be applicable to
benef iciaries added within 90 days f rom date of joining or
marriage.

If spouse and children are not enrolled within 90 days from date
of joining, he/she can add them during the subsequent window
period.

Existing Status change for an Spouse, parents-in-law and children of spouse (f rom his/her
Employee existing employee earlier marriage) should be enrolled within first 90 days of date
(that is, employee of marriage to get benef it of the cover w.e.f f rom date of
gets married during marriage. If not enrolled within 90 days, they can be enrolled
the financial year) only during the subsequent enrolment period. For any new
addition of parents / parents–in- law as benef iciaries, pre-
existing ailments or disease/ailments/conditions other than
those defined under ‘List of Tertiary/ Critical illness’ will not be
covered in the f irst year of enrolment. However this will not be
applicable to benef iciaries added within 90 days f rom date of
joining or marriage.

Re-enrollment of parents/in-laws who were deleted earlier, will

be possible f rom FY21 with a lock-in period of 3 years. Once
enrolled, the employee will not be able to delete them at least
f or the next 3 years, except in case of their unfortunate demise.
If spouse and children are not enrolled within 90 days from date
of joining, he/she can add them during the subsequent window
period.

TCS Conf idential 27

 New
Joinee/
Existing Scenarios Process for Enrolment
Employee

Life changing event New-born child or adopted child should be enrolled within first
for an existing 90 days of date of birth/date of adoption to get benef it of the
employee (child is cover w.e.f from date of birth/adoption as applicable.
born or child is
adopted during the If child is not enrolled within 90 days, he/she can add them
financial year) during the subsequent window period.

TCS Conf idential 28

 Appendix B: Schedule of Indemnities and % of Sum Insured

1. Sum assured in case of Permanent Total Disablement

% of Sum Insured
Event

1. Permanent Total Disability Loss of two limbs, two eyes or

100
one limb and one eye

2. Permanent Partial Disability Loss of one limb or one eye 50

3. Permanent Total Disablement from injuries other than those

100
named above (PTD)

4. Permanent Partial Disablement (PPD) as per percentage of

100
Sum Insured as shown below.

2. Sum assured in case of Permanent Partial Disablement

Compensation
As percentage of
Parts Lost
Sum Insured

1. Loss of toes all 20

i. great both phalanges 5

ii. great one phalanx 2

iii. other than great, if more than one toe-lost, each 1

2. Loss of hearing both ears 75

3. Loss of hearing one ear 30

4. Loss of four fingers and thumb of one hand 40

5. Loss of four fingers 35

6. Loss of thumb-both phalanges one phalanx 25

TCS Conf idential 29

 Compensation
As percentage of
Parts Lost
Sum Insured

7. Loss of index finger three phalanges or two phalanges or

10
one phalanx

8. Loss of middle finger three phalanges or two phalanges or

6
one phalanx

9. Loss of ring finger three phalanges or two phalanges or one

5
phalanx

10. Loss of little finger three phalanges or two phalanges or one

4
phalanx

11. Loss of metacarpals first or second (additional) or third,

3
fourth or fifth (additional)

Percentage as
assessed by the Panel
12. Any other Permanent Partial Disablement Doctor of the
Insurance Company.

TCS Conf idential 30

 Appendix C: Commonly used terminologies

1. Domiciliary Treatment

- Domiciliary treatment benefits are applicable only when the insured person undergoes
treatment at a dispensary or in a hospital, as an outpatient.

- Domiciliary treatment includes pharmacy cost, consulting f ees of the doctor, investigatory
tests, etc.

2. Hospitalisation

Means admission in a Hospital/Nursing Home for a minimum period of 24 consecutive hours

f or in-patient Care except for specified procedures/ treatments, where such admission could be
f or a period of less than 24 consecutive hours.

Note:

(i) To avail/claim hospitalisation benefits (for self) employee should apply for necessary
leave for the hospitalisation period. Employees should first exhaust their Sick leave and
in case of insufficient leave balance, Casual leave and Earned vacation followed by LWP
may be availed. Claim processing team may request for the leave records of an employee
to conclude the hospitalisation claims.

(ii) If hospitalisation start date (i.e. date of admission) is prior to coverage start date, then
entire hospitalisation episode is not covered under the policy. (Pre/post expenses are
also not covered).

