CITI - Group Medical Insurance Policy

FAQ Document
 Index

❖ Medical Insurance Policy Overview Point 1

❖ Broad benefits under the policy Point 2 – 9
❖ Enrollment and Premium details Point 10 – 24
❖ Tax benefits details Point 25
❖ Additional benefits / Enhancements Point 26
❖ Restrictions & exclusions of this policy Point 27 – 29
❖ Day Care procedures Point 30
❖ Portability Policy Process Point 31 – 38
❖ Last year claim process Point 39
❖ Co – pay Policy Point 40 – 42
❖ Claim Process Point 43 – 48
❖ Maternity/Surrogacy Policy terms Point 49 – 55
❖ Disability Cover Sponsored by Citi Point 56
❖ Communication Matrix Point 57
❖ Covid related terms & conditions COVID Specific FAQs Point 1 - 15

FAQ’s – Group Medical Insurance Policy 2

 1) What is the Group Medical Insurance Benefit Plan?

Self and your insured family members would get paid for expenses incurred due to any
hospitalization. Hospitalization covers various components of expenses like Stay Charges,
Operation charges, and Doctor’s fees, Nursing Charges, Investigations & Diagnostics
Charges and Medicines etc.
The hospitalization must fulfil following conditions:
Total stay in hospital should be more than 24 hours (Not applicable for those
procedures where the stay in the hospital is reduced due to advancement of medical
technology)
Hospitalization is applicable for treatment of a disease or illness and the treatment
given could not have been administered on an Outpatient basis.
The Hospital should have more than 15 beds in Metro Cities (Mumbai (MMR), Delhi
& NCR region, Chennai, Bangalore, Kolkata, Hyderabad, Secunderabad, Pune,
Ahmedabad) OR should be registered with the local authorities (this condition is
relaxed to 10 beds for non-Metro cities).

2) What are the broad benefits under Group Medical Insurance Policy?

• INR 800,000 per family floater coverage for You, Spouse/domestic partner, 2 children
& sibling (E, S/P,2C&SB) with optional top-up cover provision from INR 500,000/INR
1,000,000/INR 1,500,000/INR 2,000,000/INR 2,500,000/INR 3,000,000 at a preferential
premium to be borne by you.
• Additional Children (beyond 2): Can be covered by paying a nominal premium of INR
2,222 per child on a voluntary basis.
• Children above 25 years: Can be covered by paying a nominal premium of INR 2,854
per child on a voluntary basis.
• Sibling: Can be covered by paying a nominal premium of INR 2,836 per sibling on a
voluntary basis.
• Pre-Existing diseases are covered from day one, without any waiting period.
• Maternity Benefit (up to 2 children) from day one, with a limit of INR 1.5 Lakh in metro
cities and INR 1 Lakh in non-metro cities. Applicable for you, Spouse / Domestic
Partner. Metro Cities include Mumbai (MMR), Delhi & NCR region, Chennai, Bangalore,
Kolkata, Hyderabad, Secunderabad, Pune and Ahmedabad.
• Maternity expenses of mother availing surrogacy through another woman to be
covered as per maternity limit of INR 1.5 Lakh in metro Cities (Mumbai (MMR), Delhi &
NCR region, Chennai, Bangalore, Kolkata, Hyderabad, Secunderabad, Pune,
Ahmedabad) and INR 1 Lakh in non-metro cities.
• In the case of Twin or Triplet delivery an additional INR 25,000/- per newborn will be
paid for Second or Second & Third child respectively.
• Stay charges for any one parent (within maternity limit, single AC Room, max for 10
days) in case of newborn baby hospitalization is covered.
• New-born Child Cover from day one- Intimation to be sent about expected date of
delivery or about childbirth, within 30 days from the date of birth.
• Pre and post hospitalization expenses payable for 30 & 60 days respectively including
Maternity.
FAQ’s – Group Medical Insurance Policy 3
 • Waiver of 9 month waiting period for maternity.
• Well Baby Care expenses cover Hearing Test, Newborn Screening, Pediatrician
consultation, Neonatology Consultation under Maternity Limit during the baby’s
hospitalization however it is not covered under OPD basis.
• Newborn baby birth vaccinations are not covered.
• Complications arising out of Maternity & Surrogacy are payable up to base sum
insured.
• Coverage for Hospitalization due to Terrorism.
• Limit on voluntary separate parental base cover of INR 500,000 with top-up cover
options of INR 300,000/INR 500,000/INR 700,000/INR 1,000,000/INR 1,500,000/INR
2,000,000. You can also add 1 Parents/Parent-in-law,2 Parents / 2 Parents-In-Law, 3 (2
Parents/Parents-in-law + 1 Parent/ Parents in Laws), 4 (2Parents + 2Parents In Laws).
• Critical illness cover (ONLY FOR EMPLOYEE): On first detection during current policy
period, Lump-sum pay-out of INR 10 Lakh is payable, once during the service in Citi.
• Waiver of 1st/2nd/3rd/4th year exclusion for Special Diseases.
• Waiver of 30 days waiting period.
• Coverage of hospitalization expenses due to suicide attempt.
• Coverage for Prosthetic /Artificial Limb with repair and replacement. Coverage of
repair & replacement is restricted to you only, with per case limit of INR 4 lacs and
overall policy limit of INR 25 lakh.
• Artificial Life Maintenance covered up to 10% of Sum insured Limit (Base + Top-Up)
maximum of 15 days, following admission for a covered illness.
• Deep Brain Stimulation covered up to family sum insured - (Base + Top-Up)
• Balloon Sinuplasty covered up to family sum insured - (Base + Top-Up)
• Oral Chemotherapy covered up to family sum insured - (Base + Top-Up) E.g. If you have
Base 8 lacs and Top-Up 10 lacs then, you claim up to 18 lacs.
• Coverage of expenses towards Minor Accidental cases wherein treatment (For
Example: Plastering) is given on OPD Basis & hence, not payable under Medi claim
cover (Applicable for all insured members), is covered up to INR 20,000.
• Treatment for Psychiatric / Psychosomatic Disorders also cover charges towards
counselling conducted by a counsellor (& not just Psychiatrist) up to Outpatient Limit
of INR 1,25,000 or In-Patient hospitalization Limit up to family sum insured (Base + Top-
Up) for ES2C&S & Parent.
• Expenses incurred for Ayurvedic / Homeopathic / Unani Treatment are admissible up
to 25% of the sum insured provided the treatment for Illness and accidental injuries, is
taken in AYUSH Hospital.
• Congenital External Disorders are payable up to INR 50,000.
• Age Related Macular De-generation is payable up to Rs. 75,000 per policy period per
family.
• Genetic Disorder covers up to the Family sum insured - (Base + Top-Up) E.g. If you have
Base 8 lacs and Top-Up 10 lakh then, you claim up to 100% of total SI (18 lakh)
• Impairment of persons intellectual faculties by usages of drugs, stimulants or
depressants as prescribed by Medical Practitioners covered up to INR 25,000 per policy
period.
• Infertility Treatment for both men and women is covered. Treatments that are
undertaken on a day-care basis will also be payable up to INR 1 Lakh per cycle.

FAQ’s – Group Medical Insurance Policy 4

 (Emp/Spouse).
• Domiciliary Hospitalization / Treatment availed on OPD basis is not payable.
• Co-payment is not applicable for You, Spouse / Domestic Partner, Children and Sibling.
• Special surgeries like Cyber-knife treatment, robotic surgeries to be payable up to
Family sum insured - (Base + Top-Up).
• The room rent eligibility for you is the lowest category Single AC room or any lower
category room available with cost not higher than Single A/C room. If you opt for higher
category Single A/c room (like Deluxe or Suite room), then proportionate deduction
will be applicable on the higher room rent charges and all other charges as charged by
the Hospital except medicine charges.
• Insurance cover for declared dependents (Spouse, Children & siblings) will be
continued for the policy year up to the available sum insured limit in case of demise of
the employee.
• Ambulance charges are covered up to the limit of INR 5,000.

3) When does my Insurance Cover start?

The annual Insurance Policy starts on 1st July 2024. If you have joined before 1st July 2024
are already insured.
If you are joining post 1st July 2024, insurance cover would be insured after your
enrolment process is completed with Citi or will be issued as per Citi HR Policy. The policy
joining date will be the date you are joining Citi.

