Transcript EMPLOYEE BENEFITS MANUAL

KUONI TRAVEL GROUP, INDIA
28th December 2011
EMPLOYEE BENEFITS MANUAL
Proceed
This Employee Benefits Manual is a reference guide to the benefits provided to you by Kuoni Travel Group, India. For complete
information on the benefit terms & conditions you please refer to the policy documents/wordings provided by respective
insurers. This Benefits Manual covers the below-mentioned benefits.
1. Group Medical Scheme
2. Group Personal Accident Scheme
3. Group Term Life Scheme
All links are displayed through colored buttons which appear at various slides during the presentation.
Prepared By
Aon Global Insurance Brokers Pvt Ltd,
401-405, Dalamal House
Jamnalal Bajaj Marg, Nariman Point
Mumbai- 400021
This Benefits Manual is copyright ©2009 by Aon
Global Insurance Brokers Pvt. Ltd.
The contents of this Benefits Manual may not be
copied, modify, reproduced, distributed,
republished, downloaded, displayed to third parties,
posted, stored in the retrieval system, posted in any
network computer without the prior written
permission of Aon Global.
Proceed
Note: Confidential Document
The information contained here is only a summary of
the employee benefit insurance policy documents
which are kept by the employer. If there is a conflict
in interpretation then the terms & conditions of the
applicable policy document will prevail.
EMPLOYEE BENEFITS MANUAL
About the Employee Benefits Manual
CONTENTS
Proceed
Group Medical Plan
Group Personal Accident Plan
Group Term Life Plan
Annexure (Important Contact Points)
(To reach the desired section directly please click on the section title)
EMPLOYEE BENEFITS MANUAL
Contents
The Group Medical policy covers expenses by the insured persons(employee & family members covered) on account of
hospitalization due to sickness or accident. The policy covers expenses incurred on room rent, medicines, surgery etc.
Expenses for hospitalization are payable only if a 24 hour hospitalization has been taken. (Except for named day care
procedures, which do not require a 24 hour hospitalization). Under a scheme such as this the typical expense heads
covered are the following: room/boarding expenses as provided by the hospital or nursing home ; nursing expenses ;
surgeon, anesthetist , medical practitioner, consultant , specialist fees ; anesthesia, blood, oxygen, operation theater
charges, surgical appliance, medicines and drugs. diagnostic material and X-Ray; dialysis, chemotherapy, radiotherapy,
cost of pace maker, artificial limbs and cost of organs and similar expenses.
Plan Information
Benefit Details
General Exclusions
Enrollment Procedure
Hospitalization Procedure
(To reach the desired section directly please click on the section title)
Contents
EMPLOYEE BENEFITS MANUAL
Group Medical
Policy Details
Plan Name
Group Medical Insurance
Policy Holder
Kuoni Travel (India) Private Ltd.
Kuoni Business Travel India Pvt. Ltd.
VFS Global Services Pvt. Ltd.
Period of the Cover
12 months
Inception Date
01-Jan-2012
Expiry Date
31-Dec-2012
Insurer
The New India Assurance Co. Ltd.
TPA
Medi Assist India TPA Pvt. Ltd.
Sum Insured Limits
As per the grade of the employees
Members Covered
Employee + Spouse / or max 2 Dependent Siblings
and / or max 2 Dependent Children
and / or max 2 Dependent Parents / In-laws
Geographical Limits
India (Covers treatment in India only)
Mid-Term Revision of Sum Insured
Only on account of promotion of employee
Age-Limit
Dependent age – Day 1 to 80 years
Mid-Term Enrollment
Yes (Only for New Born Child & Newly Wedded Spouse)
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EMPLOYEE BENEFITS MANUAL
Group Medical : Plan Information
Covered Members
Particular
Description
Special Condition if any
6
-
Employee
Yes
-
Spouse
Yes
-
Child
Yes
2 dependent children (upto 25 years)
Parent / In-laws
Yes
2 dependent parents / in-laws (upto
80 years)
Sibling
Yes
2 dependent siblings (upto 25 years)
Total Members Covered per Family
Mid Term Enrollment
Particular
Description
Mid-Term Enrollment of Existing
employees’ Dependents
(as on plan start date)
Not Allowed
Special Condition if any
Mid-Term Enrollment of New Joiner (New
Employees + Their Dependents)
Allowed
(with-in 30 Days of joining)
Co-payment of 50% for first 6 months
Mid-Term Enrollment of New Dependents
(Spouse/Children)
Allowed
(with-in 30 days of said event)
Newly married employees’ spouses within the
policy year & new born children
No Individual should be covered as dependent of more than one employee
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EMPLOYEE BENEFITS MANUAL
Group Medical : Plan Information
Important Dates
Existing Employees + Dependents
Commencement Date for Existing Employees + Dependents
01-Jan-2012
Termination Date for Existing Employees + Dependents
31-Dec-2012 (midnight)
New Joiners + Dependents
Commencement Date
Date of joining
Termination Date
31-Dec-2012 (midnight)
New Dependents (due to Marriage / Birth)
Commencement Date
Date of such event
Termination Date
31-Dec-2012 (midnight)
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EMPLOYEE BENEFITS MANUAL
Group Medical : Plan Information
Policy Benefits
Policy Benefits
Standard Hospitalization
Yes
Domiciliary Hospitalization
Not Covered
Pre & Post Hospitalization
Expenses
Yes (30 days-60 days)
Day Care
Yes(Only Listed Procedures)
Maternity Benefits
Yes
OPD Expenses
Not Covered
Maternity Limits (Normal &
Caesarian Section)
Health Check Up
Yes
Not Covered
Pre & Post Natal Expenses
Yes
Room Rent Capping
New Born Baby cover day 1
Yes
Yes. 1.5% of Sum Insured for
Normal room
2.0% of Sum Insured for ICU
(No other related capping)
Pre-existing Diseases
Yes (waived)
Co-Pay
Yes
First 30-days Waiting Period
Yes (waived)
First Year Waiting Period
Yes (waived)
Ambulance Charges
Yes. Up-to INR 3,500 per
occurrence
9 Months Waiting Period
Waived Off For All Employees
Internal Congenital Diseases
Yes
Corporate Floater
Dental & Vision
Accidents & bodily injuries
Yes. INR 2,500,000 restricted
up-to INR 150,000 per
family. Applicable to listed
Critical Illnesses
Terrorism Buffer
Yes. INR 10,000,000
restricted up-to a maximum
of INR 350,000 per family
The above are only snapshots of the benefits provided under your group medical plan. Please refer Policy document for complete information on Coverage & exclusions..