3. Hospital/Nursing Home:

A hospital/Nursing Home means any institution established f or in- patient care and day care
treatment of sickness and / or injuries and which has been registered as a hospital 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:

- Has at least 10 in-patient beds, in those towns having a population of less than 10,00,000
and 15 in-patient beds in all other places;

- Has qualif ied nursing staff under its employment round the clock;

- Has qualif ied medical practitioner (s) in charge round the clock;

- Has a f ully equipped operation theatre of its own where surgical procedures are carried out

- Maintains daily records of patients and will make these accessible to the Insurance
Company’s /TPA's authorized personnel.

The term ‘Hospital/Nursing Home’ shall not include an establishment which is a Clinic,
Remodeling Clinics, place of rest (Rest Home) and / or recuperation (Recuperation
Home/Centre), a place for the aged persons, a rehabilitation centre f or drug addicts or

TCS Conf idential 31

 alcoholics, detoxification Centres, sanatoriums, Home f or mentally disturbed, a hotel or a
similar place.

4. Inpatient Care:

Inpatient care means treatment for which the insured person has to stay in a hospital for more
than 24 hours f or a covered event.

5. Day Care Centre:

A Day Care Centre means any institution established for day care treatment of sickness 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:

- Has qualif ied nursing staff under its employment

- Has qualif ied medical practitioner (s) in charge

- Has a f ully equipped operation theatre of its own where surgical procedures are carried out

- Maintains daily records of patients and will make these accessible to the Insurance
Company’s /TPA authorized personnel.

- For Day Care Centres, the minimum beds shall be overlooked but the operation theatre is
f ully equipped and functioning with advanced technology and inf rastructure f or surgical
operation required in respect of the procedures listed, Day Care Nursing Staf f are f ully
qualif ied and the doctor perf orming the surgery or procedure as well as post-operative
attending doctors should be fully qualified f or specific surgery or procedure.

Note:

(i) The above definition of Hospital/ Nursing Home may not be applicable for Ayurvedic /
Homeopathic / Unani procedures which may not require the typical set up of a Hospital/
Nursing Home. However, the expenses incurred for these methods of treatment may be
covered under the Hospitalisation benefits subject to a review on a case-to-case basis.

(ii) Incase of Ayurvedic / Homeopathy / Unani treatment, the Insurer shall be liable only
when the treatment is taken as in patient in a Government Hospital / Medical College
Hospital

Day Care Treatment/Procedures:

Day-Care Treatment/Procedure ref ers to medical treatment and or surgical procedure

which is

i. undertaken under General or Local Anaesthesia in a Hospital/Day Care Centre in less than
24 hours because of technical advancement and

ii. which would have otherwise required a hospitalisation of more than 24 hours. Treatment
normally taken on outpatient basis i.e. OPD in Hospitals/Day Care Centres is not included
under the scope of Day care Procedure.

TCS Conf idential 32

 Out Patient Department (OPD) Treatment:

OPD treatment is one in which the Insured visits a clinic / hospital or associated facility like
a consultation room f or diagnosis and treatment based on the advice of a Medical
Practitioner. The Insured is not admitted as a day care or in-patient.
Typically, day-care procedures are not covered under hospitalisation benef its since
Hospitalisation benefits are applicable only if the insured person is admitted as in-patient
to a hospital f or a minimum of 24 hours. However, there are a f ew Day-care procedures
specified by the insurance provider which may not require 24 hours of in-patient
hospitalisation but which are being covered under Hospitalisation benef it due to
advancement in medical technology i.e. surgical intervention.
Refer to Appendix D: List of Day Care Procedures where Hospitalisation benefits are
applicable

6. Medically Necessary Treatment:

Medically necessary treatment is defined as any treatment, tests, medication, or stay in hospital
or part of a stay in hospital which
­ Is required f or the medical management of the illness or injury suffered by the insured;
­ Must not exceed the level of care necessary to provide saf e, adequate and appropriate
medical care in scope, duration, or intensity;
­ Must have been prescribed by a medical practitioner,
­ Must conform to the prof essional standards widely accepted in international medical
practice or by the medical community in India.

7. Reasonable Charges:

Reasonable charges means the charges f or services or supplies, which are the standard
charges for the specific provider and consistent with the prevailing charges in the geographical
area f or identical or similar services, taking into account the nature of the illness / injury involved.

8. Unproven/Experimental treatment:

Unproven/Experimental treatment is treatment, including drug Experimental therapy, which is

not based on established medical practice in India, is treatment experimental or unproven.

