SALIENT FEATURES OF THE GROUP MEDICLAIM POLICY FOR THE YEAR The Policy shall cover Ex-employees of the company.

Transcription

1 ANNEXURE II SALIENT FEATURES OF THE GROUP MEDICLAIM POLICY FOR THE YEAR The Policy shall cover Ex-employees of the company. 2. Coverage of the policy for ex-employee is Rs 2 Lakhs p.a. consisting of self and spouse only. 3. The Policy will cover hospitalization as indoor patient only excluding domiciliary hospitalization. 4. The policy shall not cover OPD treatment. 5. Cash less treatment will be given to ex-employees. In case ex-employees obtains treatment from non-network hospital during emergency the claim shall be admitted in full. The said claim will be settled in 15 days of submission and payment will be made directly to the ex-employee. 6. AMOUNT PAYABLE FOR ADMISSIBLE CLAIMS: In the event of any claim becoming admissible under this policy, the Insurance Co. will pay the amount of such expenses as would fall under different heads mentioned below, and are reasonably and necessarily incurred thereof by or on behalf of such insured person. a) Room Boarding expenses as provided by the Hospital / Nursing home. b) Nursing Expenses. c) Surgeon, anesthetist, Medical Practitioner, consultants, specialist fees. d) Anesthesia, Blood, Oxygen, Operation Theatre Charges, Surgical Appliances, Medical, Drugs, Diagnostic Material and X ray, Dialysis, Chemotherapy, Radiotherapy, Cost of pacemaker Artificial Lambs & Cost of Organs and similar expenses. 7. The pre and post hospitalization reimbursement shall be for 30 and 60 days respectively.

2 8. Midterm inclusion:- Employees retiring during the FY shall be covered in this policy. In the event of death of an employee while in service, spouse of the deceased employee shall also be covered in this policy as midterm inclusion. Premium in r/o these inclusion shall be paid on pro-rata basis from the date of coverage. The intimation for midterm inclusion in r/o retired employee or his / her spouse shall be given within one month from the date of retirement/demise of the employee. 9. Mediclaim policy shall include all pre-existing diseases of ex-employees. 10. MEMBERSHIP CARD: The underwriter shall arrange to issue membership card to each ex-employee. These cards shall be sent directly by post / courier to ex-employee at their given addresses within 30 days of issuing of policy. 11. All NFL hospitals at units / plants shall also be taken on the network of the Insurance Company. 12. Insurance Co. shall provide a statement of employee wise mediclaim settled in respect of ex-employee at the end of each month in soft copy with a copy to CGM (HR) Corporate Office Noida. 13. ENTITLEMENT OF ROOM RENT: The employees are to be provided with room / bed in any hospital/nursing home by considering the room rent entitlement given in the statement enclosed at Annexure VIII. The room rent entitlement shall be applicable for treatment taken from hospital / nursing home located in Delhi including NCR s regions and all Capital of States / Union Territory. During hospitalisation in case of hospital / nursing homes at other places, the ceiling of room rent as indicated in column (3) of room rent entitlement given at Annexure VIII shall be restricted to 50%. 14 Premium shall be paid on quarterly basis before the beginning of each quarter. 15. During the currency of the policy no revision in premium shall be considered by NFL on the basis of actual claim ratio or any enhancement in the premium pointed out by any statutory or other authority.

3 16 HOSPITALIZATION PERIOD: Expenses on Hospitalization will be admissible only if hospitalization is for a minimum period of 24 hours. However, A) This time limit will not apply to following specific treatments taken in the Network Hospital / Nursing Home where the Insured is discharged on the same day. Such treatment will be considered to be taken under Hospitalization Benefit. Haemo Dialysis Parentral Chemotherapy Radiotherapy Eye Surgery Lithotripsy (kidney stone removal) Tonsillectomy D&C Dental surgery following an accident Hysterectomy Coronary Angioplasty Coronary Angiography Surgery of Gall bladder, Pancreas and bile duct Surgery of Hernia Surgery of Hydrocele Surgery of Prostrate Gastrointestinal Surgery Genital Surgery Surgery of Nose Surgery of throat Surgery of Appendix Surgery of Urinary System Treatment of Fractures / dislocation excluding hair line fracture, contracture releases and minor reconstructive procedures of limbs which otherwise require hospitalization Arthroscopic Knee surgery Any surgery under General Anesthesia Or any such disease / procedure agreed by TPA / Company before treatment B) Further if the treatment / procedure / surgeries of above diseases are carried out, in Networked specialized Day Care Centre which is fully equipped with advanced technology and specialized infrastructure where the insured is discharged on the same day, the requirement of