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EMPLOYEE BENEFITS MANUAL
Group Medical : Benefit Details
If any Insured Person suffers an Illness or Accident during the Policy Period that requires that Insured Person’s
Hospitalization as an inpatient, then the below-mentioned hospitalization expenses will be reimbursed under your group
medical plan.
Inpatient Treatment
•Room rent and boarding expenses
• Doctors fees (A medical practitioner)
• Intensive Care Unit
• Nursing expenses
• Anesthesia, blood, oxygen, operation theatre charges, surgical appliances,
•Medicines, drugs and consumables(Dressing, ordinary splints and plaster casts)
•Diagnostic procedures (such as laboratory, x-ray, diagnostic tests)
•Costs of prosthetic devices if implanted internally during a surgical procedure
•Organ transplantation including the treatment costs of the donor but excluding the costs of the organ
A) The expenses shall be reimbursed 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 normally for select day care 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 Hospitalization Benefit provided the procedure is approved by the TPA in advance.
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Benefit Details
EMPLOYEE BENEFITS MANUAL
Group Medical : Standard Hospitalization
The pre & post hospitalization expenses are covered under your group medical plan.
Pre-hospitalization Expenses
If the Insured member is diagnosed with an Illness which results in his / her
immediate Hospitalization and for which the Insurer accepts a claim, the
Insurer will also reimburse the Insured Member’s Pre-hospitalization Expenses
incurred within 30 days prior to his / her Hospitalization.
Duration
30 days
Restrictions
Such Medical Expenses must be incurred for the same condition for which
the Insured Person’s subsequent Hospitalization was required
Post-hospitalization Expenses
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 Posthospitalization Expenses for up to 60 day period following the date of
discharge.
Duration
60 Days
Restrictions
Such costs are incurred in respect of the same condition for which the
Insured Person’s earlier Hospitalization was required
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Benefit Details
EMPLOYEE BENEFITS MANUAL
Group Medical : Pre & Post Hospitalization Expenses
The maximum benefit allowable is as per your grade per delivery(for Normal and Caesarean deliveries) within the Sum
Insured, max up to 2 children. There are special conditions applicable to the Maternity Expenses Benefits as below:
These benefits are admissible only if the expenses are incurred in Hospital/Nursing Home as in-patients in India.
Claim in respect of delivery for only first two children and/or operations associated therewith will be considered in
respect of any one Insured Person covered under the Policy or any renewal thereof. Those Insured Persons 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.
The maternity benefit is provided under your group medical plan
Maximum Benefit
INR 35000/- for normal and INR 50000/- for Caesarean
Restriction on No. of children
2 children
9-months waiting period
Waived Off For All Employees
Pre-Post Natal expenses
Restricted within Maternity limit up to 5,000 for out patient
Baby expenses during maternity
Yes
New born baby covered from day 1
Yes
Definition
The new born child of an employee will be covered under
the Policy from the time of birth subject to intimation to the
insurer.
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Benefit Details
EMPLOYEE BENEFITS MANUAL
Group Medical : Maternity Benefits
(1)
Pre-existing Diseases
Coverage
Yes
Definition
Pre-existing Condition means any sickness, illness, disease, injury, medical or nervous condition or
related condition or symptom:
A. For which the Insured Person received any medical consultation, treatment, investigation or advice or,
B. of which the Insured Person was aware or ought to have been aware within the 36 months period prior to the
commencement of the Insured Person first being covered by the insurer.
First 30 day waiting period
Waived Off
Yes
Definition
Any disease contracted by the Insured Person (except for the “First Year diseases” listed below) during the first 30 days from the
commencement date of the Policy is not covered. This exclusion shall not apply for accident. If the insured person has been
insured continuously and without any break in the previous policy Year, the waiting period of first 30-day will not apply.