9. Alternative treatments:

Alternative treatments are f orms of treatments other than treatment "Allopathy" or "modem
medicine" and includes Ayurveda, Unani, Sidha and Homeopathy in the Indian context.

10. Active Line of Treatment:

Treatment that is directed immediately to the cure of the disease or injury is called ‘Active Line
of Treatment’. If admission to a hospital is mainly f or diagnosis of an ailment which can be
carried out as outpatient or f or a routine evaluation of the patient and the treatment involves
f ew oral medications only, it will not be covered under Hospitalisation benefits.

11. Congenital Anomaly:

Congenital Anomaly refers to a condition(s) which is present since birth, and which is abnormal
with ref erence to form, structure or position.

TCS Conf idential 33

 12. Internal Congenital Anomaly:

Internal Congenital Anomaly is not in the visible and accessible parts of the body is called
Internal Congenital Anomaly. This is covered under the purview of the policy, subject to the
review of the necessary supporting documents and the medical condition of the patient.

13. External Congenital Anomaly:

External Congenital Anomaly which is in the visible and accessible parts of the body is called
External Congenital Anomaly. Such anomalies which are lif e threatening and non-cosmetic in
nature are covered under the purview of the policy, subject to the review of the necessary
supporting documents and the medical condition of the patient.

14. Pre-hospitalisation Medical Expenses:

Medical Expenses incurred immediately bef ore the Insured Person is hospitalized, provided
that:
­ Such Medical Expenses are incurred for the same condition for which the
­ Insured Person’s Hospitalisation was required, and
­ The In-patient Hospitalisation claim for such Hospitalisation is admissible by the Insurance
Company.

15. Post-hospitalisation Medical Expenses:

Medical Expenses incurred immediately after the Insured Person is hospitalised, provided that:
­ Such Medical Expenses are incurred for the same condition for which the Insured Person’s
Hospitalisation was required, and
­ The In-patient Hospitalisation claim for such Hospitalisation is admissible by the Insurance
Company.

16. Medical expenses:

Medical Expenses means those expenses that an Insured Person has necessarily and actually
incurred f or medical treatment on account of Illness or Accident on the advice of a Medical
Practitioner, as long as these are no more than would have been payable if the Insured Person
had not been insured and no more than other hospitals or doctors in the same locality would
have charged for the same medical treatment.

17. Medical Advice:

Any consultation or advice f rom a Medical Practitioner including the issue of any prescription
or repeat prescription.
‘Hospitalisation’ claim for the same medical reason will cover medical expenses for the duration
of hospitalisation as well as f or a period of up to 30 days prior to admission to a hospital (pre
hospitalisation), and up to 60 days f rom the date of discharge f rom the hospital (post
hospitalisation) f or employee, spouse and children. For parents / parents–in-law, post
hospitalisation expenses will be covered for a period of up to 30 days from the date of discharge.

TCS Conf idential 34

 18. Room Category:

- Room eligibility f or employees and parents/parents-in-law is defined based on the Health Plan
as illustrated in the table below:

HIS Benefits
Benefits Type Gold
ESIC Gold
Plus Platinum Platinum Plus
Room Single
Double occpancy/Twin
Category_Employee, Private
Sharing
Spouse & Children A/C
Single Private A/C
Room
Category_Parents/Parents- Double occpancy/Twin Sharing
in- law

- In case the employee chooses a room which is higher than his / her eligibility, the additional
charges for the room and other related items will have to be borne by the employee.

- Hospital charges differ (for the same services) depending on the room type you have chosen
(General, Shared, Private, Deluxe, Super Deluxe etc.). Incase you avail a room higher than
your eligibility then the proportionate amount will be deducted not only for the additional room
charges over and above your eligibility but also for all other hospital charges that are linked to
the room you have chosen i.e Doctor consultation/visit, Nursing charges, Medical tests, Surgery
costs etc. Hospitals where the room categories are termed differently, room tariffs based on
your def ault plan or opted plan in case of an upgrade will be taken into consideration for
cashless approvals/reimbursement.

19. Cashless Hospitalization Facility:

- The Insurance Company through the TPA provides a Cashless Hospitalisation f acility at specific
hospitals (empanelled by the TPA). An Insured person who is hospitalised at any of the empanelled
hospital can avail this facility.

Note: The list of hospitals made available by the TPA is not exhaustive and is amended from time to
time. This list is available on TCS Health Insurance Portal home page.

