You are on page 1of 31

EMPLOYEE BENEFIT MANUAL

March 2018

Leadership, Knowledge, Solutions…Worldwide.


Program Details

Provides insurance coverage to employees for expenses


Group Medical related to hospitalization due to illness, disease or injury

Provides insurance coverage against the risk of death /


Group Personal Accident injury during the policy period sustained due to an
accident caused by violent, visible and external means

Common Definitions Frequently Asked Questions & Common Definitions

Marsh – Leadership, Knowledge, Solutions…Worldwide. 2


Group Mediclaim

Policy details
Benefits Extensions
Benefits Extensions - Definitions
Medical Benefits - Cashless Process
Planned hospitalization
Emergency Hospitalization & Process
Non - Cashless ( Reimbursement)
Non - Cashless Claims Process
Claims Documents List
Medical Benefit - General Exclusions
Mediclaim Policy - Contact Details

Marsh – Leadership, Knowledge, Solutions…Worldwide. 3


Medical Benefit – Policy Details for Employee Policy

Policy Parameter

 Insurer National Insurance Company Ltd


 TPA MediAssist India TPA Pvt. Ltd

 Policy Start Date 1st March 2018

 Policy End Date 28th February 2019

 Coverage Type Family Floater

 Dependent Coverage Employee + Spouse + Children (max 2 children)


 Co-pay Yes
 Sum Insured Category 1 – INR 2 lakh, Category 2 – INR 3 lakh and Category 3 – INR 5 Lakh

Benefits / Extensions Coverage Benefits / Extensions Coverage

 Standard Hospitalization  Yes  Day Care  Yes

 Domiciliary Hospitalization  No
 Pre existing diseases  Yes
 Dental  Restricted

 Waiver on 1st year exclusion  Yes  Vision  Restricted

 Pre-Post Hospitalization Exp.  Yes


 Waiver on 1st 30 days excl.  Yes
10% on all
 Maternity benefits  Yes claims(excl. capped
Co-pay aliments like
maternity &
 Baby cover day 1  Yes cataract)

Marsh – Leadership, Knowledge, Solutions…Worldwide. 4


Medical Benefit – Dependant Coverage

Maximum no of Members insured in a family 1+3


Employee Yes
Spouse Yes

Children Yes (for the first 2 Children, Max age 21 year )


Parents Yes , Separate Program - Voluntary
Parents-in-Law Yes , Separate Program - Voluntary

Siblings No

Others No
Mid Term enrollment of existing Dependents. Disallowed

Mid Term enrollment of New Joinees (New employees +their


Allowed (within 30 days of Joining)
Dependents)
Mid term enrollment of new dependents (Spouse/Children) Allowed (Due to Marriage and birth).

Marsh – Leadership, Knowledge, Solutions…Worldwide. 5


Medical Benefit – Policy Period

Existing Employees + Dependents

Commencement Date 1st March 2018

Termination Date 28th Feb 2019 (MIDNIGHT)

New Joinees + Dependents

Commencement Date Date of Joining

Termination Date 28th Feb 2019 (MIDNIGHT)

New Dependents (due to Marriage / Birth)

Commencement Date Intimation Date

Termination Date 28th Feb 2019 (MIDNIGHT)

Marsh – Leadership, Knowledge, Solutions…Worldwide. 6


Medical Benefit – Standard Coverage

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) Expenses on Hospitalisation for minimum period of 24 hours are admissible. However this time
limit will not apply for specific treatments i.e. Dialysis, Chemotherapy, Radiotherapy, Eye 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.

Marsh – Leadership, Knowledge, Solutions…Worldwide. 7


Pre & Post Hospitalization Expenses

Pre-hospitalisation Expenses
 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
Definition
reimburse the Insured Member’s Pre-hospitalisation Expenses for up to 30 days
prior to his / her Hospitalization.
Covered  Yes

Duration  30 Days

Post-hospitalisation Expenses
 If the Insurer accepts a claim under Hospitalization and immediately following
the Insured Member’s discharge, further medical treatment directly related to the
Definition 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.
Covered  Yes

Duration  60 Days

Marsh – Leadership, Knowledge, Solutions…Worldwide. 8


Maternity Benefits

Benefit Details

Benefit Amount  Normal delivery and C-section – up to INR 50,000

Restriction on no of children  Maximum of 2 children

9 Months waiting period  Waived off

• 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.