Other Benefits (2)
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EMPLOYEE BENEFITS MANUAL
Group Medical : Other Benefits
(2)
First Year waiting period
Waived Off
Yes
During the first year of the operation of the policy, the expenses on treatment of the following diseases are not payable. If
Insured Person has previously been insured under same health Policy continuously and without any break, the first year waiting
period will not apply. If the following diseases are pre- existing at the time of proposal, they will not be covered even during
subsequent period or renewal too.
i)
ii)
Illnesses: arthritis if non-infective; calculus diseases of gall bladder and urogenital system; cataract; fissure/fistula in anus,
hemorrhoids, pilonidal sinus, gastric and duodenal ulcers; gout and rheumatism; internal tumors, cysts, nodules, polyps
including breast lumps (each of any kind unless malignant); osteoarthritis and osteoporosis if age related; polycystic
ovarian diseases; sinusitis and related disorders and skin tumors unless malignant.
Treatments: benign ear, nose and throat (ENT) disorders and surgeries (including but not limited to adenoidectomy,
mastoidectomy, tonsillectomy and tympanoplasty); dilatation and curettage (D&C); hysterectomy for menorrhagia or
fibromyoma or prolapse of uterus unless necessitated by malignancy; joint replacement; myomectomy for fibroids; surgery
of gallbladder and bile duct unless necessitated by malignancy; surgery of genito urinary system unless necessitated by
malignancy; surgery of begnin prostatic hypertrophy; surgery of hernia; surgery of hydrocele; surgery for prolapsed inter
vertebral disk; surgery of varicose veins and varicose ulcers; surgery on tonsils and sinuses.
Other Benefits (1)
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Other Benefits (3)
EMPLOYEE BENEFITS MANUAL
Group Medical : Other Benefits
(4)
Domiciliary Hospitalization
Coverage
Not Covered
Definition
DOMICILIARY HOSPITALISATION BENEFIT means continuous 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 hospital/ nursing home but actually
taken whilst confined at home in India under any of the following circumstances, namely:
The condition of the patient is such that he/she cannot be removed to the hospital/nursing home or
The patient cannot be removed to any hospital/nursing home for lack of accommodation therein
Exclusions
•No payment for pre-hospitalisation and post-hospitalisation
expenses will be made by the insurance company under this
benefit.
•No payment will be made if the condition for which the
Insured Person requires medical treatment is:
A - Asthma, bronchitis, tonsillitis and upper respiratory tract
infection including laryngitis and pharyngitis, cough and cold,
influenza,
B - Arthritis, gout and rheumatism,
C - Chronic nephritis and nephritic syndrome,
D -Diarrhoea and all type of dysenteries including
gastroenteritis,
E -Diabetes mellitus and insipidus,
F -Epilepsy,
G -Hypertension,
H -Psychiatric or psychosomatic disorders of all kinds,
I - pyrexia of unknown origin.
Exclusions
•No payment for pre-hospitalization and post-hospitalization
expenses will be made by the insurance company under this
benefit.
•No payment will be made if the condition for which the
Insured Person requires medical treatment is:
A - Asthma, bronchitis, tonsillitis and upper respiratory tract
infection including laryngitis and pharyngitis, cough and cold,
influenza,
B - Arthritis, gout and rheumatism,
C - Chronic nephritis and nephritic syndrome,
D - Diarrhoea and all type of dysenteries including
gastroenteritis,
E -Diabetes mellitus and insipidus,
F -Epilepsy,
G -Hypertension,
H -Psychiatric or psychosomatic disorders of all kinds,
I - pyrexia of unknown origin.
Other Benefits (3)
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Other Benefits (5)
EMPLOYEE BENEFITS MANUAL
Group Medical : Other Benefits
(5)
Day Care
Coverage
Yes (Restricted to list mentioned in Standard Hospitalization)
Definition
The Medical Expenses for a day care procedure or surgery mentioned in the list of Day Care Procedures where the procedure
or surgery is taken by the Insured Person as an inpatient for less than 24 hours in a Hospital (but not the outpatient department
of a Hospital). This treatment will require the prior approval of the TPA.
Other Benefits (4)
* Day care treatment will require prior pre-authorization from the TPA prior to claim.
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Other Benefits (6)
EMPLOYEE BENEFITS MANUAL
Group Medical : Other Benefits
(6)
Room Rent Capping
Applicability
Applicable . 1.5% & 2% (no other related capping)
Definition
Room Rent Capping is a plan feature, wherein claimant need to use Hospital Room which has Rent up to 1.5% of Sum Insured
for Normal Hospitalization and 2% of Sum Insured for ICU per day. If claimant opts for a Room which has a Rent above the said
limits, then, amount over and above the Limit will have to be borne by the claimant.
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EMPLOYEE BENEFITS MANUAL
Group Medical : Other Benefits
(7)
Co-Pay
Applicability
No Co-Pay up-to INR 10,000 (excepting parental claims)
For claims above INR 10,000, the following co-pay is
applicable –
10% co-pay for employee / spouse / siblings / children
20% co-pay for parents / in-laws
50% co-pay for 1st six months of New Joiners & their
dependents
Definition
Co-Pay is a plan feature, wherein claimant needs to bear the specified percentage of the claim amount. The insurer will pay
the claim amount after deduction of the co-pay percentage.
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EMPLOYEE BENEFITS MANUAL
Group Medical : Other Benefits
(8)
Corporate Floater
Applicability
Total buffer of INR 2,500,000 restricted to INR 150,000 per
family.
Applicable only to listed critical illnesses.
Eligibility
All members are eligible.
