Group Mediclaim Insurance Policy

Transcription

1 Document Release Notice This policy on is released for use in Tata Communication Limited with effect from 31 st March 2016 and it supersedes any other policy communication in this regard.

2 Table of Contents: 1.0 Introduction Objective Scope General Provisions Coverage Sum Insured Premium Salient Features Benefits with capping on admissibility Benefit for retired employee Exclusion Process for availing benefits Policy Administration Process to obtain e-medical cards General Escalation Matrix...12 Terminology Page 2 of 12

3 Hospital/ Nursing Home: It means any institution in India established for indoor care and treatment of sickness and injuries and which Either a) Has been registered either as a Hospital or Nursing Home with the local authorities and is under the supervision of a registered and qualified Medical Practitioner. Or b) Should comply with minimum criteria as under i. It should have at least 15 in-patient beds ii. Fully equipped operational theatre of its own wherever surgical operations are carried out iii. Fully qualified nursing staff under its employment round the clock iv. Fully qualified Doctor(s) should be in charge round the clock. NB: (In class C towns condition of number of beds be reduced to 10) Surgical Operation means manual and/or operative procedures for correction of deformities and defects, repair of injuries, diagnosis and cure of diseases, relief of suffering and prolongation of life. TPA: A TPA is a company appointed by the insurer for smooth functioning of the policy. The TPA i.e. Third Party Administrator performs the following function: It maintains database of policyholders Issue health insurance identity card with unique identification numbers Handle all the post policy issues including claim settlements, cashless benefits etc. TPA appoints doctor s to study all claims to determine the pay ability of the same as per the policy issued by the Insurance Company. Page 3 of 12

4 1.0 Introduction: is introduced to enable employees to avail cashless medical benefit or reimbursement of hospitalization expenses incurred in India for the medial treatment sustained by employees and their declared dependents. 2.0 Objective: The purpose of is as follows: 3.0 Scope: 2.1 To provide employees and their family prompt and easy access to medical facilities 2.2 To provide financial assistance to employees towards hospitalization for defined medical treatments 2.3 To ensure continued health and well-being of employees and their family post retirement subject to the following conditions mentioned in clause 10.0 of the policy The policy is applicable to: 3.1 All permanent employees on rolls of Tata Communications and subsidiaries 3.2 Retired employees of Tata Communications and subsidiaries 4.0 General Provisions: 5.0 Coverage: 4.1 The Oriental Insurance Co. Ltd. is our service provider for FY with Paramount Health Services being the Third Party Administrator (TPA) 4.2 Administration of claims will be managed by TPA 4.3 For queries employees can write to 5.1 The Company will provide a floater Hospitalization Insurance Coverage (Employee + Partner + 2 set of Parents or in Laws + 2 Children (whether adopted/biological) 5.2 There is no age bar criteria for employees and their dependents 5.3 Only unemployed and unmarried Children up to the age of 25 years will be considered as dependents for the purpose of medical benefits. Page 4 of 12

5 6.0 Sum Insured: 6.1 Basic Cover: All eligible employees are covered for a Basic sum insured as mentioned in the table below: Band Sum Insured (Per Family) B1-1 to B4-2 3,00,000 P.A B5-1 & Above 5,00,000 P.A Additional Cover (Top Up): An additional flat top up cover of INR 400,000 per annum (over and above the Sum Insured) can be opted by an employee by paying premium of INR 11,500/- plus applicable service tax. It is at the discretion of employees to opt for additional cover. This option is available till 30 th June, New joiners in the current policy year have the option of increasing their Sum Insured by opting for Top up of 4lacs within 3 months of their date of joining. Employees may send the request to Askhr@tatacommunications.com to avail the top up facility. Benefits of top up:- Increased medical coverage from INR 3 and 5 Lakhs to INR 7 Lakhs and 9 Lakhs respectively to provision for unforeseen medical emergencies of self and dependents. Tax deduction INR 11,500 top up premium will qualify for deduction under section 80D 7.0 Premium: 7.1 Premium for basic cover for employees (self) and dependents is entirely borne by Tata Communications. 7.2 The top up premium of INR 11,500/- for flat additional cover of INR 4,00,000 will be entirely borne by employee and recoverable from the salary in one lump sum 7.3 There will be no refund of unutilised Top up premium in the event of separation from service during the policy year 8.0 Salient Features: 8.1 Minimum 24 hours of hospitalization for treatment of an ailment is a must to avail benefits of the policy. 8.2 However, the minimum hour of hospitalization is waived off in case of specific treatment such as Cataract, Chemotherapy, Radiotherapy, Haemodialysis, Eye Surgery (including lens implants, Injection Macugen (Pegabtanib) and Injection Avastin and Lucentis), Dental Surgery, Lithotripsy (Kidney stone removal), Dilation and Curettage (D&C), Tonsillectomy etc, taken in the Hospital/ Nursing Home and the Insured is discharged on the same day; the treatment will be considered to be taken under Hospitalisation Benefit. Page 5 of 12