Marsh – Leadership, Knowledge, Solutions…Worldwide. 9


Day Care Procedures

Day Care Procedure means the course of medical treatment or a surgical procedure listed in
the Schedule which is undertaken under general or local anesthesia in a Hospital by a
Doctor in not less than 2 hours and not more than 24 hours. Generally 8 aliments (i.e.
Dialysis, Chemotherapy, Radiotherapy, Eye surgery, Lithotripsy (kidney stone removal),
Tonsillectomy, D & C). The entire list is provided below.

Marsh – Leadership, Knowledge, Solutions…Worldwide. 10


Room rent

Room rent Expenses

Definition Defined as room, boarding & nursing charges.

Covered Yes

Sum Assured
Level (Floater) Room Rent ICU

Category 1- 1 to 4 2 Lakhs 3000 6000


Amount Restrictions (INR)
Category 2- 5 to 8 3 Lakhs 4000 8000

Category 3 - 9 to 11 5 Lakhs 5000 10000

Room rent proportionate deduction is applicable for all claims, the difference
Room category
amount will be paid by employees.

Marsh – Leadership, Knowledge, Solutions…Worldwide. 11


Case Study for Room rent proportionate deduction

Room rent proportionate deductions


Particulars Amount Reference

Eligible room rent 3000 A


Actual room rent 5000 B
% of expenses allowed 60% A/B

Total claimed amount 100000 C

Non-Medical expenses to be borne by employee 1000 D

Eligible total claim amount 99000 E

Eligible amount after proportionate room rent deduction clause 59400 F (60% of E)

40% of E to be borne by employee due to room rent clause (E-F) 39600 G

10% co-pay on eligible claimed amount to be borne by employee( F*10%) 5940 H

Total to be borne by employee (D+G+H) 46540 I

Insurance claim settlement (C-I) 53460 J

Note : I + J =C 100000

Marsh – Leadership, Knowledge, Solutions…Worldwide. 12


Benefit Extensions – Definitions

Benefits Definition Coverage Limit


Any Pre-Existing ailments such as diabetes, hypertension, etc or
related ailments for which care, treatment or advice was
Pre existing diseases recommended by or received from a Doctor or which was first Covered
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
First 30 day waiting taken by the Policyholder with the Insurer. If the Policyholder
Waived
period 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,
First Year Waiting
Hernia, Hydrocele, Congenital Internal Diseases, Fistula in anus, Waived
period
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
Any dental treatment or surgery of a corrective, aesthetic nature
Dental & Vision unless it requires Hospitalization; is carried out under general
Treatment anesthesia and is necessitated by Illness or Accidental Bodily Restricted (only incase of
Injury. accidents

Marsh – Leadership, Knowledge, Solutions…Worldwide. 13Next


Benefit Extensions – Definitions

Benefits 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
Domiciliary hospital/ nursing home but actually taken whilst confined at home in India under any of the following
Hospitalization circumstances, namely:
– The condition of the patient is such that he/she cannot be removed to the hospital/nursing
X
(NOT COVERED) home or
– The patient cannot be removed to the hospital/nursing home for lack of accommodation
therein Not Applicable
 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
Benefits not – Diarrhea and all types of dysentries including Gastroenteritis
covered under – Diabetes Mellitus and Insipidus
Domiciliary – Epilepsy
Treatment
– 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

Note: When treatment such as Dialysis, Chemotherapy, Radiotherapy is taken in the Hospital/Nursing Home/Clinic and the insured is
discharged the same day the treatment will be considered to be taken under Hospitalisation Benefit section and thus covered.
Next
Marsh – Leadership, Knowledge, Solutions…Worldwide. 14
Medical Benefit – Cashless Process