Definition
Corporate Floater is applicable FOR the below mentioned critical illnesses :
• Heart Attack - Coronary artery disease requiring surgery (Open & closed heart surgeries)
• Heart Valve Replacement. Replacement or repair of heart valves Stroke
• Cancer. All cancers including Chemotherapy & Radiotherapy
• Kidney failure (end stage renal disease) – Dialysis
• Major organ transplant
• Multiple Sclerosis
• Coronary Artery Bypass Graft / Angioplasty (PTCA). CABG & Angioplasty with stents. Surgery of Aorta
• Paralysis
• Knee replacement
• Myocardial Infarction Brain surgery. Brain stroke, non cancerous tumors & brain surgery
• Road accidents with Head injury or Fractures in two or more limbs (upper / lower) or RTA injury requiring ventilation support
• Poly trauma on prolonged life support care in ICU
Kuoni HR will confirm and approve the utilization of the Corporate Floater through a mail to Insurer and TPA
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EMPLOYEE BENEFITS MANUAL
Group Medical : Other Benefits
(8)
Terrorism Buffer
Applicability
Total buffer of INR 10,000,000 restricted to INR 350,000 per
family.
Eligibility
All members are eligible.
Terrorism Buffer
Additional amount of INR 350,000 per family up-to a maximum of INR 10,000,000 may be paid in event of hospitalization due to
terrorism.
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EMPLOYEE BENEFITS MANUAL
Group Medical : Other Benefits
(1)
i)
War or any act of war, invasion, act of foreign enemy, war like operations (whether war be declared or not or
caused during service in the armed forces of any country), civil war, public defense, rebellion, revolution,
insurrection, military or usurped acts, nuclear weapons/materials, chemical and biological weapons, radiation of
any kind.
ii)
Any Insured Person committing or attempting to commit a criminal or illegal act, or intentional self injury or
attempted suicide while sane or insane.
iii)
Any Insured Person’s participation or involvement in naval, military or air force operation, racing, diving, aviation,
scuba diving, parachuting, hang-gliding, rock or mountain climbing.
iv) The abuse or the consequences of the abuse of intoxicants or hallucinogenic substances such as drugs and
alcohol, including smoking cessation programs and the treatment of nicotine addiction or any other substance
abuse treatment or services, or supplies.
v)
Obesity or morbid obesity or any weight control program, where obesity means a condition in which the Body
Mass Index (BMI) is above 29 and morbid obesity means a condition where the BMI is above 37.
vi) Psychiatric or mental disorders (including mental health treatments and, sleep-apnoea), Parkinson and
Alzheimer’s disease, general debility or exhaustion (“run-down condition”); congenital internal or external
diseases, defects or anomalies, genetic disorders; stem cell implantation or surgery, or growth hormone therapy.
vii) Venereal disease, sexually transmitted disease or illness; “AIDS” (Acquired Immune Deficiency Syndrome) and/or
infection with HIV (Human immunodeficiency virus) including but not limited to conditions related to or arising
out of HIV/AIDS such as ARC (AIDS related complex), Lymphomas in brain, Kaposi’s sarcoma, tuberculosis.
viii) Pregnancy (including voluntary termination), miscarriage (except as a result of an Accident or Illness), maternity
or birth (including caesarean section) except in the case of ectopic pregnancy.
General
Exclusions (2)
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EMPLOYEE BENEFITS MANUAL
Group Medical : General Exclusions
(2)
ix) Sterility, treatment whether to effect or to treat infertility, any fertility, sub-fertility or assisted conception
procedure, surrogate or vicarious pregnancy, birth control, contraceptive supplies or services and complications
arising there from.
x)
Dental treatment and surgery of any kind, unless requiring Hospitalization.
xi) Treatment and supplies for analysis and adjustments of spinal subluxation, diagnosis and treatment by
manipulation of the skeletal structure or for muscle stimulation by any means (except treatment of fractures and
dislocations of the extremities).
xii) Nasal septum deviation and nasal concha resection, circumcisions, laser treatment for correction of eye due to
refractive error, aesthetic or change-of-life treatments of any description such as sex transformation operations,
treatments to do or undo changes in appearance or carried out in childhood or at any other times driven by
cultural habits, fashion or the like or any procedures which improve physical appearance.
xiii) Plastic surgery or cosmetic surgery unless necessary as a part of medically necessary treatment certified by the
attending Medical Practitioner for reconstruction following an Accident or Illness.
xiv) Experimental, investigational or unproven treatment, devices and pharmacological regimens, or measures
primarily for diagnostic, X-ray or laboratory examinations or other diagnostic studies which are not consistent with
or incidental to the diagnosis and treatment of the positive existence or presence of any Illness for which
confinement is required at a Hospital.
xv) Convalescence, cure, rest cure, sanatorium treatment, rehabilitation measures, private duty nursing, respite
care, long-term nursing care or custodial care.
xvi) Any non-allopathic treatment.
