Presentación de beneficios
22
Presentation of Benefits Microsoft Policy Period: 2021-2022 Panamerican Life Costa Rica. © 2021 Willis Towers Watson. All rights reserved.
Transcript of Presentación de beneficios
Presentation of Benefits
Microsoft Policy
Period: 2021-2022
Panamerican Life Costa Rica.
© 2021 Willis Towers Watson. All rights reserved.
Confidentiality Policy
• We Treat with confidentiality all information received by us as well as any subsequent writtenor verbal communication between our organizations. In the same way, we request that thedocumentation and information that we provide be treated in the same way.
• We appreciate that people outside this process, do not have access to our material and theinformation presented, because it is shared only and exclusively with you, the staff of yourorganization or the insurance company if need it.
WARNING
It is essential to mention that, this presentation collects the main characteristics ofthe insurance contract which, focuses on the particular conditions.
The information of the contract is provided to each insured, however, the objectiveof this presentation is to provide advice and support in the use. Contemplating that,
the contract prevails over this presentation.
SUMMARY OF COVERAGE
1.
Life
Covera
ge • Basic Death
• Funeraryexpenses
• Accidental death& dismemberment
• Accidental death
2. M
edic
al expense insura
nce • Ambulatory
expenses and emergencies
• Hospital expenses
• Maternityexpenses
• Special benefits:
• Preventives
• Treatments and therapies
3.
Denta
l C
overa
ge • Preventives
• Restorations
• Major dental expenses
• Orthodontics
1. LIFE COVERAGE
Detail of benefits
Basic deathcoverage
24 times basic monthly salary
Accidental deathDouble compensation of the insured sum
Funerary Expenses Funeral Expenses Advance Benefit up to $4,000.00 payable against funeral home bill is included, once the Death Certificate is filed. This amount will be discounted from Life Insurance and the difference will be paid to the designated beneficiary
Capital advance forserious diseases
Up to 50% for death coverage
Applicable to the insured under the policy on the date they were certified as terminally ill.
Total, and permanent disability
The sum insured to the Principal insured will be settled in 1 installment.
Incapacity by the INS, CCSS, Forensic Medicine
Accidental dismemberment
A certain amount is provided in the event of accidental dismemberment or loss of sight.
Accidental Death & Dismemberment Table
Type of loss %
Life 100%
Both arms or both hands 100%
Both legs or both feet 100%
The view of both eyes 100%
One hand and the sight of an eye 100%
One foot and the sight of an eye 100%
An arm or hand along with a leg or foot 100%
An arm or leg along with irreparable loss of
eyesight100%
Incurable paralysis that prevents all work100%
An arm 65%
Type of loss %
One leg 65%
Irreparable loss of speech 50%
Total and incurable deafness of both ears 50%
One hand 50%
One foot 50%
The sight of an eye 50%
Thumb or forefinger of a hand 25%
Finger of the hand 6%
Big toe 8%
Any other toe 4%
2. Coverage of Medical Expenses
Important Concepts
Deductible:This is the amount that the insured pays for covered health care services before your insurance plan starts paying
$100 in coverage within Central America by calendar year
$500 In International coverage by calendar year
Applies to: Medical or Surgical Hospitalizations, Prescribed Medications, some Special Benefits
Co - insurance: It is the percentage of eligible expenses with which the Insured participates. This amount is not refundable by the Company.
It is by event
Ambulatory expenses at 80%
Hospital expenses at 90%
Special benefits with differentiated coinsurance
Co payment: Applies only for medical consultation: $15
Fixed amount that the Insured must pay directly to the provider medical or hospital services, after satisfying the deductible ifapplicable, before receiving the covered services described in the policy. This amount is not refundable by the Company.
2. Coverage of Medical Expenses
Detail of Benefits For Direct Payment
Hospital Expenses
• Use of standard room: $550 at 90%
• Use of room ICU: $1100 at 90%
• Medical fees: 90% coverage
• Hospital expenses: 90% Coverage
Maternity:
• Prenatal Coverage: only for a refund, Only 9 consultations, 2 ultrasounds, 2 monitoring. Medicines, laboratories, vitamins
• Delivery coverage:
• Hospital Expenses: 90% coverage
• Medical Fees: 90% coverage
• Complications of Pregnancy 90% coverage
• International coverage has limited maximums
Ambulatory Expenses
•Outpatient Medical Consultation:
•Up to $ 90 and $15 Co payment
•Diagnostic tests: 80% coverage
•Emergency room care for accidents:
•Use of Room: 100%
Diagnostic tests: 80% coverage
Medical consultation with a specialist up to $150 and copay $15
Emergency room care for any other illness:
•$500 al 100%, the excess at 80%
•Medical consultation with a specialist up to $150 and copay $15
Medical Conditions Classified As Emergency
Illnesses:
Acute intoxication, Nephroureteral colic, Thrombosis, Vómiting and / or diarrea, Seizures, Acuteallergic reactions, Acute retention of urine, Myocardial infarction, Dehydration, Acute neurologicalepisode, Shock states of any order, comma, Acute scrotum, Severe respiratory insufficiency,Hypertensive crisis, Stroke, Chest pain (First 12 hours), Acute abdominal pain, Continuous high feverinchildren under 5 years of age, Asthma attack, los of consciousness, or drowsiness, Biliary colic
Accidental causes:
Animal Bite, Sprains, Burns, Fractures, Dislocations, Cutting, short stab, blunt, and gunshot wounds,Bleddings
2. Coverage of Medical Expenses
Details of special benefits: Only by Reimbursement
Preventives:
• Medical Checkup: Up to $ 300 at 100% only for Holders.
