india_insurance policy- apr' 14.pdf

Group Insurance Policy


Policy No. Version : HR/2014-15

Policy Effective : As per the currently applicable policy period

Approved by : HR Director / Finance Director

Prepared by : HR Manager

Preamble:

As part of the Hospitalization Insurance benefit, all employees and their named dependents (Spouse and 2 children) are eligible for Medical Insurance cover. The Group Personal Accident Program covers employees against the financial risk of death / injury sustained due to an accident caused by violent, visible and external means. The Group Term Life Insurance covers employees and ensures to reimburse sum Insured to the nominee of the deceased in case of natural or accidental death. The major features/benefits under the three policies for employees and their covered dependents are outlined here.

Applicability

This policy is applicable to all permanent employees on the rolls of Baxter (India) Pvt.

Ltd and any other Baxter managed operation(s) in India (i.e. Commercial,

Manufacturing, Regional, Integrated Delivery Center (IDC), Global Process Center(GPC)

etc.)

Duration of the policy

The Hospitalization and Personal accident policy will be effective for one year from the date of inception of policy. The current policy is with Bharti Axa General Insurance Co Ltd. is valid from 1st April 2014 to 31st March 2015. The Group term Life Insurance policy is with Future Generali India Life Insurance Co Ltd. and is valid from 1st Nov 13 to 30th Oct 14.

Group Medical (Mediclaim) Policy

The Group Medical policy covers expenses incurred by the insured person on account of

hospitalization due to sickness or an accident. The policy covers expenses incurred on


Room rent, medicines, surgery etc. Expenses for hospitalization

Payable only if a 24 hour hospitalization has been taken (Except for named day care procedures, which do not require a 24 hour hospitalization).

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.

Definitions

Third Party Administrator (TPA) is an agency appointed by the insurance company to

take care of claim settlements in health insurance. Medi Assist India TPA Pvt Ltd is the TPA for Baxter India.

Floater policyis a single policy that takes care of the hospitalization expenses of ones

entire family, declared at the time of taking the policy. Any member of the family or all put together can claim up to the maximum sum insured.

Sum Insured is the maximum amount that can be claimed under the policy. This is the limit for the policy period.

Enrollment procedure

The employee must enroll in order to obtain coverage for himself and his eligible dependents. Please contact HR and provide relevant enrollment data (viz. name, date of birth, gender). The enrollment data must reach the Insurer within 21 days of joining the company.

HR must be notified each time the employee acquires a new dependent i.e. when his/her family status changes because of marriage, birth or adoption of a child. The addition of a new spouse must be declared within 21 days of the marriage. Similarly, information about new-born child has to be declared immediately after the first discharge after the child-birth.

If an employee fails to enroll within the defined timelines, the next enrollment can be done only at next renewal.


Policy Benefits

All Employees including New Joiners Covered from Day 1:

Family Floater Sum Insured as per Entitlement: The Family Floater Sum Insured can be utilized by any member in the family unit, making the sum Insured common one for entire policy.

Family Members Eligible for coverage: Employee, Spouse and first 2 Living Dependent children upto 25 years of age.

Mid Term Additions: Midterm inclusion of dependent will be possible only in case of: a) spouse (on account of marriage during the policy term)b) children (childbirth during the policy term provided declared within 30 days of the event.

Pre and Post hospitalization for 30 & 60 days respectively: For a period upto 30 days prior to hospitalization and upto 60 days post hospitalization, relevant medical expenses incurred will be considered as part of the claim and therefore settled.

Pre Existing Disease Cover: Members are covered for any ailment that they may be having even on the date of joining the policy.

Maternity Benefit: INR 35,000/- for Normal Delivery and INR 50,000/- for Caesarean. Maternity Claims are covered from Day 1.

Baby Cover: Baby is covered from the date of birth within the Family Floater Sum Insured (in case of complications) subject to information being sent to HR within 30 days of birth.

Ambulance Charges: Covered upto INR 1,000 per event.

Room Rental Capping: Room Rent is restricted to 1.5% of Sum Insured in case of Normal Room and 3% of the Sum Insured in case of an ICU. The exceeded


amount has to be borne by the employee in the same proportion as in the Final Hospital Bill.

Claim must be filed with Medi Assist TPA within 25 days from the date of discharge from the Hospital / completion of treatment. However, the Company may at its absolute discretion consider waiver, of this Condition in extreme cases of hardship where it is proved to the satisfaction of the Company that under the circumstances in which the insured was placed it was not possible for him or any other person to give such notice or file claim within the prescribed time-limit.

Reimbursement Claim to be intimated to the TPA within 24 Hours of admission. Details can be shared on mail with the TPA SPOC.

The above Coverage is subject to the overall policy conditions and exclusions.