6 8.3 Base and top-up sum Insured can be fully/ partly used for any member of family, including self. 8.4 Pre-existing diseases: All pre-existing diseases (not otherwise excluded from the policy) are covered. All diseases will be covered from the day one of the policy start date without any waiting period. 8.5 Domiciliary Hospitalization: Domiciliary hospitalization is covered in the policy. 8.6 Pre Hospitalization: Relevant medical expenses incurred 30 days prior to the hospitalization date on disease/ illness/injury sustained shall be considered as part of claim. 8.7 Post Hospitalization: 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. 8.8 Expenses incurred towards OPD treatment for injuries arising out of accidents are covered. 8.9 Emergency Ambulance cover is restricted to INR 2500 per incident Mid-term inclusions are permitted only in the case of new joiners for new born and spouse on account of marriage. Intimation of the same to be informed to HRSSC Benefits Team within 30 days of the event The treatment for the following diseases are covered under the policy: Cancer (all types of treatment and chemotherapy radiation, injection and oral medicines including oral treatment/ cyber knife and Stem cell transplant). NO tobacco/ smoking history are considered for processing the claims. Internal and external congenital anomalies Infertility treatment covered and capped at 10k maximum. Robotic surgery Sleeve Gastrostomy (above BMI index of 50) Skin treatment Psoriasis as an OPD Psychiatric treatment PET Scan for all treatment Cerebrovascular Stroke Kidney/ major organ Transplant Liver Transplant Coronary arteries bypass graft Haemodialysis, Radiotherapy Eye Surgery, Laser Eye Treatment (including lens implants) Eye treatment through Inj. Macugen (pegabtanib) and Inj Avastin/Lucentis are covered. (Only treatment for correction of refractive error is not covered) Dental Surgery arising out of accident/ dental disease including periodontal Flap surgery. Lithotripsy (Kidney Stone Removal), Dilation and Curettage (D&C) Tonsillectomy, etc even hospitalization is less than specified period Hepatitis Virus (All types) Page 6 of 12

7 Treatment of AIDS (Acquired Immune Deficiency Syndrome) Central Precocious Puberty (CPP) (hormonal disorders are covered even if treated in OPD. 9.0 Benefits with Capping on Admissibility: 9.1 Room Charges: Room rent is capped at 2% of Sum Insured or Single AC Room whichever is less No capping on room charges for ICU Please ensure that you opt for a room as per your eligibility. In case, room opted higher than eligibility, all cascading charges will be borne by employees. Like surgeon charges, Operation theatre charges, Anaesthesia & anaesthetist charges, doctor s daily visit charges, Investigation charges & other hospital charges excluding Pharmacy & consumables. 9.2 Maternity Benefit: Insurance Company shall reimburse to the employee actual expenses not exceeding an amount of INR 75,000/- for normal delivery and INR 100,000/- for caesarean section However, any treatment arising from traceable pregnancy including maternity related disease is covered under normal sum insured Insured can claim maternity expenses for only first two living children. However maternity benefits can be extended to the 3 rd child in respect of following scenarios: Twins in case of second delivery having one child alive First delivery twins and second deliver is normal child New born babies are covered right from the time of birth. Name of the infant to be intimated to HR Shared Service Team within 30 days of the event Pre and post-natal expenses are covered up to a limit of INR 5, Dental Treatment: Root Canal Treatment is covered per family for limit of INR 30, Any dental treatment or surgery which is corrective cosmetic or aesthetic procedure including wear and tear is not included. 9.4 Eye Cataract: Surgery cost of all types of Intraocular lenses (IOL) necessitated with eye operation is covered. Maximum admissible cost INR 40, Coverage of AYUSH Treatment: Page 7 of 12

