ACCIDENT AND MEDICAL INSURANCE COVERAGE FOR MANAGEMENT CADRE EMPLOYEES (ABMCL/CHR/ )

Transcription

1 ACCIDENT AND MEDICAL INSURANCE COVERAGE FOR MANAGEMENT CADRE EMPLOYEES (ABMCL/CHR/ ) The Aditya Birla Group has always been committed to the issue of employee health and well being. Our HR Vision is also about being a people sensitive organization. It is in this context that a common scheme for Accident Cover and Hospitalization coverage for Management Cadre employees and their dependents has been designed. Annexure A highlights the salient features of the Group Accident coverage scheme. Annexure B provides the details of the Hospitalization coverage scheme Annexure C is a document highlighting the roles to be played by various constituencies in the administration of this scheme as well as the process to be followed for initiating coverage under the scheme. The initial list of hospitals that will be covered for the purposes of availing of cashless facility is is available with HR. The insurance coverage for both these schemes have been provided by New India Assurance Company Limited (NIA) and Birla Insurance Advisory Services Limited (BIASL) has specially negotiated the premium costs with NIA on our behalf. The policy administration will be through M/S Paramount Healthcare Management Pvt Ltd, the Third Party Administrators (TPA s) on behalf of NIA. We will be signing Service Level Agreements with the NIA on response time, settlement of claims, query processing etc to ensure high quality and timely service to our employees. The costs of all premiums will be borne by the respective Units to cover employees under this scheme. However, Units that have hospitals attached at their premises should do a cost benefit analysis before deciding to cover their employees for the Hospitalization coverage. At Units where similar policies are already in existence, the above policies will become applicable when the existing policies are due for renewal.

2 ANNEXURE A-Group Personal Accident Cover Scheme 1. Eligibility : All employees in Management Cadre 2. Extent of Coverage : World wide 24 Hour Cover for all employees in Management Cadre 3. Sum Insured : 48 months Salary ( Basic + Special Allowance ), subject to Minimum of Rs Lac per person and a maximum of Rs 3 Crore per person) 4. Settlement of claim : For Temporary ( Total / partial ) Disablement 1 % per week of 25 times of Salary ( Basic + Special Allowance ) subject to Maximum of Rs /- per week For Permanent (Total / partial ) Disablement / Death 48 months Salary ( Basic + Special Allowance ), subject to Minimum of Rs Lac per person and a maximum of Rs 3 Crore per person) 5. Medical Benefits Extension : 40% of Claim amount 6. Premium : Will be communicated by BIASL once details are furnished to them, in a prescribed format ( please refer to Point No 1a of Annexure C Process map ) 7. Addition / Deletions : a) Employees will be covered from the date of Joining and cease to be part of this scheme from the date of leaving / retiring. b)declaration for Joining / Leaving to be provided by 10th of Succeeding Month to NIA. 8. Cover Details : This policy offers compensation in case of death or bodily injury to the insured person, directly and solely as a result of an accident, by external, visible and violent means. The policy operates worldwide and is a 24 hours cover. This policy is basically designed to offer some sort of compensation to the insured person who suffers bodily injury solely as a result of an accident, which is external, violent and visible. Hence death or injury due to any illness or disease is not covered by the policy. The following types of coverage are offered under a Personal Accident policy:- A : Death and Permanent Total or Partial Disablement :- 1. Death cover wherein 100% of the capital sum insured is payable. 2. Loss of two limbs / both eyes / one limb and one eye wherein 100% of the capital sum insured is payable. 3. Loss of one limb or one eye wherein 50% of the capital sum insured is payable. 4. Permanent Total Disablement other than above e.g. paralysis due to an accident, wherein 100% of the capital sum insured is payable. 5. Permanent Partial Disablement i.e. where a part of the body becomes permanently disabled due to an accident, e.g. total and irrevocable loss of

3 use of a finger due to an accident. In such cases, a percentage of the capital sum insured as specified in the policy is paid. B : Temporary Total Disablement : where the insured person becomes temporarily disabled from undertaking any work as a result of an accident. In such cases, a weekly payment of 1% of the capital sum insured subject to a maximum limit, is paid for the number of weeks or part thereof (maximum 100 weeks), during which the insured person is totally disabled. The insured can claim only under any one of these sections as a result of any one accident. The policy also covers expenses incurred for carriage of dead body from place of accident to the residence subject to a limit of 1% of the capital sum insured or Rs.2,000 whichever is less. 9. Servicing : This will be done by Insurance Company (NIA) who will deal directly with at the Unit / Business level with the respective HR Departments, however BIASL can be approached in case of any dispute.

