Employee Benefits Manual

Transcription

1 Employee Benefits Manual Client Maxim India Integrated Circuit Design Pvt Ltd Document No Marsh/TFS/October2013 October 2013 Start

2 Disclaimer: This manual is intended to be general summary of the benefits offered by your company & should be regarded as guide only. While Marsh shall make every reasonable effort to ensure the accuracy and validity of the information provided here in this document. Marsh accepts no liability or responsibility for any errors or omissions in the content or for any loss or damages arising out of your reliance on information provided here. If there is a conflict in interpretation or benefit applicability, then the terms & conditions of the policy will prevail. Prepared by Manjula R Marsh India Insurance Brokers Private Limited RMZ Millennia, Ulsoor Bangalore Copyright All rights reserved. No part of this publication may be reproduced, stored in the retrieval system, or be transmitted in any form or by any means, electronic or mechanical, photocopying, recording or otherwise, without the prior written permission of MARSH. MARSH 2

3 Program Details Group Medical Provides insurance coverage to employees /dependents for expenses related to hospitalization due to illness, disease or injury MARSH 3

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5 Medical Benefit Policy Details Policy Parameter Insurer The New India Assurance Co Ltd TPA FHPL Policy Start Date 07 th October 2013 Policy End Date 06 th October 2014 Coverage Type Family Floater Dependent Coverage (Employee + Spouse + dependent Children + 2 dependent Parents) Sum Insured INR 5 lakhs per family (Parental sum Insured restricted to Rs.1.50 lakhs) Benefits / Extensions Benefits / Extensions Standard Hospitalization Yes Baby Expenses during maternity Yes Pre existing diseases Yes Day Care Yes Waiver on 30days & 1 st year exclusion Pre-Post Hospitalization Exp. Maternity benefits Ambulance Services Baby cover day 1 Yes Yes Yes Yes Yes Domiciliary Hospitalization Pre & Post natal expenses Room Rent Cap Copayment No Yes Applicable Yes, 20% on parental claims only only MARSH 5

6 Medical Benefit Dependant Coverage Maximum no of Members insured in a family (Employee Policy) Employee Spouse Children Parents Siblings/ Parents-in-Law Others Mid Term enrollment of existing Dependents Mid Term enrollment of New Joinees (New employees +their Dependents) Mid term enrollment of new dependents (Spouse/Children) Mid term change in the enrolled dependants post window period 1+5 Yes Yes Yes (for the first 2 living Children) Yes No No Disallowed Allowed Allowed Disallowed Mid term enrollment of new dependents (Spouse/Children) Allowed No Individual should be covered as dependent of more than one employee MARSH 6

7 Medical Benefit Policy Period Existing Employees + Dependents Commencement Date 07 th October 2013 Termination Date 06 th October 2014 or last working day whichever is earlier New Joinees + Dependents Commencement Date Termination Date Date of joining 06 th October 2014 or last working day whichever is earlier New Dependents (due to Marriage / Birth) Commencement Date for New dependents due to marriage Commencement Date for New dependents due to birth Termination Date Date of marriage (additions to be intimated within 30 days from the date of event) Date of Birth (additions to be intimated within 30 days from the date of event) 06 th October 2014 or last working day whichever is earlier MARSH 7

8 Medical Benefit Standard Coverage Inpatient Hospitalization - Covers expenses related to Room and boarding Doctors fees Intensive Care Unit Nursing expenses Surgical fees, operating theatre, anesthesia and oxygen and their administration Physical therapy Drugs and medicines consumed on the premises Hospital miscellaneous services (such as laboratory, x-ray, diagnostic tests) Dressing, ordinary splints and plaster casts Costs of prosthetic devices if implanted during a surgical procedure Radiotherapy and chemotherapy A) The expenses are payable provided they are incurred in India and within the policy period. Expenses will be reimbursed to the covered member depending on the level of cover that he/she is entitled to. B) 24 Hours hospitalization not required Expenses on Hospitalisation for minimum period of 24 hours are admissible in case of an active line of treatment. However this time limit will not apply for specific treatments i.e. Dialysis, Chemotherapy, Radiotherapy, Eye surgery, Dental Surgery, Lithotripsy (kidney stone removal), Tonsillectomy, D & C taken in the Hospital/Nursing home and the insured is discharged on the same day of the treatment will be considered to be taken under Hospitalisation Benefit. All /any Expenses are only payable subject to policy terms and conditions Note the list above is not exhaustive and the policy document to be referred for further details MARSH 8