4) When does my Insurance Cover end?

Insurance policy ends on 30th June 2025 or any of the following events whichever occurs
earlier would terminate your insurance cover.

• Termination or expiration of insurance policy on 30th June 2025 (in case of expiry,
it would be renewed).
• Your separation from CITI (Last Date of employment): As your insurance is
extended to the dependents, the date of termination of cover for you is also the
date of termination of cover for dependents.

5) What does the coverage amount or Family Sum Insured under the group medical insurance
policy mean?

The sum insured eligibility for family (ES2C and Sibling) is INR 800,000 on floater basis.
And you can opt for separate voluntary floater cover of INR 500,000 for up-to 4 parents
(Father, Mother, Father-in-law, and Mother-in-law).

6) What is a floater cover?

A floater cover is common insurance coverage for a set of people. In your case, this
common coverage is offered for family members, which means that any member from
FAQ’s – Group Medical Insurance Policy 5
 the family unit can use the cover up to the total limit.

7) Who all can I cover under the Group Medical Insurance policy?

• Your Spouse / Domestic Partner, 2 dependent Children under mandatory & company
sponsored cover (subject to declaration on Medical Insurance Portal – Please refer
point 11 for Portal declaration process).
** Domestic Partner shall mean and include same or opposite sex partner of the
employee. A declaration needs to be submitted by the employee for covering domestic
partner.
• Adopted Child can also be enrolled but within 30 days of court order by submitting
declaration post enrollment on the portal.
• Financially dependent siblings up to the age of 25 years can be covered by paying an
extra premium of INR 2,836/- including GST per sibling. In case, dependent sibling is
mentally/physically challenged then age limit shall not apply.
• Parents/ Parents in law or all four parents can be included under Optional & Self-Paid
cover within 30 days from the date of joining.

Note- Please note that you cannot insure your dependents like Uncle, Aunt, or your
Grandparents, etc.

8) What is the age eligibility criterion to cover dependent children, parents, and parent-in-
laws?

• Dependent children up to the age of 25 years.

• Parents / Parents-in-laws can be covered under this plan up to 100 years of age.
• Child age above 25 years can be covered by paying additional premium.

9) Both my Spouse / Domestic Partner and I are working for Citi. Can we add our children
and parents as our dependents respectively? If yes, how do we claim under the policy?

Yes, same dependents can be insured twice in the policy if member & spouse both are
working for Citi. Hence, dependents can be added twice and can be declared under cover
by either you or your Spouse / Domestic Partner. Claim amount will be restricted in case
of capped ailment/base sum insured (for enhanced benefits) and will not get double
benefit as member is covered twice in the policy.
Example 1: Cataract is limited to INR 50,000 per eye. In this case, for cataract claim only
INR 50,000 per eye can be claimed for dependent member even though member is
covered twice.
Example 2: A dependent parent member is going for Cancer treatment. In this case,
dependent member can claim INR 5,00,000 from your policy cover and INR 5,00,000 from
spouse being covered as an you under GMC Policy.

10) Is it beneficial if I cover my parents in the policy?

The coverage offered under the group medical insurance plan of Citi is INR 500,000 & has
FAQ’s – Group Medical Insurance Policy 6
 many advantages over the retail insurance available in the market. Some of them are
mentioned here:
▪ Pre-existing diseases are covered from day one.
▪ Waiver of all waiting periods
▪ Parental Coverage without health checks.

11) How can I enroll my sibling, parents/ parents in law under the policy?

You can enroll your sibling /parents/parents in law under the optional self-paid cover
(Premium shall be deducted from your salary in instalments). Please note: If in case no
changes are made to parental records, records of last year shall be continued during
subsequent renewal of the policy.
Also, during policy tenure if in case of parental demise premium will be refunded on pro rata
basis provided there is no claim reported during the policy period.

A self-declaration for sibling addition is required to be submitted within 15 days of adding the
sibling on the portal after closure of enrollment drive.

To qualify for dependent sibling, you and your sibling must meet the following criteria:

• You are financially independent, and your sibling is dependent on you for financial support.
• You and your sibling should have the same parents
• Your sibling is not enrolled in any corporate medical insurance program.
• Your parent is either deceased or financially not be able to support your sibling
• Sibling should not be married or dependent on anyone else for financial support
• The sibling should be either less than 25 Years of age, but age limit will not apply in case of
dependent sibling being mentally/physically challenged.

The Company may require you to provide proof of your sibling’s financial dependence by
producing any of the following documents:
• Ownership of a joint bank account, joint credit cards, or other evidence of joint financial
responsibility.
• In case parents are deceased, death certificate of the parents
• Other evidence of economic dependence of sibling
• Designation of your sibling as beneficiary for life insurance or retirement benefits.
• Proof of Legal Guardianship of the sibling

Process to declare:

a. Enroll sibling on the MTCB portal. (Refer Enrollment Portal Navigation embedded below)
b. Post enrollment you shall be contacted by India Insure and or HRSS and shared
declaration process & form via mail.
c. Upon you sharing the form and documents required, your enrollment is confirmed via
mail.

FAQ’s – Group Medical Insurance Policy 7

 Enrollment Portal
Navigation.pdf

12) How do I complete the enrolment process of Newborn baby/ Newly married spouse/
Domestic Partner on the Portal?

You can add your newborn baby’s details on the portal by logging in on:

• Please click on https://www.totalCompOnline.com/ and login via a Single Sign-

on (SSO) password.
• Please refer to the enrollment guide updated on Citi for you for step-by-step
guidance.
• Please note that you must complete the enrolment process within 30 days of the
date of the event (birth/adoption/marriage). While completing the enrolment
process, please click on the confirm policy details tab to ensure that your
dependent is covered.
Post enrollment you shall be contacted for declaration process for addition of above
member. Only upon successful completion of declaration process shall the member stay
added on the GMC Policy.

13) How do I know that my dependents and I are insured?

After your enrolment, an ID card from Paramount (TPA) will be made available on the
portal. This is confirmation that you or your dependents are insured. (Please note that
each insured family member gets individual TPA ID. So, if one of your family members
does not get TPA ID, chances are that the member is not insured. In such an event,
immediately contact voice contacts as mentioned at the end of this document.) Also
notify team on [email protected] immediately if you find any details mentioned on
your e-card incorrect to avoid last minute hassles during hospitalization. For e.g., DOB,
name, relation.

14) What happens if the details like DOB, Name furnished by me while enrolling are incorrect?

It is important that you provide correct information. In case of discrepancy in data

available with TPA & the actual data furnished (you may have mentioned in the online
form your mother’s age as 48 years and the claim form & hospital records have mentioned
it as 58 years), your claim may get rejected. Mismatch in age, name may lead to denial of
claim as insurance is a contract based on the concept of “UTMOST GOOD FAITH” between
the insurer and insured.

15) Do I need to intimate insurer about enrolment of new family members like in case of
Spouse / Domestic Partner addition for newly married or inclusion of new-born in case
of delivery or newly adopted child? Do I have to pay an additional premium?

Yes, to get the insurance cover for your new dependents from day one of the incidence
FAQ’s – Group Medical Insurance Policy 8
 i.e., marriage date for addition of Spouse / Domestic Partner or of his/her birth in case of
new-born baby or date of adoption, you MUST enroll within 30 days from the date of
marriage / birth / adoption. You can enroll your new dependents on the portal. You do
not have to pay any extra premium (up to 2 dependent children). In case of a third child
addition, you need to pay extra premium.
You can add your Spouse / Domestic Partner’s details by logging on to the enrolment
portal https://www.totalCompOnline.com/ and login via a Single Sign-on ( SSO) password.
Please note that you will have to complete the enrolment process within 30 days of the
date of the event (marriage/birth/adoption). You do not have to pay any extra premium.

16) If you expire during the policy year, will your dependents be covered till the policy
period?

Yes, the policy coverage will continue for the declared set of dependents (Spouse, 2
children & sibling) up to the available balance sum insured amount.
This benefit is not extended to declared set of parents/parents-in-law.

17) What are the Premium rates under the optional parental policy?