Cashless means the Administrator (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 Administrator. In such case the Administrator
will directly settle all eligible amounts with the Network Hospital and the Insured Person may not have to pay any
deposits at the commencement of the treatment or bills after the end of treatment to the extent as these services are
covered under the Policy.
List of hospitals in the MediAssist network eligible for cashless process
Hospital Network List Call center (9.00AM to 6.00pm)
1.Click on Website – www.mediassistindia.com Call Centre Toll Free number (24/7) – 1800-425-9449
2.Log on the site & click – Quick links Telephone Numbers: 080-26590504-06
3.Click on – All India Hospital List Fax Number : 080- 26590507
4.Enter the name of the city to access updated hospital list

Escalation: Mithun Ramarao Email - customercare@mediassistindia.com or


info@mediassistindia.com
Email: mithun.ramarao@mediassistindia.com
Phone: 7022969928
Address: 45/A,Green Arch,B Block,2nd floor,1st main
road,3rd phase, J.P.Nagar, Bangalore-560078

Planned Hospitalization Emergency Hospitalization

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 – Leadership, Knowledge, Solutions…Worldwide. 15


Planned Hospitalization

Member intimates TPA of the


Step 1 Claim
planned hospitalization in a Yes TPA authorizes cashless
Pre-Authorization Registere
specified pre-authorization as per SLA for planned
format at-least 48 hours in d by the hospitalization to the
All non-emergency advance TPA on hospital
hospitalisation instances must same day
be pre-authorized with the TPA, Pre – Authorization Form
as per the procedure detailed No
below. This is done to ensure www.mediassi
that the best healthcare stindia.com
possible, is obtained, and the
patient/employee is not Follow non cashless Pre-Authorization
inconvenienced when taking process Completed
admission into a Network
Hospital.

Step 2 Member produces e- Member gets treated


Admission, Treatment & Hospital sends
card at the network and discharged after
discharge complete set of claims
hospital and gets paying all non entitled
documents for
admitted benefits like
processing to TPA
refreshments, etc.
After your hospitalisation has
been pre-authorized, you need
to secure admission to a
hospital. A letter of credit will be
issued by TPA to the hospital.
Kindly present your ID card at
Claims Processing &
the Hospital admission desk. The
Settlement by TPA &
employee is not required to pay
Insurer
the hospitalisation bill in case of
a network hospital. The bill will
be sent directly to, and settled
by TPA
Next
Marsh – Leadership, Knowledge, Solutions…Worldwide. 16
Emergency Hospitalization & Process

Step 1
Get Admitted
In cases of emergency, the P
member should get admitted in
the nearest network hospital by
R
showing their ID card. O
C Member gets admitted in Pre-
No
E the hospital in case of authorization Non cashless
S emergency by showing given by the Hospitalization
Step 2 his ID Card TPA Process
Pre-Authorization by hospital
S

Relatives of admitted member


Yes
should inform the call centre within
24 hours about the hospitalization &
Seek pre authorization. The
preauthorization letter would be Member/Hospital applies Member gets treated and
directly given to the hospital. In case for pre-authorization to discharged after paying
of denial member would be informed the TPA within 24 hrs of all non medical expenses
directly admission like refreshments, etc.

Step 3 TPA verifies applicability


Hospital sends complete
Treatment & Discharge of the claim to be
set of claims documents
registered and issue pre-
for processing to the TPA
After your hospitalisation has been authorization
pre-authorized the employee is not
required to pay the hospitalisation
bill in case of a network hospital. The
bill will be sent directly to, and
settled by TPA

Marsh – Leadership, Knowledge, Solutions…Worldwide. 17


Non-Cashless (Reimbursement)

Admission procedure
• In case you choose a non-network hospital you will have to liaise directly with the hospital
for admission.
• However you are advised to follow the pre authorization procedure to ensure eligibility for
reimbursement of hospitalization expenses from the insurer.
• Please ensure you take your health card along with a valid photo ID proof like- driving
license / ration card / passport, etc for admission in the hospital.