TCS Conf idential 35

 Appendix D: List of Day Care Procedures where Hospitalisation benefits are
applicable

Surgeries/Procedures

1. Adenoidectomy

2. Appendectomy

3. Anti-Rabies Vaccination

4. Coronary angiography

5. Coronary angioplasty

6. Dilatation & Curettage

7. ERCP (Endoscopic Retrograde Cholangiopancreatography)

8. ESWL ( Extracorporeal Shock Wave Lithotripsy)

9. Excision of Cyst/granuloma/lump

10. Following Eye Surgeries:

a. Cataract Surgery (Extra Capsular Cataract Excision or Phacoemulsification + Intra Ocular

Lens

b. Corrective Surgery for blepharoptosis when not congenital/cosmetic

c. Corrective Surgery for entropion / ectropion

d. Dacryocystorhinostomy [DCR]

e. Excision involving one-fourth or more of lid margin, full-thickness

f. Excision of lacrimal sac and passage

g. Excision of major lesion of eyelid, full-thickness

h. Manipulation of lacrimal passage

i. Operations for pterygium

j. Operations of canthus and epicanthus when done for adhesions due to chronic Infections

k. Removal of a deeply embedded foreign body from the conjunctiva with incision

l. Removal of a deeply embedded foreign body from the cornea with incision

TCS Conf idential 36

 m. Removal of a f oreign body from the lens of the eye

n. Removal of a f oreign body from the posterior chamber of the eye

o. Repair of canaliculus and punctum

p. Repair of corneal laceration or wound with conjunctival flap

q. Repair of post-operative wound dehiscence of cornea

r. Penetrating or Non-Penetrating Surgery for treatment of Glaucoma

11. Pacemaker insertion

12. Turbinectomy/turbinoplasty

13. Excision of pilonidal sinus

14. Therapeutic endoscopic surgeries

15. Conisation of the uterine cervix

16. Medically necessary Circumcision

17. Excision or other destruction of Bartholin's gland (cyst)

18. Nephrotomy

19. Oopherectomy

20. Urethrotomy

21. PCNL(percutaneous nephrolithotomy)

22. Reduction of dislocation under General Anaesthesia

23. Transcatherter Placement of Intravascular Shunts

24. Incision Of The Breast, lump excision

25. Vitrectomy

26. Thyriodectomy

27. Vocal cord Surgery

28. Stapedotomy

29. Tympanoplasty & revision tympanoplasty

30. Arthroscopic Knee Aspiration if Proved Therapeutic

31. Perianal abscess Incision & Drainage

TCS Conf idential 37

 32. DJ stent insertion

33. FESS (Functional Endoscopic Sinus Surgery)

34. Fissurectomy / Fistulectomy

35. Fracture/dislocation excluding hairline fracture

36. Haemo dialysis

37. Hydrocelectomy

38. Hysterectomy

39. Inguinal/ventral/ umbilical/femoral hernia repair

40. Laparoscopic Cholecystectomy

41. Lithotripsy

42. Liver aspiration

43. Mastoidectomy

44. Parenteral chemotherapy

45. Haemorrhoidectomy

46. Polypectomy

47. Following Prostate Surgeries

a. TUMT(Transurethral Microwave Thermotherapy

b. TUNA(Transurethral Needle Ablation)

c. Laser Prostatectomy

d. TURP( transurethral Resection of Prostate)

e. Transurethral Electro-Vaporization of the Prostate(TUEVAP)

48. Radiotherapy

49. Sclerotherapy

50. Septoplasty

51. Surgery f or Sinusitis

52. Varicose Vein Ligation

53. Tonsillectomy

TCS Conf idential 38

 54. Surgical treatment of a varicocele and a hydrocele of the spermatic cord

55. Retinal Surgeries

56. Ossiculoplasty

57. Ascitic/pleural therapeutic tapping

58. Therapeutic Arthroscopy

59. Mastectomy

60. Surgery f or Carpal Tunnel Syndrome

61. Cystoscopic removal of urinary stones / DJ stents

62. AV Malf ormations (Non cosmetic only)

63. Orchidectomy

64. Cystoscopic fulguration of tumour

65. Amputation of penis

66. Creation of Lumbar Subarachnoid Shunt

67. Radical Prostatectomy

68. Lasik Surgery (non-cosmetic)

69. Orchidopexy (non-congenital)

70. Nephrectomy

71. Palatal Surgery

72. Stapedectomy & revision of stapedectomy

73. Myringotomy

(OR) any other surgeries / procedures agreed by the TPA and the Company which require less
than 24 hours Hospitalization and for which prior approval from TPA is mandatory.

