DR. REDDY S LABORATORIES LIMITED Group Mediclaim Policy for Employees

Transcription

1 DR. REDDY S LABORATORIES LIMITED Group Mediclaim Policy for Employees The Health Insurance policy (Group Mediclaim) which covers workers and employees of Dr. Reddy s Laboratories Ltd and their family members for the period from 1 st September 2016 to 31 st August 2017 has been renewed with National Insurance Ltd. M/s. Family Health Plan Limited (FHPL) continues to be the Third Party Administrator (TPA) for Dr. Reddy s. FHPL will guide and assist the employees during the process of hospitalization and claims reimbursement. National Insurance Ltd. will administer the scheme through FHPL. FHPL will arrange ID cards for employees and the covered family members through their website In the interim period, the Mediclaim ID cards /Employee ID Cards / Authorization letter from Unit HR are valid and will be accepted by the network hospitals. The enrollment of dependents can be done online on the FHPL website ( Enrollment is mandatory to avail the Mediclaim facility. Process for Emergency Medical Treatment In Network Hospitals: 1. The Employee / Family members can directly approach the hospitals along with the identity cards issued by FHPL (Mediclaim ID cards /Employee ID Cards / Authorization letter from Unit HR in the interim period.) If the treatment is for dependents, in addition to the above, a Xerox copy of photo ID proof of patient is mandatory at the time of admission. The photo ID proofs which can be used are Ration card, Voter ID, PAN card, Passport, etc.. 2. The hospital authorities will inform FHPL about the admission and the line of treatment basis which FHPL will authorize the cashless facility appropriately. 3. The employee shall verify the bill charged by the hospital and sign the claim form only after the amount is verified. In Non-Network Hospitals: 1. The Employee / Family members can directly approach the hospitals for treatment. 2. Employee shall give intimation to Mediclaim Helpdesk (FHPL) at GBS and Unit HR department within 48 hours of admission into the hospital. Mediclaim Helpdesk Contact details: TOLL FREE No Name of FHPL Representative, Mr. Saravar Khan Mobile: Landline No.: ID : mediclaimhelpdeskgbs@drreddys.com If the intimation is not given in the stipulated time the claim cannot be processed.

2 3. The employee shall settle the hospital bills on his/her own and obtain all relevant documents as mentioned below within 7 days of discharge from hospital. The employee shall submit the below documents to Mediclaim Help Desk at GBS. i. Claim forms (as per prescribed format) duly filled in all respects and signed ii. Hospital final Bill with break-up and cash paid receipts in Original iii. Diagnostic Reports with Dr Prescriptions and bills in Original iv. Prescriptions and medicine bills in Original v. Discharge summary vi. Any other documents like copy of case sheet, etc vii. Prescriptions, bills and reports for the pre and post hospitalization treatment Note: Any other document requested by the FHPL for processing the claim should be provided by the employee within the stipulated time. 4. Employees are supposed to co-operate by submitting the necessary documentary evidence as required by Ms Family Health Plan (TPA) Limited (FHPL). Please refer annexure 1 for contact details. Mediclaim Helpdesk shall scrutinize the claim documents and submit to FHPL for further action. In case there are claims pertaining to documents which is not received by FHPL, intimation will be sent to employee to submit the same. Claims pertaining to documents not received will not be processed beyond the third reminder by M/s Family Health Plan (TPA) Limited or M/s National Insurance Ltd. 5. M/s Family Health Plan (TPA) Limited (FHPL) shall settle the claim, if payable, through NEFT mode or shall send the cheque in favor of employee to the Mediclaim Helpdesk which will be forwarded to the Unit HR through GBS. Planned Medical Treatment In Network Hospitals: 1. The Employee / Family members will directly approach the hospitals 48 hours (two days) in advance along with the identity cards issued by M/s. Family Health Plan Limited. (FHPL) (Mediclaim ID cards /Employee ID Cards / Authorization letter from concerned Unit HR team in the interim period). Simultaneously the employee will also intimate M/s. Family Health Plan Limited. (FHPL). 2. The hospital shall fill up Pre-Authorization Format and send to M/s. Family Health Plan Limited (FHPL), Health Administration Team cell at Hyderabad by Fax/ . 3. M/s. Family Health Plan Limited (FHPL) will authorize the treatment and inform the hospital within 4 hours of receiving the intimation. 4. The employee / family members will avail the treatment as per the planned date. 5. At the time of discharge, employee shall fill up and sign the claim forms. The employee shall verify the bill charged by the hospital and sign the claim form only after the amount is verified.

3 Reimbursement of Pre & Post Hospitalization Expenses: Group Mediclaim Policy covers the expenses incurred during 30 days prior to hospitalization and 60 days after hospitalization for Major surgeries. Employee can seek reimbursement of such expenses by submitting the claim through a filled claim form and attaching all relevant documents, bills and receipts. The employee can send the claim to Mediclaim Help Desk who will arrange for the reimbursement of approved claim amount to the employee. Employees can contact Mediclaim Helpdesk/ M/s. Family Health Plan Limited (FHPL) at the address and phone numbers mentioned below for necessary assistance, guidance and clarifications during admissions into the hospitals/claims etc.

