Memorandum of Understanding

Transcription

1 Memorandum of Understanding (Forming and Attaching Part of Policy No /46/10/ , /46/10/ , /46/ 10/ W.e.f 01 st November 2011 to 31st October, 2012) This memorandum of understanding [MOU] arrived at Gurgaon this 1 st Day of Nov between M/s. National Insurance Company Limited a company, incorporated under the Companies Act 1956, represented by Divisional Office - No. XVII, 12th Community Centre, 1st & 2nd Floor, East of Kailash New Delhi , having its registered office at No 3 Middleton Street, Calcutta [hereinafter referred to as [NIC] which term shall mean and include unless repugnant in this context, all its successors and assigns of the' FIRST PART. And FIS Global Business Solutions India Pvt. Ltd, FIS Global Recovery Services India Pvt. Ltd, FIS Payment Solutions & Services India Pvt. Ltd incorporated under the Companies Act 1956) represented by Prashant Sharma having its corporate office at 402, i Park, Plot No. 15, Udyog Vihar-Phase IV, Gurgaon, Haryana , which term shall mean and include unless repugnant in this context, all its successors, group companies, divisions and assigns of any other office of the Other Part POLICY DURATION, PREMIUM & COVERAGE 1. The policy shall commence on 01-Nov-2011 and remain effective till 31-Oct The Premium rate will be; 90% (Net) of one month s basic salary for grade* 1, 2 and 3 or whichever is lower. 30% of one month s basic salary or whichever is higher grade 4 and 5 25% of one month s basic salary for grade 6 *Explanation: FIS Grade (AP1, AP2, AP3) to be read as Grade 1 FIS Grade (P1, P2, P3) to be read as Grade 2 FIS Grade (SP1, SP2, SP3) to be read as Grade 3 1

2 FIS Grade (LP) to be read as Grade 4 FIS Grade (SL) to be read as Grade 5 FIS Grade (E) to be read as Grade 6 3. No change in the premium payable during the policy period as differential which could be on account of an increment or promotion. (* Grade 1, 2, 3,4,5 and 6 (or I,II,III,IV,V and VI) refer to FIS AP,P,SP,LP,SL and E employee bands respectively) 4. Hospitalization benefit entitlement is capped at 20 months basic salary or 5 Lacs whichever is lower for grade 1,2,and 3 with a co-pay clause of : 25% in case of claim being towards parents hospitalization 15% in case of claim being towards self, spouse and children (upto two children only) Each claim against hospitalization entitlement will be settled as per above conditions Example: If the hospitalization entitlement is Rs and an employee makes two claims in the policy period thus: 1 st claim for dependant parents 25% of the claim amount.) The amount claimed = Rs Reimbursement thru NIC will be 75% of the claimed amount i.e. Rs /- and the eligibility will be reduced by Rs /- 2 nd claim for other family member 15% of the claim amount) Balance available amt. Rs /- 5. For grade 4,5 and 6 the formula for calculating the limit of Hospitalization is as follows : Annual Premium payable/90%*20 (e.g. premium payable is then the eligibility would be 84333/90%*20 = /- or 5 lacs whichever is higher The eligibility is with a co-pay clause of: 25% in case of claim being towards parents hospitalization 15% in case of claim being towards self, spouse and children (upto two children only) Each claim against hospitalization entitlement will be settled as per above conditions 6. Domiciliary benefit entitlement for all grades is restricted to 90% of the premium paid with a co-pay clause of 10%. Example: 2

3 Basic premium of basic 90% of premium paid co pay 10% of each claim per eligibility net reimbursement against total eligibility Further, there will be no mid -term change in reimbursement eligibility on account of increased basic due to increment or promotion. Also domiciliary benefit entitlement of all associates up to Level 3 (AP, P, and SP) will be pro-rated on quarterly basis. Hence bills submitted in one quarter will be cleared basis available quarterly eligibility and the remaining bills will be cleared in next qtr depending on the utilization of quarterly entitlement. Also, unutilized amt of the past qtr/s can be carried forward to the next quarter/s. 8. Maternity benefit is restricted to Rs 30,000/- in normal delivery cases and Rs.50, 000/- in cesarean cases (Upto 2 children). (please refer appropriate paragraph under the section Hospitalization in subsequent pages) 9. Dental (please refer appropriate paragraph under the section Domiciliary in subsequent pages) for associates up to level 3 Rs. 1500/- per family member per annum and for associates in level 4 and above Rs. 2500/- per family member per annum ( to be paid under overall domiciliary limits). 10. Vision correction glasses or lenses excluding goggles/sunglasses (please refer appropriate paragraph under the section Domiciliary in subsequent pages) - for associates up to level 3 Rs. 1500/- per family member per annum and for associates in level 4 and above Rs. 2500/- per family member per annum ( to be paid under overall domiciliary limits). 11. Health Checkup for grade III and above employee (please refer appropriate paragraph under the section Domiciliary in subsequent pages) only for employee only once in policy period - Maximum Rs. 4000/- (to be part of Domiciliary limits only) and a maximum of Rs 1000/- per year per family under domiciliary limits of individuals for Grade I & II. 12. The scheme will cover the employee and immediate family (spouse and dependent children- maximum 2) automatically. The scheme will cover dependent parents additionally on the basis of a declaration by employee giving their name, age, address and confirming that they are NOT covered under any other employer sponsored medical scheme (e.g. Central Govt. Sponsored medical scheme) and that they are wholly or substantially dependent on the employee for their medical needs. The names of all dependents will also be needed to be given to NIC alongwith the name of the employee, his date of joining and his current applicable basic salary. It is 3

