Group Mediclaim Insurance Policy

Transcription

1 Group Mediclaim Insurance Policy Document Release Notice This policy on Group Mediclaim Insurance Policy is released for use in Bharti Airtel Limited and its subsidiaries/associate companies with effect from 01 st June 2016 and it supersedes any other policy communication in this regard Page 1 of 13

2 Table of Contents: 1.0 Introduction Objective Scope General Provisions Coverage Sum Insured & Premium Salient Features Benefits with capping on admissibility Exclusion Co Payment Process for Coverage Process for availing benefits Ex-Employee Policy Administration Helpdesk & Contact details..13 Page 2 of 13

3 Terminology 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. 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 study all claims to determine the pay ability of the same as per the policy issued by the Insurance Company. Page 3 of 13

4 1.0 Introduction: Group Mediclaim Insurance Policy Group Mediclaim Insurance Scheme is introduced in order to enable employees to avail cashless medical benefit or reimbursement of hospitalization expenses incurred in India for the treatment of illness/diseases or injuries sustained by employees and their beneficiaries (declared dependents) during the period of insurance. 2.0 Objective: The purpose of Group Mediclaim Insurance Scheme is as follows: 3.0 Scope: 2.1 To provide employees and their family prompt and easy access to medical facilities. The policy is applicable to: 3.1 All permanent employees on rolls of Bharti Airtel Limited and its subsidiaries/associate companies. 4.0 General Provisions: 5.0 Coverage: 4.1 National Insurance Co. Ltd. is our service provider for the scheme with Family Health Plan ltd being the Third Party Administrator (TPA). 4.2 Entire administration of claims is online through Family Health Plan Ltd. 4.3 For queries employees can write to 5.1 Employee have an option to enroll self and dependents as per below grid. Self Self+Parents Self+Spouse+Kids Self+Spouse+kids+parents Self+Spouse+Kids+Parents in law 5.2 Employees have an option to enroll either parents or parents in law one set of parents. 5.3 There is no age bar criteria for employees and their dependent parents and parents in laws. 5.4 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 13

5 5.5 Mandatory self- coverage of 3 Lac will be applicable for all employees in case the employee is voluntarily not opting through the enrolment website. 5.6 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 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 Select Company> Username will be your employee ID (without B00). Password will be your Date of Birth on DD/MM/YYYY format. Website will be opened for data updation from 03rd June to 20th June Later on no existing employees who have joined on or before 31st May 2016 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. 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. Page 5 of 13

6 6.0 Sum Insured: 6.1 Basic Cover: All eligible employees can opt for family floater coverage as per below table, the premium against the same will be adjusted from CTC in subsequent month on prorate based: Annual Premium including Service 15% ( In Rupees) Band B1 & Below B2 & Above Family Floater 3 Lac 5 Lac 3 Lac 5 Lac Self 2,415 4,025 2,415 4,025 Self +Spouse+2kids 4,830 8,050 4,830 8,050 Self + Parents 9,488 15,813 16,388 27,313 Self+Spouse+2kids+parents 12,075 20,125 18,975 31,625 Self+Spouse+2kids+Parent in laws 12,075 20,125 18,975 31,625 Additional Cover(Top Up): An additional flat top up cover of INR 5 lac and 10 lacs per annum (The option is available only for employees opting for Rs. 5 lac base coverage) can be opted by an employee by paying premium as per below grid. It is at the discretion of employees to opt for additional cover. However this option is available till 20 th June, Family Floater Premium for TOP UP Coverage Additional 5 Lac Additional 10 lac Self 2,156 4,313 Self +Spouse+2kids 4,313 8,625 Self + Parents 8,625 17,250 Self+Spouse+2kids+parents 12,650 25,300 Self+Spouse+2kids+Parent in laws 12,650 25,300 New joiners in the current policy year have the option of increasing their Sum Insured by opting for Top up in the following month of their date of joining the company. Benefits of top up:- Increased medical coverage from INR 5 Lakhs to INR 10 Lakhs and 15 Lakhs respectively to provision for unforeseen medical exigencies of self and dependents. Page 6 of 13

7 7.0 Salient Features: 7.1 Minimum 24 hours of hospitalization for treatment of an ailment is a must to avail benefits of the scheme. 7.2 However, the minimum hour of hospitalization is waived off in case of specific treatment such as Cataract, Chemotherapy, Radiotherapy, Hemodialysis,, Lithotripsy (Kidney stone removal), 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 Hospitalization Benefit. 7.3 Base and top-up sum Insured can be fully/ partly used for any member of family, including self. 7.4 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. 7.5 Domiciliary Hospitalization: Domiciliary hospitalization is not covered in the policy. 7.6 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. 7.7 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. 7.8 In addition to other treatment covered in general terms & policy of the insurance company, the treatment for the following diseases are also 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 Robotic surgery Psychiatric treatment Genetic disorder Cerebrovascular Stroke Kidney/ major organ Transplant(including donor treatment) Liver Transplant ( Including donor treatment) Coronary arteries bypass graft Haemodialysis, Radiotherapy Cataract ( Capped 2-3 lac Rs. 25K, 4-5 lac Rs. 40K per eye) Dental Surgery arising out of accident Lithotripsy (Kidney Stone Removal), Dilation and Curettage (D&C) Hepatitis Virus (All types) Treatment of AIDS (Acquired Immune Deficiency Syndrome) Central Precocious Puberty (CPP) (hormonal disorders are covered even if treated day care). Page 7 of 13

