Group Medical Insurance Parental Policy

Transcription

1 Group Medical Insurance Parental Policy Department Distribution HR Total Rewards All Hewlett Packard Enterprise entities in India DOCUMENT REVISION HISTORY Version 1.0 Reasons for Change Insurance Renewal Effective Date 1-Nov-2008 Review Date Prepared by Approved by 31st October 2009 India Total Rewards HR Director Critical Illness India Total Nov Oct-2009 HR Director List Rewards Introduction of 31st March India Total 1.2 1st April 2009 HR Director Co-pay 2010 Rewards Policy India Total HR Vice - Nov Nov 2012 Changes Rewards President Review and India Total HR Vice- 1.4 Ailment Cap 1-Nov Nov Rewards President enhancements Review and India Total HR Vice- 1.5 Ailment Cap 1-Nov Nov Rewards President enhancements Review and India Total HR Vice- 1.6 Ailment Cap 1-Nov Nov Rewards President enhancements Review and India Total HR Vice- 1.7 Ailment Cap 1-Nov Nov Rewards President enhancements Hewlett Packard Enterprise Restricted Hewlett-Packard Company. This document is not to be copied or distributed without the express written consent of Hewlett-Packard Company. No part of this document may be used for purposes other than those intended by Hewlett-Packard Company.

2 Table of Contents 1 Objective 2 Scope 3 Abbreviations/ Definitions 4 Eligibility 5 Salient Features 6 Policy Details 7 Process Flow 8 Points of Contact 9 Escalation Matrix 1. Objective To provide employees with a group mediclaim insurance policy for coverage of their parents (father, mother and / or parents in-law). The premium will be funded by the employee and the policy will cover all hospitalization expenses incurred for the treatment of illness / diseases or injury sustained. 2. Scope Coverage of hospitalization expenses including pre & post hospitalization expenses up to 30 days prior to and 60 days post, respectively. 3. Abbreviations/ Definitions TPA Third Party Administrator OPD Out- Patient Department UIIC United India Insurance Company PPN Preferred provider network, are the hospitals where treatment is available to employees at rates negotiated by insurance company. Non PPN are hospitals who have refused to participate in the negotiated packages for the insurance company. Coverage period- Hewlett Packard Enterprise Financial Year ( 1st Nov of current year upto 31st Oct of the following year) Sum Insured - The maximum amount that an insurance company will pay out in the event of a claim Coverage amount Used interchangeably with sum insured Co-pay A payment or defined deductible to be paid by the insured person upon availing medical services. This usually represents as a percentage of the coverage amount, and is different from non admissible. Floater A plan where the overall sum insured can be utilized by any of the insured members. 2

3 Corporate buffer utilization will be available only for Critical Illnesses/Accident and applicable only for those employees who have opted for the top-up plan. However, If an employee was not aware of the ailment (a recent diagnosis/ unforeseen) or an accident which turned out to be critical he/she will be eligible for critical illness buffer whether they have a top up or not. And this will be approved as an exception on a case by case basis upto the limit of the corporate buffer availability. Please write to your respective HR SPOC and Mediassist at hpe@mediassistindia.com 4. Eligibility All regular employees of Hewlett Packard Enterprise in India are eligible to opt for this program. The program is voluntary in nature and applicable only after the employee exercises the option to participate. 5. Salient Features Employees can opt to cover their parent(s) and/or parent(s) in law at the time of joining. In case they opt for this program, the premium applicable will be recovered from their salary. The policy provides a basic cover of Rs. 1 lakh per parent, for the coverage of parents up to a max of 4 members under the insurance policy, providing a total floater cover of Rs. 4 lakhs (considering 4 Members enrolled ) Irrespective of the number of dependents covered, the buffer will remain at 1 lakh per year. The policy covers pre existing diseases. The insurance company will pay service charges for the services rendered by Medi Assist Prorated premium is refundable when the employee quits only in case there are no claims for the current policy period. A minimum period of 24 hours hospitalization is mandatory for availing this benefit. Cases of chemotherapy, radiotherapy, kidney dialysis, eye surgery (cataract) etc, wherein, the person is not admitted for 24hours, comes under the preview of hospitalization and is claimable. Room charges for ordinary private rooms will be payable. The insurance cover will cease once the employee leaves Hewlett Packard Enterprise. Co pay of 80:20 basis will be applicable for all hospitalization claims cashless or reimbursement in other than PPN hospitals, Co pay of 90:10 will be applicable for agreed surgical procedures in PPN hospitals, Co pay of 80:20 will be applicable for other than agreed surgical procedures in PPN hospitals, & pre & post hospitalization claims as applicable. If the final bill is in excess of available sum insured then the co-pay is calculated on the available sum insured and not on final bill amount. Expenses reimbursable under the program are room, boarding, nursing, anesthetist, consultant, specialists fees, Anesthesia, blood, oxygen, operation theatre charges, surgical appliances, medicines and drugs, diagnostic materials, x-ray/scan and other expenses defined under the insurance program. 3