4 minimum beds will be overlooked provided following conditions are met. i. The operation theatre is fully equipped for the surgical operation required in respect of sickness / ailment / injury covered under the policy ii. iii. Day Care nursing staff is fully qualified The doctor performing the surgery or procedure as well as post operative attending doctors are also fully qualified for the specific surgery / procedure C) The condition of minimum 24 hours hospitalization will also not apply provided i. The treatment is such that it necessitates hospitalization and the procedure involves specialized infrastructural facilities available only in hospitals BUT ii. Due to technological advances hospitalization is required for less than 24 hours AND/OR iii. Surgical procedure involved has to be done under General Anesthesia Exclusions: i. Injury or disease directly or indirectly caused by or arising from or attributable to War, Invasion, Act of Foreign Enemy, War like operations (whether war be declared or not) or by nuclear weapons / materials. ii. iii. iv. Circumcision (unless necessary for treatment of a disease not excluded hereunder or as may be necessitated due to any accident), vaccination, inoculation or change of cosmetic or of aesthetic treatment of any description, plastic surgery other than as may be necessitated due to an accident or as a part of any illness. Surgery for correction of eye sight cost of spectacles, contact lenses, hearing aids etc. Any dental treatment or surgery which is corrective, cosmetic or of aesthetic procedure, filling of cavity, root canal including wear and tear etc unless arising from disease or injury and which requires hospitalization for treatment.

5 v. Convalescence, general debility, run down condition or rest cure, congenital external diseases or defects or anomalies, sterility, any fertility, sub-fertility or assisted conception procedure, venereal diseases, intentional self injury / suicide, all psychiatric and psychosomatic disorders and diseases / accident due to and or use, misuse or abuse of drugs / alcohol or use of intoxicating substances or such abuse or addiction etc. vi. vii. viii. ix. All expenses arising out of any condition directly or indirectly caused by, or associated with Human T-cell Lymphotropic virus Type III (HTLD III) or Lymohadinopathy Associated Virus (LAV) or the Mutants Derivative or Variations Deficiency Syndrome or any Syndrome or condition of similar kind commonly referred to as AIDS, HIV and its complications including sexually transmitted diseases. Expenses incurred at Hospital or Nursing Home primarily for evaluation / diagnostic purposes which is not followed by active treatment for the ailment during the hospitalized period. Expenses on vitamins and tonics etc unless forming part of treatment for injury or disease as certified by the attending physician. Naturopathy treatment, unproven procedure or treatment, experimental or alternative medicine and related treatment including acupressure, acupuncture, magnetic and such other therapies etc. x. Expenses incurred for investigation or treatment irrelevant to the diseases diagnosed during hospitalization or primary reasons for admission. Private nursing charges, Referral fee to family doctors, out station consultants / surgeons fees etc. xi. xii. Genetical disorders and stem cell implantation / surgery. External and or durable medical / non medical equipment of any kind used for diagnosis and or treatment including CPAP, CAPD, infusion pump etc. Ambulatory devices i.e. walker, crutches, belts, collars, caps, splints, slings, braces, stockings etc of any kind, diabetic foot wear, glucometer/ thermometer and similar related items etc and

6 also any medical equipment which is subsequently used at home etc. xiii. xiv. xv. xvi. All non medical expenses including personal comfort and convenience items or services such as telephone, television, Aya / barber or beauty services, diet chare, baby food, cosmetic, napkins, toiletry items, etc. guest services and similar incidental expenses or service etc. Change of treatment from one pathy to other pathy unless being agreed / allowed an recommended by the consultant under whom the treatment is taken. Treatment of obesity or condition arising there from (including morbid obesity) and any other weight control programme, services or supplies etc. Any treatment required arising from Insured s participation in any hazardous activity including but not limited to scuba diving, motor racing, parachuting, hang gliding, rock or mountain climbing etc. unless specifically agreed by the Insurance Company. xvii. Any treatment received in convalescent home, convalescent hospital, health hydro, nature care clinic or similar establishments. xviii. xix. xx. Any stay in the hospital for any domestic reason or where no active regular treatment is given by the specialist. Out patient diagnostic, Medical or Surgical procedures or treatments, non-prescribed drugs and medical supplies, Hormone replacement therapy, Sex change or treatment which result from or is in any way related to sex change. Massages, steams bathing, shirodhara and alike treatment under ayurvedic treatment. xxi. Any kind of service charges, surcharges, admission fees / registration charges etc. levied by the hospital xxii. xxiii. Doctor s home visit charges, attendant / nursing charges during pre and post hospitalization period. Treatment which is continued before hospitalization and continued even after discharge for an ailment / disease /

7 injury different from the one for which hospitalization was necessary. 17 HOSPITAL / NURSING HOME: means any institution in India established for indoor care and treatment of sickness and injuries and which either a) Is duly licensed and registered as a Hospital or Nursing Home with the appropriate authorities and is under the supervision of a registered and qualified medical Practitioner. OR b) In areas where licensing and registration facilities with appropriate authorities are not available, the institution must be one recognized in locality as Hospital / Nursing Home and should comply with minimum criteria as under: i. It should have at least 15 in - patient medical beds in case of Metro cities, A Class cities & B class cities or 10 inpatient medical beds in case of C class cities. Classification of cities shall be as per Govt. of India Notification issued in this respect from time to time. ii. Fully equipped and engaged in providing Medical and Surgical facilities along with Diagnostic facilities i.e. Pathological test and X-ray, ECG etc. for the care and treatment of injured or sick persons as in - patient. iii. Fully equipped operation theatre of its own, wherever surgical operations are carried out. iv. Fully qualified nursing staff under its employment round the clock. v. Fully qualified Doctor (s) should be physical in-charge round the clock.