Policy Exclusions

The following are deducted / Not Paid under a standard Health insurance policy:

1. Administration charges,Admission / Registration fees, File / Records Management charges

2. Service / Surcharges. Bed booking / Reserving charges 3. Patients Attendant charges, Special Nurse / Attendant charges, FIR / MLC

charges 4. Telephone / Photocopy / Courier / Insurance Processing Fees, etc. 5. Others (non-insurance, items not related to treatment) 6. Lasik treatment is not covered. 7. Infertility and Male Sterility are not covered. 8. Septoplasty is Excluded from the scope of the policy. 9. Treatment on trial/experimental basis are not covered under the scope of the

policy. 10. Voluntary medical termination of pregnancy during the first 12 weeks from the

date of conception is not covered. 11. Expenses related to a device contributing/replacing function of an organ and

expenses on prosthesis are excluded. *For complete information refer policy wordings/Benefits PPT uploaded on the link www.askbaxhr.in. Diseases Where 24 Hours Hospitalization Is Not Required:

Dialysis, Chemotherapy, Radiotherapy, Eye Surgery ( Cataract), Dental Surgery, ( arising out of an Accident), Lithotripsy (Kidney stone removal), Tonsillectomy ,D & C taken in the Hospital/Nursing Home. Etc.


Capping/ Co-Payments in Certain Diseases:

Cyberknife treatment / Stem Cell Transplantation:- 50% Co Pay shall be applicable as per Entitlement.

Claims Procedure

a. Cashless Process

Dos and Donts for Cashless Facility:

1. Kindly ensure that the Pre-Authorisation form is completely filled and signed by the Insured and the Treating Doctor.

2. Kindly ensure to mention the mobile number on the Pre-Authorisation form 3. In case of planned hospitalisation, please send the Pre-Authorisation form in

advance (not before 15 days of admission date) to Medi Assist TPA. 4. In case of emergency hospitalisation, please send the Pre-Authorisation form

within 24 hours from the time of hospitalisation


5. Non-payable items to be borne by the Insured 6. In case of cashless denial, Insured to pay hospitalisation expenses. 7. Do not refer the network list of any other service provider. Medi Assists Hospital

List is available on the Intranet. 8. Do not wait until the discharge time to raise the enhancement request.

b. Reimbursement Process

Reimbursement of the hospitalization expenses can be claimed where Cashless

Hospitalization facility is not availed or treatment is availed in a Non-network Hospital.

The employee will have to settle the hospital bill, collect all original hospitalization

documents and submit the documents to our office for their scrutinizing the same in

terms of the policy and check the admissibility or otherwise of the claim/expenses.

Reimbursement claims may be filed in the following circumstances:

a. Hospitalization at a non-network hospital

b. Post-hospitalization and pre-hospitalization expenses

c. Denial of preauthorization on application for cashless facility at a network hospital

One of the very basic requirements of insurance is Claim Intimation. It simply means

intimating us or the Insurance Company / TPA about the hospitalization. The same

needs to be done within a time frame of 24 hours from the date of admission.


The documents that employee needs to submit for a hospitalization reimbursement

claim:

1. Duly filled Claim form (signed by the Insured and the Treating Doctor) 2. Discharge summary (with details of complaints and the treatment availed) 3. Final Hospital Bill (detailed break-up) along with interim bills 4. Payment Receipts. 5. Doctors consultation papers 6. All investigation reports (E.g. Original Blood report, X-ray, Sonography, CT Scan,

MRI, etc.) 7. All pharmacy bills supported by doctor prescriptions 8. Implant sticker / invoice, if used (E.g. lens details in cataract case, stent details in

angioplasty) 9. Medico Legal Certificate (MLC) and / or FIR for all accident cases 10. For miscellaneous charges - detailed bills with supporting prescription of the

Treating Doctor 11. Photocopy of MAID Health card 12. Cancelled cheque of the Employee for NEFT Transfer of Funds.

All documents should be in Original. * This is not an exhaustive list; any other document could be required post assessment of the case.

Dos and Donts for Availing Reimbursements:

1. Always keep a photocopy of the claim documents submitted to Medi Assist TPA. 2. Kindly ensure that the Claim form is completely filled and signed by the Insured

and the Treating Doctor. 3. Kindly ensure to mention the mobile number on the Claim form. 4. Mention correct and complete communication address with the pin code on the

claim form. 5. All claim documents are to be submitted in original within 25 days from the date

of discharge.


Group Personal Accident Policy

The Group Personal Accident Program covers employees against the financial risk of death / injury sustained due to an accident caused by violent, visible and external means. Definitions

"Accident" means a sudden, unforeseen and unexpected physical event beyond the control of the Insured/Insured Person resulting in bodily injury, caused by external, visible and violent means. "Bodily Injury" means any accidental physical bodily harm solely and directly caused by external, violent and visible means which is verified and certified by a Physician but does not include any sickness or disease. Accidental Death is death due to an accident. Temporary Total Disability (TTD) is if an employee is temporarily disabled and cannot

engage in any employment or occupation. Permanent Partial Disability is if an employee is partially disabled wherein the result

is irrecoverable loss of use or actual loss by physical separation of body part. Permanent Total disability is if an employee is permanently and totally disabled wherein the employee cannot engage in employment or occupation.

