Consolidated Group Mediclaim Policy

Transcription

1 Consolidated Group Mediclaim Policy National Insurance Company Limited has been finalized as the service provider to provide Medical Insurance services to the employees of Bharti Airtel & Group companies. Following are the premium rates for different slabs which will be applicable during the period of this policy; Annual Premium (Inclusive Service 12.36%) Description Self 2,374 3,257 4,274 5,429 Self + Spouse + 2 Children 4,672 6,409 8,412 10,681 Self + 1 Parent 10,802 14,814 19,440 24,688 Self + 2 Parents 14,631 20,067 26,334 33,444 Self + Spouse + Kids + 1 Parent 13,099 17,964 23,578 29,942 Self + Spouse + Kids + 2 Parent 16,930 23,219 30,471 38,695 Rs. 300 will be deducted over and above the aforementioned premium on account of insurance service cost. The Policy coverage has started from 1st June :00 Hrs. Instructions have been passed on to the TPA and the Insurance Company to accept the claims, if any, despite non receipt of ID cards till the time the employee data is finalized by Airtel and the e-cards are issued to the employees. Please note the following; FHPL ( Family Health Plan (TPA) Limited has been introduce as TPA to service this policy this year. Employees who have claimed in the last 2 policy years cannot reduce the sum insured in this year policy, however they can increase the sum insured if they so desire. The minimum sum insured for employees opting for ( Self+Spouse+Kids) should be 3 Lacs instead of 2 Lacs for employees in Band 1 and above. Employees to take up higher sum insured (at least 3 lacs) in case they are opting to enroll parent(s) for employees in Band 1 and above. Mandatory self coverage of 2 Lac will be applicable for all employees in case the employee is voluntarily not opting through the enrolment website. REQUIREMENT FROM THE EMPLOYEES: The following are the requirements from the employees; All employees (irrespective of covered in last year or not) should update the coverage details and choose the new sum insured in the website at.

2 Bharti Airtel Limited and its Subsidiaries/Associate Companies Username will be your employee ID. Password will be your Date of Birth on DD/MM/YYYY format. Please don t forget to use /. You can access the web portal with your Employee ID (without B00) as username and Date of Birth as password. Website will be opened for data updation from 03 rd June to 20 th June Later on no existing employees who have joined on or before 31 st May 2015 will be able to update the website or opt for the Mediclaim coverage. All subsequent additions and deletions shall be happening through the website. The website will be available from 5th to 20th of every month for updation. Only new joinees and newly wedded spouse / new born child details can be updated during this period. New joinees will be converted to self-coverage of 2 Lacs in case they did not opt for the coverage in the very next month of their joining through portal. Newly wedded spouse can be added within 30 days of marriage and new born child can be added within 30 days from the date of birth. There will be no physical cards. E-cards can be downloaded from the enrolment website by the employee as per the requirement throughout the year. E-cards can also be downloaded through mobile app. All premiums paid by the company shall be fully adjusted from employee s TCTC by the Central Payroll team. In case an employee (or family member covered under this insurance) is leaving the organization during the policy period after receiving the claim benefits, prorate deduction of premium till the policy end date will be recovered from the employee through full & final settlement. In this case insurance coverage will end on the last working date with the organization. ANNEXURE 1 - SCOPE of Consolidated Mediclaim Policy Coverage: Sum Insured will be the following; Rs /- Rs /- Rs /- Rs /- Mandatory self coverage of 2 Lac will be applicable for all employees in case the employee is voluntarily not opting through the enrolment website.