Note: Procedures / treatments usually done in OPD (apart from the Day Care Procedures
mentioned above) are not payable under the Policy even if converted as an in-patient in the
Hospital for more than 24 hours.

TCS Conf idential 39

 Revision List

Document Policy
Policy
Release Revision Section Rationale for Change revision/
Revision Effective
/Revision Description No. change type Document
No. date
Date revision

Upgradation of HIS
24.0 01 April 13 May plans by two levels from Provisions Employees are Add Policy
2021 2021 def ault now permitted Revision
to move 2
levels up their
def ault plan

Maternity limits towards

24.0 01 April 13 May Normal and C-section Def ined Benef its - Maternity Modify Policy
2021 2021 Deliveries revised up to Maternity Benefits benef its Revision
INR 75,000 & INR revised basis
1,00,000 respectively review of HIS

Room eligibility for

24.0 01 April 13 May parents/parents-in-law Appendix C Basis review of Modify Policy
2021 2021 revised to Single HIS Revision
Private AC room under
Platinum plan
Segregation and
24.0 01 April 13 May categorization of Appendix C Structural Modify Document
2021 2021 various sections and Revisions in
clauses under the document Revision
appropriate heads to classify
various
sections and
clauses in the
policy
appropriately

Re-enrollment of
23.0 01 April 23 April deleted parents / in- Enrollments under Policy Review Modify Policy
2020 2020 laws with a lock-in HIS and Revision
period of 3 years

TCS Conf idential 40

 Document Policy
Policy
Release Revision Section Rationale for Change revision/
Revision Effective
/Revision Description No. change type Document
No. date
Date revision

Once enrollment of
23.0 01 April 23 April parents/ in laws has Deletion from HIS Policy Review Added Policy
2020 2020 been deleted , they will Revision
not be able to renroll
them f or next 3 years

Inclusion of Same sex

22.0 01 21 October partners as Appendix A Policy Review Modify Policy
October 2019 benef iciaries Revision
2019
Added Sex
22.0 01 21 October Reassignment Surgery Def ined Benefits Policy Review Add Policy
October 2019 and Mental Illness to Revision
2019 the def ined list of
benef its

Maternity delivery
22.0 01 21 October charges to be payable Def ined Benefits Policy Review Add Policy
October 2019 up to 3 children Revision
2019

Other cancer therapies

22.0 01 21 October covered subject to a Def ined Benefits Review of the Modify Policy
October 2019 maximum limit of the policy and Revision
2019 Base Sum insured per scheme
year per f amily. (Limit of
Rs. 60000 per year in
case of other
benef eiciaries/family
has been removed)

22.0 01 21 October Addition of the GIPSA Claims Procedure For additional Add Document
October 2019 Clause - GIPSA is an clarity Revision
2019 association of
Insurance companies
that has negotiated
rates and packages at
GIPSA specific
hospitals. Treatments
availed at GIPSA
governed hospitals will
be covered upto the
GIPSA rates or rates
def ined in this policy,
whichever is lesser.

TCS Conf idential 41

 Document Policy
Policy
Release Revision Section Rationale for Change revision/
Revision Effective
/Revision Description No. change type Document
No. date
Date revision

22.0 01 21 October Additional Calrity on Appendix C – Room For additional Add Document
October 2019 Room Tarif fs – Hospital Category clarity Revision
2019 charges differ
depending on the room
category

Non network hospitals -

21.0 01 April 13 April Advance intimation of Claim Procedure Review of the Modify Policy
2018 2018 atleast 72 hours is policy and Revision
required. If not scheme
provided, 10%
deduction on
admissible amount will
apply
Network Hospitals -
Cashless f acility must
be availed f or which
prior intimation is
required. 10%
deduction will apply in
case of reimbursement
f rom network hospital.

No deductions will apply

in case of emergencies
/ accidents.

21.0 01 April 13 April Single room f acility for Appendix C  Review of the Add Policy
2018 2018 parents will be provided Commonly used policy and Revision
to employees holding Terminologies  scheme
the Platinum Plus Plan. Room Category
For all other plans, twin-
sharing room for
parents will be retained.