General
Exclusions (1)
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General
Exclusions (3)
EMPLOYEE BENEFITS MANUAL
Group Medical : General Exclusions
(3)
xvii) All preventive care, vaccination including inoculation and immunizations, any physical, psychiatric or
psychological examinations or testing during these examinations; enteral feedings (infusion formulas via a tube
into the upper gastrointestinal tract) and other nutritional and electrolyte supplements, unless certified to be
required by the attending Medical Practitioner as a direct consequence of an otherwise covered claim.
xviii)Charges related to a Hospital stay not expressly mentioned as being covered, including but not limited to
charges for admission, discharge, administration, registration, documentation and filing.
xix) Items of personal comfort and convenience including but not limited to television, telephone, foodstuffs,
cosmetics, hygiene articles, body care products and bath additives, barber or beauty services, guest services as
well as similar incidental services and supplies, and vitamins and tonics unless vitamins and tonics are certified to
be required by the attending Medical Practitioner as a direct consequence of an otherwise covered claim.
xx) Treatment rendered by a Medical Practitioner which is outside his discipline or the discipline for which he is
licensed; referral-fees or out-station consultations; treatments rendered by a Medical Practitioner who shares the
same residence as an Insured Person or who is a member of an Insured Person's family, however proven material
costs are eligible for reimbursement in accordance with the applicable cover.
xxi) The costs of any procedure or treatment by any person or institution that We have told You is not to be used.
xxii) The provision or fitting of hearing aids, spectacles or contact lenses including optometric therapy, any treatment
and associated expenses for alopecia, baldness, wigs, or toupees, medical supplies including elastic stockings,
diabetic test strips, and similar products.
xxiii)Any treatment or part of a treatment that is not of a reasonable cost, not medically necessary; nonprescription
drugs or treatments.
xxiv) Artificial limbs, crutches or any other external appliance and/or device used for diagnosis or treatment.
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EMPLOYEE BENEFITS MANUAL
Group Medical : General Exclusions
•You must enroll in order to obtain coverage for yourselves and your eligible dependants. Please contact your HR and
provide relevant enrollment data (viz. name, date of birth, gender). Your enrollment data must reach the Insurer within
30 days of your joining the company.
•Please notify HR each time you acquire a new dependent i.e. when your family status changes because of marriage,
birth or adoption of a child. The acquisition of a new spouse must be declared within 30 days of the marriage. Similarly,
information about new-born child has to be declared immediately after the first discharge after the child-birth.
•If you fail to enroll within the defined timelines, the next enrollment can be done only at next renewal.
Notify TPA
with revised
details
Error in data printed on card
No Error
Provide required
details of yourself
and your
dependents to
the HR
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HR sends the
data to the
insurer for
endorsements
Insurer updates
their data,
endorses
member and
sends the detail
to the TPA
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TPA updates the
active member
database and
issues e-cards
ID cards can be
printed by
Employee / HR
from the online
system
ID card received
by employee
Employee
verifies details on
the ID card
Use card for
cashless
hospitalization
EMPLOYEE BENEFITS MANUAL
Group Medical : Enrollment Procedure
You can avail either cashless facility or submit the claim for reimbursement.
Definition of Cashless
•Cashless hospitalization means the Administrator may authorize (upon an Insured person’s request) for direct
settlement of eligible services and the corresponding charges between a PPN Network Hospital and the Administrator.
In such case, the Administrator will directly settle all eligible amounts with the PPN Network Hospital and the Insured
Person may / may not have to pay any deposits at the commencement of the treatment or bills after the end of
treatment to the extent these services are covered under the Policy. Denial of cashless does not mean that the
treatment is not covered by the policy.
Definition of Reimbursement
•In case you choose a non-network hospital, you will have to liaise directly with the hospital for admission.
•However, you will have to intimate TPA with-in 24 hours of admission . You are advised to follow the pre authorization
procedure to ensure eligibility for reimbursement of hospitalization expenses from the insurer.
•To know about cashless or reimbursement, please click the desired section mentioned below:
Cashless
Reimbursement
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EMPLOYEE BENEFITS MANUAL
Group Medical : Hospitalization Procedure
There are 2 types of cashless hospitalization.
•
Planned hospitalization
•
Emergency hospitalization
IMPORTANT: CLAIM INTIMATION : within 48 Hours of Admission
CLAIM SUBMISSION : within 30 days of Discharge
For all benefits under or contingent on a claim under Benefit1)a) being accepted, The insurer or the TPA must be
informed of any event or occurrence that may give rise to a claim under this Policy within 30 days of discharge from
Hospitalization.
•
Click on the respective section below.
Cashless : Planned Hospitalization
Cashless : Emergency Hospitalization
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Hospitalization
Procedure
EMPLOYEE BENEFITS MANUAL
Group Medical : Cashless Hospitalization
Step 1
Pre-Authorization
Step 2
Admission, Treatment & discharge
(1)
•All non-emergency hospitalization instances must be pre-authorized
with the Help Desk of the TPA. Please click on the button created at
the right side for the detailed procedure. This is done to ensure that
the best healthcare possible, is obtained, and the Insured Member is
not inconvenienced when taking admission into a Network Hospital.
•The Insured Person shall provide any documentation and
information to the insurer or the TPA at request to establish the
circumstances of the claim
Process
•After your hospitalization 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 Insured Member is not required to
pay the hospitalization bill in case of a network hospital. The
bill will be sent directly to, and settled by, TPA.
Process
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 need to be submitted separately as part of noncashless claims.
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Cashless Hospitalization:
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EMPLOYEE BENEFITS MANUAL
Group Medical : Cashless Hospitalization – Planned
(2)
Pre-Authorization
Member intimates TPA of the
planned hospitalization in a
specified pre-authorization
format 48 hours prior to
hospitalization
Claim
Registered
by the TPA
on same
day
Yes
No
Follow non cashless
process
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TPA issues letter of credit within
12 hours for planned
hospitalization to the hospital
The letter will depend on the
plan benefits and available
sum insured.