4 Hospitalization for the purpose of conducting investigations/evaluations is not covered. Expenses not related to the active line of treatment like personal telephone calls, food, admission/registration charges are not payable Dental treatment or surgery is admissible only in case of accident. Ayurvedic treatments are covered in the policy in case of hospitalisation in government approved hospital or in any Institute recognized by the Government and/or accredited by quality Council of India / National Accreditation Board on Health. All documents like the discharge summary, reports, investigations, bills and the prescriptions should be submitted in original. The employee may retain a copy of the same. Voluntary Top up is available from INR 2,00,000 to INR 10,00,000 Max. Any pre hospitalization and post hospitalization expenses that is payable is to be submitted to Medi Assist along with a signed reimbursement claim form. Any procedure which does not require hospitalisation of 24 hours and is not considered as advancement in medical technology is not covered. Enhancement is subject to the Insurers approval. Corporate buffer utilization will be available only for Critical Illnesses/Accident and applicable only for those employees who have opted for the top-up plan. However, If an employee was not aware of the ailment (a recent diagnosis/ unforeseen) or an accident which turned out to be critical he/she will be eligible for critical illness buffer whether they have a top up or not. And this will be approved as an exception on a case by case basis upto the limit of the corporate buffer availablitiy. Please write to your respective HR SPOC and Mediassist at hpe@mediassistindia.com 6. Policy Details 6.1 Enrollment Enrollment will commence each year after the policy Renewal Enrollment requires you to review the list of dependents and the sum insured (especially in case of top-up) Employees need to enroll to Group Parental Medical Insurance Policy in order to avail medical benefits, under which you can enroll dependents (Parents or parents-in-laws). Please refer section 7.1 below for detailed steps to enroll your dependents. Window will be open to enroll your dependents in October. Employees will receive communication from Hewlett Packard Enterprise for updating their dependents during renewal Coverage will be effective from the 01 st November New Joinees who have joined Hewlett Packard Enterprise in the month of september and October parents will be covered for current year till 31st October 2016 and the coverage will be continued for policy period. 4

5 6.2 Coverage This policy is limited to 4 members parents & parents in law & provides a floater cover of Rs 100,000 per parent thereby providing a total floater cover of Rs 400, Premium Table The below premium table for your reference Parental policy inclusive of Service Tax 15% Age Band Upto 60 10,373 10, ,132 11, ,271 12, ,966 13,294 above 75 13,599 13,938 Note: The Service Tax mentioned is dependent on the Govt. tax rules and is currently 15% 6.4 Voluntary Top-up Voluntary top-up can be increased upto INR 10,00,000. For those employees who wish to avail additional coverage/sum insured the option to increase the Sum Insured on floater basis is available. By contributing a nominal premium, the floater Sum Insured can be increased excluding the critical illness buffer. The table given below shows the premium payable by the employee for additional Sum Insured under parent policy. Please Note there is lock in period of 2 years for Top-up. Employees can opt for higher sum insured but not reduce. Once the employee increases the sum insured his lock in period for 2 years will start from the year he enhances his cover. If employee does not opt/ login to Medi Assist portal to make change in the plan after 2 years, the top up would continue as per last 2 years plan and the lock-in period would again get triggered for 2 years 5