4 possible for an employee to exercise a one time option of substituting parents in law instead of parents (for female employees only). 13. In order to make this scheme reasonable, clear, and tenable for all parties concerned, and still sustain the spirit of the scheme, and to remove any ambiguity in terms of permissible claims, both FIS and NIC have agreed to the following: 14. Apart from allopathic, NIC would allow claims under the policy, bills of homeopathic and ayurvedic treatments subject to the prescriptions for such medicines being from Registered Medical Practitioner. 15. It is agreed between FIS and NIC that NIC would cover all pre-existing diseases under this MOU. Domiciliary 1. Claim of bills without prescriptions: Both NIC and FIS believe that only a doctor is the authority for suggesting medicines for ailments, and it would be dangerous to suggest or encourage otherwise. However, some "over-thecounter" drugs and common personal medicines like analgesics, paracetamol, cough syrups etc. normally bought without prescription, will also be allowed for reimbursement under the policy. It is also understood that NIC will accept all bills legibly written and has the right to reject any bills that are over written/soiled, duration of taking the medicines should be mentioned in the prescriptions. This provision excludes bills for common antiseptics like Dettol Soaps and toiletries and health drinks such as Complan, Horlicks etc. 2. Consultation Fee by itself may not be adequate: A Doctor's consultation fee receipt by itself without any supporting documents may not be accepted by NIC. They must be accompanied by the Doctor's diagnosis and / or prescription. 3. General Health Check-up: This is within the purview of this MOU and NIC would restrict the expense to a maximum of Rs 1000 per year per family under overall domiciliary limits of individuals for Grade I & II. Health check-up for employees from grade 3 and above is admissible under domiciliary benefit only once in the policy period and the upper limit for this is Rs. 4000/-. NIC, however, will allow anything over and above this limit if there is a recommendation for check-up or investigation against a specific diagnosis but subject to the available overall limit under domiciliary benefit. 4. Dental treatment: In general, if such treatment is based on medical reasons (not for cosmetic reasons) then claims will be entertained by NIC for associates up to level 3 to a maximum of Rs. 1500/- per family member per annum and for associates in level 4 and above Rs. 2500/- per family member per annum 4

5 under the overall domiciliary limit to cover specific dental treatments like extraction of teeth, filling, root canal treatment including pyorrhea, etc. but subject to the available limit under domiciliary. 5. Eye treatment I Vision correction: On the basis of proper prescription, the expenses towards corrective glasses and frames or corrective contact lens will be reimbursed by NIC for associates up to level 3 to a maximum of Rs. 1500/- per family member per annum and for associates in level 4 and above Rs. 2500/- per family member per annum. This excludes sunglasses/goggles. Further it is also agreed that In those cases where eye power is plus/minus 7 then correction by surgery is permissible and will be paid under hospitalization even though the stay is less than 24 hrs. Hospitalization: 1. Hospitalization benefit is only admissible if the stay in hospital is 24 hrs or more (please also refer point 7 and 8 of this section). The limit for hospitalization is as mentioned in point 2 in the section on Policy Duration, Premium and Coverage and applicable only for expenses incurred (including room rent), so long as hospitalization is recommended by a doctor for necessary investigation and treatment or for evident emergency cases. In case an employee approaches a hospital independently and the hospital is not on the list of network hospitals of NIC or Third Party Administrator (TPA) & nursing homes for this purpose, it is recommended that employees use a reputed hospital, or at least one with a minimum capacity of 15 beds as such hospitals then necessarily have to comply with certain minimum infrastructural and other necessary standards. Bills for hospitalization expenses submitted to NIC will be accompanied by the original Discharge Report /Summary signed by a doctor, all prescriptions, and reports of all investigations along with EGG / Films / Scans and Scan reports. Few institutions may be black listed by TPAs on the basis of significant level of irregularities discovered. A list of such hospitals will be circulated and any new addition to the list will be informed by TPAs then and there. TPAs will summarily reject bills from such institutions. Also, TPAs would honour reimbursement of 15 days pre hospitalization and 30 days post hospitalization bills within the overall limit under Hospitalization. (please also refer to point 8 of this section) 2. The room rent entitlement for Hospitals have been categorized as under: Grade 1- Rs.2000 per day Grade 2 - Rs.3000 per day Grade 3 Rs.4000 per day Grade 4 and above - Rs.6000 per day 5

