27th March Presentation on Group Mediclaim Policy-2013-14___16April2013

8/12/2019 27th March Presentation on Group Mediclaim Policy-2013-14___16April2013

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Employee Communication

Global Compensation & Benefits

Group Mediclaim InsurancePolicy2013-2014


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Group Medical Insurance Policy

INDEX

Policy Highlights

Standard Exclusions

Health Plan Services

Service Providers

Modality

Contact Numbers


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Policy Highlights

This policy is with effect from 2 March 2013 to 1 March 2014

In case you have enrolled for one of the optional plans last year, to cover the dependents this year you

need to login to Medimanage portal and complete your online enrolment. Else you will be covered for

mandatory sum insured of Rs 75,000 for yourself only.

The Current year policy does not have Now and never clause. So even if you have not covered your

dependents under last year policy, you can add them under current year policy

PREMIUM DETAILS:


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Payroll Deduction Process for Offshore Employees:

Under the Option - 0:Currently the premium adjusted in employees CTC is INR 1400 pa, since the revised

premium rate is INR 2654 pa (Incl. ST) for the sum insured of INR 200000 - the premium differential amount of

INR 1254 shall be deducted in 4 equal installments from the monthly payroll.

The premium for optional coverage shall be deducted in 4 equal installments. Employees can avail tax

benefits under section 80D. In case individuals resign during the year, the total premium paid will not be

reimbursed. For individuals resign during the deduction period, the premium due to be deducted from the

individual will be adjusted in the final settlement. In case employee opt for optional coverage then the

coverage for employee and dependents will continue till policy expiry. The mandatory coverage for Rs. 75,000

will get deactivated in case of separation from Mphasis Ltd. (Last working day).

Policy Highlights


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Payroll Deduction Process for Onsite Employees:

The premium for optional coverage shall be deducted in 4 Months for Srilanka & 2 months for

other onsite locations.

Policy Highlights

The insurance premium amounts paid by you for your dependants qualify under section 80D of IndianIncome Tax Act as tax savings this is applicable to you upon your return to offshore during the IT

assessment year.

In case employees resign during the year, the premium paid will not be reimbursed. If employees resign

during the deduction period, the premium due to be deducted from the individual will be adjusted in the

final settlement. However, the employee will be able to utilize the policy cover for the rest of the policy

period.


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Policy Highlights

Below are the enhancement in benefit for current year policy.

1.For optional plan 0 & I, the sum insured has been increased to Rs 200,000 from 150,00

2.Co-payment for employees is reduced to 15% from 20%

3.Room rent capping is increased to 1.5% from 1% for Normal room

4.Room rent capping is increased to 3% from 2% for ICU

5.Minimum co-payment amounting Rs 2,500 has been removed. The policy will have flat 15% co-

payment for employees and flat 20% co-payment for dependents on admissible claim amount6.Removal of Now & Neverclause.

7.The limit for certain ailment has been increased as mentioned in below table.


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Pre-Existing Diseases covered

Maternity Cover from Day OneCoverage up to INR 30000 for Normal Delivery and INR 40000 for Caesarean

Female employees can avail the maternity benefit without adding the spouse in the policy.

New Born Child Cover from Day One- Subject to intimation is given about expected date of delivery or within 30 days of babys birth

Waiver of First Year Exclusions

Waiver of 30 Days Waiting Period

Waiver of Pre-health check up

Floater coverage

Policy Highlights


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Policy Highlights

The insurance cover Pays for

Only In-patient Expenses i.e. only when you are hospitalized & treated for disease/illness

Pre-Hospitalization Expenses for 30 days prior to date of Admission in hospital & related tosame illness

Post-Hospitalization Expenses for 60 days after the date of Discharge from hospital & relatedto same illness

But does Not Pay for

Out Patient Expenses i.e. Diagnostics, investigations, consultations etc. which do not result

into hospitalization

Non Medical Expenses like Telephone Charges, Food Bill of attendants, Registration Charges,Toiletries, Service Charges etc.


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Policy Highlights

Expenses Reimbursed under this policy

Room Rent (Nursing & boarding charges) limited to 1.5% of the sum insured with minimum limitof Rs. 1,500 per day (Normal Room rent will be Rs. 1,500 for Sum Insured of Rs. 75,000, Rs.3,000/- for Sum Insured of Rs. 2,00,000/-, Rs. 4,500 for Sum Insured of Rs. 3,00,000 & Rs.7,500/- for Sum Insured of Rs. 5,00,000)

ICU Charges limited to 3% of the sum insured with minimum limit of Rs. 3,000 per day (Intensive Care Unit Room rent will be Rs. 3,000 for Sum Insured of Rs. 75,000 & Rs. 6,000 forSum Insured of Rs. 200,000, Rs. 9,000 for Sum Insured of Rs. 3,00,000 & Rs. 15,000/- for Sum

Insured of Rs. 5,00,000). All other charges as mentioned below would be linked to your eligibility of the room rent & in

case, if you opt for higher rent room, all other charges would be paid only in proportion ofroom rent eligible.