6 Please find below example Employee does not login. Topup continues at INR Employee does not login Topup continue at INR 400,000. Lock-in reset for 2 years Employee opts for a top up of INR Employee logs in and no change Employee continues at Top Up of INR Employee logs in Topup continue at INR 400,000. Lock-in reset for 2 years Employee logs in. Topup enhanced to INR Lockin reset for 2 years. Employee logs in Topup enhanced to INR 600,000. Lock-in reset for 2 years Note: Though the lock in triggers every 2 years, top-up premiums payable vary year on year. Please refer to the premium table for the details. The below table shows the additional premium payable if you opt for additional cover over the basic sum insured for your parents and will be deducted from payroll if opted. Parental top-up inclusive service Top-up SI lakhs 5,290 5,445 4lakhs 8,198 8,441 6lakhs 11,244 11,575 8lakhs 16,396 16,882 10lakhs 20,496 21,102 6

7 Premium contribution towards voluntary top-up cover is through equal monthly deductions from the employee payroll and is exempt from taxes as per Section 80 (D) of the Income tax Act. New joinees in the month of September Prorated premium for the expiring policy year will be deducted in one installment in November Additionally premium for policy year will be deducted in three installments from November-16 to Janauary-17. New joinees in the month of October Prorated premium for the expiring policy year will be deducted in one installment in December Additionally premium for policy year will be deducted in three installments from December -16 to February Corporate Buffer Buffer Utilization will be available only for Critical Illnesses/Accident Critical illness means the following: 1. Cardiac Surgeries 2. Cancer Surgeries 3. Brain Tumor Surgeries 4. Pace-maker implantation 5. Hip replacement 6. Renal surgeries 7. Hospitalization due to any serious/grievious injury arising out of an accident 8. RFA for cardiac arrhythmia apart from Pacemaker implantation 9. Multiple sclerosis (IPD and OPD) 10. Hopitalisation due to any other life threatening disease/condition as mutually agreed by Hewlett Packard Enterprise HR and UIIC 11. Administration of critical illness buffer is on first-come,first serve basis during the coverage period. 12. Critical Illness buffer is applicable only for those employees who have opted for the Top-Up option However, If an employee was not aware of the ailment (a recent diagnosis/unforeseen) or an accident which turned out to be critical he/she will be eligible for critical illness buffer whether they have a top up or not. And this will be done on case to case basis. Please write to your respective HR SPOC and Mediassist. 6.6 Co pay 7

8 To encourage better and judicial utilization of Health Insurance benefits in Preferred Provider Network Hospitals, co-pay has been rationalized below For Agreed Surgical procedures in PPN Hospitals 10% For all Hospitalization Claims- cashless or Reimbursement in non PPN Hospitals 20% For non - agreed surgical procedures in PPN Hospitals 20% Pre- & Post-Hospitalization Claims As applicable 6.7 Ailment Cap Treatment costs are capped for the following procedures : Hysterectomy Rs 50,000/- Hernia(unilateral) Rs 50,000/- Cataract(Per Eye) Rs 25,000/- per eye Any complication for above ailments will be restricted to above defined limits only. Any cost incurred over & above the prescribed limit is payable by employee. 6.8 Additional Coverage Oral Chemotherapy/Adjuvant Therapy/Harmonal Therapy Biodegradable stents to be covered with Sub-limit of INR 150,000/-, Ambulance charges INR 2,500 from any point to Hospital in case of emergency only Lasik Treatment is payable only if the refractive error is beyond +/- 7.5 Ayurvedic treatments are covered in the policy in case of hospitalisation in government approved hospital or in any Institute recognized by the Government and/or accredited by quality Council of India / National Accreditation Board on Health. 6.9 Room Rent Eligibility: Eligibility is limited to single private A/c room subject to maximum room rent cap of Rs 5,000/- which ever is less per day in case of hospitalization. Room eligibility defined above includes Boarding charges and Nursing charges In case, the insured patient occupies a higher category room, the differences in charges have to be borne by the employee. However, there is no room rent cap applicable if admission is in Intensive Care Unit Exclusions under the policy 8