The coverage options and premium amount are as per table below for parental members
for a floater sum insured of INR 500,000 which are applicable for parental members:
Annual Premium
Detail
s including GST

Parental Premium for 1 (Parents / Parents in Laws) INR 29,552

Parental Premium for 2 (Parents / Parents in Laws) INR 56,677

Parental Premium for 3 (Parents / Parents in Laws) INR 70,375

Parental Premium for 4 (2 Parents + 2 Parents in Laws) INR 79,875

Note: Premium payable will be deducted in instalments from your salary. The above-
mentioned amount includes GST.

18) What is a Top Up cover? What are the benefits and can spouse/domestic partner,
dependent children, siblings be covered under the Top Up cover?

Top Up cover is a facility under which you can opt for higher coverage for self, spouse /
domestic partner, first 2 dependent children & siblings, which is over and above your base
sum insured. This cover will trigger only when the base sum insured exhausts.
Separate Plan with Top Up cover for Parents is now available.

19) What are the options for ESC & sibling Top Up cover and premium amount?

The available options and premium amount are mentioned below:

FAQ’s – Group Medical Insurance Policy 9
 Annual Premium
Top up Sum insured Options (Including GST)

INR 500,000 INR 3,249

INR 1,000,000 INR 4,374
INR 1,500,000 INR 4,875
INR 2,000,000 INR 5,415
INR 2,500,000 INR 7,822
INR 3,000,000 INR 10,168

Please Note:
▪ Premium payable will be deducted in instalments from your salary.
▪ The top up cover as mentioned above is applicable only for You + Spouse /
Domestic Partner + 2 dependent Children+ Sibling only and not for parents.

20) Is there any Top-Up Plan where I can cover for my Parents?

Parents can be covered under Parental Top-up Plan covering parents declared either
under the E1P, E2P, E3P or E4P Plan in the policy which has come into force with effect
from July 1, 2024.
The details of the Plan are as follows:
A. If you are willing to opt for the Parental Top-Up Plan must necessarily enroll their
parents or parents in law in under the E1P, E2P, E3P or E4P
B. Premium for the Parental Top-Up Plan would be borne by you and recovered from your
salary.
C. The details of the Parental Top-Up Plan are as follows:

Annual Premium (in INR including GST)

Sum Insured Limit
1P 2P 3P 4P
INR 300,000 6,855 7,617 9,598 10,664
INR 500,000 10,513 11,683 15,082 16,758
INR 700,000 19,052 21,169 27,330 30,366
INR 1,000,000 27,266 30,294 39,025 43,360
INR 1,500,000 38,804 43,116 55,421 61,576
INR 2,000,000 55,532 61,703 79,134 87,924

D. The following 2 examples will enable you to understand how the Parental Top-Up
Policy will work.
FAQ’s – Group Medical Insurance Policy 10
 Scenario A

1. You have opted for a Parental Top-Up Cover with Sum Insured Limit of INR 3 Lacs
2. 1st Claim of INR 8 lacs (Covid-19 Claim)
3. 2nd Claim of INR 3 lacs for non-Covid hospitalization in the same policy year

How will the Top-Up Policy Trigger?

1. Claim up to INR 5 Lacs will get paid out of the Base Policy Sum Insured Limit of INR 5 Lacs
2. Post exhausting Base Policy Sum Insured Limit, the Top-Up Policy with Limit of INR 3 lacs
will get triggered so, with this process, The 1st Claim of INR 8 Lacs (COVID-19 Claim)
Settled.
1. Balance Sum Insured available under the Top-Up Plan post settlement of COVID-19
claim is ZERO
2. 2nd claim of INR 3 Lacs (Non-Covid-19) will not get paid out as sum insured is
exhausted.

Scenario B

1. You have opted for a Parental Top-Up Cover with Sum Insured Limit of INR 5 Lacs
2. 1st Claim of INR 12 lacs (non-Covid)
3. 2nd Claim of INR 3 lacs for Covid-19 in the same policy year

How will the Top-Up Policy Trigger?

1. Claim up to INR 5 Lacs will get paid out of the Base Policy Sum Insured Limit of INR 5 Lacs
2. Post exhausting Base Policy Sum Insured Limit, the Top-Up Policy with Limit of INR 5
lacs will get triggered.

SO, WITH THIS PROCESS, OUT OF THE 1ST CLAIM OF INR 12 LACS, ONLY 10 LAC GETS
SETTLED AND 2 LAC gets Deducted as sum insured is exhausted.

1. Balance Sum Insured available under the Top-Up Plan post settlement of 1st claim is
ZERO.
2. 2nd Claim of INR 3 Lacs for COVID-19 treatment will not be paid as sum insured is
exhausted.

21) I have completed the enrolment and opted for a cover of my Spouse / Domestic Partner,
2 parental members, sibling, and myself? How will the premium deduction be done?
Will the premium be charged for all the members insured?

The premium for Yourself, Spouse / Domestic Partner and 2 dependent children is paid
by the company. The premium deduction will be made from your salary in equal
instalments for parental cover opted by you. For sibling cover in Base policy, you will to
have pay additional premium. For further details on deduction pattern, you can get in

FAQ’s – Group Medical Insurance Policy 11

 touch with HRSS team.

22) I have paid full premium for my dependent family members. Why should their cover
cease to exist when I leave the job?

This group insurance coverage with special benefits is offered to you (& hence to your
family members) as an employee of CITI. When you cease to continue as employee of
CITI, all your benefits (like host of other benefits that you get as CITI you) are withdrawn.
As this insurance policy is offered to you & your family members together in single bundle,
the same gets withdrawn automatically when you leave the company. The last day of
insurance coverage for you & your family members would be your Last Working Day
(LWD) with CITI. However, you can port your policy benefits as per IRDA guidelines &
BAJAJ ALLIANZ retail insurance product available as per the process mentioned in
portability section of these FAQs.

23) I have opted for parental cover during the enrolment drive, but now I do not wish to
cover my parents in the policy. Can I cancel the cover, as I do not wish to pay the
premium for parental cover?

The cover once opted for, cannot be cancelled during the policy year. You can discontinue
the cover during the enrolment window of the next policy renewal, subject to availability
of such facility at that point in time.

24) If I decide to exit Citi, what happens to my parental coverage? Will it continue till the
policy end date?

No, the policy coverage will cease to exist once you resign from Citi. However, you have
an option of migrating to a retail medical insurance policy with continuity benefit, which
will be applicable as per IRDA Guidelines. (Refer question 34 no for details).

25) When I choose optional coverage, is there any Income tax benefit? Will tax benefit be
reflected in Form 16? Can I get income tax benefit for premium paid for Top Up Cover?

• Yes, Income Tax benefit under section 80D can be availed & it shall be reflected in
your Form 16.
• This benefit is available for Top up Premiums also. Tax benefit can only be availed for
declared set of parents. Parents-in-law premium is not covered under Tax benefit.
o You need to contact HRSS for Premium paid receipt for claiming in old tax
regime.
• This benefit is not available for those who are opting for new tax regime.

26) What are the additional benefits provided under this Plan?

In addition to the expenses being paid for the main hospitalization, you also get
reimbursement of related expenses incurred for same disease / illness 30 days before the
Date of Admission to Hospital (Called Pre-Hospitalization Expenses including maternity).
FAQ’s – Group Medical Insurance Policy 12
 This could be the doctor’s fees, Preliminary investigations & diagnostics, and the medicine
charges. You also get reimbursement of expenses incurred for same disease / illness 60
days after the Date of Discharge from the hospital (Called Post- Hospitalization Expenses
including Maternity). This could be follow-up consultation with doctor, Medicines, &
confirmatory diagnostics etc.