Surgeon, Anesthetist, Medical Practitioner, Consultants, Specialists Fees.

Anesthesia, Blood, Oxygen, Operation Theatre Charges, Surgical Appliances, Medicines &Drugs, Dialysis, Chemotherapy, Radiotherapy, Artificial Limbs, Cost of Prosthetic devices

implanted during surgical procedure like pacemaker, Relevant Laboratory / Diagnostic test,X-Ray etc..


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Procedure Limits.

Sr. No Procedures Restricted Amount

(in INR)

1. Maternity (Normal) 30,000

2. Maternity (Caesarean) 40,000

3. Cataract (per eye) 20,000

4. Cholecystectomy 45,000

5. Hernia 40,000

6. Hysterectomy 45,000

7. Joint replacement (per life) 1,50,000

8. TURP for BPH 42,000

9. Cardiac bypass(CABG) 2,25,00010. Angioplasty (PTCA) including stent/s 2,25,000

11. Coronary angiogram (CAG) 18,000

* There wi l l be no co -pay appl icable for the abov e l isted treatments / procedures.


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The Company shall not be liable to make payment for any claim directly or indirectly caused by,

based on, arising out of or howsoever attributable to any of the following except covered by way of

an extension:

Circumcision unless necessary for treatment of a disease, illness or injury not excluded hereunderor due to an accident.

Genetic disorder and stem cell implantation/surgery.

Dental treatment or surgery of any kind unless necessitated due to an accident and requiringminimum 24 hours hospitalization or treatment of irreversible bone disease involving the jawwhich cannot be treated in any other way, but not if it is related to gum disease or tooth disease ordamage.

Birth control procedures, hormone replacement therapy and voluntary termination of pregnancyduring the first 12 weeks from the date of conception.

Routine medical, eye and ear examinations, cost of spectacles, laser surgery for cosmetic purposesor corrective surgeries, contact lenses or hearing aids, vaccinations except post-bite treatment orfor new born baby up to 90 days, issue of medical certificates and examinations as to suitability for

employment or travel.

Standard Exclusions


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Any condition directly or indirectly caused due to or associated with human T-call Lymph tropicvirus type III (HTLV-III) or Lymphadinopathy Associated Virus (LAV) or Acquired ImmuneDeficiency Syndrome (AIDS), AIDS related complex syndrome (ARCS) and all diseases / illness /injury caused by and/or related to HIV and sexually transmitted diseases.

Vitamins and tonics unless forming part of treatment for disease, illness or injury and prescribedby a Medical Practitioner.

Instrument used in treatment of Sleep Apnea Syndrome (C.P.A.P.) and Continuous PeritonealAmbulatory Dialysis (C.P.A.D.) and Oxygen Concentrator for Bronchial Asthmatic condition or anyother external devices used during or after treatment.

Artificial life maintenance, including life support machine use, where such treatment will notresult in recovery or restoration of the previous state of health.

Treatment for developmental problems including learning difficulties e.g.. Dyslexia, behavioralproblems including attention deficit hyperactivity disorder(ADHD).

Treatment for general debility, ageing, convalescence, run down condition or rest cure,congenital external anomalies or defects, sterility, infertility including IVF, impotency, venerealdisease, puberty, menopause or intentional self-injury, suicide or attempted suicide(whethersane or insane).

Certification / Diagnosis / Treatment by a family member or from persons not registered asMedical Practitioners under the respective Medical Councils, or any diagnosis or treatment thatis not scientifically recognized or experimental or unproven.

Standard Exclusions


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Ailment requiring treatment due to use, abuse or a consequence of an abuse of any substance,intoxicant, drug, alcohol or hallucinogen and treatment for de-addiction, or rehabilitation.

Any illness or hospitalization arising or resulting from the Insured person or any of his familymembers committing any breach of law with criminal intent.

Any treatment received in convalescent homes, convalescent hospitals, health hydros, nature cureclinics or similar establishments.

Prostheses, corrective devices and medical appliances, which are not required intra-operatively forthe disease/ illness/ injury for which the Insured Person was hospitalized.

Treatment of any mental illness or sickness or disease including a psychiatric condition,disorganization of personality or mind, or emotions or behavior, Parkinson's or Alzheimersdisease even if caused or aggravated by or related to an accident or Illness or general debility orexhaustion (run-down condition)

Any cosmetic surgery unless forming part of treatment for cancer or accident or burns, surgery forsex change or treatment of obesity/morbid obesity or treatment/surgery complications/illnessarising as a consequence thereof.