4 Annexure B-MEDICLAIM COVERAGE SCHEME FOR ADITYA BIRLA GROUP UNITS IN INDIA Key Details of the Scheme : 1. Sum Insured : Job Band range (in Rs) Family Floater (in Rs) Maternity Benefit (in Rs) Executive B up to JB5 5,00,000 50,000 JB6 to JB9 3,00,000 50,000 JB10 and below 2,00,000 50,000 Dental care (in Rs) 5,000 3,500 3,000 Coverage is for all Management Cadre employees in the Group. In case of the above limits being exhausted, applications for further coverage could be considered on a first incurred, first serve basis across the Group Premium : Premium payable per individual employee would as follows : Job Band Range Sum Insured Premium 10.20% Premium Executive B upto JB JB 6 to JB JB 10 and below Beneficiary All employees, their spouse, 2 children and dependent parents will be eligible for coverage under this scheme. In case of employees with no dependent children, immediate blood relations such as brother or sister can also be covered provided they are dependents on the employee. Similarly, dependent in-laws can also be covered instead of dependent parents. In any case total group size of Family will be restricted to 6 persons including employee himself / herself. Once covered as a dependent of the employee, exclusions from this list can only be in case of death of the dependents or the individuals covered ceasing to be dependent on the employee.

5 The coverage applies in respect of all employees, whether Indian or foreign nationals. However, this policy will pay in Indian rupees in respect of hospitalization inside India only. In case of employees where the current eligibility for hospitalization is on actuals, the approach should be to first claim all such expenses under this scheme and any balance not covered under such scheme should then be put up to the Business / Unit for separate approval. Employees who retire but would like to continue coverage under the scheme can also be considered wherein the coverage is on the same terms as for existing employees; the premium may be higher depending upon past claim experience and is payable by the individuals in such cases. A Separate policy will be issued to such retiring employees. The coverage in such cases will be limited to self, spouse and dependent children if any. This payment should be made to the Unit that they last retired from. It will be the responsibility of the respective Units to correspond with such individuals at the time of coverage / renewal of policy and collection of premium. This is applicable for employees who retire on or after November 1, Managers who will be eligible to avail of any benefits under the scheme for retiring employees dated April 23, 2003 can continue to avail of the same until further notice. 4. Duration The term of the policy is one year and it will be renewable on an annual basis. 5. Policy Administration This policy will be serviced through M/S Paramount Health Care Management Pvt Ltd,the Third Party Administrators (TPA). More details on this will be communicated to you by BIASL. 6. Additions / Deletions Through declaration to be made by 10 th of succeeding month In case of new employees, cover starts from the date of joining In case of separations/ retirements, coverage ceases automatically from date of ceasing employment. Mid-year additions to the family of employees can be done (Premium for addition & deletion would be done on pro-rata basis. To ensure coverage from due date Insured will maintain cash deposit with Insurance Co. Amount will be communicated once premium for each unit is worked out. 7. Nature and Scope of cover : Group comprehensive health care plan wherein the benefit amount stated for each person will apply for hospitalization + pre hospitalization + post hospitalization + day care procedures as follows: Cash-free benefit (minimum 24 hours hospitalization or in respect of day care surgeries) for hospitalization arising out of sickness or accident. Claim will be settled directly by the Insurer.

6 This policy pays for costs incurred for up to 30 days before hospitalization and for up to 60 days after hospitalization, where the claim for hospitalization has been admitted. Additionally, the Policy has specially been extended in our case to cover :- 1. Maternity Expenses including Neo Natal Expenses up to the limit of Rs.50,000/- per person per annum. 2. Dental Care Expenses ( As per the Sum Insured category wise stated In the table under the head of Sum Insured mentioned at Sr. No. 1 above) 3. Ambulance Charges up to Rs. 1500/- 4. New Born from day one, days waiting period waived 6. Waiting period for Maternity benefit waived 7. Pre existing exclusion waived 8. Dependent parents / in laws above the age of 70 covered. 8. Important policy features: The policy will pay in respect of the Hospitalisation Expenses as per the Indemnity Limit (Sum Insured ) stated hereinabove under the Head of Sum Insured at Sr. no. 1 above. If the Insured is diagnosed with an Illness or suffers Accidental Bodily Injury, which necessitates his Hospitalization, the Insurer will reimburse the Insured Person s consequent Hospitalization Expenses for: 1. Room and board as per the following categories : Job Band Type of Room Executive B to Job Band 5 AC Deluxe Single Room Job Band 6 to Job Band 9 Single AC / Aircooled Room Job Band 10 and below AC / Aircooled Sharing Room 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 Organ transplantation including the treatment costs of the donor but excluding the costs of the organ