Apart from the above, we have few special coverages defined & payable under this policy
which are normally not available under the standard Group Medical Insurance Policy. The
details of those benefits are as follows:

Benefit Maximum Eligibility

CITI Sponsored ESC Top-Up Plan
for employees with disabilities
INR 2,000,000 (Only for employee) Refer point 57 for process
(Govt. issued disability certificate
mandatory)
Maternity Limit INR 100,000 Non-Metro, INR 150,000 in Metro cities
1 Parent/Parents-in-Law / 2 Parents / 2 Parents-In-Law / 2
Voluntary Parental Cover
Parents/Parents-in-Law + 1 Parents/Parents-in-Law / 2 Parents-In-
Combinations
Law + 2 Parents-In-Law
Voluntary parental cover INR 500,000
Critical Illness (ONLY FOR YOU) Detection – Lump-sum pay-out of INR 10,00,000
onetime benefit.
Critical Illness as per IRDA list-
- Cancer of specific
severity
- First heart attack of specified
severity
- Open chest CABG
- Open heart replacement or
repair of heart valves
- Coma of specified
severity
- Kidney failure requiring regular Permanent loss of employment - Defined coverages as per ASR
dialysis
- Stroke resulting in permanent
symptoms
- Major organ/Bone marrow
transplant
- Permanent paralysis of
limbs
- Motor neuron disease with
permanent symptoms
- Multiple Sclerosis with persisting
symptoms
< = INR 10.00 lacs- INR 30 lacs
Critical Illness – Grid is as per > = INR 10.01 lacs <INR 20.00 lacs- INR 60 lacs
Annual Salary Limit > = INR 20.01 lacs <INR 50.00 lacs- INR 150 lacs
> = INR 50.01 lacs <INR 100.00 lacs- INR 200 lacs
FAQ’s – Group Medical Insurance Policy 13
 > = INR 100.00 lacs-INR 300 lacs
Adopted kids for same gender
Covered
partners
Parents of domestic partners Covered
Twin / Triplet Additional INR 25,000 per newborn
Stay charges for any one parent
(within maternity limit, single AC
Covered
Room, max for 10 days) in case of
newborn hospitalization
Per eye charges for cataract
including pre & post expenses INR 50,000
cover.
Angiogram INR 50,000 Per person per policy period
Surgeon, Anesthetist, Specialists
NO CAPPING
Fees - Max
OT charges - Max NO CAPPING

Psychiatric / Psychosomatic
Disorders (ES2C)
In-patient Limit = WITHIN FAMILY SUM INSURED – Family sum
Treatment for Psychiatric /
insured (Base + Top-Up) E.g. If you have Base 8 lacs and Top-Up 10
Psychosomatic Disorders to also
lacs then, you claim up 18 lacs.
cover charges towards counselling
Outpatient Limit = INR 1,25,000
conducted by a counsellor (& not
just Psychiatrist)

Infertility Treatment (Treatment

which are undertaken on daycare Treatment for men covered as well. Max up to INR 1 lac per family.
basis should also be payable)
Air Ambulance Charges Covered On Actuals with overall policy limit of 25 lacs
Complications of surrogacy Covered up to Base sum insured – (8 lacs) Base policy sum insured
Inclusion of disorders of adult In-patient Limit = Within Family Sum Insured (Base + Top-up sum
personality; disorders of speech insured)
and language incl. stammering, Outpatient Limit = INR 1,25,000 E.g. If you have Base 8 lacs and Top-
dyslexia Up 10 lacs then, you claim up to 18 lacs.
Behavioral and
Covered up to 50% of Family sum insured – (Base + Top-Up) E.g. If
Neurodevelopmental disorder
you have Base 8 lacs and Top-Up 10 lacs then, you claim up to 50%
including autism (long term
of total SI (18 lacs) = 9 lacs.
therapy)
Repair / replacement of Covered (Restricted to you) with Overall policy limit of 25 lacs and
prosthetic limbs per incident limit of 4 lacs.
Covered for member of 18 years or above with following severe co-
morbidities:
I – Obesity related cardiomyopathy
Bariatric surgery for BMI > 35
II – coronary heart disease
III – Severe Sleep Apnea
IV – Uncontrolled Type-2 Diabetes

FAQ’s – Group Medical Insurance Policy 14

 Long Term Physiotherapy
Covered with limit of INR 100,000 per case.
(Physiotherapy going for more
Based on Doctor's Prescription within overall policy limit of INR 100L.
than 2 months)

Sleep Apnea test to be performed (will be reimbursed only if tested

positive)
Sleep Disorder Test and Remedy Cost of CPAP / BIPAP Machine due to report and as advised by the
Doctor
Cost of Machine is restricted to Rs.2 lacs per machine

Eye Power Correction / Lasik Covered with restriction of eye power +/-5 or greater. Coverage is
Treatment restricted to ES2C only
HIV / AIDS / Sexually Transmitted Covered up to Family Sum Insured – (Base + Top-Up) E.g. If you have
Diseases Base 8 lacs and Top-Up 10 lacs then, you claim up to 18 lacs.
Covered up to Family Sum Insured – (Base + Top-Up) E.g. If you have
Oral Chemotherapy
Base 8 lacs and Top-Up 10 lacs then, you claim up to 18 lacs.
Advanced cancer treatments
Covered up to Family Sum Insured – (Base + Top-Up) E.g. If you have
including hormonal therapy and
Base 8 lacs and Top-Up 10 lacs then, you claim up to 18 lacs.
Immunotherapy

Targeted Hormonal Therapy: Covered up to Family Sum Insured – (Base + Top-Up) E.g. If you have
Breast Cancer Base 8 lacs and Top-Up 10 lacs then, you claim up to 18 lacs.

UTHERINE ARTERY
EMBROLIZATION AND HIFU (HIGH Covered up to Family Sum Insured – (Base + Top-Up) E.g. If you have
INTENSITY FOCUSED Base 8 lacs and Top-Up 10 lacs then, you claim up to 18 lacs.
ULTRASOUND)

Covered up to Family Sum Insured – (Base + Top-Up) E.g. If you have

Balloon Sinuplasty
Base 8 lacs and Top-Up 10 lacs then, you claim up to 18 lacs.

Covered up to Family Sum Insured – (Base + Top-Up) E.g. If you have

Deep Brain Stimulation
Base 8 lacs and Top-Up 10 lacs then, you claim up to 18 lacs.

Covered up to Family Sum Insured – (Base + Top-Up) E.g. If you have

Intravitreal Injections
Base 8 lacs and Top-Up 10 lacs then, you claim up to 18 lacs.

Covered up to Family Sum Insured – (Base + Top-Up) E.g. If you have

Stereotactic Radio Surgeries
Base 8 lacs and Top-Up 10 lacs then, you claim up to 18 lacs.

Covered up to Family Sum Insured – (Base + Top-Up) E.g. If you have

Bronchial Thermoplasty
Base 8 lacs and Top-Up 10 lacs then, you claim up to 18 lacs.

Vaporization of Prostrate (Green

Covered up to Family Sum Insured – (Base + Top-Up) E.g. If you have
Laser Treatment or Holmium laser
Base 8 lacs and Top-Up 10 lacs then, you claim up to 18 lacs.
Treatment)

FAQ’s – Group Medical Insurance Policy 15

 IONM (intra operative neuro Covered up to Family Sum Insured – (Base + Top-Up) E.g. If you have
monitoring) Base 8 lacs and Top-Up 10 lacs then, you claim up to 18 lacs.

Stem Cell Therapy: Hematopoietic

stem cells for bone marrow Covered up to Family Sum Insured – (Base + Top-Up) E.g. If you have
transplant for hematological Base 8 lacs and Top-Up 10 lacs then, you claim up to 18 lacs.
conditions to be covered
Artificial Life Maintenance
including life support machine
use, where such treatment will
not result in recovery or
restoration of the previous state
of Health under any circumstances Covered up to 10% of family Sum insured Limit (base + top-up)
unless in a vegetative state as maximum of 15 days, following admission for a covered illness.
certified by the treating medical Family Sum Insured – (Base + Top-Up) E.g. If you have Base 8 lacs
practitioner. Explanation: and Top-Up 10 lacs then, you claim up to 10% of total SI (18 lacs) =
Expenses up to the date of 1.8 lacs.
confirmation by the treating
doctor that the patient is in
vegetative state shall be covered
as per the terms and conditions of
the policy contract.
Puberty and Menopause related
Disorders: Treatment for any
symptoms, Illness, complications Covered up to 25% of Family sum insured – (Base + Top-Up) E.g. If
arising due to physiological you have Base 8 lacs and Top-Up 10 lacs then, you claim up to 25%
conditions associated with of total SI (18 lacs) = 4.5 lacs.
Puberty, Menopause such as
menopausal bleeding or flushing

27) Are there any specific restrictions on my hospital expenditure?

