Group MediClaim Top Up Policy for Management Employees

Transcription

1 Group MediClaim Top Up Policy for Management Employees Stay Ahead, Be Assured - India Group refers to the in this document. This policy is meant exclusively for the perusal of, and strictly for circulation within, the. Please note that sharing of information contained in this policy, other than with employees of the without written consent from Group Human Resources, would be construed as a breach of the Group s Code of Conduct.

2 Policy Title Employee Value Proposition Group MediClaim Top Up - GMC Top Up and GMC Top Up Plus Policy A World of Opportunities Enrich your Life Applicability Originator & contact information This policy is applicable to all Business Units in India. The policy shall be applicable to all India based Management Cadre employees at Job Band 11 and above. GCOE- Rewards & Benefits (abg.rewardspolicy@adityabirla.com) Effective date 12 th Dec 2017

3 Table of Contents S. No. Particulars Page No. 1 Purpose 4 2 Definition 4 3 Eligibility & Applicability 4 4 GMC Top Up and GMC Top Up Plus Policy Benefits 4 5 GMC Top Up and GMC Top Up Plus Policy Sum Insured (SI) Choices and additional GMC Top Up Plus Coverage 5 6 Waiver on co pay on premium for GMC 7 7 GMC Top Up and Top Up Plus Premium 7 8 Policy Terms 9 9 Deductible or Threshold limits 9 10 Enrolment Process, Certificate of Insurance (Col) and E cards 9 11 Renewals 9 12 Claim Process Treatment of employee Life Cycle events Operating set up for GMC Top Up & Top Up Plus Policy 12 Annexures I: Enrolment Guidelines for Employees II: Enrolment and Cash Deposit Guidelines for HR III: Definitions of additional inclusions in GMC Top Up Plus Policy 17 3

4 1. Purpose The Group recognizes that different employees may have different medical insurance needs and that the Group provided medical insurance plan may not suit all requirements. The Group MediClaim Top Up (GMC Top Up) Policy is a part of the Enrich Your Life pillar of our Employee Value Proposition (EVP) A World of Opportunities. The Group, through this policy, provides flexibility to the employees to invest, in additional medical insurance, to support their family and themselves at Group negotiated rates. The Group MediClaim Top Up Plus is an enhanced offering with Sum Insured limits and treatments. 2. Definition The Group MediClaim Top Up Policy, hereafter referred to as the GMC Top Up Policy, and the Group MediClaim Top Up Plus Policy GMC Top Up Plus Policy, are plans that enable an employee to opt for an additional Sum Insured (SI) over and above the existing Group MediClaim Policy, hereafter referred to as the GMC Policy. If the total claims of an employee, in a policy year, exceed the sum insured via the GMC Policy (threshold), the GMC Top Up and GMC Top Up Plus Policies takes care of the additional hospitalization expenses up to the limit chosen by the employee. An employee can opt for either GMC Top Up or GMC Top Up Plus. 3. Eligibility & Applicability All employees in Job Bands 11 & above working in India and who are enrolled under the GMC Policy are eligible to enroll for the GMC Top Up or the GMC Top Up Plus Policy. This policy is applicable to all Business Units in India, which provide Group MediClaim, from 1 st April. Going forward, all acquired units shall also adopt for the GMC Top Up Policy, at the time of adopting the GMC Policy. The GMC Top Up/ Top Up Plus Policy is a floater policy with a single sum insured and a single premium for the whole family with terms matching the terms of the Group Mediclaim Policy. INSURER : Aditya Birla Health Insurance Company Limited(ABHI) POLICY PERIOD : 12 th Dec 2017 till 11 th Dec 2018 POLICY TYPE : GMC Top Up / Top Up Plus Policy BROKER : Aditya Birla Insurance Brokers Ltd ( ABIBL) TPA : Same as per the GMC Policy 4. GMC Top Up and Top Up Plus Policy Benefits a. Customized Group Product for Employees GMC Top Up and GMC Top Up Plus are tailor made products specially designed for the Group employees. 4