7 9. Other customized features a. Individual health ID cards for each group member. b. Access to a 24-hour health help-line. c. Access to a hospital network (managed by a professional third part medical administrator) of over 1400 hospitals across more than 250 cities. There is also a provision to add the names of any additional hospitals that the respective Units might want to add as part of coverage under this scheme. 10. Settlement of Claim : In cases where there is no cashless transaction, the expenses incurred by an employee will be settled within 7 working days after the submission of relevant documents to the Insurance Company. 11. Servicing : Respective Office of Insurance Company nearest to the respective Units and the TPA will do this. 12. List of Exclusions i. Circumcision unless necessary for the treatment of an Illness not otherwise excluded in this Section, or required as a result of Accidental Bodily Injury. ii. iii. iv. Vaccination, inoculation, cosmetic treatments (including any complications arising out of or howsoever attributable to any cosmetic treatments or the replacement of an existing breast implant), aesthetic treatments, experimental, investigational or unproven procedures or treatments, devices and pharmacological regimens of any description. Vitamins and tonics unless forming a necessary part of the treatment for Illness as certified by the attending Doctor. Any dental treatment or surgery of a corrective, cosmetic or aesthetic nature unless it requires Hospitalization, is carried out under general anesthesia and is necessitated by Illness or Accidental Bodily Injury. (Dental care as per the limit selected is covered, even if Hospitalization does not takes place) v. Personal comfort and convenience items or services such as television,telephone, barber or beauty service, guest service and similar incidental services and supplies. vi. The treatment of obesity (including morbid obesity) and any other weight control programs, services, or supplies.

8 vii. viii. Durable medical equipment (including but not limited to wheelchairs, crutches, artificial limbs and the like), (namely that equipment used externally from the human body which can withstand repeated use; is not designed to be disposable; is used to serve a medical purpose; is generally not useful in the absence of a Illness or Injury and is usable outside of a Hospital) unless required for the treatment of Illness or Accidental Bodily Injury. Diagnostic, X-ray or laboratory examination not incidental to or inconsistent with the diagnosis and treatment of the Illness or Injury for which the Insured Person was hospitalized. ix. The Insured Person s participation in any hazardous activities, including but not limited to scuba diving, motor-racing, parachuting, hang-gliding, rock or mountain climbing, as a member of the armed forces, the paramilitary, the security forces, the fire or ambulance services, lifeboat service, police force and the like whether part time or full time, voluntary or paid. x. Charges incurred in connection with the provision or fitting of hearing aids, eyeglasses or contact lenses. xi. xii. xiii. xiv. xv. Any travel or transportation costs or expenses. The use, misuse, or abuse of alcohol, substances or drugs (whether prescribed or not). Outpatient prescribed or non-prescribed medical supplies including elastic stockings, bandages, gauze, syringes, diabetic test strips, and similar products; non-prescription drugs and treatments. War, invasion, acts of foreign enemies, hostilities whether war be declared or not, civil war, revolution, insurrection, mutiny, martial law, terrorism or terrorist acts. Ionizing radiation or contamination by radioactivity from any nuclear waste or from combustion of nuclear fuel or otherwise; or the radioactive, toxic, explosive or other hazardous properties of any explosive nuclear assembly or nuclear component thereof, or asbestosis or any related condition resulting from the existence, production, handling, processing, manufacture, sale, distribution, deposit or use of asbestos, or asbestos products.

9 xvi. xvii. Invitro fertilization (IVF), gamete intrafallopian transfer (GIFT) procedures, and zygote intrafallopian transfer (ZIFT) procedures, and any related prescription medication treatment; embryo transport; donor ovum and semen and related costs, including collection and preparation; voluntary medical termination of pregnancy. HIV, AIDS and all related medical conditions. xviii. Costs incurred on all method of medical treatment except allopathic. xix. Any condition after the point at which it is certified by the attending Doctor to be of such a nature that further medical treatment may serve to stabilize or maintain it but is unlikely to result in a material improvement within a reasonable timeframe.