9 9 Injuries or diseases caused by war and war like operations Circumcision Vaccination and Inoculation Cosmetic treatment Plastic surgery Spectacles and Contact lenses Hearing Aids Naturopathy treatment Hospitalizationfor the purpose of conducting investigations/evaluations Expenses not related to the active line of treatment like personal telephone calls, food, admission/registration charges are also not payable Domiciliary hospitalization treatment taken without being hospitalized. Dental treatment or surgery of any kind unless arising due to an accident and requiring hospitalization. Convalescence General weakness Sterility Venereal disease Self injury. Diagnostic expenses without any disease Sterilization procedures Treatment of infertility/sub-fertility Assisted conception procedures External congenital disease Anomalies, defects Suicide attempt Psychiatric and psychosomatic disorders Illnesses induced by direct / indirect use of alcohol / intoxicating drugs Vitamins and Tonics unrelated to treatment. Injuries or diseases caused by nuclear weapons Maternity and related expenses Pre and post expenses related to maternity claim Unproven procedure/ treatment, experimental or alternative medicine/treatment including and not limited to acupuncture, acupressure, magneto-therapy, RFQMR, etc. Treatment procedures/drugs administered to delay the progression of an ailment ( Eg, Avastin injections for intravitreal treatment) Biological, hormonal chemotherapy Genetic disorders/stem cell implantation/surgery External equipments like CPAP, CAPD, infusion Pump etc., ambulatory devices like walker/ crutches/ belts/ collars/caps/ splints/ slings/braces/ stockings/ diabetic foot-wear/ glucometer/ thermometer similar related items & any medical equipment which could be used at home subsequently Treatment for obesity or condition arising there from (including morbid obesity) and any other weight control program/ services/ supplies. Massages/ Steambath/ Surodhara & alike Ayurvedic treatment. Any treatment availed under other traditional system of medicine like Homeopathy, Unani etc are not covered.

10 Any kind of service charges/surcharges, admission fees/registration charges etc. levied by the hospital. No other forms of renal dialysis is covered except Haemodailysis. Pharmacy bills for OPD are not covered Any procedure which does not require hospitalisation of 24 hours and is not considered as advancement in medical technology, is not covered. PET scan is not payable if conducted for diagnostic purpose. Out-patient Department Claims: Coverage not available for parents/inlaws 6.11 Leaving Hewlett Packard Enterprise When an employee exits the company, the group medical base cover and the voluntary top-up cover are cancelled w.e.f date of leaving. Pro-rata refund is provided to the employee, incase NO claim has been registered from any of the members in current policy year. As an additional benefit a porting option is provided. The policy issued is a voluntary policy and the terms & conditions, sum insured and the pricing of a Retail policy will be applicable. Employee would get the benefit of continuation of cover by converting his existing policy to a retail one. The premium for the same has to be paid by the employee directly to United India. Hewlett Packard Enterprise would only facilitate in getting the details towards issuance of the policy. Employee needs to raise a CHR case 45 days in advance with a few simple details as mentioned below The details required for porting are: Employee number Employee name Last working day Contact number id Please Note: The moment employee is out of the organisation he/she loses the option to port the policy. 10

11 6.12a. International Transfer Parental policy will continue with no extra premium payments till the end of the policy tenure(i.e. 31st of October) Employee needs to contact UIIC for renewal of retail policy with 45 days from date of expiry and UIIC will provide premium and other details. 6.12b- Alignment to new Entity There will be no changes in the coverge Policy will continue till 31st October 2017 Same dependents will be carried forward No Premium refund 6.12 c. WFR/MSA Exists reach out to your HR business partner 7. Process Flow 7.1 Enrollment for Hewlett Packard Enterprise sends communications to employees with regards to enrollment Logon to Medi Assist website Change status to single / married & click on update Add / verify dependents in add dependent tab and submit Payroll will deduct premium from employees salary in three equal installments from November16 to January Cashless / Planned hospitalization STEP 1. Minimum of 2 days (48 hours) notice to be given to Medi Assist (TPA) by filling up and sending the Request for Cashless Hospitalization. This needs to be done in conjunction with the hospital where the hospitalization is scheduled. Request for Cashless Hospitalization form can be obtained from: Hewlett Packard Enterprise Intranet The hospital: Administration / Reception Medi Assist offices 11