Yes, there are restrictions as mentioned below (Applicable on Parental Claims Only.)
▪ Per Eye charges for Cataract – INR 50,000. Per person per policy period
▪ Angiogram– INR 50,000. Per person per policy period
▪ Angioplasty Procedure & Angioplasty stent– INR 500,000. Per person per policy period

Apart from the above-mentioned restrictions, for multiple surgeries in single admission/
hospitalization claim there is a restriction on the coverage over admissible amount:
Primary Surgery 100% Charges of admissible amount
Secondary Surgery 50% Charges of the admissible amount
Tertiary Surgery 25-30% Charges of the admissible amount

28) What are the Reasonable & Customary Charges?

Yes, the charges for services or supplies, which are the standard charges for the specific
provider & consistent with the prevailing charges in the geographical area for identical or
FAQ’s – Group Medical Insurance Policy 16
 similar services, considering the nature of the illness/Injury Involved
Necessary, customary, and reasonable is the maximum amount considered & eligible for
reimbursement under the policy. This amount will be determined based on the review of
the prevailing charges made by physicians/surgeons for a similar health service within a
specific community or geographical area.
Example 1: If 10% of hospitals are charging 1 lakh or more for one ailment and 90% are
charging 80,000 or less for the same service/ disease /illness and in the same geographical
area, then the maximum covered amount will be 80,000 or less.
Insurers use the claims data available with them. They may compile a database comprising
a minimum of 500 claims. compare the rates and decide on reasonable rates for any
procedure.
In common procedures, the reasonable and customary limit can be defined by the
limit fixed in PPN packages for a similar hospital in the same geographical area.
Example 2: If the reasonable and customary charge as per Insurance Company and
market experience is Rs. 100 for a particular implant which is being generally used in
the surgery and in your bill, the charge for the same implant (same in the sense of
achieving the same result from a medical standpoint) is Rs. 200, the insurance cover
will reimburse Rs. 100 and not Rs. 200.

29) What are the Standard exclusions of this policy?

Any medical expenses incurred for or arising out of:

o War invasion, Act of foreign enemy, War like operations, nuclear weapons, ionizing
radiation, contamination by radio activity, by any nuclear fuel or nuclear waste or from
the combustion of nuclear fuel.
o Circumcision, cosmetic or aesthetic treatment, plastic surgery unless required to treat
injury or illness.
o Vaccination & Inoculation except COVID-19 related vaccination.
o Cost of braces, equipment or devices, non-durable implants, eyeglasses, Cost of
spectacles and contact lenses, hearing aids including cochlear implants, durable
medical equipment.
o All types of Dental treatments except arising out of an accident.
o Convalescence, general debility, ‘Run-down’ condition or rest cure, use of intoxicating
drugs/alcohol, use of tobacco leading to cancer.
o Bodily injury or sickness due to willful or deliberate exposure to danger (except to save
human life), intentional self-inflicted injury, arising out of non-adherence to medical
advice.
o Treatment of any Bodily injury sustained whilst or because of active participation in
any hazardous sports of any kind.
o Treatment of any bodily injury sustained whilst or because of participating in any
criminal act.
o Diagnosis, 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 is required at a Hospital/Nursing Home.
o Vitamins and tonics unless forming part of treatment for injury or disease as certified
by the attending Medical Practitioner.
FAQ’s – Group Medical Insurance Policy 17
 o Naturopathy Treatment.
o Expenses related to any unproven treatment, services and supplies for or in connection
with any treatment. Unproven treatments are treatments, procedures or supplies that
lack significant medical documentation to support their effectiveness.
o Oxygen Concentrator for Bronchial Asthmatic condition.
o Domiciliary Hospitalization.
o Treatment taken outside India.
o Unproven / Experimental Treatment.
o Change of treatment from one system to another unless recommended by the
consultant/ Hospital under whom the treatment is taken.
o Service charges or any other charges levied by the hospital, like registration/admission
charges.
o Treatments such as Rotational Field Quantum Magnetic Resonance (RFQMR), External
Counter Pulsation (ECP), Enhanced External Counter Pulsation (EECP), Hyperbaric
Oxygen Therapy.
o Expenses related to any admission primarily for diagnostics and evaluation purposes.
o Any diagnostic expenses which are not related or not incidental to the current
diagnosis and treatment.
o BREACH OF LAW - Expenses for treatment directly arising from or consequent upon
any Insured Person committing or attempting to commit a breach of law with criminal
intent.
o Treatments received in health hydro’s, nature cure clinics, spas or similar
establishments or private beds registered as a nursing home attached to such
establishments or where admission is arranged wholly or partly for domestic reasons.
o Embryo freezing charges on standalone basis is not covered.
o Standalone Investigation charges like PET Scan, CT scan etc. are not covered.
o Other standard exclusions specific to the insurance company.

30) Which are the Day Care procedures admissible under the policy?

For the day-care procedures covered under the policy, please refer to the list below for a
few examples: Final admissibility is decided by PARAMOUNT TPA & the insurance
company.

Anti-Rabies Vaccination Piles / Fistula

Hysterectomy Dilatation & Curettage (D & C) of Cervix
Appendectomy Prostate
Inguinal/Ventral/Umbilical/Femoral Hernia Eye surgery
Coronary Angiography Radiotherapy
Lithotripsy (Kidney Stone Removal) Fracture / dislocation excluding hairline
Fracture
Coronary Angioplasty Sinusitis

FAQ’s – Group Medical Insurance Policy 18

 Parenteral Chemotherapy Gastrointestinal Tract system
Dental surgery following an accident Stone in Gall Bladder, Pancreas, and Bile Duct
Hydrocele Haemo-Dialysis
Urinary Tract System Tonsillectomy

31) I am putting in my papers. Whom shall I get in touch with to avail portability?

You shall receive detailed instructions when you receive various forms as part of your
relieving / Handing Over procedure. One of the forms would have instructions on
portability.
Please note that, the initiation of portability has to be done at least 15 working days
before the date of separation by you through an email to HR along with details like your
date of Joining, Date of Separation, Alternate Mobile No, & Alternate E mail ID. Post
which, the same will be shared with Portability Team at [email protected]
who will help you in getting the necessary insurance credit certificate as well as getting
the new insurance cover started for you based on the receipt of appropriate premium
from you. You can get in touch with your HR SPOC who will help you with your Off-
Boarding formalities.

32) Who is eligible for portability?

If you have completed one year with Citi, then you and your dependents (Employee,
Spouse, Child, Parents, Parents in law) are eligible for portability.
• Dependent sibling coverage is not eligible for portability.

33) What is Portability? How is it beneficial to me?

Portability is a facility created by IRDAI (Insurance Regulatory & Development Authority of India
- Insurance sector regulator in India) to help the insured member carry the time credit of
their insurance plan when they exit from a group plan to a retail plan.
Example 1: If you & your dependents have been insured under Citi plan for the last 4
years & you decide to separate from Citi and start your own business or join some other
organization. At such a time, your Citi insurance will cease to exist with effect from your
last working day & you have to buy a retail insurance plan. Retail plans typically have
restrictions like 30 Days waiting period, 1st & 2nd Year Exclusion & Pre-existing diseases
cover only after 4 years of cool off period etc. These clauses are restrictive by nature &
hence, some of your claims will not be paid due to these conditions.
However, if you port your insurance plan, you will get waivers for all these conditions as
you already have a 4-year insurance credit history.
Example 2: If you & your dependents have been insured under the Citi plan for the last 2
years & you decide to separate from Citi and start your own business or join some other
organization. At such a time, your Citi insurance will cease to exist with effect from your
last working day & you have to buy a retail insurance plan. Retail plans typically have
restrictions like 30 Days waiting period, 1st & 2nd Year Exclusion & Pre-existing diseases
FAQ’s – Group Medical Insurance Policy 19
 cover only after 4 years of cool off period etc. These clauses are restrictive by nature &
hence, some of your claims will not be paid due to these conditions.
However, if you port your insurance plan, you will get waivers for all these conditions for
2 years as you already have a 2-year insurance credit history, and a waiting period of 2
years shall be applicable.

34) Can I port the insurance policy to any insurer of my choice?