10 ANNEXURE C -Roles of Various constituencies in the process Role of various constituencies in the implementation of the Group Personal Accident / Hospitalization Coverage Policy. Business / Unit HR: 1. To collect information from Unit a) No. of employees to be covered under GPA : S.N Unit Location Employee s Name Designation 48 Months Salary (Basic +Special Allowance) b) Details of Employees and their dependents to be cover under Mediclaim in following format : Details of DOB Employee s Job Dependents (Dependent Sr.No Unit Location Name Designation Band DOB (Name and s) Relation) 2. Details To send details in the above format to BIASL to work out actual premium for GPA. ( for Mediclaim premium, Units will work out premium based on premium chart refer to Point no 2 of Annexure B) To interact with BIASL for any assistance. After submission of initial details, all additions / deletion will be informed to Insurance Company in a same format (Sr. no. 1 above ) by 10 Th of succeeding month with a copy to TPA 3. To nominate person to coordinated with BIASL / TPA / Insurance Co./ Employees 4. To inform BIASL about: a) Details of Existing cover, if any b) Date of expiry of Policy, c) Existing Insurer If the Unit / Business already has an existing policy, then they will migrate to the above scheme on date of expiry of such policy.

11 A list of hospitals for the purposes of hospitalization as covered by the TPA is being sent separately. Units should inform BIASL about any additional Hospitals that they would like to add to the above by providing the following details : Name of Hospital, Address, Telephone No., and facilities available for inclusion in list of Hospitals for Cashless facility. BIASL: 1. BIASL will work out premium distribution Unit wise and will inform to respective Units in case of GPA (for Mediclaim Units will work out premium based on premium chart please refer to Point no 2 of Annexure B) 2. Respective Units will send the List of employees in a format as explained hereinabove alongwith premium cheque to BIASL for onward submission to Insurance Co, to initiate the cover. Thereafter for every addition / deletion Unit will send premium to Insurance Company directly. BIASL will provide the necessary contact details to facilitate the above 3. BIASL will inform TPA about Name and address of contact person at Unit to receive cards for distribution to concerned employees, 4. BIASL along with the TPA will lay down procedure for: - a) Intimation of claim b) Submission of documents c) Follow ups / replying to queries d) Settlement of claim / disbursement of claim proceeds. 5. tatus of pending claims will be informed by TPA / Insurance Co. to the respective Units on Monthly basis. 6. ontact Points within BIASL : For any clarifications with BIASL, please contact the following: Name Contact Numbers Surendra Mehta rendra@adityabirla.com Anand Panchariya andpanchariya@adityabirla.com Vishakha M vishakham@dityabirla.com Note : Membership Cards will be issued by TPA and will be sent to Unit directly.for any addition /deletions TPA will issue / cancel cards as per the advise received from the Insurance company and same will be sent to UNIT directly.

12 To summarize, the process to be followed by the Business / Unit for coverage is as follows: The Business / Unit to decide the date of coverage for all Management Cadre employees under these schemes (If there is no existing policy then this will be with immediate effect, else on expiry of existing policy. Units with Hospitals to do a cost benefit analysis before deciding on coverage for the same.) HR at the Business / Unit level to compile details of employees and dependents and compute the premium payable as detailed in Annexure B and C above. HR to seek clarifications from BIASL if necessary on the above. HR to propose one single contact point for this process from the Business / Unit and then forward these details along with the cheque for the premium to BIASL BIASL to verify all details and forward the same to the Insurance Company (NIA) NIA to forward all details to TPA (Paramount) for administration of the above policy TPA to send the complete kit to the contact point at each location for distribution to each employee. This would include the member ID Card for employees and dependents covered in the family, list of hospitals covered for cashless medical facility, the process to be followed in case of hospitalization, contact details of TPA along with toll-free contact line and Frequently Asked Questions (FAQ s) HR to continuously update details of new joinees, resignations etc, with the Insurance Company and TPA on a monthly basis. HR to also provide details on additional hospitals that need to be added, on an ongoing basis to the Insurance Company and the TPA as and when required.