Process Complete
EMPLOYEE BENEFITS MANUAL
Group Medical : Cashless Hospitalization – Planned
(3)
Admission, Treatment & Discharge
Member produces TPA ID card at
the network hospital and gets
admitted
Member gets treated and
discharged after paying all non
entitled benefits like
refreshments, etc.
Hospital sends complete set of
claims documents for processing
to the TPA
Claims Processing by TPA (with
approval by Insurer)
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Release of payments to the
hospital
EMPLOYEE BENEFITS MANUAL
Group Medical : Cashless Hospitalization – Planned
(1)
If any treatment, consultation or procedure for which a claim may be made is required in an emergency, then Insurer or the
TPA must be informed no later than 24 hours of commencement of such treatment, consultation or procedure.
Step 1
Get Admitted
Step 2
Pre-Authorization by
hospital
Step 3
Treatment & Discharge
In cases of emergency, the member should get admitted in the
nearest network hospital by showing their ID card. The treatment
should not be put on hold irrespective of the time of receipt of preauthorization.
Relatives of admitted member should inform the call centre within 24
hours about the hospitalization & seek pre authorization. The pre
authorization letter would be directly given to the hospital. In case of
denial, member would be informed directly.
After your hospitalization has been pre-authorized, the employee is not
required to pay the hospitalization bill in case of a network hospital.
The bill will be sent directly to, and settled by, TPA.
Cashless Hospitalization:
Home
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Cashless Hospitalization
- Emergency(2)
EMPLOYEE BENEFITS MANUAL
Group Medical : Cashless Hospitalization – Emergency
(2)
Emergency Hospitalization Process
Member get admitted in the
hospital in case of emergency by
showing his ID Card. Treatment
starts.
Hospital sends complete set of
claims documents for processing
to the TPA
Member / Hospital applies for
pre-authorization to the TPA
within 24 hrs of admission
Member gets treated and
discharged after paying all non
entitled benefits like
refreshments, etc.
TPA verifies applicability of the
claim to be registered and issue
pre-authorization
Yes
Preauthorization
given by the
TPA
No
Claims Processing by TPA & Insurer
Release of payments to the
hospital
Follow non cashless
process
Cashless Hospitalization:
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Cashless Hospitalization
- Emergency(1)
EMPLOYEE BENEFITS MANUAL
Group Medical : Cashless Hospitalization – Emergency
(1)
Admission procedure
In case you choose a non-network hospital, you will have to liaise directly for admission.
However, you will have to intimate TPA with-in 48 hours of admission . You are advised to follow the pre authorization
procedure to ensure eligibility for reimbursement of hospitalization expenses from the insurer.
Discharge procedure
In case of non network hospital, you will be required to clear the bill 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
1. After the hospitalization is complete and the patient has been discharged from the hospital, you must submit the
final claim within 30 days from the date of discharge from the hospital.
2. Under hospitalization claims, you are also permitted to claim for treatment expenses 30 days prior to hospitalization
and 60 days after the date of discharge. This is applicable for both network and non-network hospitalization.
Reimbursement Hospital
Process
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Hospitalization
Procedure
EMPLOYEE BENEFITS MANUAL
Group Medical : Reimbursement
(2)
Reimbursement Hospital Process
Member intimates TPA
before or as soon as
hospitalization occurs
(but no later than 24 Hrs)
Yes
Insured admitted as
per hospital norms. All
payments made by
member
Claim registered by
TPA after receipt of
claim intimation
Is claim liable
(coverage /
applicability)
Yes
TPA performs
medical scrutiny
of the documents
No
No
TPA checks document
sufficiency
Is documentation
complete
as required
Yes
No
Contents
Is document
received
within 30
days from
discharge
GMC Home
Hospitalization
Procedure
Claims processing done
within 15 working days
Send mail about deficiency
and document requirement
Insured sends relevant
documents to TPA
office within 7 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 e-mail
Claim Rejected
Claims cheque sent to the HD
along with Discharge voucher
and copy of payment receipt
for claimant’s sign-off.
A
EMPLOYEE BENEFITS MANUAL
Group Medical : Reimbursement
No.
Document Required
1
Signed claim form for on behalf of the Insured Person
2
Original Bills( with bill no; signed and stamped by the hospital) (including but not limited to
pharmacy purchase bills, consultation bills, diagnostic bills) and any attachments thereto like
receipts or prescriptions in support of any amount claimed which will then become Our property.
3
All reports, including but not limited to all medical reports, case histories, investigation reports,
treatment papers, discharge card & discharge summaries.
4
A precise diagnosis of the treatment for which a claim is made.
5
A detailed list of the individual medical services and treatments provided and a unit price for
each.
6
Prescriptions that name the Insured Person and, in the case of drugs, the drugs prescribed, their
price and a receipt for payment. Prescriptions must be submitted with the corresponding Medical
Practitioner’s invoice.
7
Break up with details of pharmacy items, materials, investigations even though it is there in the
main bill
8
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.
9
In case of non- network hospitalization, please get the hospital and doctor’s registration number
in hospital letterhead and get the same signed and stamped by the hospital.
10
Being examined by any Medical Practitioner We authorize for this purpose when and so often as
We may reasonably require.
Contents
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EMPLOYEE BENEFITS MANUAL
Group Medical : Claims Document List
No.
