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Employee Insurance Benefits

First American India Policy Period – 01st Jul 2016 – 30th Jun 2017

MARSH

Facilitators

1

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Medical Benefit

Coverage Details

Cashless Process

Non-Cashless

Claims Process

Claims Document List

Benefits Extensions – Definitions

Prudent Utilization of Benefit

Help desk at First American

General Exclusions

GMC Contact Details

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• Policy covers financial assistance in the event of hospitalization of covered member

• Hospitalization of member is considered in Insurance when there is treatment for

1. Diagnosed Ailment

2. Requiring Active line of treatment – treatment which can be done only in hospital not

on out patient basis. This is determined by the TPA doctor based on set medical protocols for

various ailments and procedure.

3. For at least 24 hours

• Exception to the conditions are

- Day care procedures – procedure taking less than 24 hours due to advancement in

medical technology (dialysis , cataract)

- Pre and Post hospitalization (30 & 60 days) on settlement of the main hospital bill.

• Hospitalization may be required as per treating doctor based on the presenting signs and

symptoms, but only post complete diagnosis, admissibility of treatment would be established.

• Hospitalization for Diagnosis only , where no active line of treatment or self inflicted or elective

surgery for betterment etc. are common rejections.

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Benefit Design Group Medical Plan

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Medical Benefit – GMC Coverage Details Policy Parameter

Insurer Oriental Insurance Co

TPA Good Health TPA

Policy Start Date 1st July 2016

Policy End Date 30th Jun 2017

Coverage Type Family Floater

Dependent Coverage 1 + 5 - Employee + (Spouse + 2 Dependent Children + 2 Parents / 2 Parents IL) as per company

policy conditions.

Sum Insured INR 300,000

Co – Pay 10% of Co payment applicable for all parents / parents IL claims.

Benefits / Extensions Coverage

Standard Hospitalization • Yes

TPA services • Yes

Pre existing diseases • Yes

Waiver on 1st year exclusion • Yes

Waiver on 1st 30 days excl. • Yes

Maternity benefits • Yes

Pre & Post Natal Expenses • Yes

Well Baby Expenses • Not covered

Benefits / Extensions Coverage

Baby cover day 1 • Yes

Room rent eligibility • Yes

OPD • No

Day Care • Yes

Domiciliary Hospitalization • No

Dental & Vision • Restricted (only in case

of accident)

Pre-Post Hospitalization Exp. • Yes

Ailment Capping • No*

* Except Cataract, Maternity & Dental

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Medical Benefit – Dependent Coverage

Maximum no of Members insured in a family 1 + 5

Employee Yes

Spouse Yes

Children Yes (for the first 2 living Children)

Parents Yes

Parents-in-Law Yes

Employee can choose enroll parents / parents In law

Siblings No

Others No

Please note all existing depended coverage can be done at inception of policy or 30 days from date of joining. This includes

Spouse, children and Parents / In laws

Mid Term enrollment of existing Dependents Disallowed

Mid Term enrollment of New Joinees (New employees +their

Dependents)

Allowed provided intimation to HR within 30 days from the

date of event

Mid term enrollment of new dependents (Spouse/Children) Allowed provided intimation to HR within 30 days from the

date of event

No Individual should be covered as dependent of more than one employee

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Maternity Benefits

• These benefits are admissible in case of hospitalization in India.

• Covers first two living 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.

•Well baby charges or cost incurred at hospital where there is no treatment was administered to the new born are not covered under the policy.

Benefit Details

For Normal Delivery • INR 30,000/- within the Floater Sum Insured

For C – Section / Cesarean Delivery • INR 50,000/- within the Floater Sum Insured

Restriction on no of children • Maximum of 2 Children

9 Months waiting period • Waived off

Baby wellness charges • Not covered

Pre-Post Natal Expenses • Not covered

Baby Day One Cover

All new born babies are eligible to be covered form date of birth. In unfortunate event of baby requiring inpatient

hospital care , the policy extends the coverage

• Subject to declaration to HR / Insurer with in 30 days from the date of the event

• the baby gets covered within the available family floater sum insured for the policy year

•Well baby charges are not covered – the charges / treatment cost spent towards baby check up , vaccination,

inoculations etc

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Medical Benefit – Standard Coverage

• 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 Hospitalization for minimum period of 24 hours are admissible. However this time limit will not apply for

specific treatments i.e. Dialysis, Chemotherapy, Radiotherapy, 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 Hospitalization Benefit, however under pre authorization (cashless) only.