9 Pre & Post Hospitalization Expenses Pre-hospitalisation Expenses Definition Covered Duration If the Insured member is diagnosed with an Illness which results in his / her Hospitalization and for which the Insurer accepts a claim, the Insurer will also reimburse the Insured Member s Pre-hospitalisation Expenses for up to 30 days prior to his / her Hospitalization. Yes 30 Days Post-hospitalisation Expenses Definition Covered Duration If the Insurer accepts a claim under Hospitalization and immediately following the Insured Member s discharge, further medical treatment directly related to the same condition for which the Insured Member was Hospitalized is required, the Insurer will reimburse the Insured member s Post-hospitalisation Expenses for up to 60 day period. Yes 60 Days Note: Pre and post hospitalization expenses are payable only if the expenses are related to the ailment of the main hospitalization claim. Also if there is a hospitalization in the pre/post period with no active line of treatment the room rent would not be payable however the related diagnostics would be payable. MARSH 9

10 Maternity Benefits Benefit Details Benefit Amount Restriction on no of children 9 Months waiting period Waived off Pre-Post Natal Expenses Baby Expenses INR 50,000 for normal & INR 75,000 for C-Sec within the Family Floater Sum Insured Restricted to the first 2 children Incurred on an out patient basis upto 5% of the maternity sub-limit specified in the table below or Rs.5000 whichever is lower Up to 5% of the maternity Sub-limit or Rs.5000 whichever is lesser These benefits are admissible in case of hospitalisation in India. Covers first two children only. Those who already have two or more living children will not be eligible for this benefit. Expenses incurred in connection with voluntary medical termination of pregnancy during the first 12 weeks from the date of conception are not covered. Medical termination of pregnancy post 12 weeks would be covered with in the maternity limit MARSH 10

11 Day Care Procedures HOSPITALISATION means admission in any Hospital/Nursing Home in India upon the written advice of a Medical practitioner for a minimum period of 24 consecutive hours. Day care procedures as below which does not require 24 hour hospitalization would be covered under the policy OR any other Surgeries / Procedures agreed by TPA/COMPANY which require less than 24 hours hospitalisation due to subsequent advancement in Medical Technology. Anti Rabies Vaccination Appendectomy Coronary Angiography Coronary Angioplasty Dental surgery following an accident Dilatation & Curettage (D & C) of Cervix Eye surgery Fracture / dislocation excluding hairline fracture Gastrointestinal Tract system Haemo-Dialysis Hydrocele Hysterectomy Inguinal/Ventral/Umbilical/Femoral Hernia repair Lithotripsy (Kidney Stone Removal) Parenteral Chemotherapy Piles / Fistula Prostate Radiotherapy Sinusitis Stone in Gall Bladder, Pancreas, and Bile duct Tonsillectomy Urinary Tract System MARSH 11

12 Room rent Room rent Cap per Day 1% of SI for normal & 2% of SI for ICU Sum Insured INR 5 lacs INR 5000 for normal & INR for ICU IMPORTANT NOTE : In The Event Of A Member Occupying A Room Higher Than The Above Limits, All The Related Expenses Like Doctor S Fees, Surgery Charges, Nursing Charges, Etc Will Be Scaled Down In Proportion To The Eligible Room Charges MARSH 12

13 Ambulance Services Ambulance Expenses Definition Covered Amount Restriction The Insurer will pay for Emergency ambulance road transportation by a licensed ambulance service to the nearest Hospital where Emergency Health Services can be rendered. Coverage is only provided in the event of an Emergency. The Policy will cover Ambulance charges in connection with admitted claim incurred to shift the insured person from Residence/accident site to Hospitals in emergency cases and from one Hospital/Nursing Home to another Hospital/Nursing Home/Diagnostic centre for better care/diagnosis, 1% of the sum insured or Rs.2000 which ever is lower MARSH 13

14 Benefit Extensions Definitions Benefits Definition Coverage Limit Pre existing diseases First 30 day waiting period First Year Waiting period Any Pre-Existing ailments such as diabetes, hypertension, etc or related ailments for which care, treatment or advice was recommended by or received from a Doctor or which was first manifested prior to the commencement date of the Insured Person s first Health Insurance policy with the Insurer Any Illness diagnosed or diagnosable within 30 days of the effective date of the Policy Period if this is the first Health Policy taken by the Policyholder with the Insurer. If the Policyholder renews the Health Policy with the Insurer and increases the Limit of Indemnity, then this exclusion shall apply in relation to the amount by which the Limit of Indemnity has been increased During the first year of the operation of the policy the expenses on treatment of diseases such as Cataract, Benign Prostatic Hypertrophy, Hysterectomy for Menorrhagia or Fibromyoma, Hernia, Hydrocele, Congenital Internal Diseases, Fistula in anus, Piles, Sinusitis and related disorders are not payable. If these diseases are pre- existing at the time of proposal they will not be covered even during subsequent period or renewal too Covered Waived Waived MARSH 14