12 Mandatory Details that are required to be filled in the form By yourself / Dependent Name of person who needs the hospitalization Hewlett Packard Enterprise Employee ID Relationship: Self / Dependent By treating Doctor Proposed date of admission History of illness / ailment Approximate duration of hospitalization. Approximate expenses (To be filled up by the hospital) STEP 2. The request for Cashless Hospitalization form needs to be sent to cashless@mediassistindia.com Admission for a minimum period of 24 hours for the treatment to be considered as hospitalization for the purposes of Mediclaim. However, cataract, dialysis & radiotherapy labeled as day care treatment is included under Mediclaim in spite of the time for treatment being less than 24hours. STEP 3. Medi Assist will process the request for Cashless Hospitalization in accordance with the terms and conditions of the health policy issued. In case the request is authorized The authorization in case of coverage will be intimated vide fax by Medi Assist to the concerned hospital within 24 hours of the receipt of request. An approval for Cashless Hospitalization does not automatically mean that all expenses will be paid for. During discharge of the patient and on preparation of the final bill, all expenses that are not payable under the terms and conditions of the health insurance policy amount will have to be paid by the patient to hospital. Medi Assist will directly pay the allowed expenses to the hospital. Co pay of 80:20 basis will be applicable for all hospitalization claims cashless or reimbursement in other than PPN hospitals, Co pay of 90:10 will be applicable for agreed surgical procedures in PPN hospitals, Co pay of 80:20 will be applicable for other than agreed surgical procedures in PPN hospitals, & pre & post hospitalization claims as applicable. Hospital will bill Medi Assist up to the amount specified in the Pre-authorization Letter subject terms & conditions of the health insurance policy. 12 In case the request is denied Denial of Cashless requests does not necessarily imply denial of the claim. In the event of refusal of the Cashless request by Medi Assist, the Insured / Dependent is requested to avail treatment, settle the bills with the Hospital and then submit the same to Medi Assist for a possible reimbursement along with the other required claim documents. Submit Reimbursement (Please refer section 7.2 below)

13 Please ensure that you fill and sign the claim form and each of the hospital bills before discharge from the hospital. (Forms available at administration / billing department of the hospital) Medi Assist will collect all original documents directly from the hospital Cashless / Unplanned hospitalization due to emergency STEP1. Insured / Dependent insured s attendee to fax the Request for Cashless Hospitalization form duly completed to Medi Assist within 24 hours from time of admission, faxed to Mediassist fax numbers STEP2. The Request for Cashless Hospitalization will be processed in accordance with the terms and conditions of the health policy issued. Based on the same, the authorization in case of coverage or the inadmissibility of liability if the hospitalization is not covered, will be intimated vide fax by Medi Assist to the concerned hospital within 6 hours of the receipt of request. In both cases, should Medi Assist deny the Request for Cashless Hospitalization, the hospital shall treat the insured / dependent as any other patient for the purpose of payment of services rendered and Medi Assist will not be liable in such a case, In case the request is authorized The authorization in case of coverage will be intimated vide fax by Medi Assist to the concerned hospital within 24 hours of the receipt of request. An approval for Cashless Hospitalization does not automatically mean that all expenses will be paid for. During discharge of the patient and on preparation of the final bill, all expenses that are not payable under the terms and conditions of the health insurance policy amount will have to be paid by the patient to hospital. 7.3 Reimbursement claims 13 In case the request is denied Denial of Cashless requests does not necessarily imply denial of the claim. In the event of refusal of the Cashless request by Medi Assist, the Insured / Dependent is requested to avail treatment, settle the bills with the Hospital and then submit the same to Medi Assist for a possible reimbursement along with the other required claim documents. In case cashless facility is not available due to either the request being denied or if the treatment is availed at a non network hospital, you will have to settle the bills due to hospitalization directly with the hospital. STEP 1: Preliminary notice of claim with particulars relating to policy number, name of insured beneficiary, nature of illness, treating doctor & hospital should be intimated to Medi Assist within 7 days from the date of hospitalization. Submit the claim to Medi Assist (detailed as below) 1. You need to provide the following documents in original a) Duly filled and signed claim form, available at Hewlett Packard Enterprise Intranet / hpe.mediassistindia.net / Medi Assist offices b) Detailed discharge summary including name of the patient, age, date & time of admission & discharge, history of ailment, treatment given, and advice on discharge

