Transcript Employee Insurance Manual

Employee Insurance Manual
Luminous Power Technologies
What are the Insurance Benefits available to me ?
Who are my Insurance Vendors?
How do I utilize my benefits ?
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Insurance Portfolio
Group Hospitalization
Provides insurance coverage to employees and their dependents for expenses
related to hospitalization due to illness, disease or injury
Group Personal Accident
Provides for coverage against the risk of death/injury sustained due to an accident
to employees .
Group TermLife
Provides life insurance protection to employees in case of death.
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Medical Benefit
Coverage Details
Cashless Process
Non-Cashless
Claims Process
Claims Document List
Benefits Extensions – Definitions
General Exclusions
GMC Contact Details
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Medical Benefit – Coverage Details
Policy Parameter
 Insurer
United India Insurance Company Limited
 TPA
Vipul MedCorp TPA Pvt Ltd.
 Policy Start Date
15th Mar’14
 Policy End Date
14th Mar’15
 Coverage Type
Family Floater Cover
 Dependent Coverage
1 + 5 - Employee + Spouse + 2 Dependent Children + 2 Parents
 Sum Insured
Graded Sum Insured
Benefits / Extensions
Coverage
 Standard Hospitalization
 Yes
 TPA services
 Yes
 Cashless 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
 Baby cover day 1
 Yes
 Domiciliary Hospitalization
 No
Benefits / Extensions
Ambulance Charges
 Day Care
Coverage
 Yes upto a max of INR 2000
per employee
 Yes
 2% of SI for normal & 4% of SI
 Room Rent Capping
for ICU hospitalization or INR
6,000/- whichever is low
 Pre-Post Hospitalization Exp.
 Yes
 Co-pay
 ESC- 10% & Parents -30%
 Cataract – INR 30,000/-,
Disease Capping
Total Knee Replacement/ Hip
Replacement – INR 250,000/-
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Medical Benefit – Dependant 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
No
Siblings
No
Others
No
Mid Term enrollment of existing Dependents
Disallowed
Mid Term enrollment of New Joinees (New employees +their
Dependents)
Allowed
Mid term enrollment of newly wedded Spouse
Allowed, within 30 days from Date of Marriage
Mid term enrollment of new born baby
Allowed, within 30 days from Date of Birth
No Individual should be covered as dependent of more than one employee
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Medical Benefit – Policy Period
Existing Employees + Dependents
Commencement Date
15th Mar’14
Termination Date
14th Mar’15
New Joinees + Dependents
on intimation through HR
Commencement Date
Date of joining
Termination Date
14th Mar’15
New Dependents (due to Marriage / Birth)
on intimation through HR
Commencement Date
Date of such event
Termination Date
14th Mar’15
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Medical Benefit – Coverage Levels
Sum Insured
Family Floater Cover
Level 3 & below ; Technician/Asst . Engineer/Data Entry Operator
etc
INR 200,000/-
Level 6 ,5,4 ; Manager & below
INR 250,000/-
Level 7 & 8 ; RM/Sr Manager , AGM/DGM
INR 350,000/-
Grade 8 & above ; GM & above
INR 450,000/-
Restrictions on sum insured
Not Applicable
Employee
Not Applicable
Dependents
Not Applicable
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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, 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.
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Pre & Post Hospitalization Expenses
Pre-hospitalisation Expenses
Definition
• 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.
Covered
• Yes
Duration
• 30 Days
Post-hospitalisation Expenses
Definition
• 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.
Covered
• Yes
Duration
• 60 Days
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Maternity Benefits
Benefit Details
For Normal Delivery
 INR 35,000/- in Metro Cities & INR 25,000/- in other cities
For C – Section / Cesarean Delivery
 INR 50,000/- in Metro Cities & INR 35,000/- in other cities
Restriction on no of children
• Maximum of 2 children
9 Months waiting period
• Waived off
Pre natal & post natal expenses
• Covered in in-patient (within maternity sublimit)
New born baby
• Covered from day one
Congenital Internal Disorder
• Covered
• These benefits are admissible in case of hospitalization 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.
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Medical Benefit – Cashless Process
Cashless means the Administrator 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.
www.vipul medcorp.com
Toll Free No: 1800 102 7477
+91 124 4833900
[email protected]
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.