• Optical Checkup: Up to $ 200 at 90% -deductible applies Only for Holders
• Gynecological Control: 90% coverage -Deductible applies
• Medical consultation
• PAP
• Mammography for over 40s
• Urological Control: 90% coverage - Deductible applies
• Medical consultation
• PSA in blood for over 40 years
• Healthy Child Control: 90% coverage -Deductible applies
• Query
• Vaccinations
• Vitamins
Therapies and Treatments:
• Alcohol and Drug Treatment: Prior Authorization - Deductible applies: 90% coverage
•Injections, Inhalotherapies and physiotherapies: Prior Authorization -Deductible applies: 90% coverage
•Allergy Treatment Prior Authorization -Deductible applies: 90% coverage
•Treatment of Sexually Transmitted Diseases: 90% coverage - Deductible applies
•Psychiatric and psychology consultations and Treatments: Consultation up to $40 at 50% -Deductible applies
•Medications with 50% coverage -Deductible applies
Contraception:
• Vasectomy: (Prior Authorization): 90% coverage - Deductible applies
• Salpingectomy: (Prior Authorization): 90% coverage - Deductible applies
Main Exclusions
• Studies and treatments for sleep disorders, genetic, snile or nervous alopecia, attentional síndrome, learning
disorders, hyperkinesis or hyperactivism, obesity, weight control, dietary control and gastric reduction, bariatric
surgery, nutritionist consultations for weight control and anyanother obesity procedure or treatment, any other
eating disorder.
• Expenses related to the diagnosis, treatment and correction of visual refraction, including, but not limited to
keratotomy, keratoplasty, keratomeulusis, keratoconus, and laser excimer for myopia astigmatism,
farsightedness, and presbyopia. Likewise, those related to the fitting of lenses or any other innovative
treatment to correct visión effects.
• Consultations or therapies by psichologists, speech therapists and those that are due to mental illnesses
and fuctional nervous disorders.
• Any drug used for birth control, even if it prescribed for therapeutic purposes, such as oral parenteral
contraceptives, contraceptive materials or devices or similar and abortifacient
Main Exclusions
• Due to epidemics declared by the ministery of health, or by the homologous entity in any other country where the
insured is found and is infected. The cases treated before the declaration and after the lifting of the declaration will
be covered under this policy
• Expenses corresponding to vaccines, with the exception of those indicated in the table of benefits and any
expense of a procedure, study or treatment considered experimental, investigative or preventive.
• Injuries or ilnesses suffered as a result or participating in criminal acts or activities, war or action of war,
declared or not, rebellion, revolution, strikes, riots, riot or civil commotion, terrorism, serving in a pólice or
military unit as well as in those groups outside the law.
• Injury or illness caused to the self intentionally, whether in state of sanity or insanity or while under the
influence of intoxication or illicit drugs improper use of any drug prescribed by a doctor or resulting from
addiction to any such drug
3. Dental Coverage
Generalities Máximum
Annual Renewable Maximum per Combined Calendar Year.
Applicable to types I, II y III.$1,000
Calendar Year Deductible per Insured Person for Types I,
II, III. $50
For periodontology treatment (included in type II), the amount
payable will not exceed a lifetime maximum of:$1,000
Maximum per calendar year combined applicable to type IV -
Orthodontics. Exclusively for dependent children.$1,000
Special Benefits. Only for a Refund
Dental Special Benefit
Refunds
Type I
Oral exams, prophylaxis, fluoride applications, X-rays,
Laboratory tests and other diagnostic tests, sealants. 100%
Type II
Space holders, emergency palliative treatments, simple (routine)
extractions, surgical extractions, oral surgeries, Alveolectomy,
anesthesia, therapeutic injections, restoration, endodontics and
periodontology80%
Type IIIInlays, wedges, crowns, denture or bridge repair and
prosthetics.50%
Type IV Orthodontics 50%
Pre authorizations
• Expenses in excess of $ 300
• Medical or Surgical Hospitalizations
• Some special Benefits
• Response time of the insurer 48 Hours.
• Programmable event authorizations must be sent to [email protected]
• Pre-authorizations for medical emergencies must be coordinated with Palig through [email protected]
Claims for Refund
• Claims form.
• Electronic Bills
• Prescriptions for treatment or diagnostic tests
• Results or Reports of the exams practiced
• Response time for Refunds is 10 to 15 days.
• Claims should be sent to [email protected]
Correct Use of Policy
Pre-authorization Form
Complete insured and patient information
Complete by the treating physician
For cases of scheduled surgeries or covered delivery,
the detail of the medical fees and the hospital quote
must be presented
Insured’s signature and date
Claim Form Part A
Complete information for the insured and the patient.
Complete from point 1 to point 9
Insured’s signatura and date
Claim Form Part B
Full information treating physician
Diagnosis Symptom
Onset date Findings If you refer tests, medications,
etc.
Full information treating physician Stamp.
Signature
Date of attention.
Data of the treating physician
Dental Form
Complete section by the insured, signature required of the insured
Complete section for dental doctor, signature, stamp and medical code required
Comunication Channels
Unity App
• App Store: Unity Regional
• Google Play: Unity App
Microsite: https://www.unitymicrositios.com/Microsoft-en
Palig provider network: https://www.paligmed.com/es/
Attention to general inquiries: [email protected]
Virtual Attentions: https://calendly.com/visitas-virtuales-unity
Important Contacts
Mariela Morales
Account Executive
Cell Phone: (506) 8463-7639
Chat en línea: www.unity.co.cr
Micrositio: https://www.unitymicrositios.com/Microsoft-en
Descargue nuestra App: Unity en Play Store y
AppStore
¡Thank you!
© 2021 Willis Towers Watson. All rights reserved.