5 b. Self and Family care at an affordable price The GMC Top Up and GMC Top Up Plus policies offers flexibility of additional medical insurance coverage at group negotiated price. The Group employee base makes the product cost efficient. c. Key Policy terms are same as for the GMC policy The family floater cover is for a maximum of 6 members including self and family same as chosen by the employee as part of the GMC Policy (including Parents/ Parents in Law, Siblings) No pre policy medical tests are required for enrolling and pre - existing diseases stand covered from date of enrollment. 5. GMC Top Up and GMC Top Up Plus Policy Sum Insured (SI) Choices and Additional GMC Top Up Plus Coverage GMC Top Up / Top Up Plus Policy has the following additional SI options- For GMC Top Up Policy an employee has to opt for a minimum Top Up SI of INR 2 lacs with additional SI at intervals of 1 lac up to a maximum additional SI of up to INR 6 lacs. Exhibit 1.0: GMC Top Up Sum Insured Choices 5

6 For GMC Top Up Plus Policy, the SI minimum is INR 7 lacs, followed by options of INR 10 lacs, 15 lacs, 20 lacs and 25 Lacs. Exhibit 1.1: GMC Top Up Plus Sum Insured Choices The GMC Top Up Plus Policy offers additional coverages. Additional Coverage under GMC Top Up Plus Policy: Robotic Surgery Avastin and Remicade Injections Oral and Adjuvant Chemotherapy Dental (only Root Canal Treatment) for INR 25,000 sub limit of INR 10,000 per person. Additional maternity cover of INR 50,000 (over and above GMC Policy limit) Refer Annexure III for definitions of the additional coverage 6

7 6. Waiver on co pay on premium for GMC On enrollment for GMC Top Up or GMC Top Up Plus, the 10% co-payment on the premium applicable, shall be waived off. The other co-payment of premium (eg for parents etc) if applicable, will continue. The co -payment on claims under the GMC Policy shall also continue. Sum Insured (INR) Premium Co Pay Waiver (INR) 2,00,000 1,803 3,00,000 2,445 5,00,000 3, GMC Top Up and Top Up Plus Premium i. The annual premium for GMC Top Up Policy in the Year as per below table: Exhibit 2.0: Premium Calculations- GMC Top Up ii. The annual premium for GMC Top Up Plus Policy in the Year as per below table: Exhibit 2.1: Premium Calculations- GMC Top Up Plus Note: a) Service Tax is applicable and charged extra on the premium, 18% b) Kindly note the above is Sum Insured and Premium for the year c) Premium for subsequent renewal cycles shall be communicated in advance to the renewal date The premiums for GMC Top Up/ GMC Top Up Plus Policy are negotiated by the Corporate Management Services Division committee. There may be an 7

8 increase/decrease in the premium value in the future, basis the portfolio behavior and claims outgo at renewal. The same will be communicated to the employees before the renewal date. Employees enrolling for GMC Top Up/ GMC Top Up Plus Policy can claim benefit under section 80D of the Income Tax Act as per current tax regulations. 8. Policy Terms All policy terms offered in the GMC Policy, for inclusion as well as exclusion**, are offered as part of the GMC Top Up/GMC Top Up Plus Policy, except the following: Terms specifically excluded from GMC Top Up/ GMC Top Up Plus Policy: a. Ambulance charges b. Co-pay amount and any other Non-Medical expenses deducted under GMC policy are also not payable under the GMC Top Up Policy. c. Any amendments made in the GMC Policy shall be applicable to GMC Top Up and GMC Top Up Plus Policy as well. d. Dental treatment excluded for GMC Top Up Policy, however Dental is covered for Root Canal Treatment under GMC Top Up Plus. Refer Annexure III for definitions of the additional coverage ** Except for the additional coverage under GMC Top Up Plus Policy which shall be as per Clause 5 9. Deductible or Threshold limit A deductible is the portion of the claim amount that is not paid by the insurer of the GMC Top Up / GMC Top Up Plus Policy and has to be paid by the insured person or the GMC Policy before the benefit of the GMC Top Up Policy can be triggered. In case of GMC Top Up Policy, the deductible will be the sum insured of an employee in the GMC Policy. Example: An employee has a Sum Insured of INR 2 Lacs in the GMC Policy and has opted for a GMC Top Up of INR 3 Lacs. If there is a claim of INR 5 Lacs then 2 Lacs get paid from GMC Policy and for the balance 3 Lacs GMC Top Up Policy will be triggered. 10. Enrolment Process, Certificate of Insurance (Col) and E cards The enrolment link will be shared via by Aditya Birla Insurance Brokers (ABIBL). The premium for the GMC Top Up Policy will be deducted via payroll. A Certificate of Insurance (CoI) will be issued by the insurer once the enrolment is confirmed. The employee should share a copy of this certificate with her/his dependents for any medical emergency. E cards will be issued by the TPA and shared with the individual employees. E- Cards are required as reference for claims and cashless purpose. 8