4 Salient Features of Group Mediclaim Policy covering Employees & Workers of Dr. Reddy s and their family members 1. Coverage : Members covered are six (including self) 1. Employee 2. Spouse 3. Dependent Parents / In-Laws upto age of 80 Yrs: Max 2 in any combination 4. Dependent Children: Only 2 Children who are either above an age of 24 years or not dependent are not eligible for coverage. Married children are not covered. 2. Overall Family Limit: Category Coverage for Limit Remarks 1 Workmen in CTO- 1; 2 & 4 INR 2,05,000/- Limit per parent is INR and FTO 1 & 2 1,00,000/- 2 All Staff including Baddi (not covered under ESI) and Field Staff 2A Workmen CTO- 5; 6 & FTO-3 INR 3,00,000/- INR 3,00,000/- Maximum permissible claim for Parents is INR 2,00,000 (INR Two lacs only ) for one Parent or both put together. There will be 20% co-payment on the Critical Illness claims and 10% co-payment for all other claims of the Parents. Maximum permissible claim for Parents is INR 2,00,000 (INR Two lacs only ) for one Parent or both put together without any co-payment on the claim amount of the Parents. 3. Contribution: The subsidized premium contribution to the medical insurance scheme during the period 1 st September 2016 to 31 st August 2017 is as mentioned below Member Contribution Self Nil Spouse INR 1500/- Per Child INR 1500/- each Per Parent/ In-law INR 5500/- each Per Parent/In-law if claimed in last one year INR 6500/- each Note: The contribution mentioned above will be same across role bands including trainees.

5 4. Special Features: i. Pre-existing diseases are covered ii. No waiting Period of 1 month and no 1 st year diseases exclusion for new employees iii. Maternity Benefits without waiting period for new members also. iv. New Born Baby coverage would commence from day one under overall family limit. Intimation of the new born should be given within 24 hours to Mediclaim Help Desk. v. Cover for hospitalization exceeding 24 hours at a stretch. Exceptions apply. vi. Company has taken a limited insurance coverage corporate buffer under this scheme for the policy period of In case of medical needs: For self, spouse and dependent children - Additional benefit from the corporate buffer may be released subject to merit of the case, company s prior permission and availability of buffer. For dependent parents / In-laws- Additional INR 1 Lac from the buffer may be released [subject to company s prior permission and availability of buffer] with a 20% co-payment, only for critical ailments. Please refer annexure 2 for the details of the critical ailments. Utilization of buffer would be permitted only after exhausting Sum Insured as per policy and Additional insurance coverage (top-up), if availed. In case of employee not availing Additional insurance coverage (Top-up), and has exhausted the sum insured, buffer utilization would be permitted subject to additional deduction Rs.5000 per lakh of buffer utilization. 5. Additional Coverage (Top Up) Employees can opt for additional coverage of 1 to 10 Lakhs beyond the overall family limit outlined in Sec. 2 above. To avail this benefit, employee needs to pay a subsidized premium linked to his/her age. Below table has details of the premium to be paid: TOP UP COVERAGE PREMIUM CHART (EXCLUDING SERVICE TAX) Age group of employee Top-up Sum Insured (Rs.) ,00, ,00, ,00, ,00, ,00, ,00, ,00, ,00, ,00, ,00,

6 Base Sum Insured the overall family limit employees are entitled to. Top-up sum Insured the additional coverage employees wish to avail. Please note that the amounts above are excluding service tax. Service tax will be charged on the additional premium. 6. Critical Illness Coverage If an employee is diagnosed with one of the listed critical illnesses (annexure 2) for the first time, they will get a lump sum of INR 3 lacs (5 lacs in case of cancer) to help with costs associated with these diseases. This is a company provided benefit and there is no premium required to be paid by employee. In case you want additional cover of 3 more lacs (5 lacs for cancer), you can avail the same by paying an extra premium for this coverage. Details of the same are given below. CRITICAL ILLNESS COVERAGE RATES FOR (EXCLUDING SERVICE TAX) Up to Above Age Band Rate per Lac (INR) ,650 2,400 3,600 5, ,000 For more details, please refer to the Critical Illness policy details. 7. Some restrictions in policy: 1. Eye : Any treatment for eye except Cataract not covered. Cataract - Rs. 30,000/- Maternity Cases: Normal Delivery : Maximum of Rs 50,000 /- Caesarian Section : Maximum of Rs 60,000/- 2. Limits on room Room and Nursing expenses as provided by the Hospital on a twin sharing basis on actuals not exceeding 1 % of sum insured per day Intensive care (ICU/ICCU) expenses as provided by the Hospital on actuals not exceeding 2 % of Sum insured per day. 3. Admission for Investigations: For investigation purpose admission in the hospital is not covered. 4. Few ailments/diseases not covered are as mentioned below: 1. Dental procedures 2. Lasik procedures/any Rx related to correction of sight not covered. 3. Congenital external ailments/conditions (squint, hypospadias etc.) 4. Alcohol related accidents/ailments 5. Myopia. 6. Intentional self injury/suicide attempt 7. Cosmetic procedures, excision of warts 8. HIV related conditions. 9. Circumcision 10. Infertility. 11. Sterilization.

7 Annexure 1 : Address / Contact Numbers M/s. Family Health Plan (TPA) Limited. (FHPL) : Address: M/s. Family Health Plan (TPA) Limited. (FHPL), Ground Floor, Srinilaya-Cyber, Spazio, Road No.2, Banjara Hills, Hyderabad Ph: Fax No / preauthfax@fhpl.net TOLL FREE No Annexure 2: List of Critical Ailments Critical Ailments shall mean the following diseases only: Renal Failure requiring Kidney Transplantation & Dialysis Cerebro Vascular Strokes Open and Close Heart Surgery (inclusive of C.A.B.G.) Malignancy diseases which are confirmed on Histopathological Report Encephalitis (Viral) Neurosurgery Total Replacement of Joints Liver Disorder associated with complications Cirrhosis of Liver Grievous injury which include multiple fracture of long bone, head-injury leading to unconsciousness, burns of more than 40%, injury requiring artificial ventilator support plus Vertebral Column Injury