TCS Conf idential 42

 Document Policy
Policy
Release Revision Section Rationale for Change revision/
Revision Effective
/Revision Description No. change type Document
No. date
Date revision

21.0 01 April 13 April Employees can view Provisions  Policy review Delete Document
2018 2018 coverage and premium Benef its, Revision
details of their def ault Entitlements &
health plan and the next Coverage
higher plan they can opt
f or via GESS.

20.0 01 April 04 April Enrollment section Enrollments under For additional Add Policy
2018 2018 detailed to specify that HIS clarity Revision
at the start of enrolment
period, employee will be
re-tagged to the def ault
plan and will have the
f lexibility to choose the
immediate next higher
plan, if needed.

20.0 01 April 04 April Specified that an Claim Procedure Review of the Add Policy
2018 2018 advance intimation of policy and Revision
Hospitalization is scheme
mandatory (except in
case of emergencies).
Employees must opt for
hospitals which are part
of the network list and
avail the cashless
f acility. A percentage
deduction on the bill
amount will apply in
case of requests for
reimbursements and/or
f or hospitals which are
not a part of the network
list.

20.0 01 April 04 April Parents/Parents-in-law Appendix C  Review of the Add Policy

2018 2018 will be eligible for Commonly used policy and Revision
double occupancy (twin Terminologies  scheme
sharing) AC room Room Category
across all health plans

TCS Conf idential 43

 Document Policy
Policy
Release Revision Section Rationale for Change revision/
Revision Effective
/Revision Description No. change type Document
No. date
Date revision

20.0 01 April 04 April No Liability on the Terms and Explicitly Modify Document
2018 2018 Insurance company for Conditions mentioned in Revision
settlement of claims for the policy to
any treatment taken provide clarity.
f rom the Black-listed
Hospitals/Clinic/Medical
Prof essionals.

19.0 01 Apr 20 Oct Benef it in case of Provisions -> In line with Modify Policy
2017 2017 Accidental Injury Benef its/Entitlements Legal statute Revision
leading to Permanent & Coverage
Total Disability revised
f rom minimum of 10
lakhs to 11 lakhs

19.0 01 Apr 20 Oct Updated the Provisions -> For additional Add Policy
2017 2017 Ambulance Expenses Benef its/Entitlements clarity Revision
section to bif urcate Air & Coverage
and Road Ambulance
and the respective
coverage

19.0 01 Apr 20 Oct For any new addition of All Sections where Review of the Add Policy
2017 2017 parents/parents-in-law applicable policy and Revision
as benef iciaries, scheme
specified that any
diseases/conditions
(other than those
def ined under
Tertiary/Critical Illness)
will not be covered in
the f irst year of
enrolment. Clarified that
this will not be
applicable to
benef iciaries added
within 90 days from
date of joining or
marriage.

TCS Conf idential 44

 Document Policy
Policy
Release Revision Section Rationale for Change revision/
Revision Effective
/Revision Description No. change type Document
No. date
Date revision

19.0 01 Apr 20 Oct Specified that IUI or any Def ined Benef its -> Documentation Add Document
2017 2017 medical treatment for Maternity Benefits of existing Revision
inf ertility is admissible practice
only under domiciliary
limit. Sterility or f amily
planning treatments are
not admissible.

19.0 01 Apr 20 Oct Cancer care section Def ined Benef its -> Review of the Add Policy
2017 2017 updated to include Cancer Care policy and Revision
Radiotherapy. Limit for scheme
other therapies revised
f rom 1 lakh per year to
the Base sum insured
per year in case of the
employee.

19.0 01 Apr 20 Oct Clarif ied that expenses Def ined Benef its -> Review of the Add Policy
2017 2017 f or treatment of Sleep Treatment of policy and Revision
Apnea would be Obstructive Sleep scheme
payable only if the Apnea
employee is using a
CPAP or BiPAP
machine.

19.0 01 Apr 20 Oct Benef it in case of Stem Def ined Benef its -> Review of the Modify Policy
2017 2017 Cell therapy revised Stem Cell Therapy policy and Revision
f rom 1 lakh per year to scheme
50% of the Base sum
insured per year f or the
employee.

19.0 01 Apr 20 Oct Def ined a maximum Def ined Benef its -> Review of the Add Policy
2017 2017 limit of 25% of the Base Alternative system of policy and Revision
sum insured for Medicines scheme
treatment under
alternative system of
medicines.