8 9.5.1 AYUSH (Ayurveda, Yoga, Unani, Siddha and Homeopathy) treatment are covered up to 25% of the Sum Insured provided the treatment for illness/ disease and accidental injuries in such cases is taken in Government hospitals or a hospital attached to a medical college. Any rejuvenation therapies including wellness, massage and usage of SPA will not be covered under this policy. 9.6 Infertility treatment: Infertility treatment covered and capped at INR 10,000 maximum. IVF & IUI not covered Benefits for retired employees: 10.1 All employees of Tata Communications and its subsidiaries enrolled under the policy can continue with the existing policy post retirement at the same rate of premium as applicable under the policy in the concerned financial year, however pro-rated premium amount for the remaining period of the policy will be borne by the retiring employee. For e.g. if an employee retires in the month of June and chooses to continue with the policy then in this case the premium for the period post June till 30 th March will be borne by the retiring employee as per the applicable rate for that year The premium rates are charged on a family floater basis irrespective of number of family members covered For continuation of the coverage in the subsequent years, retired employees are required to communicate their decision to HR Shared Services team in the month of March every year Retired employees have the option to continue with the medical coverage year on year provided there is no break in the period of coverage Exclusion: The company shall not be liable to make any payment under this policy in respect of any expenses whatsoever incurred by any Insured person in connection with or in respect of: Injury/ disease directly or indirectly caused by or arising from or attributable to War invasion, Act of foreign enemy, war like operations (Whether war be declared or not) The cost of Cosmetic Surgery, Spectacles and Contact lenses, hearing aids Expenses on Vitamins and tonics unless forming part of treatment for injury or disease as certified by the attending physician Circumcision unless necessary for treatment of a disease not excluded here under or as may be necessitated due to an accident, vaccination or inoculation or change of life or cosmetic or aesthetic treatment of any description, plastic surgery other than as may be necessitated due to an accident or as a part of any illness. Page 8 of 12

9 11.5 Hospitalization occurring on account of suicide attempt will not be covered Any hospitalization occurring on account of voluntary abortion will not be covered. However if the doctor advises abortion on account of any health problems of the patient/ insured will be covered Beauty treatment of any description 11.8 Family Planning Operations (Vasectomy or Tubectomy) etc Plastic Surgery (other than necessitated due to accident) Accident treatment under the influence of Alcohol or intoxicating drugs Injury or Disease directly or indirectly caused by or contributed to by nuclear weapons/ materials Naturopathy Treatment Disease or accident due to adventure sports Vaccinations given to the new born baby after birth Any Medical test or treatment related to Genetic disorder will not be payable Hospital Charges and consumable medical items as declared by the IRDA are not covered under the Policy: Telephone/ Fax expenses Private nurses, conveyance bills, food and beverages Washing and Laundry charges, transportation charges External implants and accessories like crutches, abdominal belts, waterbed, spectacles etc. Expenditure on Non-medical items as declared by the Insurance company in the Paramount portal will be borne by the employee and paid directly to the hospital Cosmetic items like Soap, Oils, and Powders etc. Other expenditure which is not related to the illness/ hospitalization Expenses incurred on any accompaniment family or others during the hospital stay will not be covered under the policy The above list is illustrative and not comprehensive. Cost of such services have to be borne by the employee and paid directly to hospital at the time of discharge Process for Availing Benefits: Page 9 of 12