14 c) Detailed numbered and dated hospital bill with break-up of every expense (viz., room rent, doctor consultation, nursing, OT materials, laboratory, etc.,) d) All diagnostic / lab reports like x-ray, scan, ECG. (Not films / Scans) e) Cash/Credit card payment receipt f) Original prescriptions with medical bills. Reimbursement claims can be submitted to the Medi Assist Helpdesk coordinators available as per the schedule below: Bangalore DAY LOCATION Timings HPE Executive Contact Monday Electronics City Tuesday Kalyani Tech Park, cosmos C V RAMAN NAGAR Olympia Building Wednesday Electronics City Path Block, 2nd floor, Capetown 3rd floor (Ebony facility) near Admin desk Mahesh Purushotham Purushotham Path Block, 2nd floor, Capetown. Mahesh Thursday Friday Mahadevpura Salarpuria, Adugodi Electronics City SHEZAN Room in GF Near Reception Discussion room (behind Reception, ground room) Path Block, 2nd floor, Capetown. Purushotham Purushotham Mahesh Village Tech Park Purushotham Chennai Monday OTP, Chennai Ground floor Lingeshwaran Friday Trill Park -OMR Mumbai 12th floor cafeteria in both site C & D Basheer Thursday Oberoi Commerze th Floor Reception Avinash Bait Hyderabad Wednesday ilabs Kolkata 4th floor D-Block at Reception Area Mohashin Wednesday Tuesday 14 Rajarhat (Alternate Wednesday) Cyber Green (Alternate Tuesdays) Pantry Area Abhigyan Gurgaon Avinash Kumar

15 1. Employees who do not have access to the above helpdesks can also submit the reimbursement claims to Mediassist directly at the below address, by mailing the documents through courier: Please mention employee number on the documents if sending by courier. Hewlett Packard Enterprise Team Medi Assist India TPA Tower D, Fourth Floor, IBC Knowledge Park, 4/1, Bannerghatta Road, Bangalore Any request for additional information/documents (If required) will be made within 3 working days of receipt of the claim by . The required documents should be submitted within 10 days from the receipt of the intimation. 3. Medi Assist process and will settle the claim within 7 working days on receipt of complete documentation. 4. Hospitalization claims must be lodged within 15 days of discharge from the hospital. Post hospitalisation bills for reimbursement must be submitted within 67 days from the discharge from the hospital 5. Claims not having post hospitalisation expenses must be lodged within 30 days of discharge from the hospital. Claims having post hospitalisation bills for reimbursement must be submitted within 67 days from the discharge from the hospital 1. Points of Contact Toll Free hpe@mediassistindia.com 2. Escalation Levels Names Mobile number ID Escalation 1st Level Chaitra hpeescalation@mediassistindia.com Escalation 2rd Level Sumanth G S Sumanth.gs@mediassistindia.com Escalation 3th Level Sukanya Balachander - sukanya.c@mediassistindia.com Escalation 4th Level Manjula J - manjulaj@mediassistindia.com 15

16 Escalation Matrix 1. your concern to Mediassist contacts with your employee number. 2. Raise a Ask HR query 3. Contact your HR Generalist 16