9 11. Renewals Employees can re-enroll in the GMC Top Up / GMC Top Up Plus Policy annually. Employees can review (enhance or reduce) their Top Up SI at renewal. For enhancements in Sum Insured compared to last policy year, following restriction applies on claim settlement: o In case of a claim by the insured person in the last policy year ( ), for the same ailment, the maximum claim settlement in the current policy year, will be the Top Up Sum Insured of the previous policy year. Example: GMC Top Up Sum Insured in Claim made by employee Y in for ailment X GMC Top Up Sum Insured in Maximum claim settlement in by same employee Y for ailment X will equal to GMC Top Up Sum Insured in INR 2 Lakhs INR 1.5 lakhs INR 5 lakhs INR 2 Lakhs Further, all employees who were not enrolled during the previous year would also stand eligible for enrolment. Employees who have enrolled into the GMC Top Up Policy and who opt out of the policy in a subsequent year would not be able to re-enrol into the GMC Top Up Policy for the next 3 annual renewal cycles, unless the opt out was due to transfer to another entity. 12. Claim Process The claim process under GMC Top Up/ GMC Top Up Plus Policy is as follows - i. On receipt of reimbursement claim/cashless claim, the claim is registered on the GMC Policy & processed. ii. If GMC sum insured is exhausted, the claim will automatically get registered under GMC Top Up / Top Up Plus Policy. iii. A claim form is required to process the claim under the GMC Top Up/ Top Up Plus Policy, for which a query will be raised by a TPA to the employee. iv. Decision of the reimbursement claim/cashless claim under GMC Top Up / Top Up Plus Policy will be communicated to the employee by TPA. 9

10 Claim Process Top Up will be activated post any Corporate buffer utilization 13. Treatment of Employee Life Cycle Events Transferred employees who have enrolled for the GMC Top Up/Top Up Plus Policy continue to be covered till the date of policy expiry. Enrollment for subsequent policy period is detailed below: a. Transfers i. Transferred to a unit having GMC Top Up/ Top Up Plus Policy At renewal, transferred employees will get covered under the new business unit GMC Top Up / GMC Top Up Plus Policy. ii. Transferred to a unit not having GMC Top Up/ Top Up Plus Policy or Transfer outside India If there is no GMC Top Up / Top Up Plus Policy with the new unit, the employee will not be able to enroll for the policy. In the event the employee is getting transferred back to a unit, where GMC Top Up/ Top Up Plus Policy is available, then the employee would be eligible for enrollment at renewal, waiving the 3 year waiting period. 10