Discharge procedure
• In case of non network hospital, you will be required to clear the bills and submit the
claim to TPA for reimbursement from the insurer. Please ensure that you collect all
necessary documents such as – discharge summary, investigation reports etc. for
submitting your claim.

Submission of hospitalisation claim


• You must submit the final claim with all relevant documents within 15 days from the
date of discharge from the hospital.
Claims Process Claim Docs
Marsh – Leadership, Knowledge, Solutions…Worldwide. 18
Non-Cashless Claims Process

Member intimates TPA before Insured admitted as per Insured sends relevant A
Claim registered by TPA after
or as soon as hospitalization hospital norms. All payments documents to TPA office
receipt of claim intimation
occurs (email) made by member within 15 days of discharge

Is document
Is claim TPA performs medical scrutiny
received
payable? of the documents •Insured will create the
Yes within 15
Yes days from summary of Bills (2
discharge copies) and attach it with
the bills
No No
•The envelope should
contain clearly the
Claim Rejected
Employee ID & Employee
e-mail

Is Payment to be made to
TPA checks document documentati Claims processing done as employees he discharge
sufficiency on complete per SLA voucher and copy of
as required payment receipt to be sent
Yes
to Biocon.
No

Send mail about deficiency


A
and document requirement

Next
Marsh – Leadership, Knowledge, Solutions…Worldwide. 19
Claims Document List

Completed Claim form with ECS form and Cancel Cheque


Employee id card & patient photo id card copies

Hospital bills in original (with bill no; signed and stamped by the hospital) with all
charges itemized and the original receipts
Claims Form

Discharge Report (original)

Attending doctors’ bills and receipts and certificate regarding diagnosis (if separate from
hospital bill)

Original reports or attested copies of Bills and Receipts for Medicines, Investigations
along with Doctors prescription in Original and Laboratory
Check List
Follow-up advice or letter for line of treatment after discharge from hospital, from
Doctor.

Provide Break up details including Pharmacy items, Materials, Investigations even


though it is there in the main bill

In case the hospital is not registered, please get a letter on the Hospital letterhead
mentioning the number of beds and availability of doctors and nurses round the clock.
Minimum beds required is 15 for a hospital for –Bangalore/Kolkatta/Hyderabad/Delhi
NCR/Chennai/Mumbai. For other locations, please contact your TPA for admissibility.

In non- network hospital, you may have to get the hospital and doctor’s registration
number in Hospital letterhead and get the same signed and stamped by the hospital, if
required.

*Please retain photocopies of all documents before submitting it


to Mediassist.
Marsh – Leadership, Knowledge, Solutions…Worldwide. 20
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, Homeopathy, Ayurvedic treatments.
• 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 / fertility treatment
• Voluntary termination of pregnancy during first 12 weeks (MTP)
• Others: Example- Service Tax, Luxury Tax, barber or attendant charges etc.
• OPD claim Next
Marsh – Leadership, Knowledge, Solutions…Worldwide. 21
Mediclaim Policy – Contact Details

Mediassist Escalations Matrix


Activity Escalation Contact No Non Voice E-mail ID
Customer service Toll Free no customercare@mediassistindia.com or
General queries 18004199449 info@mediassistindia.com
SPOC Mithun 7022969928 mithun.ramarao@mediassistindia.com