6 3. In case of ICU, the entitlement will be double of the Room rent entitlement. 4. Doctor s/surgeon s/anesthetist s fee will be restricted to 25% of total entitlement of the associate. This fee means only consultation fee and it does not include medicines etc. 5. It is also agreed between FIS and NIC that the hospitalization expenses of such beneficiaries will be reckoned with from the date of admission to the hospital and not the date of discharge from the hospital and the claims shall be admissible in the current Policy only. 6. Maternity: Benefits for maternity will be applicable for self or spouse, and the newborn child, as part of the limit for hospitalization. Any expenses arising out of account of maternity but not within this specified period (ante-natal or postnatal) would only be reimbursed by NIC out of the limits for domiciliary expenses. The newborn will be covered additionally & separately as dependent from the date of birth, but only on adding the child's name, within a month from the date of birth of the child, to the list of dependents sent to NIC. It is agreed between FIS and NIC that NIC would waive off the waiting period of 9 months in maternity cases under this MOU. Maternity benefit is restricted to a maximum of Rs 50,000/- with details as follows: Normal delivery 30,000 and Caesarian upto 50,000. (Upto 2 children) 7. Termination of pregnancy: This will be covered under the hospitalization limits (even if this requires hospitalization for less than 24 hrs), but only if done on the advice of a qualified doctor and on medical grounds. Expenses arising out of voluntary termination of pregnancy will not be covered under this and NIC will not entertain such claims. However, medical expenses arising out of spontaneous termination of pregnancy (commonly termed as miscarriage) will be covered and reimbursed by NIC. 8. Hospitalization benefits applicability (less than 24 hours): There are few exceptions viz. advanced technology based surgeries where hospital stay is not necessarily required for 24 hours or more e.g. cataract and few other laser surgeries and in such cases hospitalization benefit will be extended to the employee (please also refer previous point of this section) 9. Artificial life I limb support: Expensive items like pacemaker, artificial limbs etc. will be covered by the scheme. Expenses of such items would be reimbursed by NIC at actuals subject to the available limit under Hospitalization. 10. Norms for prescription: Prescriptions should preferably be on the doctor's or institution's letterhead, or else the registration' number of the signing doctor should be legible. Signature of the doctor,' not below the rank of MBBS or 6

7 equivalent is mandatory for processing of admission under the scheme. However, for hospitalization, prescription slips of the Institution those are generally given by the nursing staff for purchase of medicines will be adequate. 11. Bill for recommended investigations: Such bills, if submitted to NIC must be accompanied by the doctor's prescription as well as the report of the investigation. 12. Original bills to be submitted: All bills submitted to NIC must be in original, as photocopies will not be accepted. It would be preferable if prescriptions, diagnostic reports, discharge summaries and reports of investigations were also submitted in original. However, NIC appreciates instances where an employee prefers or required to retain the originals and allow them to submit photocopies. NIC can demand for production of originals, should they need to verify. All OPD bills to be submitted within 90 days of issuance of such bills and all hospitalization bills to be submitted within 30 days from the date of discharge except otherwise separately notified by FIS & NIC of any changes. Intimation for Hospitalization shall be provided by the member within 7 days of such hospitalization to NIC/TPA. GENERAL 1. Transfers I deputation overseas: In case of transfer or deputation overseas, NIC will treat this as akin to cessation of service of the employee till the date the employee returns. However the dependents in India will still be covered under the currency of the scheme. 2. Reasonableness of claims: NIC and FIS - have the right to question a claim, even if technically correct in all respects, if prima facie the amount claimed is evidently disproportionate to the services rendered by the medical institution or practitioner. 3. Buffer premium to be received in advance by NIC: FIS shall maintain sufficient buffer premium in advance with NIC for automatic inclusions of the employees/dependents under this scheme at the inception of the policy. 4. Premium payment for new employees: The list of new joinees for coverage from the effective date of their joining FIS along with the list of dependents as specified will be updated every month by the concerned group company HRD and will be provided by FIS to NIC and the TPA. Changes in dependent's status and deletions for employees who leave services of the company must also be submitted at the same time. Such a list must be sent to NIC accompanied by a cheque for premium payable for the new joinees (along with basis of calculations). However, it should be understood that no claims for employees whose intimation in such manner has not been given to NIC would be entertained by NIC. 7