11 b. Exit / Resignation/ Retirement Employees will continue to be covered till the expiry of GMC Top Up Policy Year i.e. till 11 th Dec. The premium paid by the employee will not be refunded to the employee. In case of Death, the coverage will stop for the employee, but it will continue for the dependents till completion of the policy year. The premium will not be refunded to the legal heirs. 14. Operating Set Up for GMC Top Up/Top Up Plus Policy a. Service Provider The Insurance Company will be evaluated periodically by the CIP committee. The Third Party Administrator for the GMC Top Up/Top Up Plus Policy will be the same as for the GMC Policy. Aditya Birla Insurance Brokers Ltd. (ABIBL) will be the interface between the employee and Insurer / TPA for the GMC Top Up/ Top Up Plus Policy. b. Key steps for GMC Top Up/ Top Up Plus Policy implementation The key steps and guidelines for GMC Top Up / Top Up Plus Policy implementation and enrolment is provided for Business and Unit HR in Annexure II. Business / Unit HR teams are expected to implement the GMC Top Up/Top Up Plus Policy for the respective Businesses / Units. Unit HR is requested to extend the reach of GMC Top Up/ Top Up Plus Policy amongst all employees. c. Escalation Matrix and Contact points In case of queries, clarifications and grievances, you may use the following matrix to communicate or escalate: Levels Responsibility id SPOC Shekhar Shinde gmctopup.abibl@adityabirlacapital.com Level 1 Siddhi Warang siddhi.warang@adityabirlacapital.com Level 2 Rewards and Benefits GCOE, Group HR abg.rewardspolicy@adityabirlacapital.com 11

12 Aditya Birla Insurance Brokers Ltd Mr. Shekhar Shinde Aditya Birla Insurance Brokers Limited C wing, 2nd Floor, Mafatlal Chambers, N M Joshi Marg, Lower Parel East, Mumbai Tel: Mob: Or Siddhi M Warang Aditya Birla Insurance Brokers Ltd. Office No. 4 & 5, 2nd Floor, 18, Ashok Sankul 1, Ashok Nagar, Range Hills Road, Pune Tel: Mob:

13 Annexure I: Enrolment Guidelines for Employees Enrolment Process of GMC Top Up/ Top Up Plus Policy for Existing employees and New Joiners- i. Enrolment link will be shared through an by Aditya Birla Insurance Brokers (ABIBL) ii. Employee will be able to view the Sum Insured (SI) choices, premium payable for each of the choices and the terms and conditions. Employee can select the Sum Insured (SI) choice and enroll. iii. Premium would be calculated on a pro-rata basis from the DOJ/Enrolment month subject to availability of CD balance. iv. At the launch of the policy, employees have an enrolment window till 24 th Dec v. The policy will incept on 12-Dec-2017 for all employees enrolling till 24-Dec vi. On completion of the window period, the enrolment drive will be closed and no further enrolment will be allowed for employees. Any extension of enrolment window will be decided by management in consultation with the Insurance provider. vii. In case an employee is interested in enrolment post the window period, he will be eligible for enrolment during the next renewal period. viii. New hires joining post 11 th Nov 2017 will have a 60 day window period from date of joining to enroll. ix. The premium for the GMC Top Up / GMC Top Up Plus Policy will be deducted via payroll. x. A Certificate of Insurance (COI) will be issued by the insurer once the enrolment is confirmed. xi. E cards will be issued by the TPA and shard with the individual employees. E cards would be required as reference for claims and cashless purpose. In case of any queries, please contact the id.: gmctopup.abibl@adityabirlacapital.com Please Note: The date of coverage is subject to availability of sufficient Cash Deposit (CD) balance with the insurer. 13

14 Annexure II: Enrolment and Cash Deposit (C.D.) Guidelines for HR Enrolment guidelines for Business / Unit HR to manage the process- General Guidelinesi. The enrolment link will be provided by to employees whose data has been shared by Unit HR for addition in GMC Policy. The link will be shared in the campaigns. ii. The enrolment link will be provided only to the employees whose data is shared by Unit HR for coverage in the GMC Policy within the enrolment period. iii. First time enrolment data along with the premium calculation will be sent to the iv. Business / Unit HR teams on 26 th Dec Business / Unit HR to ensure that the required amount of CD balance is remitted in the insurer account on or before 07 th Dec Please refer section on CD Account creation and the account details of the Insurer are shared below. v. Information on subsequent month enrolments will be shared with Business / Unit HR along with the detailed timelines of the due date of the enrolments and payments, vi. The enrolment is open till 11 th Jan Sr. No NAME OF BANK HDFC BANK 1 BRANCH Fort, Mumbai 2 BENEFICIARY NAME ABHICL - GROUP COLLECTION A/C 3 CURRENT ACCOUNT NO IFSC CODE HDFC MICR CODE Insurance company account details for Premium payment: 14