No, for the first year, you must compulsorily port the policy with the same Insurance
company as your Group Policy Insurer. In our case, the policy would be ported to The Bajaj
Allianz Assurance Co. Ltd. Retail Insurance policy matching closest to your corporate sum
insured plan. However, if you still want to shift to another insurer of your choice, you can
do so after completing one year of insurance coverage under The Bajaj Allianz Assurance
Co. Ltd plan. The next portability would be as per standard guidelines of IRDA for
portability from one Retail Product to another. Kindly note that portability is governed by
3 broad guidelines i.e., Porting to the same insurance company as the Group plan, porting
with the same members who are covered under the Group Plan and port with the same
sum insured limit as under the Group Plan.

35) Can I port the insurance policy only for my dependents?

No, you must mandatorily include self and all dependents as covered in the corporate
policy. A fresh portability policy only for parents and parents-in-law is not allowed.

While porting parents you may not include them in a single floater, a separate policy must
be taken in which you may cover only 2 parents in one policy.

For example: If 4 parents are enrolled under GMC policy. In that case, parents must be
covered under one separate policy and parents in law must be covered under a separate
policy.

36) What is the benefit in terms of the sum insured that shall be available, if I decide to
port my policy?

You can port your basic sum insured of INR 800,000 (ESC) & Top-up Sum Insured to your
individual cover with Bajaj Allianz General Insurance Company.
For either Parents or Parents in law, sum insured of INR 500,000 separately.

37) What will be my premium for such a ported policy? Will it be the same as my corporate
plan?

No, the premium would be as per the retail insurance plan that you may opt for based
on the sum insured. These are pre-published rates & you must pay the premium as per
those rates only. The rates will be made available to you once you reach out for
assistance at [email protected].

FAQ’s – Group Medical Insurance Policy 20

 38) Can I port the policy if I moved overseas from Citi?

Yes, you can opt for the portability policy for your dependents (2 parents and 2 Parents in
law) by paying extra premium.

39) What about my claims under last year’s policy (July 1, 2023 – June 30, 2024)? Will this be
paid or not?

You need not worry about your claims under previous policy. As the admissibility of the
claim depends upon the date of admission at hospital, all hospitalization claims having
date & time of admission on or before 30th June 2024, 12.00 midnight would be paid
under policy, irrespective of date of discharge. In case of reimbursement claims, please
ensure that you submit the same to Paramount Health Insurance TPA office within 15
days from date of discharge. Claims submitted later would not be accepted.
All post hospitalization expenses of the earlier claim, even if they are incurred after 1st
July 2024, would be paid under the previous policy.

40) What is Co-pay? What is the percentage of Co-payment applicable on parental claims?

Co-pay essentially means sharing of expenses by the employee and insurance company.
The parental dependents admitted to the hospital have to bear INR. 5000 or 10% of the
admissible claim, whichever is higher, as Co-Payment.
For example, if the total bill is INR 75,000 and the total admissible claim is INR 70,000,
(Non- medical expenses being INR 5000), insurance company pays INR 63,000 & the
parental dependent must pay for INR 12,000 of which INR 7,000 would be towards co-
payment (10% of admissible claim) & INR 5,000 would be towards non-medical expenses.

41) Will Co-pay be applied on all the parental claims submitted?

Yes, it will be applied on each & every parental claim submitted under this policy including pre-
hospitalization and post hospitalization claim.

42) Is the co-pay payable on each of the parental claims that I make? i.e., Pre-
Hospitalization, Main Hospitalization & Post-Hospitalization

Yes, the pre & post Hospitalization claims are treated as part of Main Hospitalization claim
& hence, the co-pay of 10% of the admissible claim is payable. Here is one example of
how this works. You have submitted your Pre-Hospitalization Claim (INR 1,400) & Main
Hospitalization Claim (INR 5,600) together. The total amount payable is INR 7,000. Hence
the co-pay would be deducted as INR 7,000, 10% of INR 7,000 = INR 700. When you submit
the claim for post-Hospitalization (INR 2,000), there will be a deduction in the post
Hospitalization claim of 10%.

43) How do I avail the Hospitalization benefit?

This benefit can be availed in two forms: -

FAQ’s – Group Medical Insurance Policy 21
 Cashless

This insurance plan is administered by Third Party Administrator M/s PARAMOUNT

HEALTH SERVICES & INSURANCE TPA PVT. LTD. They have a network of hospitals all over
India where your insured dependents can get hospitalized & take the treatment without
paying the eligible expenses upfront from your pocket. (Applicable for only Medical
Expenses. For Non-Medical expenses, you must make the payment as per hospital’s
policy.) Cashless hospitalization allowed only in hospitals that are part of the network
hospital list.
• Planned Cashless:
In the case of Planned Surgeries, you can choose to inform the TPA by mailing
[email protected] of the likely hospitalization, which hospital,
dates, doctor, cost.
1. TPA to utilize the 72 hours to give your perspective of other hospitals
which you can consider.
2. TPA Negotiates with the Hospital.
3. E-Cashless is provided by TPA.

Reimbursement

In this traditional form, after your or dependent’s hospitalization is complete; you need
to make the payment for these expenses & then get the eligible amount reimbursed from
The Bajaj Allianz Assurance Co. Ltd. Reimbursement claim documents should be
submitted within 15 days from date of discharge.
You must collect all original documents as per the document checklist available on the
enrollment portal (refer enrollment portal navigation guide), register the claim & courier
it to the Paramount TPA office address mentioned below within 15 days from the date of
discharge. You can claim by emailing scan documents to
[email protected].

The originals are to be couriered to the TPA office mentioned below:

Courier address:

Paramount Health Services & Insurance TPA Pvt. Ltd

401-402, Sumer Plaza,
Marol Maroshi Rd, Marol,
Andheri East, Mumbai,
Maharashtra 400059.

Documents for reimbursement of claims to be submitted

within 15 days from the date of discharge.
Please opt for room rent within your eligibility. In case you opt for a room higher than
your eligibility, your entire claim amount would be deducted in proportion to the room
rent availed.

FAQ’s – Group Medical Insurance Policy 22

 Please note: TPA shall be settling the claim amount only after receiving the Originals.

44) Where and how to check the Hospitals empaneled under Network list of Insurer as well as
TPA?
Identify whether the hospital is part of TPA Network List by visiting the following link
and mention insurer as Bajaj Allianz and group code as CITI. As the provider network list
is subject to constant updating, we request you to refer to Paramount website or
the updated /black-listed (Excluded) hospital list in your state/city with the
hospitalization.

https://www.paramounttpa.com/Home/ProviderNetwork.aspx

Note - (Cashless and Reimbursement claims under blacklist/Excluded hospital will not
be considered by Ins co.)

45) What is the process to avail cashless facility?

▪ Identify whether the hospital is part of TPA Network List. If yes, please inform
PARAMOUNT TPA and understand the hospital tariff.
▪ Obtain Cashless Request Form from the Insurance Desk of Hosp.
▪ Fill up the form with details like your name, TPA ID No. Relationship etc.
▪ Hospital will fill up details like Date of Admission & Discharge, Ailment,
Treatment Plan, Estimated Expenses & send the Fax to TPA
▪ TPA will scrutinize the Request & send the Approval / Rejection / Query Request
to Hospital
▪ At this stage, if you need any support, please get in touch with Paramount TPA
Coordinators
▪ Patients can get admitted & treatment can start. If the actual bill is more than
the approved amount, additional approval is required.
▪ Ask the hospital to fax the Discharge card & Final Bill at least 4 hours before the
discharge & get the additional approval from TPA.
▪ On discharge, Sign bill & Claim Form, Pay non-medical charges, Co-pay etc.

Note: You (or dependents attending the patient), after the hospital has faxed the Pre-
authorization request, can call the Cashless Coordination of TPA & inform them about the
request.

TPA desk of Paramount will identify issues, if any & will resolve the same after
interaction with member at hospital or hospital staff to ensure smooth & timely
approval of request.

46) How do I claim the amount if the hospitalization is in non-network hospital?

You must collect all original documents and register the claim. Please submit the original
documents as per the document checklist available on enrollment portal (refer

FAQ’s – Group Medical Insurance Policy 23

 enrollment portal navigation guide). The claim documents must then be couriered to
Paramount Health Services & Insurance TPA Pvt. Ltd office within 15 days from the date
of discharge. You should get the settlement within 21 working days from the date of
submission of your claim or the date of fulfilling all the additional documents, whichever
is later.
Additional documents (Deficiency documents) if any need to be submitted within 15 days
from the date of first intimation of the additional required documents.