Standard Exclusions


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Charges incurred primarily for diagnostic, X-ray or laboratory examinations or other diagnosticstudies not consistent with or incidental to the diagnosis and treatment even if the samerequires confinement at a Hospital/Nursing Home.

Costs of donor screening.

Any form of non-Allopathic treatment, Naturopathy, Ayurvedic, Homeopathy, acupuncture,reflexology, chiropractic treatment or any other form of indigenous system of medicine.

Insured Persons whilst engaging in speed contest or racing of any kind (other than on foot),bungee jumping, parasailing, ballooning, parachuting, skydiving, paragliding, hang gliding,mountain or rock climbing necessitating the use of guides or ropes, potholing, abseiling, deep

sea diving using hard helmet and breathing apparatus, polo, snow and ice sports or involving anaval military or air force operation.

Insured Person whilst flying or taking part in aerial activities (including cabin crew) except as afare paying passenger in a regular Scheduled airline or air Charter Company.

Ionizing radiation or contamination by radioactivity from any nuclear fuel or from any nuclearwaste from the combustion of nuclear fuel.

All expenses directly or indirectly, caused by or arising from or attributable to foreign invasion,act of foreign enemies, hostilities, warlike operations (whether war be declared or not or whileperforming duties in the armed forces of any country), civil war, public defense, rebellion,revolution, insurrection, military or usurped power.

Standard Exclusions


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All non-medical expenses including but not limited to convenience items for personal comfort

not consistent with or incidental to the diagnosis and treatment of the disease/illness/injury forwhich the Insured Person was hospitalized, Ambulatory devices, walker, crutches, belts, collars,splints, slings, braces, stockings of any kind, diabetic footwear, gluco-meter/thermometer andany medical equipment that is subsequently used at home.

Service charges or any other charge levied by the Hospital, except registration/admissioncharges.

Any stay in Hospital without undertaking any treatment or any other purpose other than forreceiving eligible treatment of a type that normally requires a stay in the hospital

Emergency Ambulance expenses

Expenses incurred towards Funeral expenses

Standard Exclusions


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Enrollment Process

In case you have enrolled for one of the optional plans last year, to cover the dependents thisyear you need to login to Medimanage portal and complete your online enrolment. Else you willbe covered for mandatory sum insured of Rs 75,000 for yourself only.

Update the status changes in the family within 30 days by logging intohttp://www.medimanage.com

If Married, provide info about spouse (Name/DOB/Relationship)

Had a new born, provide info about baby (Name/DOB/Relationship)

If any member covered under plan expires

Please note that you can neither exchange nor add your dependents during the policy period. Thedetails given by you at commencement of policy would be final.

Only exceptions to above rule would be addition of spouse (when newly married) & child (newborn baby), provided slot is available for coverage of the member.


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ID cards for Hospitalization

Identifies you as Mphasis Health Plan member

Photo for identification

If hospital insists on photo identification, can be produced along with any other Photo ID

like Mphasis I.D.

Each Health Plan member gets separate card.

Non-Transferable

Provides you Emergency admission at Network hospital


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How to avail Insurance Services?

HOSPITALISATION AT NETWORK HOSPITAL

After consultations & investigations, your doctor advises you hospitalization (Called as Planned

Hospitalization) OR

You need an Emergency Hospitalization

HOSPITALISATION AT NON NETWORK HOSPITAL

You complete your hospitalization, pay the bills & follow-up with TPA

Process of Reimbursement of expenses.

For all the non-emergency claims (both cashless or reimbursement ), at least 3 days before the

hospitalization, an intimation MUST be sent to [email protected], providingfollowing details : (Employee ID, Employee name, Patient name, Hospital Name, Date of

Admission & Reason for Hospitalisation)

For emergency claims, an intimation can be sent within 72 hours of hospitalization.
mailto:[email protected]:[email protected]:[email protected]:[email protected]


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Planned Hospitalization

Obtain the Pre-Authorization Form from Mediclaim Desk of Network Hospital

Details to be filled

Name of the person to be hospitalized

Mediassist ID & Employee ID No.

Relationship (Self/Spouse/Son/Father/Mother etc.)

To be filled by Treating Doctor

Proposed date of admission

History of illness / ailment

Approximate duration of hospitalization

Approximate Expenses (to be filled in by Hospital Administration)


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Planned Hospitalization

Hospital Administration would fax the Pre-authorization Form to Mediassist

The Mediassist Staff would scrutinize the form

Mediassist will fax the Authorization Letter to the concerned hospital within 24 hours.

You can get hospitalized & the treatment can start.

In case, the authorization amount received from Mediassist is lesser than the expected

final bill, please inform hospital to fax the Detailed Final Bill and Discharge Card at least

four hours before the discharge to Mediassist and they will issue the approval for

balance amount.