8 NATIONAL FERTILIZERS LIMITED Annex.-III Details of Indoor Medical claims settled in r/o Ex- Employees by Oriental Insurance Company during the FY to Financial Year Claim settled No of Cases Amount (Rs in Lakhs) (upto 30th No. 2010)

9 NATIONAL FERTILIZERS LIMITED CORPORATE OFFICE NOIDA ANNEXURE-IV DEVIATION STATEMENT (Please strike off the clause that is not applicable and tick the other) 1. THIS IS TO DECLARE THAT WE DO NOT HAVE ANY DEVIATIONS FROM THE STIPULATIONS OF YOUR TENDER AND ACCORDINGLY ACCEPT ALL THE STIPULATIONS WITHOUT ANY RESERVATIONS WHATSOEVER. OR 2. WE HAVE NOTICED THE FOLLOWING CONTRADICTION/ DISCREPANIES IN/ BETWEEN THE TENDER STIPULATIONS. (Signature of the Tenderer)

10 NATIONAL FERTILIZERS LIMITED CORPORATE OFFICE NOIDA ANNEXURE V DECLARATION SHEET I, hereby certify that all the information and data furnished by me with regard to this tender specification are true and complete to the best of my knowledge. I have gone through the specification, conditions and stipulations in detail and agree to comply with the requirements and intent of specification. I, further certify that I am the duly authorized representative of the under mentioned tenderer. I, further certify that my company meets all the conditions of eligibility criteria laid down to take part in the tender. I, further certify that my company is in the mediclaim insurance business in India at least for 5 years as on schedule date of tender opening. I, further specifically certify that my company is having insurance participation in minimum 5 Public Sector Units and a leader of Mediclaim insurance in last five years. (Clause 1.3 of Annexure I). I, further specifically certify that my company has not been Black Listed / De Listed or put to any Holiday by any Institutional Agency / Govt. Department / Public Sector Undertaking in the last three years. (Clause 1.4) of Annexure I). (Signature of the Tenderer)

11 NATIONAL FERTILIZERS LIMITED CORPORATE OFFICE NOIDA ANNEXURE - VI CERTIFICATE OF DECLARATION FOR CONFIRMATION OF IRDA GUIDELINES I, hereby certify that our offer no..dated..against tender specification No.. does not amount to any breach of IRDA guidelines. I further confirm that in the event of disclosure at a later stage that the same are not in line with IRDA Guidelines & NFL is put to any disadvantage or face cancellation of the Policy or any claim becomes substandard/untenable, the whole liabilities arising out of this shall lie squarely on us. I, further certify that I am the duly authorized representative of the Insurer and competent to agree as above. (Signature of the Tenderer)

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13 AGE PROFILE OF EX-EMPLOYEES AS ON Annexure-VII-(a) AGE (Years) Less Than 50 Yrs Yrs Yrs Yrs Yrs Yrs Above 75 Yrs Total (Nos) Existing New (appx.) Total

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15 Annexure-VII-(b) AGE PROFILE OF SPOUSE OF EX-EMPLOYEES AS ON AGE (Years) Less Than 50 Yrs Yrs Yrs Yrs Yrs Yrs Above 75 Yrs Total (Nos) Existing New (appx.) Total

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17 NATIONAL FERTILIZERS LIMITED CORPORATE OFFICE NOIDA Annexure VIII ROOM RENT ENTITLEMENT OF EX-EMPLOYEES / DEPENDENTS AS ON S.No. Post Held at the time of leaving the Service of NFL GRADE Maximum Room Rent Entitlement Per Day (Rs) (1) (2) (3) 1 Functional Directors&CMD A E-7 to E-9 B W-11, W-12,and E-1 to E-6 C W-10 and E0 D W0 to W9 E 975

18 NATIONAL FERTILIZERS LIMITED CORPORATE OFFICE NOIDA Annexure-A S.No I Particulars Ex- Employees (Earlier Covered in Premium Per Member (Rs) Service Tax (Rs) Total Premium Per Member (Rs) No of members for evaluation 1186 Total Premium (Rs) the Policy) Dependents (Spouse only) 1074 Total II Ex- Employees (Fresh entrants not 901 covered earlier) Dependents (Spouse only) 822 Total Total ( I+II) 3983