3 General Terms & Conditions Coverage of family members: Parents selected last year cannot be removed this year; exception to change only on account of death is allowed. Any changes opted by employee will automatically be rejected by the system and will be converted to the current coverage plan with the existing members. This year employees are free to add dependents who were not covered in last year policy period. However, removal of dependents is possible only for spouse and children from last year covered members. Parents covered last year can only be removed on account of demise. Family Floater: Coverage will be on family floater basis. Family consisting of self, spouse, first two living children and parents. Employee will have the option to decide on family members to be covered irrespective of last year coverage except deletion of parents. Parents in law & siblings are excluded from this policy. Mid-term inclusion: Mid-term inclusion is permitted only for new joinees, new born children and newly wedded spouse. New members under this policy will not be permitted during the policy period except as above, hence include your parents at the first instance itself. Additions and deletions on prorate basis of premium. Day one coverage for new joinees will be applicable in this policy. Policy Period: The Policy coverage should start from 1 st June 2015 and will expire on 31 st May 2016 Age Limit: No age limit. Maternity Expenses: Maternity coverage within overall floater sum insured with maximum limit of Rs /- for normal delivery and Rs.60000/- for cesarean for 2& 3 Lacs sum insured categories. In 4 & 5 Lac sum insured categories the limit will be Rs.60000/- for normal delivery and Rs.75000/- for cesarean. Room rent capping will be applicable for all maternity cases. Maternity benefits will be a part of the policy up to the Maternity limit as applicable for normal delivery and cesarean. Any hospitalization on account of maternity or a complication of maternity will be considered under this Maternity Limit itself. Insured can claim maternity expenses for only first two living children. However, in case the second delivery is for twins then all maternity benefits (all additional expenses within the above limit) will be applicable for the third child. Day one child coverage will be applicable in this policy.

4 Bharti Airtel Limited and its Subsidiaries/Associate Companies Waiting period of nine months has been waived off in case of maternity benefits for all members. No co-payment will be applicable for maternity benefits. Maternity Benefits to include Pre and Post hospitalization and OPD coverage subject to the overall capping under maternity. Please note that this will include any costs / treatments / hospitalizations on account of maternity or a complication thereof. Co-Payment: Co-payment is the amount to be paid by the employees at the time of hospitalization directly to the hospital. Co-payment applicable in the policy is as per the slab given below. This will not be applicable for capped ailments, all implants and accidental cases. Description Co payment % Parents 10% Self, Spouse & Kids 5% Congenital Anomaly means an external Congenital Anomaly refers to a condition which is present since birth, in the visible and acceptable parts of the body, and which is abnormal with reference to form, structure or position. An Internal Congenital Anomaly refers to a metabolic or anatomic deviation from the normal pattern of development that is apparent at birth or at a later stage. Internal Congenital Anomaly will be payable but external Congenital Anomaly will not be payable in this policy. Room Rent: Cap on room rent shall be 1.5%/semi private room whichever is higher of opted sum insured for 2 & 3 Lac sum insured categories and 2%/ single private room whichever is higher of opted sum insured for 4 & 5 Lac sum insured categories. All other charges will commensurate with respective room rent capping. This means incase an employee opts for a higher category room, all additional expenses on account of the difference in the room category will be borne by the employee including doctor s fees, nursing and investigations charges and any other charges associated with the room rent. This will be calculated on the percentage difference in the room rent eligibility (1.5% or 2% basis on sum insured opted by employee) Vs the actual room rent opted by the employee. For e.g. in case an employee opt for a room of Rs.7000 against his eligibility of Rs.3500, Insurance Company will settle only 50% of the total bills and all other capping in this policy will be applicable on this 50% amount. This amount is inclusive of nursing care, RMO Charges, OT charges, and administration charges. However, this will not be applicable on drugs and consumables. There will be no capping applicable for ICU charges which will be paid on actuals.