TCS Conf idential 45

 Document Policy
Policy
Release Revision Section Rationale for Change revision/
Revision Effective
/Revision Description No. change type Document
No. date
Date revision

19.0 01 Apr 20 Oct Inclusion of Floater Provisions -> Documentation Modify Document
2017 2017 cover f or ESIC Benef its/Entitlements of existing Revision
associates. Clarified & Coverage practise
that ESIC associates
may avail benefits
under ESIC or HIS.

18.0 01 Apr 06 Apr Revised insurance Provisions Review of the Modify Policy
2017 2017 cover & benefits. Option policy and Revision
to choose a higher plan. scheme

Specified that pre-

18.0 01 Apr 06 Apr intimation is required Procedure Review of the Add Policy
2017 2017 in case of a planned policy and Revision
hospitalization. scheme

18.0 01 Apr 06 Apr Basic Hospitalisation Provisions Policy review Modify Policy
2017 2017 renamed to Base Cover Revision
and Higher
Hospitalisation cover
renamed to Floater
Cover.

18.0 01 Apr 06 Apr Medical Advice section Appendix C Review of the Add Policy
2017 2017 updated on room policy and Revision
category details. scheme

18.0 01 Apr 06 Apr Parents/parents-in-law Provisions – Review of the Modify Policy

2017 2017 can be enrolled in Enrollments under policy and Revision
subsequent enrollment HIS scheme
period. However for
such new additions no
pre-existing ailments
covered in f irst year of
enrolment.

TCS Conf idential 46

 Document Policy
Policy
Release Revision Section Rationale for Change revision/
Revision Effective
/Revision Description No. change type Document
No. date
Date revision

18.0 01 Apr 06 Apr Peritoneal dialysis Procedure Review of the Add Policy
2017 2017 added to the list of not policy and Revision
covered ailments under scheme
the domiciliary
Hospitalisation benefits.

17.0 01 Apr 12 Aug Pro - rated basic Appendix A Policy review Modify Policy
2016 2016 premium amounts table Revision
f or Parents and
Parents- in-law based
on the quarter in which
the employee joins or
gets married.

17.0 01 Jun 12 Aug Renamed LWP Provisions Policy review Modify Policy
2016 2016 f inancial assistance to Revision
Critical Illness – LWP
Benef it Cover.

17.0 01 Jun 12 Aug The weekly amount Provisions Policy review Modify Policy
2016 2016 payable through Critical Revision
Illness – LWP Benefit
Cover revised.

17.0 01 Apr 12 Aug Cancer Benefit Provisions Policy review Modify Policy
2016 2016 introduced. Revision

16.0 01 Apr 01 Apr C5 & equivalent grades Throughout the Review of the Modify Policy
2016 2016 moved to higher document policy and Revision
category f or benefits scheme
and coverage.

16.0 01 Apr 01 Apr Revised insurance Provisions Review of the Modify Policy
2016 2016 cover & benefits. policy and Revision
scheme

16.0 01 Apr 01 Apr Enrolment of Provisions – Review of the Modify Policy

2016 2016 Parents/parents-in-law Enrollments under policy and Revision
to be allowed once in 3 HIS scheme
years.

TCS Conf idential 47

 Document Policy
Policy
Release Revision Section Rationale for Change revision/
Revision Effective
/Revision Description No. change type Document
No. date
Date revision

16.0 01 Apr 01 Apr Children above 25 Provisions – Review of the Add Policy
2016 2016 years not eligible for Enrollment under policy and Revision
enrolment. HIS scheme

16.0 01 Apr 01 Apr Air Ambulance Provisions - Benefits Review of the Add Policy
2016 2016 Expenses benefit / Entitlement and policy and Revision
added. Coverage scheme

16.0 01 Apr 01 Apr Def ined Benefits Def ined Benefits Review of the Add / Policy
2016 2016 section updated with policy and Modify Revision
Cancer Care, Daycare scheme
Medical Expenses,
Cochlear Implants,
Treatment for
Obstructive Sleep
apnea, Treatment of
obesity, Stem cell
Therapy, DIVYAANG
benef it. Additional
updates also made to
other existing sections.

16.0 01 Apr 01 Apr Updated Upper limits Provisions & Defined Review of the Modify Policy
2016 2016 f or Permanent Total / Limits policy and Revision
Partial Disability and scheme
Joint Replacement
expenses.

TCS Conf idential 48