Document Templates
1
Cashless Process
2
Cashless Request Form
3
Reimbursement claim Check List
4
Reimbursement Process
5
Reimbursement Claim Form
6
Preferred Private Network (PPN) List
Contents
GMC Home
EMPLOYEE BENEFITS MANUAL
Group Medical : Claims Document List
The group personal accident policy indemnifies the insured or the dependants of the insured person as the case may be up to the sum
insured opted for under the policy, in case of a death or disability caused due an accident. The Group Personal Accident policy covers
Accidental Death , Permanent Total Disability and Permanent Partial Disability as key risks.
Plan Information
Benefit Details
General Exclusions
Claim Procedure
Document Checklist
(To reach the desired section directly please click on the section title)
Contents
EMPLOYEE BENEFITS MANUAL
Group Personal Accident
Plan Name
Group Personal Accident Plan
Policy Holder
Kuoni Travel (India) Pvt. Ltd.
Kuoni Business Travel India Pvt. Ltd.
VFS Global Services Pvt. Ltd.
Distance Frontier Tour India Pvt. Ltd.
Kuoni Destination Management
Period of the Cover
12 months
Inception Date
01-Jan-2012
Expiry Date
31-Dec-2012
Insurer
The New India Assurance Co. Ltd.
Basis of Sum Insured
Flat amount
Members covered under the plan
Only Employee
Geographical Limits
World Wide
Sum Insured
INR 1,000,000 per employee
Contents
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EMPLOYEE BENEFITS MANUAL
Group Personal Accident : Plan Information
Mid Term Enrollment of Members
Particular
Description
Mid Term enrollment of existing Employee
Not Allowed
Mid Term enrollment of New Joiners
Allowed *
Midterm revision of sum insured
Not Allowed
Special Condition if any
Important Dates
Existing Employees
Commencement Date
01-Jan-2012
Termination Date
31-Dec-2012
New Joiners
Commencement Date
Date of joining
Termination Date
31-Dec-2012
Note
All existing employees are covered under the policy from the inception date of the policy.
For new employees, your enrollment data must reach the Insurer within 30 days of your joining the company. Please contact your HR and provide enrollment data (viz.
name, date of birth, gender).
Contents
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EMPLOYEE BENEFITS MANUAL
Group Personal Accident : Plan Information
Benefit
Coverage
Accidental Death
Yes (100% of Sum Insured)
Permanent Total Disability
Yes (100% of Sum Insured)
Permanent Partial Disability
Yes (% as per attached table)
Temporary Total Disability
No
Medical Expenses
No
Terrorism
Yes
Geographical Limit
World Wide
Emergency Ambulance Charges
INR 1,000 per occurrence
Carriage of dead body (including cremation charges)
2% of sum insured, maximum of INR 2,500
Child education welfare fund
INR 10,000 per dependent child (restricted to 2 children)
incase of death of Employee
Natural Calamity
Yes
Snapshots of the Benefits covered under the policy. Please refer the policy wording on “Attachment” slide if you need detailed information.
Contents
GPA Home
EMPLOYEE BENEFITS MANUAL
Group Personal Accident : Benefit Details
1)
for Bodily Injury or Sickness occasioned by Civil War or Foreign War.
2)
for Bodily Injury or Sickness caused or provoked intentionally by the Insured Person.
3)
for Bodily Injury or Sickness due to wilful or deliberate exposure to danger, (except in an attempt to save human life), intentional self-inflicted injury, suicide or
attempt thereat, or arising out of non-adherence to medical advice.
4)
for Bodily Injury or Sickness sustained or suffered whilst the Insured Person is or as a result of the Insured Person being under the influence of alcohol or drugs or
narcotics unless professionally administered by a Physician or unless professionally prescribed by and taken in accordance with the directions of a Physician.
5)
for Bodily Injury due to a gradually operating cause.
6)
for Bodily Injury sustained whilst or as a result of participating in any sport as a professional player.
7)
for Bodily Injury sustained whilst or as a result of participating in any competition involving the utilisation of a motorised land, water or air vehicle.
8)
for Bodily Injury whilst the Insured Person is travelling by air other than as a fare paying passenger on an aircraft registered to an airline company for the transport
of paying passengers on regular and published scheduled routes.
9)
for Bodily Injury sustained whilst or as a result of participating in any criminal act.
10)
for Bodily Injury or Sickness resulting from pregnancy within twenty-six (26) weeks of the expected date of birth.
11)
for Bodily Injury or Sickness caused by or arising from the conditions commonly known as Acquired Immunodeficiency Syndrome (AIDS) or Human
Immunodeficiency Virus (HIV) and/or any related illness or condition including derivatives or variations thereof howsoever acquired or caused. The onus shall
always be upon the Insured Person to show that Bodily Injury or Sickness was not caused by or did not arise through AIDS or HIV.
12)
for Bodily Injury or Sickness caused by or arising from or due to venereal or venereal related disease.
13)
for Bodily Injury sustained whilst or as a result of active participation in any violent labour disturbance, riot or civil commotion or public disorder.
14)
for Bodily Injury sustained whilst on service or on duty with or undergoing training with any military or police force, or militia or paramilitary organisation,
notwithstanding that the Bodily Injury occurred whilst the Insured Person was on leave or not in uniform.
15)
for treatments for nervous or mental problems, whatever their classification, psychiatric or psychotic conditions, depression of any kind, or mental insanity.
16)
any pathological fracture.
17)
for cures of any kind and all stays in long term care institutions (retirement homes, convalescence centres, centres of detoxification etc.).