5 Hospitalization: Expenses of hospitalization for a minimum period of 24 hours shall be covered. However this limit will not apply for treatments specified in the standard policy terms of National Insurance which is available on intranet. Exceptions will be subject to the following conditions; The treatment is such that it necessitates hospitalization and the procedure involves specialized infrastructural facilities available in hospitals. Due to technological advances hospitalization is required for less than 24 hours only. Procedures / treatments usually done in out patient department are not payable under the policy even if converted as an in-patient in the hospital for more than 24 hours. Admissions for investigations are generally not covered unless there is a threat to the life of the patient like cardiac ailments or any other critical ailments. Any One Illness: Any one illness will be deemed to mean continuous period of illness and it includes relapse within 45 days from the date of discharge from the hospital / nursing home where the treatment has been taken. Occurrence of the same illness after a lapse of 45 days as stated above will be considered as fresh illness for the purpose of this policy. Domiciliary hospitalization: Domiciliary hospitalization will not be covered in the policy. Ambulance Benefits: Maximum up to Rs.5000 per hospitalization or actual whichever is low. However, this can be used only for taking a patient to the hospital or shifting a patient from one hospital to another. Under no circumstances, this can be used for shifting a patient from hospital to home. Pre-hospitalization expenses: Relevant medical expenses incurred 30 days prior to the hospitalization date on disease / illness / injury sustained shall be considered as part of claim. Post-hospitalization expenses: Relevant medical expenses incurred 60 days after the discharge date from the hospital on disease / illness / injury sustained shall be considered as part of claim. Pre-existing diseases: All pre-existing diseases are covered. All diseases will be covered from the day 1 of the policy start date without any waiting period. Terrorism Coverage: Injury / disease directly or indirectly caused due to terrorism will be covered. However injury / disease directly or indirectly caused due to war, invasion act of foreign enemy, war like situations (whether war be declared or not) will not be covered.

6 Ailment / Surgical Procedure capping: These capping is the maximum amount payable by the insurer, however, the actual payable amount will be this capped amount or actual amount whichever is lower. No copayment will be applicable for these ailments. List of ailments capped is given below. Sl No. Procedure / Ailments Maximum Capping (RS) CARDIOLOGY 1 Angiography Anigoplasty (stent / implant cost additional and will be paid on actuals) CABG E.N.T 4 Cataract 2 & 3 Lac coverage category Cataract 4 & 5 Lac coverage category GENERAL SURGERY 6 Appendectomy (Lap) Appendectomy (Open) ORTHOPAEDICS Total Knee Replacement (Unilateral) + Cost of Implant additional 8 (bilateral will be double of this cost, stent / implant cost additional and will be paid on actuals) 9 HIP Replacement (stent / implant cost additional and will be paid on actuals) UROLOGY & NEPHROLOGY Dialysis +Cost of Fluids 3500 Maternity capping will be as per the details mentioned above in maternity clause. Coverage of AYUSH Treatment: AYUSH (Ayurveda, Yoga, Unani, Siddha and Homoeopathy) treatment will be covered in this policy. There will not be any cashless facility available for these treatments. This will be on reimbursable basis and there has to be a minimum stay of 10 days in a government hospital / Medical College is mandatory. Any rejuvenation therapies including wellness, massage and usage of SPA will not be covered in this policy. Claim intimation: Employee should intimate the TPA within 24 hours of hospitalization in case of unplanned treatment and before 48 hours of hospitalization in case of planned treatments. This will be applicable for both cashless as well as reimbursement cases.

7 Submission of Claims: Claim submission date would be 30 days after the discharge of the patient from the hospital. Post hospitalization claims should reach the TPA within 90 days of the discharge of the patient from the hospital or within 30 days from the last treatment taken date. Medical Examinations: There will not be any medical examinations for the members covered in this policy. Grievance Redressal System: The decision of the insurance company on claim settlement will be final and binding. Employee should approach the grievance cell of the insurer / Insurance Ombudsman / IRDA for Grievance Redressal. Policy exclusions: Hospitalization occurring on account of suicide attempt / intentional self-injury will not be covered. Expenses incurred on investigations shall not be covered in case an ailment is not coming out of the investigations even if the hospitalization is for more than 24 hours. However, this will not be applicable for accident & critical ailment cases like cardiac related ailments, etc. Treatment of AIDS is not covered Dental treatments including root canal treatments will not be covered in the policy. However any dental surgery on account of accident will be covered. All other general exclusions provided in the standard policy of the insurer which is not related to any clause mentioned above. Mediclaim Helpdesk 1) TPA : FHPL ( Family Health Plan ( TPA) Ltd For any claim intimation please write to delhipreauth@fhpl.net 2) Employee Helpdesk : HIBS address: assist@hibsprotect.com Contact details: , , , In case of any disconnect you can escalate your case on the following number: ,