C) Anesthesia, Blood, oxygen, OT charges, Surgical appliances, Medicines, drugs, Diagnostic Material & X-ray, Dialysis,

Chemotherapy, Radiotherapy, cost of pacemaker, artificial limbs and cost of stent and implant.

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Benefits For

FAI Definition

Pre existing diseases

Covered 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

First 30 day waiting

period

Not

Applicable

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

First Year Waiting

period

Not

Applicable 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

Baby Cover Day 1

Covered 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 after 90 days as

additional member as mentioned elsewhere under this Policy.

Ambulance

Covered The Insurer will pay Rs.2000/- for Emergency ambulance and other 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.

Dental & Vision

Treatment

Not

Applicable Treatment cost for root canal, tooth fillings, scaling of teeth and Optical care cost of eye glasses besides cosmetic

treatment, frames, contact lenses & hearing aid cost would not be paid / covered/

Day Care

Covered 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, Cataract surgery, Lithotripsy (kidney stone

removal), Tonsillectomy, D & C)

Benefit Extensions – Definitions

X

X

X

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Once in 15 days

FAI would share New Joiners and Deletions with Oriental,

Marsh

In 2 working days

Marsh would compute the premium send it to OIC for endorsement

issuance

In 4 working days

OIC would issue endorsement and confirm to Good Health

TPA / Marsh / FAI

In 2 working days

Good Health TPA upload e cards and Welcome mailers

would be shared with all employees

1. Employee Joining

2. Employee to enroll his / her

dependents with HR with in

30 days of Joining.

3. Employee gets e cards and

welcome mailers by latest 35th

day from joining

Employee Experience

Group Medical Plan Enrollment Process and Time lines

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Group Medical Plan Enrollment Process and Time lines

Insurance Policy Allows enrollment of members

• New Joiners and their eligible dependents – within 30 days from the date of

• Existing Employees

• New additions in family like new born child or newly wedded spouse

• Declarations to be made within 30 days from date of event (birth /

marriage)

• Names not required for New born babies (can be enrolled as baby of

member)

• Any delay in intimation would decline coverage regardless of the eligibility

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Member approaches TPA

Network Hospital for Cashless Treatment

Hospital verifies member details and send

pre-authorization by fax to TPA

Good Health TPA verifies pre-authorization details with

policy benefits and send response the

Fax to Hospital (TAT - 4 hrs)

Approved letter send by

Good Health TPA

Hospital admits patient

and Provide Cashless

treatment

Query letter send to

Good Health TPA

Hospital fax the reply for

Queries Asked by

UHC doctors

Denial letter send by

Good Health TPA

Query Denial

Hospital

Approved

Member can apply for

reconsideration through

reimbursement

Group Medical Plan Cashless Claim Process

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Group Medical Plan Cashless Claim Process ..2

Admission procedure

• Identify the hospital form the updated list of Network hospitals on Good Health Plan TPA Website for

cashless.

• The network hospital are not preferential hospitals , Cashless Network is a market arrangement for member’s

convenience. As a consumer, member is liable to get , procure & share requisite data with TPA .

• The hospital would share a pre-authorization form, which must be partly filled by the member and partly by

hospital and treating doctor

• This form highlights the initial diagnosis , line of treatment and estimated length of stay and cost of treatment

• This form is faxed / sent online to GHPL . (Please insist the form is sent to Bangalore for priority clearing)

• The requisite / Industry accepted / agreed TAT is 4 hrs to revert form the time of receipt of documents.

• TPA may ask for more documents if the line of treatment or admissibility in policy is not clear or other wise

documents are not in order. Approval TAT starts all over again on receipt of the documents from hospital.

• The initial approval is generally granted for fraction of the requested amount

• As initial request has diagnosis, line of treatment and price estimate which is tentative , pre-

authorization approval is also tentative

• This allows TPA to negotiate with the hospital at discharge.

• If a claim is rejected on initial approval, members are required to apply for reimbursement for second opinion

on the same. Cashless process is usually fast track process and reconsiderations are possible.

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Interim Enhancement

• For claims which are of higher cost and require longer stay, hospital would from time to time raise interim

enhancement during the stay at Hospital

• Hospital shares the exact treatment details over fax/ online for enhancement of initial approval

Discharge procedure

• Upon clearance / discharge advise from the doctor , the hospital shares the complete set of documents

including discharge summary , final bill , reports etc

• This process to share the details with TPA takes 3-4 hrs after the doctor’s discharge advise.