On discharge, Sign the bills, claims form & pay the non-medical charges only. Co-pay is

15% for employee & 20% for dependent on admissible claim.


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Emergency Hospitalization

Get the patient hospitalized at the desired / nearest network hospital In case, if the hospital insists for deposit, pay the same & get it returned once Mediassist

settles the claim with Hospital.

Let the patient stabilize

Follow standard Pre-Authorization process

Follow the standard discharge process


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Cashless Hospitalization

Mediassist will only pay for the Medical Expenses/Hospitalization

You need not make any payment for the medical expenses

You must pay for the non-medical expenses on discharge or whenever asked by hospital

The bills for medical expenses would be sent to Mediassist by the hospital & they would

directly settle the same with hospital.

Please note that the Network Hospital list is updated frequently & hence, please refer to

the list available on your Personalized Page @ Medimanage Portal (Left Hand Side Links).

Also, please confirm that the hospital is part of Mediassist Network at the time of your

hospitalization.

Please refer to the Red Flagged Hospital List available on Medimanage Portal LHS Links.

No claim (Neither Cashless Nor reimbursement) would be paid for if treatment is taken at

these hospitals.


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Non-Network Hospitalization

You get hospitalized in any registered hospital with local municipal authority or a hospital

having minimum 15-beds

Get Discharge after making all the necessary payments

Also obtain the Hospital Registration Number

Submit all the necessary documents (in original) along with Claims Form within 30 days (As

per the list available on Intranet) to the Claims Collection Cell arranged by Medimanage at

your worksite once a week.

As per new regulatory norms, you are also requested to submit the original cancelled

cheque for your account for online transfer for settlement of your claim.


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Reimbursement Claims

Documents mentioned herein should be submitted in ORIGINAL

Discharge Card

Detailed Hospital Bill

Pre-numbered Cash Paid Receipts for payments made to hospital

Pre-numbered Cash Paid Receipt for Co-pay amount paid to hospital

Prescriptions, Reports & Bills for all Diagnostics Tests (No Films, only Reports

Prescriptions & Bills for all Medicines purchased

Gravida Status (No. of Living Children) in case of Maternity Original cancelled cheque for online transfer of settled amount

Note: For all the non-emergency claims (both cashless orreimbursement ), at least 3 days before

the hospitalization, an intimation MUST be sent to [email protected] following details : (Employee ID, Employee name, Patient name, Hospital Name,Date of Admission & Reason for Hospitalization)

For emergency claims, an intimation MUST be sent within 72 hours of hospitalization. Hospitalization bills should be submitted for claim within 30 days from Date Of Discharge

Pre-Hospitalization bills should be submitted for claim along with the main hospital bills only

Post-Hospitalization bills should be submitted for claim within 90 days from Date Of Discharge
mailto:[email protected]:[email protected]:[email protected]


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Service Providers

Medimanage Insurance Broking Pvt Ltd

Insurance Broker

Medi Assist (I) Pvt. Ltd.

Third Party Administrator who would settle all your Hospitalization Claims

through Cashless or Reimbursement

L & T General Insurance Company Ltd.

Insurer


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Modality

For any queries, login to http://www.medimanage.com, use the MyCommunication tab and provide complete details.

Also provide your Telephonic Contact Details & preferred time of contact

Medimanage Representative will contact you & speak to you personally & help

you out with your problems

Response within 24 hours
http://www.medimanage.com/http://www.medimanage.com/


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Contact Number

Important Points of Contact

Contact Person Voice Contact ResponsibilityEnrolment Co-ordinator

Maheshwari Pillai 022 67282903 All India

Reimbursement Claim Co-ordinators

Manjunath 080 2211 3334 South

Sachin Poojary 022 67282934 Rest of India

Cashless Co-ordinators

Vanitha M. 97422 46961 / 080 2211 3334 Bangalore

Mohan Babu 91766 46961 / 044 2811 1108 Chennai

Urmila Mogre 98200 46961 / 022 67282921 Rest of India

Ganesh Yadav 99200 46961 / 022 67282920 Rest of India

First Level Escalation - Enrolment

Surendra B.022 67282924

All [email protected]

First Level Escalation - Cashless and Reimbursement claim

Neelam M.022 67282957

Rest of [email protected]

Durga Sharma80 22113334

[email protected]

Final Escalation (Enrolment, cashless and reimbursement claims)

Nilima Lalsare022 67282980

All [email protected]

For all queries, visit www.medimanage.com and use Communications & Claims module
http://www.medimanage.com/http://www.medimanage.com/


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Thank You

Thank You

C 2011 MphasiS

The information contained herein is subjected to change without notice.

27th March Presentation on Group Mediclaim Policy-2013-14___16April2013

Documents

Transcript of 27th March Presentation on Group Mediclaim Policy-2013-14___16April2013