15 Benefit Extensions Definitions Benefits Definition Coverage Limit Dental & Vision Treatment Baby Cover Day 1 Any dental treatment or surgery of a corrective, aesthetic nature unless it requires Hospitalization; is carried out under general anesthesia and is necessitated by Illness or Accidental Bodily Injury. In consideration of additional premium, this policy is extended to cover the new born child of an employee covered under the Policy from the time of birth till 90 days. Not withstanding this extension, the Insured shall be required to cover the newly born children within 30 days as additional member as mentioned elsewhere under this Policy. Not Covered Covered MARSH 15

16 Benefit Extensions Definitions Benefits Domiciliary Hospitalization (NOT COVERED) Benefits not covered under Domiciliary Treatment Definition DOMICILIARY HOSPITALISATION BENEFIT means Medical treatment for a period exceeding three days for such illness/disease/injury which in the normal course would require care and treatment at a hospital/ nursing home but actually taken whilst confined at home in India under any of the following circumstances, namely: The condition of the patient is such that he/she cannot be removed to the hospital/nursing home or The patient cannot be removed to the hospital/nursing home for lack of accommodation therein Expenses incurred for pre and post hospital treatment, and Expenses incurred for the treatment for any of the following diseases: Asthma Bronchitis Chronic Nephritis and Nephritic Syndrome Diarrhea and all types of dysentries including Gastroenteritis Diabetes Mellitus and Insipidus Epilepsy Hypertension Influenza, Cough, and Cold All Psychiatric or Psychosomatic disorders Pyrexia of unknown origin for less than 10 days Tonsillitis and upper respiratory tract infection including Laryngitis and Pharyngitis Arthritis, Gout and Rheumatism X Not Applicable MARSH 16

17 Medical Benefit General Exclusions Injury or disease directly or indirectly caused by or arising from or attributable to War or War-like situations Circumcision unless necessary for treatment of disease Congenital external diseases or defects/anomalies HIV and AIDS Hospitalisation for convalescence, general debility, intentional self-injury, use of intoxicating drugs/ alcohol. Venereal diseases Injury or disease caused directly or indirectly by nuclear weapons Naturopathy Any non-medical expenses like registration fees, admission fees, charges for medical records, cafeteria charges, telephone charges, etc Cost of spectacles, contact lenses, hearing aids Any cosmetic or plastic surgery except for correction of injury Hospitalisation for diagnostic tests only Vitamins and tonics unless used for treatment of injury or disease Infertility treatment Voluntary termination of pregnancy during first 12 weeks (MTP) OPD Claims Claims (of high value) submitted without prescriptions/diagnosis Health foods Costs incurred as a part of membership/subscription to a clinic or health centre Naturopathy Cost of appliances, spectacles, contact lenses, hearing aids Non-medical expenses like Hospital surcharge, telephone bills, cafeteria bills MARSH 17

18 Medical Policy Policy Change for Policy Terms Existing Coverage Renewal Coverage Pre Existing Covered Covered Maternity Covered Covered Ailment Capping Not Applicable Not Applicable Room Rent Eligibility INR 5000 for normal and INR for ICU INR 5000 for normal and INR for ICU Co payment No Co-payment 20% Co-pay on parental claim MARSH 18

19 PROCEDURE FOR CARD ISSUANCE FOR NEW EMPLOYEE / ADDITIONS IN FAMILY 1. Declaration of Employee with family details through H.R within 30 days of Joining Period 2. Data sent for cards issuance to the TPA/Insurer. 3. New cards issued within 15 working days of receipt of data from HR. IN THE INTERIM PERIOD TILL THE CARDS ARE ISSUED,IN CASE OF ANY MEDICAL EMERGENCY,EMPLOYEE CAN AVAIL OF CASHLESS BENEFIT BY QUOTING HIS EMPLOYEE NUMBER. Newly wedded spouse & new born children need to be declared within 30 days of marriage and 30 days of birth respectively For seamless transactions of cashless please contact the FHPL SPOC MARSH 19 Health Administration Team