18)
for investigations, operations or treatment of a purely cosmetic nature; or for obesity; or undertaken to facilitate pregnancy or to cure impotence or to improve
potency.
19)
for Bodily Injury sustained whilst or as a result of active participation in any hazardous sport such as parachuting, hangliding, parasailing, off-piste skiing or bungee
jumping.
Contents
GPA Home
EMPLOYEE BENEFITS MANUAL
Group Personal Accident : General Exclusions
Employee / Beneficiary
notifies HR, who in turn would
intimate Insurer and submit required
claims documents within 30 days of
the event
On obtaining all relevant
documents, Insurer begins
processing the claims
Yes
On approval, the cheque is sent to
the HR, from where it is given to the
Employee / Beneficiary
Contents
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Claim Investigation and Review
within 5 days of submission of all the
required documents
Is claim
approved
within 10
days
No
On rejection of the claim, Insurer
would provide a valid reason for the
rejection to HR / Employee /
Beneficiary
EMPLOYEE BENEFITS MANUAL
Group Personal Accident : Claim Procedure
Dismemberment/
Disablement Claims
Death Claims
Document Details
Document Details
1
Completed Claim form
1
Completed Claim form
2
Doctor's Report
2
Doctor's Report
3
Municipal death certificate
– verified by the employer.
3
Disability Certificate from the
Doctor, if any
4
First Investigation Report
4
5
Postmortem report
Investigation / Lab reports (xray etc.)
5
Original Admission /
discharge card, if
hospitalized
6
Police Inquest report,
wherever applicable
This is an indicative list of documents and there may be additional documents required by the insurer.
It is mandatory to provide the details for nomination of beneficiary.
Contents
GPA Home
EMPLOYEE BENEFITS MANUAL
Group Personal Accident: Document Checklist
Policy Details
Plan Name
Group Term Life Insurance Policy
Policy Holder
Kuoni Travel (India) Pvt. Ltd.
Kuoni Business Travel India Pvt. Ltd.
VFS Global Services Pvt. Ltd.
Distance Frontier Tour India Pvt. Ltd.
Kuoni Destination Management
Period of the Cover
12 months
Inception Date
01-Jan-2012
Expiry Date
31-Dec-2012
Insurer
Future Generali Life Insurance Co. Ltd.
Sum Insured Limits
Graded
Members Covered
Employee only
Geographical Limits
Worldwide
Mid-Term Revision of Sum Insured
Yes due to increment or promotion
Age-Limit
Upto 60 years
Coverage
On Event of death due to any means
Contents
Documents
Checklist
EMPLOYEE BENEFITS MANUAL
Group Term Life : Plan Information
Death Claim Benefit
Document Details
1
Claim Form – Duly filled
signed and stamped.
2
EFT Mandate form – Duly
filled signed and stamped.
3
Municipal death certificate
– verified by the employer.
4
FIR (Incase of accident /
sucide)
5
Postmortem report (Incase
of accident / sucide)
This is an indicative list of documents and there may be additional documents required by the insurer.
It is mandatory to provide the details for nomination of beneficiary.
Contents
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EMPLOYEE BENEFITS MANUAL
Group Term Life: Document Checklist
Third Party Administrator
Medi Assist India TPA Pvt. Ltd.
24 X 7 Customer Service Center
1800 425 9449
Fax Number For Cashless (9:00 am to 9:00 pm)
1800 425 9449
011-4162 4844
022-6637 6933
Web Site
www.mediassistindia.com
Account Manager
Mr. Saran Singh
Contact Number
+91-9321 632 117
Email Id
[email protected]
Escalation point 1
Mr. Sameer Sikhwal
Contact Number
+91-9321 822 322
Email Id
[email protected]
Escalation point 2
Dr. Amee Shukla
Contact Number
+91-9320 642 244
Email Id
[email protected]
Helpdesk Executive
Ms. Varsha Tawade
Contact Number
+91-9323 331 066 / 022-6656 2087
Email Id
[email protected]
Contents
Annexure Contd.
EMPLOYEE BENEFITS MANUAL
Annexure
Medical & Accident Insurance Co.
The New India Assurance Co. Ltd.
Account Manager
Mr. Mukund Mishra
Contact Number
022-2663 3283
Email Id
[email protected]
Escalation point 1
Ms. Nalini Venugopal
Contact Number
022-2663 3214
Email Id
[email protected]
Life Insurance Co.
Future Generali Life Insurance Co. Ltd.
Relationship Manager
Ms. Smitha Deshpande
Contact Number
+91-9833 271 172 / 022-6615 2054
Email Id
[email protected]
Escalation point 1
Mr. Chetan Trivedi
Contact Number
+91-9820 638 447
Email Id
[email protected]
Contents
Annexure Contd.
EMPLOYEE BENEFITS MANUAL
Annexure
For Escalations
Aon Global Insurance Brokers Pvt Ltd
Relationship Manager
Apurva Sarupria
Contact Number
022-6657 5622/ +91-9820 302 353
Email Id
[email protected]
Escalation point 1
Annamma Bhatoye
Contact Number
022-6656 0566/ +91-9819 755 664
Email Id
[email protected]
Escalation point 2
P. Sachidanand
Contact Number
022-6656 0603
Email Id
[email protected]
Thank You
EMPLOYEE BENEFITS MANUAL
Annexure
EMPLOYEE BENEFITS MANUAL
Thank You