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Planned Hospitalization
Step 1
Pre-Authorization
All non-emergency hospitalisation
instances must be pre-authorized
with the TPA, as per the procedure
detailed below. This is done to
ensure that the best healthcare
possible, is obtained, and the
patient/employee is not
inconvenienced when taking
admission into a Network Hospital.
Step 2
Admission, Treatment &
discharge
Claim
Registered by
the TPA on
same day
Member intimates TPA of the
planned hospitalization in a
specified pre-authorization format
at-least 48 hours in advance
Follow non cashless
process
Member produces ID card
at the network hospital
and gets admitted
TPA authorizes cashless as
per SLA for planned
hospitalization to the
hospital
No
Pre – Authorization Form
Cashless
Request Form
Yes
Member gets treated and
discharged after paying
all non entitled benefits
like 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 the Hospital admission
desk. 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
Pre-Authorization
Completed
Hospital sends complete
set of claims documents
for processing to TPA
Claims Processing &
Settlement by TPA &
Insurer
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Emergency Hospitalization & Process
Step 1
Get Admitted
In cases of emergency, the member
should get admitted in the nearest
network hospital by showing their ID
card.
Step 2
Pre-Authorization by hospital
Relatives of admitted member
should inform the call centre within
24 hours about the hospitalization &
Seek pre authorization. The
preauthorization letter would be
directly given to the hospital. In
case of denial member would be
informed directly
Step 3
Treatment & Discharge
After your hospitalisation has been
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
P
R
O
C
E
S
S
Preauthorization
given by the
TPA
Member gets admitted in
the hospital in case of
emergency by showing his
ID Card
No
Non cashless
Hospitalization
Process
Yes
Member/Hospital applies
for pre-authorization to the
TPA within 24 hrs of
admission
Member gets treated and
discharged after paying all
non medical expenses like
refreshments, etc.
TPA verifies applicability of
the claim to be registered
and issue pre-authorization
Hospital sends complete set
of claims documents for
processing to the TPA
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Non-Cashless
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.
Intimation of hospitalization claim
• You must intimate hospitalization claim within 48 hours from date of admission on
•[email protected]
•www.vipulmedcorp.com
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 hospitalization claim
• You must submit the final claim with all relevant documents within 21 days from the date of discharge from the
hospital.
Claims Process
Claim Docs
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Non-Cashless Claims Process
Member intimates
TPA/LuminousTeam before or
as soon as hospitalization
occurs
Yes
Is claim
payable?
Claim registered by TPA after
receipt of claim intimation
Insured admitted as per hospital
norms. All payments made by
member
TPA performs medical scrutiny of
the documents
Yes
No
Is document
received
within 21 days
from
discharge
No
Claim Rejected
TPA checks document
sufficiency
Is
documentatio
n complete
as required
Yes
Claims processing done as per
SLA
Insured sends relevant
documents to TPA helpdesk
within 21 days of discharge
A
•Insured will create the
summary of Bills (2 copies)
and attach it with the bills
•The envelope should
contain clearly the
Employee ID & Employee email
Payment to be made to employee.
The discharge voucher and copy of
payment receipt to be sent to
Luminous Reward Team.
No
Send mail about deficiency and
document requirement
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Claims Document List
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)
Claims Form
UIIC
Form
Claim
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
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.
*Please retain photocopies of all documents submitted
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Benefit Extensions – Definitions
Benefits
Definition
Pre existing
diseases
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
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
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
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 after 90 days as additional member as mentioned elsewhere under this Policy.
Congenital
Disorder
This is a condition existing at birth and often before birth, or that develops during the first month of life , regardless of
causation. Of these diseases, those characterized by structural deformities are termed "congenital anomalies" and
involve defects in or damage to a developing fetus.
Ambulance
The Insurer will pay 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.
Day Care
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, Dental Surgery, Lithotripsy
(kidney stone removal), Tonsillectomy, D & C)
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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)
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Medical Benefit – Contact Details
Contacts
Vipul MedCorp
TPA
United India
Insurace Co. Ltd.