10 12.1 Cashless Hospitalization - Admission: Under this option, the insurance company pays the Hospital Authorities upfront on behalf of the floater policy holder provided the necessary conditions are satisfied. This is applicable only in case of Network hospitals, i.e. the hospital that insurance company has tie ups with. Pre-Authorization is necessary to avail of the cash free services in the hospitals. Although, in some hospitals as per their norms, the insured person might need to pay a sum of deposit, which on discharge will be reimbursed to them by the hospitals. The insured person to contact with the hospitals in advance; visit TPA website for the latest list of hospitals. The insured person needs to fill the pre-authorization form at hospital s TPA helpdesk. The hospital fills the pre-authorization form with estimated expenditure, complete medical details, line of treatment etc. with hospital s authorized person s signature and hospital stamp. Pre-Authorization form to be sent to TPA by the hospital prior to admission into the hospital. After due scrutiny of the medical case and taking into consideration terms, conditions exclusion clauses, cover limits etc., once the insured person s eligibility is established, TPA will issue an Authorization Letter to hospital within 2 hours of receiving of the complete documents from the hospital. The insured person needs to approach the Reception Counter of the hospital with his/ her ID card on the day of admission to the hospital. The Hospital/ Nursing Home will admit him/ her and extend the credit facility up to the amount guaranteed by TPA subject to availability of bed. The original documents will be retained by the hospital and sent to TPA within 7days of discharge. The insured person should also keep a copy of all documents. The patient or hospital has to check and sign the final hospital bills at the time of discharge from the hospital. In case one chooses to get treated in a non-network hospital, no cashless facility would by extended by TPA Reimbursement Facility: In case one chooses to get treated in a non-network hospital, no cashless facility would by extended by TPA. However employee may settle the bill and claim for the reimbursement as per eligibility. The insured person/ family to get admitted as per the rules of hospital and make payments for the treatment taken. Pay the hospitalization bill. Employee within 30 days of discharge of patient to send across the list of relevant documents in original along with completely filled claim form to Corpo Mediclaim Helpdesk, A 10 Building, 4 th floor, Alandi Road, Dighi, Pune On clearance, TPA would settle the claim reimbursement amount directly to the employee s bank account via NEFT within 15 days based on the details mentioned in the blank cheque submitted by the employee along with the claim form 12.3 Checklist for submission of Claims: Page 10 of 12

11 Claim Form duly filled and signed All Hospital Bills/ Payment receipts in original Discharge Summary/ Card in original All investigation report in original Bills and receipt for investigation done outside the hospital in original Prescription, Pre hospitalization bills in original Bills of medicines and surgical appliances if purchased by employee in original Blank cheque required for claim settlement Copy of ID proof (voter s ID, driving license or PAN Card) and address proof in case the claim reimbursement amount is INR 1,00,000 or above 13.0 Policy Administration: 13.1 will be coordinated on Pan India basis by the HR Shared Services Team Process to obtain e-medical cards Logon to Enter your employee code as User Name Enter your date of birth in DD/MM/YYYY format as your Password E.g. If your employee code is and date of birth is 14-Dec-1970, then: User Name: Password: 14/12/1970 Click on the submit button Select e-medical cards to print and click on the Print button 15.0 General 15.0 You can access the following by logging onto Claim forms Claim procedures Claim status Helpline numbers Cashless procedure List of Pan India network hospitals 16.0 Escalation Matrix Page 11 of 12

12 Please use the escalation matrix below for further support Category Representing the TPA Representing Tata Communications Level 1 Mr. Pradeep Patil corpomediclaim@tatacommunications.com Ph: , IP: Mobile : Mr. Rahul Chalke Rahul.chalke@tatacommunications.com Ph : , IP Mobile : Level 2 Level 3 Level 4 Dr. Vaibhav Patil vaibhav.patil@paramounttpa.com Ph: , IP: Mobile : / Mr. Vinayak Palav Mobile : Vinayak.Palav@paramounttpa.com Manager Ms. Roshni Ganjawala Ph: Mobile Roshni.Ganjawala@paramounttpa.com AVP - CUSTOMER RELATIONS Ms. Yasmeen Yasmeen@tatacommunications.com Ph : , IP Mobile : Mr. Sunny Achantani Sunny.achantani@tatacommunications.com Ph: , IP Mobile: ***** Page 12 of 12