Memorandum of Understanding

Transcription

1 Memorandum of Understanding (Forming and Attaching Part of Policy No /46/12/ & /46/12/ W.e.f 01 st November 2012 to 31st October, 2013) 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 And FIS Payment Solutions & Services India Pvt. Ltd incorporated under the Companies Act 1956) represented by Mamta Wasan 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-2012 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 FIS Grade (LP) to be read as Grade 4 1

2 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%*25 (e.g. premium payable is then the eligibility would be 32000/90%*25 = 888,889 /- 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%. 2

3 Basic Example: 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 I & II shall be Rs. 1000/-, for grade III employee Rs. 4000/- and for employees in grade IV and above Rs. 6000/- to be part of Domiciliary limits & for Self only (please refer appropriate paragraph under the section Domiciliary in subsequent pages). 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 possible 3

4 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 within OPD limits. 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-the-counter" 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 employee under overall domiciliary limits of individuals for Grade I & II. For employees in grade 3 Health check-up admissible under domiciliary benefit is Rs. 4000/-. For grade 4 and above Health check-up admissible under domiciliary benefit is Rs. 6000/- (revised rate) once in the policy period. 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 under the overall domiciliary limit to cover specific dental treatments like extraction of teeth, filling, root canal 4

5 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.8000 per day (revised rate) 3. In case of ICU, the entitlement will be double of the Room rent entitlement. 5

6 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 post-natal) 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 maternity 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 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. 6

7 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. 5. Premium Adjustment: Premium of employees leaving the policy on termination of service will be adjusted against the monthly premium on prorated basis as per the below table. Premium Adjustment Calculation Table** No. of Months left for current cycle Premium Adjustment Rate 1 5 months 40% of premium More than 5 months & upto 9 months 50% of premium More than 9 months 75% of premium ** No adjustment against terminated employee who ve availed any benefit 7

8 6. Additional Benefit-60% of vaccination charges for Cervical Cancer has been provided under prescription for Women employees to be paid under the policy. This will be over and above the OPD & Hospitalization benefit. 7. Coverage of 3rd & 4th Child-Inclusion of 3rd & 4th child in lieu of parents/ parent-inlaws during the current policy period wherein an employee can nominate the 3rd or 4th child by withdrawing the nominations of either parents/parent-in-laws as applicable. The nominated 3 rd & 4 th child will be enrolled from the date of declaration of doing so by the employee. Once the nominations of parents/parent-in-laws are withdrawn they cannot be re-nominated during the policy period. Maternity benefit for the 3 rd & 4 th child is not covered under this clause. Copay on hospitalization for this coverage shall be applicable as that of parents i.e. 25% Copay. However, for all OPD claims it will be 10% Copay. 8. Policy Carry forward option-fis employees who ve been enrolled in the GHMI policy of FIS with NIC for the last 4 years can carry forward the policy after termination of employment with FIS or after superannuation from service of FIS. For the purpose of calculation of above period the start date of membership in the policy to the date of termination from the policy shall be reckoned with to assess the eligibility and consideration from NIC. This benefit provides an employee & his/her family to be covered for all Pre-existing disease on leaving the company however, features like Maternity & OPD will not be applicable. Policy feature & Premium will apply as per the individual Medical Policy offered by NIC for Self & Family at their sole discretion. A separate policy document or certificate will be issued by NIC on application by the respective employee. 9. NIC shall not be liable to make any payment under the section OPD of this policy in respect of any expenses whatsoever incurred by the employees in connection with or in respect of Primarily for Congenital external defects or Anomalies, Sterility, Infertility, Venereal Disease, Psychiatric and Psychosomatic disorders, Complication of AIDS/STD, External/Durable Medical/ Non- Medical equipments of any kind, Ambulatory devices, Naturopathy including Acupuncture, Acupressure, Megnatotherapy, Massages/Steam bath/surodhara/panchkarma, Vitamins and Tonics, Correction of Eye sight, Contact Lenses, Hearing aids, Cosmetic or Aesthetic. 10. 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: 8

9 No. of Months left for current cycle Amount of Premium 1-5 months 50% of full premium More than 5 months & upto 9 months More than 9 months 75% of full premium Full premium payable 10. The policy will continue to be served by the existing Third Party Administrator (TPA) Alankit Health Care TPA Limited 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 TPA Alankit to administer the policy. 11. NIC shall release float fund to Alankit Health Care TPA Limited (TPA) exclusively for FIS against the bank guarantee of Rs lacs (Twenty Five Lacs only) submitted by the TPA (Alankit Health Care TPA Limited) for settling claims exclusively under FIS Policy. 12. NIC will ensure timely replenishment of floats so that TPA Alankit can settle claims within the prescribed time limits. Also, it is agreed that should there be a situation when TPA Alankit is not able to release the payments to FIS against the settlements in a particular month latest by 15 th of the month, NIC will ensure to release the payment to FIS against TPA Alankit s reimbursement advice for that month. Signatories: (1) For & on behalf of FIS Global Business Solutions India Pvt. Ltd. (Mamta Wasan) Senior Vice President-Human Resources (2) For & on behalf of National Insurance Co. Ltd. (H. K. Chandra) Sr. Divisional Manager National Insurance Company Ltd Division - XVII, New Delhi 9