You can send the documents to below address:

Paramount Health Services & Insurance TPA Pvt. Ltd

401-402, Sumer Plaza,
Marol Maroshi Rd, Marol,
Andheri East, Mumbai,
Maharashtra 400059.

47) What is the list of mandatory documents required for registering a reimbursement claim?

Following is the detailed list of documents. Please note that all reimbursements
documents should be ORIGINAL.
• Claim Forms Signed by You and Hospital: In Form A, all details must be filled in
& should be signed by YOU only. In Form B, the details are to be filled in and
signed by the Hospital. Claim form can be downloaded from India Insure
portal/Paramount Website.
• Discharge Card: It contains details like Date of Admission & discharge, patient’s
condition while getting hospitalized, brief diagnosis & treatment administered
at hospital & doctor’s advice on discharge.
• Letter of 1st Consultation and advice for hospitalization: This is the document
in which your doctor advises you to get hospitalized for medical treatment of
disease or a Surgical Procedure. It should be on the letterhead of the Doctor &
should mention the date.
• Proper Hospital Bills with all Receipts Duly Stamped & Signed: This is the most
important document & in absence of it, no payment can be made. The bill
should be detailed. Also insist that the Registration No. of the hospital is
mentioned on the bill. The receipt for the payments made should be pre-
numbered and preferably pre-printed.
• Medicine Bills with Doctor’s prescriptions for the same: Each medicine bill
must have a date on it & should bear the patient’s name too. In the case of
psychiatric/psychosomatic claims, photocopying of prescriptions is mandatory.
Please Note: Non-Allopathic Doctors cannot prescribe Medicines for follow
ups. Only MD/MS Allopathic Doctors prescribed medicines can be claimed.
• Investigation Reports, Bill Receipts & Treating doctor 's advice letter for all
the tests performed: For all the tests conducted, the same MUST be advised by
the doctor. A receipt of payment should be produced & the report should be
submitted. Kindly note that X-Ray films, CT Scan Films, MRI films and USG films
are not required to be submitted. Kindly submit the paper reports only. Only a

FAQ’s – Group Medical Insurance Policy 24

 report by a competent doctor is good enough. In case of X-ray film required,
same will be communicated separately. In addition, kindly note that if the
Hospital bill mentions charges for 20 (example) pathology tests, reports of all
20 tests must be submitted. Failure to submit 1, will result in the claim being
held under shortfall and subsequent settlement (post 3 reminders) without
charges for the missing pathology test.
• Consultation Papers & Receipts: This is proof of payment made to doctor for
consultations. As these payments are small in denominations, we often forget
to get these receipts & lose on the payments. Please insist on receipt every
time you visit the doctor for consultation.
• Photo ID proof & address proof of claimant (patient): Reimbursement claims,
which are above 1 Lakh, please attach Photo ID proof & address proof of
patient.
• Cancelled Cheque: Request you to submit the cancelled cheque for your bank
account with account holder name, IFSC code.
• Indoor case paper & Form C also required.
• It is very important to note that the ORIGINAL HOSPITALIZATION PAPERS
must be submitted. Hence, kindly keep a photocopy for your medical records.
Disclaimer: At the time of claim processing, TPA officials may require additional
documents in case submitted documents are not enough for claim processing.

48) What happens if I must be hospitalized in case of emergency, e.g.in case of an accident?

In case of such emergency events –

▪ Please take the patient to the nearest good hospital & start the treatment.
▪ Let the patient stabilize.
▪ Follow the standard procedure for Cashless Authorization in case of network
hospital and Reimbursement in case of non-network hospital.

49) My husband & I both of us work with CITI & reside in Metro city (Delhi). My delivery is
due in a couple of months. How much maternity benefit can I avail? Will it be INR
300,000 i.e., INR 150,000 through my husband’s coverage & INR 150,000 through my
own coverage?

No, it would be INR 150,000 only. The maternity limit is per event per policy benefit
wherein the benefit limit is fixed to INR 150,000 for metro cities & that is the maximum
amount that you can claim.

50) I work in CITI & my wife works in some other organization. My wife’s delivery is due in
a couple of months. How can I make a reimbursement claim as my wife also has a group
medical insurance policy from her organization?

You can claim the maternity expenses under the CITI policy up to the limit of INR 150,000
in Metro cities Metro Cities (Mumbai (MMR), Delhi & NCR region, Chennai, Bangalore,
Kolkata, Hyderabad, Secunderabad, Pune, Ahmedabad) or INR 100,000 in Non-Metro
FAQ’s – Group Medical Insurance Policy 25
 cities. If actual expenses incurred by you are more than this limit, then you can check your
Spouse / Domestic Partner’s Medical Insurance policy terms and conditions. There is a
defined process to apply for settlement of the 2 nd claim (claim beyond Citi settlement
amount). You may reach out to [email protected] for further details.

51) Who can avail Surrogacy?

The Insurer shall pay to the hospital or reimburse you, in respect of the medical expenses
of the employee related to surrogacy. Expenses shall be payable only if the dependent
spouse of employee has been unable to attain or sustain a successful pregnancy through
reasonable, and medically necessary infertility treatment.

52) What is the limit for Surrogacy in the policy?

▪ Surrogacy through another woman to be covered as per maternity limit of INR

1.5 Lac in Metro Cities (Mumbai (MMR), Delhi & NCR region, Chennai, Bangalore,
Kolkata, Hyderabad, Secunderabad, Pune, Ahmedabad) and INR 1.00 Lac (Non-
metro).
▪ In case of complications of surrogacy that are life threatening, the limit will be
Base sum insured.

53) What are the important conditions that I MUST know in case I have to make a claim
under the policy?
• Maternity Benefit from day one, limited to INR 150,000 for Normal & C-Section
Delivery in Metro cities (Mumbai (MMR), Delhi & NCR region, Chennai, Bangalore,
Kolkata, Hyderabad, Secunderabad, Pune, Ahmedabad) & INR 100,000/- for
Normal & C-Section Delivery in Non-metro cities.
• Complications arising out of Maternity during hospitalization are payable up to full
sum insured.
• Room Rent limit: Lowest Category Single A/C Room as available in hospital OR any
lower category room available with cost not higher than Single A/C room, if you
opts for higher category A/c room (like Deluxe or Suite room) then proportionate
deduction to be applicable on the higher room rent charges (Actual RR charges -
Single AC Room charge) ICU room charges will be paid as per actual expenses
incurred. All the other expenses are linked to room rent eligibility.
• Co-pay of INR 5,000 or 10% of admissible claim amount whichever is higher for
parent/in law claims only.
• PPN (Preferred Provider Network) Rates applicable.

54) Can I claim for expenses incurred in Hospitalization for Miscarriage/Abortion?

Yes, you can. Miscarriage/Abortion claims can be filed & will be paid under Maternity
limit. However, please note that Voluntary Termination of pregnancy is not payable.

55) Which documents are required for Surrogacy claims?

FAQ’s – Group Medical Insurance Policy 26

 Maternity expenses of the surrogate mother shall be payable under Maternity. Surrogate
means a woman who carries a pregnancy for the insured person. Legal affidavit regarding
intimation of surrogacy/ Legal affidavit regarding all 3 parties’ mutual agreement for
Surrogacy shall be submitted to the Company. Additionally, a letter of treating doctor is
required declaring that spouse of you has been unable to attain or sustain a successful
pregnancy through reasonable, and medically necessary infertility treatment.

All other documents will remain the same as per maternity claims reimbursement.

56) In case I have a permanent disability what is the additional benefit I get?

You are covered under policy with 8 lacs base sum insured. Upon sharing Govt. certified
disability certificate, you may avail CITI sponsored 20 lacs ES2C Top-Up Sum insured.
For example, if you opted for 30 lacs top-up Sum insured CITI 20 lacs premium shall be borne
by CITI and only 10 lacs sum insured premium shall be borne by you.