• TPA’s TAT would start post receipt of documents

• The requisite / Industry accepted / agreed TAT is 4 hrs to revert from the time of receipt of documents.

• TPA may ask for more documents if the line of treatment or admissibility in policy is not clear or other wise

documents are not in order. Approval TAT starts all over again on receipt of the documents from hospital.

How do I know what is the status

1. Good Health shares SMS (mobile) and emails for the registered number and email id at every step on real

time basis e.g. on receipt of request , shortfall of documents , approval etc

Its important that all members updated their active mobile numbers. This would give timely updates &

reduce heartburns

2. IWP / Website : individual login is updated real-time

3. Mobile App / Mobile internet : updates can be viewed real-time.

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Group Medical Plan Cashless Claim Process ..3

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Admission procedure

• In case of a non-network hospital member will have to liaise directly with the hospital for treatment and

insurance claim documents

• Member should intimate Good Health TPA within 24 Hrs of admission and request for intimation number and

seek claim registration number.

• Member will pay and clear the bills before discharge from the hospital

• Member will collect all necessary documents such as discharge summary, detailed investigation reports, final bill

with detailed break-up of expenses, stamped paid receipts etc. for reference

• To obtain reimbursement of the expenses, member should submit the final claim with all relevant documents

within 30 days from the date of discharge from the hospital along with the intimation number

Group Medical Plan Reimbursement Process

Note: Members are advised to register the claim with Good Health TPA (via call or mail) on or

before the date of admission

Note: Onus to procure and submit requisite documents from hospital is on the member. TPA

would not be able to support / consider aberrations.

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Member intimates Good Health

TPA before or as soon as

hospitalization occurs

Member avails treatment from the

hospital and clears the payment

Document

received within

30 days from

discharge

Claim Rejected

No

TPA Does Medical scrutiny of the

claim documents

Document

sufficiency

check

Yes

No

Claims processing done in 15

working day

Member receives mail about

document deficiency in 7

working days

A

A

Claim settled and amount

paid to FAI in total of 21

working days

Yes

No

Yes

Claim payable?

Important Points

• All documents are required to be submitted in originals only. Member are advised to retain copies of all originals submitted to TPA

• Medical help desk can only do physical verification of documents . Document shortfall may be raised on medical scrutiny by TPA.

• Multiple queries / shortfall for claim are not allowed by TPA. GHP can only ask query on shortfall document.

• If shortfall documents are not submitted within 30 days from date of intimation, the claim is closed in the system.

Group Medical Plan Reimbursement Process

Member submits claim

documents at FAI helpdesk

within 30days of discharge

Help desk scrutinized

physical document

sufficiency

Yes

No

FAI re-credit the amount in

23 working day

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*Please retain photocopies of all documents

submitted

• Download claim form from your FAI

Intranet Portal

• All documents are indicative additional

documents will be called by the TPA

doctor.

Completed Claim form with Signature

Hospital bills in original (with bill no; signed and stamped by the hospital)

with all charges itemized and the original receipts

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,

Stickers in case of Implants E.g.: Lens ( Cataract), Stents ( Heart Surgery)

etc.

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.

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

All claims must be intimated to

the TPA within 24 hrs of

Hospitalization and claim

registration no. must be

obtained

Group Medical Plan Claims Document List

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• Intentional self injury , suicide, all psychiatric and psychosomatic disorder and diseases / accident due to and or use ,

miss use or abuse of drugs/ alcohol or use of intoxicating substances or such abuse or addiction etc.

• Expenses incurred at hospital and nursing home primarily for evaluation / diagnostic purposes which is not followed by

active treatment for the ailment during the hospitalized period

• Expenses incurred for investigation or treatment irrelevant to the disease diagnosed during hospitalization or primary

reason for admission reason. Private nursing charges , referral fee to family doctor, outstation consultants / surgeons fee

etc

• Genetical Disorder 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 devises that is walker , crutches , belts, collars , caps , splints, slings , braces,

stocking etc of any kind , diabetic footwear, glucometer / thermo meter and similar related items etc and also any medical

equipment which is subsequently used at home etc.

• Treatment of obesity or condition arising there from (including morbid obesity) and any other weight control program,

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 , hand gliding , rock or mountain climbing etc

• Spill over claims from other insurance policies for capped ailment like maternity and cataract.