15 i. Cash Deposit (CD) Account with Aditya Birla Health Insurance Co. Ltd. ii. A separate CD account has to be created by ABHI in the name of the unit prior to policy placement. iii. The following documents will be required for CD creation- Company s details as mentioned below Complete Unit Name PAN Number Cancel Cheque copy Registered Office Address iv. Minimum balance in the CD is calculated as follows: Minimum balance to be made available in the CD account is 25% of the GMC Top Up Policy and 25% of the GMC Top Up Plus Policy Example: Unit Headcount: 100 employees CD Balance calculation: 25 employees from GMC Top INR 6 lacs of sum insured + 25 employees from GMC Top Up INR 7 lacs of sum insured is illustrated as below: Overall Unit HC : 100 GMC Top Up GMC Top Up Plus Total Headcount ( A) Sum Insured ( B) INR 6 lacs INR 7 lacs NA Premium at sum INR 6,444 INR 10,030 NA insured above ( C) (Inclusive of brokerage & Service tax) Total value ( A * C) INR 1,61,108 INR 2,50,757 INR 4,11,865 Total CD balance required: INR 411,865 v. Business / Unit HR to replenish the CD account if the balance drops below the required amount. For Monthly endorsements after inception enrolment, the CD balance to be maintained at the rate of minimum 10% of the placement premium. vi. On receipt of CD amount the Insurer will create a CD account and generate a unique number for each policy / Unit. vii. Business / Unit HR to ensure that sufficient balance is available in their CD account for employee coverage. viii. There may be change in the minimum balance requirement in CD, basis the participation. ix. In case the CD balance is more than the minimum requirement, then the unit may request for partial refund of CD amount, from ABIBL. 15

16 Annexure III: Definitions of additional inclusions in GMC Top Up Plus Policy i. Dental Dental (only Root Canal Treatment which can be followed with a routine and reasonable ceramic capping) is for INR 25,000 (over and above GMC policy limit) with a sub limit of INR 10,000 per person in a policy year. ii. Maternity Cover up to maximum INR 50,000/- per maternity delivery under the Maternity Benefit in respect of each insured family. Refer the GMC policy for definition of maternity and coverage. iii. Oral & Adjuvant Chemotherapy Applicable only for cancer cases Anti-cancer drugs [Chemotherapy drugs] like Methotrexate, Cyclophosphamide, Blenoxane, L-Asparaginase, Leuprolideacetat etc. are administered as intramuscular or oral. These will be covered, on OPD as well as IPD/Day care basis. Adjuvant Chemotherapy treatments like Injection Rituximab, Infliximab/Remicade, Enbrel/ Etanercept therapy, Zolandronic acid (aclasta) therapy, Herceptin: (Traszutumab), Injection Falsodex are administered. These will be covered on IPD/Day care basis. iv. Robotic Surgery GMC Policy excludes Robotic Surgery except for treatment of Cancer and Neurosurgery. The conventional procedure cost is covered in GMC policy and the difference towards Robotic costs, will be covered in the GMC Top Up Plus Policy. The GMC Top Up Plus Policy covers robotic surgery charges up to the limit (INR 25 Lacs) specified in the Certificate of Insurance incurred on the Insured Person s Inpatient Hospitalization or Day Care Treatment during the policy Period for ultramodern medicine provided that the Hospitalization is for Medically Necessary Treatment and the In-patient Hospitalization or Day Care Treatment is in accordance with the above conditions set out in agreement with the Insurer (ABHI) mentioned in the Group Management cadre policy

17 v. Specific Injections Injection Remicade - Remicade (infliximab) and similar injections used to treat Rheumatoid Arthritis, Psoriatic Arthritis, Ulcerative Colitis, Crohn s Disease, Ankylosing Spondylitis, severe or Disabling Plaque Psoriasis and other autoimmune illnesses, will be covered. Intravitreal (Avastin) Injection - Injection Avastin/Lucentis and similar Intravitreal Injections will be covered. End of Document 17