Process for availing CITI sponsored Top-Up:

a. You reach out to [email protected] indicating that you are disabled and share
Government of India issued disability certificate.
b. India Insure team reviews certificate and confirms sponsorship of 20 lakhs top-up to you.
c. In case you have taken a top-up of less than or equal to 20 lakhs: Top-up to be overridden
to 20 lakhs and no recovery to be made from you subject to completion of declaration.
d. In case you have taken a top-up of more than 20 lakhs: Recovery to be adjusted as
difference of selected top-up premium and 20 lakhs top-up premium.
e. Communication to be sent to you informing you about the revised recovery.

57) How is the premium charged to newly joined employee?

Please note for newly joined employee premium is charged on pro-rate basis. Premium
amount charged is from date of joining till Policy end date (i.e. 30th June 24).
Let us understand this with example:
{(If Employee A joins CITI on 1st December 24 then premium will be calculated for his
voluntary plans selected from 1st Dec 24 till 30th June 25 on prorate basis).
If employee leaves CITI on 30th April 25 then premium for 1st May 25 till 30th June 25 is
refunded from the policy)}.

58) In case of any query regarding this policy, whom should I get in touch with?

Please refer to the below communication matrix to understand the teams, who shall be
responsible for resolving your queries.
Please get in touch with them for any of the following issues.
✓ Checking whether enrolment is done or not.
✓ Getting your Card
✓ In case of delay or problems in getting the Cashless
FAQ’s – Group Medical Insurance Policy 27
 ✓ In case of delay or problems in getting the reimbursement claim
✓ Changes in the enrolment information
✓ Any other query regarding this Health Plan.

Communication Matrix – Paramount Health Services TPA Team

CITI Dedicated 24/7 Helpline Number 022 66629817

For Cashless Queries [email protected] 7400413912
Other Queries Like Reimbursement, E
[email protected] 7400413913
Card, Claim Status Etc.
HELP DESK / PRIMARY SPOC
Chennai Help Desk
Ms. Elavarsi E [email protected] 7400413903
1
Chennai Help Desk Mr. Mohammed
[email protected] 7400413903
2 Muddasar
Pune Help Desk Mr. Akash Gaikwad [email protected] 7400413905
Mr. Bhushan
Mumbai Help Desk [email protected] 7400406826
Adhatrao
ESCALATIONS
Mumbai Escalation Ms. Harshada
[email protected] 74004 06830
Level 1 Nachare
Mumbai/ Central
Mr. Pravin Bhosale [email protected] 74004 06840
Escalation Level 2
Ms. Roshni
Final Escalation [email protected] 93230 36115
Ganjawala

Communication Matrix – India Insure Brokers Team

Primary Email Support [email protected]

Enrolments [email protected] 7075203186
Claim Escalations
Portability/ Anshuman
[email protected] 9100440785
Escalation 1 Vaidyanathan
Escalation 2 Ashish Singh [email protected] 9515661887
Escalation 3 Milind Chavan [email protected] 9769211550

FAQ’s – Group Medical Insurance Policy 28

 COVID-19 SPECIFIC FAQ’s

1. Is treatment towards COVID-19 covered under Citi India’s Health Insurance Program?

Treatment towards COVID-19 care is covered under Citi India’s Health Insurance Plan.
2. What are the exact coverages under Covid Care treatment?

1. Expenses of any medical test and doctor consultation if followed by a hospitalization

with an active line of treatment to cure COVID-19 within 30 days from the date of first
test and doctor consultation.
2. Post Discharge expenses related to same treatment up to 60 days from the date of
discharge duly certified by the treating doctor.
3. All the hospitalization expenses for COVID-19 treatment except copay and non-
medical charges where hospitalization is more than 24 Hrs. with an active line of
treatment.
3. Are there any expenses which are not covered?

1. Expenses of any doctor consultation or medical test which is not followed by any
hospitalization to cure COVID-19
2. Any hospitalization is just for diagnostic purposes.

4. Are there any specific protocols to be followed to undergo COVID-19 Tests?

1. Yes. There are government approved diagnostic labs authorized to undertake COVID-
19 Tests. Please ensure that you use the services available from such centers only
should there be a need.
2. Additionally, please note that Tests cannot be conducted without a prescription from
a Registered Medical Practitioner.
5. What do I do in case there is any need for hospitalization due to treatment for COVID-19?

1. Kindly contact the TPA Helpline number provided, and assistance will be provided to
the best of their ability. Please note that due to this pandemic outbreak, beds in
Private Hospitals are in shortage. Representatives of Paramount Health Services &
Insurance TPA Pvt. Ltd will surely assist you but unfortunately, due to the scarcity, we
will not be able to provide you with any assurance.

➢ Contact Points

1. What is my first point of contact if I am detected positive?

Inform your manager and Call helpline - CAC: 022 66629817 to get doctoral support.

FAQ’s – Group Medical Insurance Policy 29

 2. What is my point of contact in a critical situation?

Call helpline - CAC: 022 66629817 to talk to the doctor for initial diagnosis and
recommendation. Escalate it to your BU head /HRG in critical cases for support.

3. How much time does CAC take to get back with Bed availability?

Seeing the current situation in the country will not be able to commit any timeline. CAC
team will put in best efforts for searching the bed and assist you in getting it arranged but is
not guaranteed.

4. How to download your E card? (Ecard is a verification card to submit at hospitals for
cashless claims)

Login to TotalCompOnline.com and login via a Single Sign-on ( SSO) password > Medi Claim
Insurance & download it from home page & in case you are unable to download write an
email to [email protected] or [email protected] with your 10
digit GEID.
They will share a PDF within a few hours.

5. In the case of Home Care Package, what are the different Covid related treatment
expenses, and you can claim and how.

You are also eligible for reimbursement subject to the limit defined of INR 75,000/- per
family during policy period.
You and your dependents who are currently covered under the Bajaj Allianz Assurance
Group Medical Insurance policy effective period 2024-2025 are eligible to claim under this
policy.
Consultation, medication, Positive Covid test, blood test etc. can be claimed by
submitting reimbursement.
6. Can Home Care Package expenses can be claimed if it is administered by a local
Registered Practitioner (and not via hospital)

Yes, any registered doctor under local municipality with clinic.

7. Is Home Care Treatment cashless or reimbursable?

Home care treatment is reimbursable by submitting relevant proof.

8. Oxygen Cylinders will be reimbursed?

Yes – If Rented; Not Reimbursable if purchased. Prescription needed.

9. Can I check myself into a hotel and claim the reimbursement?

FAQ’s – Group Medical Insurance Policy 30

 In-Home/In-Hotel care reimbursement is provided ONLY towards hospital administered In-
Home/In- Hotel care packages.

10. What are documents I need to keep ready for reimbursement/claim process?

1. Original Claim form

2. COVID positive Report (RT PCR Positive mandate)
3. Original HRCT Report
4. Doctor 1st consultation letter
5. Prescription, advise note of treating doctor (on letter head)
6. Doctors advise letter for home quarantine with mention period.
7. Cancel cheque with your printed name.
8. Aadhar card copy (Patient & you)

11. What is the claim process?

You can claim by emailing scan documents and courier original documents on below address.

[email protected]

Courier address:
Paramount Health Services & Insurance TPA Pvt. Ltd
401-402, Sumer Plaza,
Marol Maroshi Rd, Marol,
Andheri East, Mumbai,
Maharashtra 400059

12. What is the timeline for reimbursement of Covid related claims?

There is no definite timeline to submit claims but generally it should reach TPA’s office within 3
months. Claim documents in original to be couriered to TPA’s office is Mandatory, you can
courier the originals within 30 days after lockdown is lifted.

13. Can you claim the reimbursement of homecare package under INR 75,000/- from the last
year’s treatment bills.?

You can claim for expenses incurred during policy period i.e., 1st July 2024 to 30th June 2025.

➢ Vaccination

14. Can I claim Covid19 vaccination reimbursement and what is the process?

You can reimburse 2 doses plus booster vaccination costs towards the COVID-19 vaccine for
themselves and their eligible dependent family members (excluding parents & parents in
law). This will be administered by our TPA (Third Party Administrator) i.e., PARAMOUNT
HEALTH SERVICES & INSURANCE TPA PVT. LTD, under our Group Medical Insurance Policy
FAQ’s – Group Medical Insurance Policy 31
 with Bajaj Allianz Assurance. The process to claim reimbursement remains the same as that
of claiming other forms of medical reimbursements. Cost of vaccine will be paid on actuals.

FAQ’s – Group Medical Insurance Policy 32