8 5. Premium Adjustment: Premium of employees leaving the policy on termination of service will be adjusted against the monthly premium on prorated basis. 6. Additional Benefit-60% of vaccination charges for Cervical Cancer has been provided under prescription for Women employees to be paid by NIC. This will be over and above the OPD & Hospitalization benefit. 7. For new employees, the coverage is Pro-rated from day of joining the scheme, and the point in the premium cycle at which they join. To make this tenable for NIC, and also to be fair to FIS the premium for such new hires will be calculated as per the table below: No. of Months left for current cycle Amount of Premium 1-5 months 50% of full premium More than 5 months & upto 9 months 75% of full premium More than 9 months Full premium payable 7. The policy will continue to be served by the existing Third Party Administrator (TPA) Alankit Health Care TPA Ltd the cost of which is included in the premium payable as per point 1 under the section Policy Duration, Premium and Coverage of this MOU. This MOU will serve as the guideline and reference document for TP Alankit to administer the policy. 8. ADDENDUM TO MOU As an additional feature to the ongoing GHMI policy NIC shall provide the following inclusions to be read along with MOU policy clause No. 12 & Employees can also nominate 3 rd & 4 th Child by excluding their dependent parents (Both mother & father/father-in-law & mother-inlaw) from the policy. 2. All Pre-existing diseases for the 3 rd & 4 th child will not be covered during the 1 st year of such inclusion/nomination in the policy. 3. Once additional child (3rd and / or 4th) is nominated the nomination of parent/s or in-laws (as mentioned in the relevant clause) is not allowed. 4. An employee can nominate maximum 4 dependent children altogether in the policy. 8

9 GHMI SLA ESCALATION MATRIX-TPA ALANKIT W.E.F 01 ST NOV Service Requests In support of services outlined in this Agreement, the Service Provider will respond to service related queries and/or requests submitted by the Customer or its employees/location HR representatives within the following time frames: 48 hours for issues regarding Claim approval/query/claim Rejection//Portal update/sms & alerts/ivr functioning/escalation and provide resolution within 72 hours (3 days) 24 hours for issues relating to Payment cheque/payment Advice/MIS report and provide resolution within 48 hours (2 days) Provide Cashless approval within 2 hours of application forwarded by the Network Hospitals. In case of query raised by TPA approval should not exceed 5 6 hours maximum 6.3 Touch Points on Service Availability & Service Request In line with the requirement of the SLA the following will be the contact points on matters specific to Claim submission/claim query/claim rejection/claim payment/sms & alerts/ivr facility can be sought from the service provider TPA Alankit TPA Alankit First Point of contact Name of Contact Person & Contact Details 1. Ms. Richa Arora (For Delhi/NCR) Id: richaa@alankit.com Contact No.: Mr. Rajesh (For Mumbai) Id: alankitmumbai@alankit.com Contact No.: Mr. J C Mittal (For Chennai) Id: jcmittal@alankit.com, alankitchennai@alankit.com Contact No.:

10 6.4 Escalations Level 1: All service requests raised by members of the policy on all matters specific to claim query/ rejection/payment/sms & alerts/ivr facility not provided by the service provider at the local level GGN (Delhi NCR), Mumbai & Chennai touch points shall be directed to the following for redress: TPA Alankit Corporate Touch points Mr. Manoj Bhatia Manager (Corporate) id: Contact No.: TAT for Redressal 48 hours from receipt of such escalation by TPA Alankit Level 2: All escalations not resolved at level 1 shall be directed to the following for redress of all matters specific to the Policy & MOU and SLA FIS Touch points Mr. Rajesh J. Bodra Human Resources, Corporate HR id: Rajesh.Bodra@fisglobal.com TPA Alankit Corporate Touch points Mr. Arun Gupta Head, Corporate & Mr. R. K. Kachroo Executive Director Id: arung@alankit.com, rkkachroo@alankit.com, TAT for Redressal 48 hours from receipt of such escalation 10