First Level Point
Second Point
Mr. Abhishake Bahl,
+91- 9311986332
[email protected]
Mr. Pawan Choube
Email
[email protected]
First Level Point
Mr. G Narayan Swamy,
Email:
[email protected]
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GROUP TERM LIFE POLICY
Benefit Details
Enrollment in the program
Claims Procedure
Contacts
Next
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GTL – Benefit Details
Policy Parameter
Insurer
Birla Sun Life Insurance Co ltd
Policy Start Date
1st Apr’14
Policy End Date
31st Mar’15
Sum Assured
One Times of Annual Gross Salary (Minimum SI INR 400,000/-)
Coverage
For Employees only
Coverage Details
 Yes
Death
In the event of death of a member from any cause (natural/accidental),
provided that this shall occur while the assurance in respect of such
member shall be in force, an amount determined in accordance with the
Policy Schedule shall be paid
Suicide Exclusion Clause
Yes ( Waived off )
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Enrollment in the program
All existing employees are covered under the policy from 1st Apr 2014. The policy ends on 31st Mar 2015.
Eligibility criteria:
•Having attained 18 years of age and being under 59 years of age (last birthday)
•All regular, full-time & permanent employees of Luminous
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Claims Procedure
Claimant/Assignee notifies Luminous
Reward Team, who in turn would
intimate Marsh and submit required
claim documents to the insurer within
30 days of the event
Yes
On obtaining all relevant
documents, Insurance Co. begins
processing the claims
Is claim
approved
within 7
days
Claim Investigation and Review
within 5 days of submission of all
the required documents by the
Insurer
No
On rejection of the claim, Insurer would
provide a valid reason for the rejection to
Luminous Reward Team/Claimant/
Assignee
On approval, the cheque is sent to
Employer within 7 working days, from
where it is given to the Claimant/ Assignee
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GTL- Document Checklist
•
•
•
•
Employer's declaration
Claimant's statement
Documents required for death –
employee – employer
Death Certificate
GTL Claim Form
(Claimant
statement)
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GTL Benefit – Contact Details
Contacts
Birla Sun Life
Insurance Co.
Ltd.
First Level Point
Second Point
Helpline
Ms. Divya Talwar
[email protected]
Email
[email protected]
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Group Personal Accident Policy
Benefit Details
Claims Procedure
Document Checklist
Exit
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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.
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 above
 Yes (100% of Capital Sum Insured)
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GPA – Benefit Details
Coverage Details
Permanent Partial Disability
 Yes, as per benefit chart
Temporary Total Disability
Weekly Benefit-1% of CSI or Rs. 5000/-Or actual weekly salary,
whichever is lower for 104 weeks
Geographical Limits
 World wide
Terrorism
 Covered
Education benefit* (Payable in case of Accidental death of an
employee )
 Yes @ 10% of sum insured or Rs.100,000/- whichever is lower
Medical Extension (Payable towards medical expenses for
treatment of accidental injury)*
 10 % of CSI or 40% of admissible claim or actual, whichever is
lower
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GPA – Details for PPD
* Indicative list, Please refer to policy document
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GPA – Claims Document Checklist
Weekly Benefit Claims
Death Claims
1. Completed Claim form
2. Doctor's Report
3. Disability Certificate from
the Doctor, if any
4. Investigation/ Lab
reports (x-ray etc.)
5. Original
Admission/discharge
card, if hospitalized
6. Employers Leave
Certificate & Details of
salary
1.
2.
3.
4.
Completed claim form
Attending Doctor's report
Death Certificate
Post Mortem/ Coroner's
report
5. FIR ( First Information
Report)
6. Police Inquest report,
wherever applicable
Dismemberment/ Disablement
Claims
1. Completed claim form
2. Doctor's Report
3. Disability Certificate from
the Doctor
4. Investigation/ Lab reports
(x-ray etc.)
5. Original Admission/
discharge card, if
hospitalized.
6. Police Inquest report,
wherever applicable
GPA Claim Form
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Help Desk - Contacts
Name
Phone
E mail
Mukesh Jadly
9810972767
[email protected]
Mr K.K Arora
9643003608
[email protected]
Mr A.K Bareja
9643003605
[email protected]
Ms Indu Sharma
9643003493
[email protected]
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