Escalation Kannan kannan.gopalan@medibuddy.in

Marsh Contact Details

Matrix Name Designation Contact No E mail ID

First Level John Kenneth AM 8884092891 John.Kenneth@marsh.com

Second Level Sasmita Salwan SRM 9620188805 sasmita.salwan@marsh.com

Marsh – Leadership, Knowledge, Solutions…Worldwide. 22


Helpdesk Contact Details

Helpdesk Timing

Complete Helpdesk Executive and his Contact


Location
Every Monday and Address number
Thursday

Biocon House 11.00 AM to 12.00 Noon HR Office Mr Madhu - 9148566495

Biocon Campus 12.30 Noon to 1.30 PM HR Office Mr Madhu - 9148566495

Biocon Park 2.30 PM to 3.30 PM HR Office Mr Madhu - 9148566495

Hyderabad 1st and 3rd Wednesday HR Office Mr Pothu Sridhar - 9394822299

Vishakhapatnam 3rd Thursday HR Office Mr Pothu Sridhar - 9394822299

Marsh – Leadership, Knowledge, Solutions…Worldwide. 23


Next

Marsh – Leadership, Knowledge, Solutions…Worldwide. 24


Group Personal Accident Policy

Benefit Details
Documents Checklist
General Exclusions
Contact details

Marsh – Leadership, Knowledge, Solutions…Worldwide. 25


GPA – Benefit Details
This insurance provides compensation/payment up to a financial limit as assigned by the company, to the insured person or his legal personal
representative, if the insured person suffers death or disablement due to an accident. The cover is worldwide but payment of claim can only be
made in India and in Indian Rupees.

Policy Parameter

Insurer  National insurance company

Policy Start Date  1st March 2018

Policy End Date  28th Feb 2019

Members Covered  Employees

Sum Insured  2X CTC minimum 12 lakh max 3 crore

Coverage Details

Accidental Death  Yes (100% of Capital Sum Insured)

Loss of both eyes OR 2 limbs OR 1 limb and 1 eye  Yes (100% of Capital Sum Insured)

Loss of one eye OR 1 limb  Yes (50% of Capital Sum Insured)

Permanent Total Disablement from injuries other than those named  Yes (100% of Capital Sum Insured)
above

Permanent Partial Disability  Yes (Please refer to Policy for list)

Temporary Total Disability  Weekly Benefit - 1 % of Sum Insured or Maximum INR 5,000 / per week
up to 100 week

Geographical Limits  World wide

Terrorism  Covered

Carriage of Remains  NA

Medical Extension  40% of Death/Disability claim amount or 10% of SA or actuals whichever is


less triggered only when claim is admissible under above table
Marsh – Leadership, Knowledge, Solutions…Worldwide. 26
GPA – Documents Checklist

Weekly Benefits Claims Death Claims Dismemberment/ Disablement Claims

Completed claim form Completed claim form Completed claim form

Doctor's report Doctor's report Doctor's Report

Disability Certificate from the doctor, if any Death certificate Disability certificate from the doctor

Investigation/ Lab reports Post Mortem/ Coroner's report Investigation/ Lab reports

Original admission/discharge card, if hospitalized FIR ( First Information Report) Original admission/ discharge card, if Hospitalized

Employers leave certificate & salary details Police Inquest Report, wherever Applicable Police Inquest Report, wherever applicable

Marsh – Leadership, Knowledge, Solutions…Worldwide. 27


GPA – General Exclusions

1. Service on duty with any armed force


2. Insanity
3. Venereal disease
4. AIDS
5. Influence of intoxicating drink or drugs
6. Aviation other than as a passenger (fare paying or otherwise) in any duly licensed standard
type of aircraft any where in the world
7. Nuclear radiation or nuclear weapons material
8. Any consequence of war, invasion, act of foreign enemy, hostilities (whether war be declared or
not), civil war, rebellion, revolution, insurrection, mutiny, military, or usurped power, seizure,
capture, arrest,, restraint, detainment’s of all kings, princes, and people of whatever nation,
conditions and qualities so ever
9. Childbirth, pregnancy or other physical causes peculiar to the female sex
10. While committing any breach of law with criminal intent

Marsh – Leadership, Knowledge, Solutions…Worldwide. 28


GPA – Contact Details

Base Contact
Providers Contact Number

MOBILES : +91 8884499500


National Insurance Company LTD
Mr Murali
Email :
s.murali@nic.co.in, 604100@nic.co.in

Marsh – Leadership, Knowledge, Solutions…Worldwide. 29


FAQ’s & Common Definitions

Documents and links

GMC FAQ’s

GPA FAQ’s

Marsh – Leadership, Knowledge, Solutions…Worldwide. 30


Marsh – Leadership, Knowledge, Solutions…Worldwide. 31