20 Process for e-card Click on Click on e-card Select Maxim India from corporate drop down menu. Enter your User ID and Password ( User Id and password will be communicated to you by FHPL shortly) Login successful Click on individual name, welcome message will appear and than click on e-card to view and download the e-card. You may retain print copy of this at your home and office. Login Failure Please contact FHPL respective zone account manager for immediate assistance MARSH 20

21 Medical Benefit Cashless Process Cashless means the TPA may authorize upon a Policyholder s request for direct settlement of eligible services and it s according charges between a Network Hospital and the TPA. In such case the TPA will directly settle all eligible amounts with the Network Hospital and the disallowed amount would be paid by the insured member List of hospitals in the FHPL network eligible for cashless process Please check for the updated Network Hospital list on the FHPL (New India Assurance company Limited) Note : Patients seeking treatment under cashless hospitalization are eligible to make claims under pre and post hospitalization expenses. For all such expenses the bills and other required documents needs to submitted separately as part of the claims reimbursement. MARSH 21

22 Hospitalization in Network Hospitals EMERGENCY ADMISSIONS In FHPL Network Hospitals Admission of Patient Starting of Treatment Provide Hospital Administration your Health Identity card Pre Authorization form to be filled up by treating Doctor and Hospital Admin to Fax it to FHPL FHPL to confirm validity of Person Covered to Hospital for Cashless On Discharge: MARSH 22

23 Hospitalization in Network Hospitals PLANNED ADMISSIONS Empanelled Hospitals Pre Authorization Letter to be filled up by the treating Doctor and the Hospital has to send it to FHPL 48 hrs before admission. FHPL to confirm the validity of employee insured and preauth will be processed as per policy terms and conditions. Patient gets admitted. MARSH 23

24 Pre-authorization Process for Cashless Member approaches Hospitals with FHPL ID Card Hospital sends Intimation to FHPL TAT : less than 2 hrs for routine cases Eligibility Not Covered Out of Pocket payment Regularization within 24 Hrs Process of cashless authorization is decentralized Covered List of network hospital visit our website. Authorization as per eligibility Cashless treatment at NWH MARSH 24

25 Protocol for Availing Treatment in Non Network Hospital Member avails treatment at any hospital and intimates FHPL with in 24 hours & takes an intimation No. and flashes at time submitting the claim Member submits bills to FHPL within 15 days of discharge FHPL verifies the documents submitted In case of incomplete documents recovery of documents for scrutiny FHPL processes claims Settle the Claim in 15 working days MARSH 25

26 Procedure for Reimbursement Pay and settle the bills & collect the following documents from the hospital. Submit the same to FHPL representative within 15 days of discharge : 1. NIA claim form, duly filled & signed by the claimant. 2. Discharge Summary 3. Final Bill with breakup 4. Receipts for the payment made. 5. All Laboratory investigation reports 6. In case of surgical packages detail breakup of the package. 7. Medicine bills with prescriptions. 8. In case of maternity, gravida status to be mentioned in discharge summary. 9. Cancelled cheque. 30 Days pre & 60 Days Post hospitalization. 1. NIA claim form, duly filled & signed by the claimant. 2. Original investigation reports along with bills & receipts. 3. Consultation receipts. 4. Medicine bills with prescriptions. Please Note: All the documents should be submitted in Original and please retain copy of all the documents for further references MARSH 26

27 Call Centre Dedicated member helpline 24 x 7 Nationwide Toll free X 7days accessible Electronically supported systems Managed by professionally skilled manpower Assistance in information on Network hospitals Enrollment status Support services in an Emergency Coverage eligibility Claims- documentation support, query handling General information on health plan MARSH 27

28 Important Always keep a copy of FHPL ID card in your wallet and remember your UHID (FHPL ID card number). Without FHPL e-card /UHID you cannot avail cashless benefits and claiming for benefits. While contacting FHPL personnel, please introduce yourself by your name, UHID and corporate you are working for. Always remember 5 6 FHPL network hospitals near to your work location and residence. In case of any emergency in odd hours, kindly contact our 24/7 toll free number ( ) For downloading e-card(s), claim forms, network hospital list, kindly follow the link For e-card queries or resetting your e-card login password, please write to csblr@fhpl.net MARSH 28

29 Escalation Matrix FHPL Level of Contact Contact Person Contact no: ID Ist Level Suresh. P sureshp@fhpl.net IInd Level Mr. Rahul Krishnan rahul.krishnan@fhpl.net IIIrd Level Mr. Jom George jom.george@fhpl.net MARSH 29

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