* Indicative list, Please refer to policy document

Group Medical Plan General Exclusions

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• Circumcision unless necessary for treatment of disease

• Congenital external diseases or defects/anomalies

• Treatments/ procedures attributing Fertility, sterilization. HIV and AIDS, Venereal diseases

• Hospitalization for convalescence, general debility, intentional self-injury, use of intoxicating drugs/ alcohol, obesity

• Naturopathy, chiropractic medicine, herbalism, traditional Chinese medicine, Ayurveda, meditation, yoga, biofeedback,

hypnosis, homeopathy, acupuncture, and nutritional-based therapies. Any experimental or unproven procedure / treatment

• Any non-medical expenses like registration fees, admission fees, charges for medical records, cafeteria charges,

telephone charges, hospital surcharges etc

• Surgery for correction of eye sight, Cost of spectacles, contact lenses, Lasik Surgery , hearing aids, cost of appliances,

spectacles, contact lenses, hearing aids

• Any cosmetic or plastic surgery except for correction of injury

• Hospitalization for diagnostic tests only

• Vitamins and tonics unless used for treatment of injury or disease

• Infertility treatment sub fertility or assisted conception , Voluntary termination of pregnancy during first 12 weeks (MTP),

• Vaccinations & inoculation, OPD Claims, Claims submitted without prescriptions/diagnosis/ original bills ,

• Costs incurred as a part of membership/ subscription to a clinic or health center, Health foods, Dietary supplements

Cosmetic or aesthetic treatment of any description, plastic surgery other than necessitated due to an accident or illness.

• Any dental treatment or surgery

• Injury or disease directly or indirectly caused by or arising from or attributable to War or War-like situations, nuclear

weapons

….. Cont * Indicative list, Please refer to policy document

Group Medical Plan General Exclusions

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MARSH 19

1) ADMINISTRATIVE EXPENSES

• Admission charges

• Registration charges

• Medico-legal charges

• Attendant stay charges

• Relative stay charges

• Additional stay

• Gate pass/Attendant pass

• Conveyance charges

• Booking charges

• Overhead charges

• Establishment charges

• Tax/Luxury charges

• Surcharge/Service charges

• Incidental charges

• Waste disposal charges

2) DOCUMENTATION EXPENSES

• Documentation charges

• Discharge summary

• Medical records charges

• Birth certificate

• Death certificate

• Medical certificate

• TPA charges

3) CONSUMABLES

• Antiseptic/ disinfectant solutions

• Soap

• Powder (talc)

• Oil

• Cream

• Sanitary pads/Diapers

• Toiletries & stationeries & cosmetic expenses

• Cassette/CD/Film charges

• Oxygen cylinder

• ECG electrode charges

• Mortuary/coffin charges

• Housekeeping charges

• Preparation charges

• DONOR charges

• Vaccination charges

• Outstation consultants / surgeons

• Referral charges

• HIV Charges

• RMO/ duty doctor charges

• Assistant charges for minor cases

• Expenses towards sterilization

4) SERVICES

• Private nurse charges

• Telephone charges

• Fax charges

• Food/beverages

• Diet & dietician charges

• Electricity charges

• Water charges

• T.V / Internet charges

• Newspaper/magazine

• A/C charges

• Stationary charges

• Lines/Laundry charges The list is indicative, actual deduction would vary

Group Medical Plan Deduction / Non payable expenses

MARSH

Health Insurance is a benefit for the employee and their dependents. One has to utilize the benefit with utmost

caution and prudence.

The ever increasing cost for the benefits require a proactive involvement from all of us.

The following steps are recommended, ensuring the benefits is prudently utilized by the employee and dependents

covered

Cashless is generally found to be expensive, explore reimbursement if possible –

---“Act with prudence/ discretion on your choice of hospital/service provider”

Please ensure to crosscheck the final bill sent to the TPA for the following:

You are Billed only for the services utilized for e.g. category of room, diagnostics undergone , medicines

consumed

Total of the bill

In case of any planned hospitalization, approach the hospital in advance(48 hrs) and request pre

__authorization. This enables TPA to further negotiate the rates with the hospital

To approach hospitals with caution – most expensive is not necessarily the best. .

Try to negotiate

Ask WHY & WHAT is billed to you ( as a consumer , we have the right to know)

Group Medical Plan Prudent Utilization of Benefit

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Thank You