8 8.0 Benefits with Capping on Admissibility: 8.1 Room Charges: Cap on room rent shall be 1.5%/semi private room whichever is higher of opted sum insured for 3 Lac sum Insured category and 2%/ single private room whichever is higher of opted sum insured for 5 Lac sum insured category No capping on room charges for ICU Employees are requested to opt for a room as per their eligibility. In case the room opted for is higher than the eligibility, there will be cascading effect (proportionate incremental deductions) on surgeon charges, Operation theatre charges, Anaesthesia and anaesthetist charges, doctor s daily visit charges, Investigation charges, other hospital charges etc. excluding Pharmacy/consumables. These incremental charges will be borne by the employee 8.2 Maternity Benefit: Maternity coverage within overall floater sum insured with maximum limit of Rs. 50,000/- for normal delivery and Rs.75,000/- for cesarean for 3 Lacs sum insured category. In 5 Lac sum insured category the limit will be Rs.60,000/- for normal delivery and Rs.1,00,000/- 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. 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 Page 8 of 13

9 8.3 Eye Cataract: Surgery cost of all types of Intraocular lenses (IOL) necessitated with eye operation is covered. Description Amount Cataract 3 Lac coverage category, per eye Cataract 5 Lac coverage category, per eye 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. 8.5 Infertility treatment: Infertility treatments are not covered in policy. 9.0 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:- 9.1 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). 9.2 The cost of Cosmetic Surgery, Spectacles and Contact lenses, hearing aids. 9.3 Expenses on Vitamins and tonics unless forming part of treatment for injury or disease as certified by the attending physician. 9.4 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. 9.5 Hospitalization occurring on account of suicide attempt will not be covered. 9.6 Any hospitalization occurring on account of voluntary abortion will not be covered. 9.7 Beauty treatment of any description Page 9 of 13

10 9.8 Family Planning Operations (Vasectomy or Tubectomy) etc. 9.9 Plastic Surgery (other than necessitated due to accident) 9.10 Accident treatment under the influence of Alcohol or intoxicating drugs 9.11 Injury or Disease directly or indirectly caused by or contributed to by nuclear weapons/ materials 9.12 Naturopathy Treatment 9.13 Disease or accident due to adventure sports 9.14 Vaccinations given to the new born baby after birth 9.15 Hospital Charges and consumable medical items as declared by the IRDA are not covered under the Scheme: 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 All other general exclusions provided in the standard policy of the insurer which are not related to any clause mentioned above 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. Relationship Co Payment % Parents/Parent in laws 10% Self, Spouse & Kids 5% Page 10 of 13

11 11.0 Process for Coverage: 11.1 On becoming eligible, employee and the family member(s) would be issued an Electronic ID card by TPA. All executives and their covered dependents as on June 16, as well as new employees can access and print their individual non photo electronic ID cards by accessing the TPA website Mediclaim Identity Cards: Such ID cards are valid as long as the executive is working for Bharti Airtel Ltd. and is covered under this policy In case of planned hospitalization, employees must inform TPA in 3 days advance to info@fhpl.net for smooth claim processing Along with this ID card, a separate photo ID card should be carried at the time of hospitalization for the purpose of identification. The card is issued only for identification purpose and should not be construed as an Authorization to the hospitals to proceed with the treatment Dependents once declared cannot be changed during the policy period. No midterm inclusion of dependents is allowed except in case of spouse due to marriage and birth of a child. Please note that information for addition of spouse in case of marriage and new born should be intimated TPA (info@fhpl.net ) one month of the event by writing your Name, Employee code and Name, Age, Date of Birth, Gender and relation of dependent. Failure to do so will result in the said dependents getting covered from next policy Process for Availing Benefits: 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 Hospital. In case of planned hospitalization, employees must inform TPA in 3 days advance to info@fhpl.net for smooth claim processing. 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. Page 11 of 13

12 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 may also keep a copy of all documents. The patient/employee 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. Employee/patient to intimate the TPA 3 days in advance for planned treatment & In case for emergency immediately after hospitalization. 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 Family Health Plan (TPA) Limited, Plot No.277, 1st Floor, Udyog Vihar, Phase-IV Gurgaon, Haryana PIN : Phone: 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: 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) Note: This is not the complete list, Insurance company may demand any other related documents if require/important for processing of claims. Page 12 of 13

13 13.0 Ex-Employees Insurance: 13.1 Group Policy benefits will be ceased/terminate on last working day of employee In case an employee (or family member covered under this insurance) is leaving the organization during the policy period after receiving the claim benefits, prorated deduction of premium till the policy end dated (31 st May 2017) 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 Employee has an option to explore portability the insurance into retail policy for availing the discount of initial waiting period. However Insurance Company has all rights to accept or deny the proposal Policy Administration: 14.1 Group Mediclaim Insurance Policy will be coordinated for Pan India by HR Shared Services Team. Mediclaim Helpdesk TPA: FHPL (Family Health Plan (TPA) Ltd Family Health Plan Ltd ( Helpdesk Details) Scope Contact no For general enquiry info@fhpl.net For cashless delhipreauth@fhpl.net For enrollment related delhienrollment@fhpl.net TPA Helpdesk airtelsupport@in.fhpl.net Corporate Relationship Manager cssupport@fhpl.net Corporate Account Manager kunal.sahi@fhpl.net Sachin Gupta ( Team HR) Sachin6.gupta@airtel.com Mobile app of TPA: FHPL Sparrow available on online play/app store. Corporate ID : 2908 User ID : EMP ID (Without B00) Password : Date of Birth (DDMMYYYY) Page 13 of 13