Sum Insured is the maximum amount that can be claimed under the policy. This is the limit for the policy period.

Policy Benefits

Accidental Death is covered upto 100% of Capital Sum Insured (CSI).

Permanent Total Disablement (PTD) is covered upto 150% of Capital Sum Insured (CSI) Permanent Partial Disablement (PPD) is covered % of CSI (As per the chart)


Temporary Total disability (TTD) : Temporary Total Disability is restricted to 1% of the sum insured or actual wages or Rs 10,000/-, whichever is less, per week, for 100 weeks Medical Reimbursement is covered for INR 15,000 or actual whichever is less, under the basic cover (Death +PTD+PPD+TTD) Expenses for Carriage of Mortal Remains incurred for transportation of Insured persons dead body (death due to accident) from the place of accident to the place of

residence subject to lesser of 2% of Sum Insured or INR 5,000. Funeral Expenses - 1% of Sum Insured or Rs. 5000 or actual expenses, whichever is less Educational Grant - In case of Death or PTD of the insured, for one dependent child below 23 years of age, Rs. 10000 and in case of two dependent children below the age of 23 years, Rs. 20000. Terrorism is covered; however terrorism activity arising out of Nuclear, Biological and/or Chemical means is excluded from the scope of this policy Policy Exclusions

Participation in actual or attempted felony, riot, civil commotion, crime misdemeanor Committing any breach of law of land with criminal intent. Death or disablement resulting from Pregnancy or childbirth Perils of the sea are excluded from the scope of the policy Professional sports team in respect of specific benefit for inability to perform Participation in any kind of motor sport contest, while engaged in aviation, or whilst

mounting or dismounting from or travelling in any aircraft for events like sky diving etc

Radioactivity, Nuclear risks, ionizing radiation


Claims Procedure

Documents to be provided

Documents for weekly Benefits Claims

Completed claim form Doctors Medical and Fitness Certificate Disability certificate from the doctor, if any Investigation /lab reports( X- ray etc) Original admission/discharge card, if hospitalized. Employers leave certificate & details of salary.

Documents for Death Claims

Completed claim form Death Certificate FIR Copy Police Inquest report, wherever applicable


Group Term Life Insurance

The Group Term Life Insurance covers employees and ensures to reimburse sum Insured to the nominee of the deceased in case of natural or accidental death. Definitions

"Natural Death" means death that occurs from natural causes, as disease or old age, rather than from violence or an accident. Accidental Death is death due to an accident.

Policy Benefits

Basic Death Benefit - 2 Times of Annual Base Salary. Pays the Sum Assured in case of a natural /accidental death to the Nominee.

Critical Illness Benefit Pays the Sum Assured in case an employee develops a critical illness like Heart Disease, Cancer, stroke etc. This is over and above the Basic Life Sum Insured. Same as Death Benefit subject to a maximum of INR 10 Lacs.

Terminal Illness BenefitProvides an accelerated benefit whereby a percentage of death benefit is paid in advance on diagnosis of a terminal disease. Same as Death Benefit subject to a maximum of INR 50 Lacs. (Terminal Illness is any condition from which an insured member is diagnosed to be suffering from a disease which in the opinion of two Registered Medical Practitioner specializing in the relevant field of medicine, is likely to lead to death of the life insured within six months from the date of such diagnosis. The insured member must no longer be receiving treatment other than that for symptomatic relief.

Claims Procedure


Documents to be provided

Documents to claim accidental death

Duly Filled Claim form by the Employer FIR copy Post mortem copy Death Certificate issued by Municipal Corporation

Documents to claim natural death

Duly Filled Claim form by the Employer Death Certificate issued by Municipal Corporation

Interpretation & Clarifications

Any Interpretations/ clarifications to this policy will be issued by HR and Finance director.

Policy approved by:

Ongmu Gombu, Sandeep Devgon HR Director Finance Director Date Date

Policy checked by:

Priyank Parakh National HR Manager Date

Policy Prepared by:

Vaishali Srivastava, HR Manager

Date


Annexure

Contact Points HR Baxter India Pvt Ltd

Ashima Raju Assistant Manager, HR Contact No: 0124-4500242

Email ID: [email protected]

Insurer Bharti Axa General Insurance Co Ltd

Shivalee Sharma Relationship Manager Contact Number: 9810507763 Email ID: [email protected] TPA Medi Assist India TPA Pvt Ltd

1. Rahul Kumar (SPOC For BAXTER Employees) Contact Number: 09310981166 Email ID:- [email protected]

2. Sarika Bhatia (SPOC For BAXTER Employees)

Contact Number: 08130591191 Email ID:- [email protected]

For Reimbursement claim:-

Intimation must be given within 24 hours from admission or prior to Date of Discharge at [email protected] To submit re-imbursement claims after discharge within 25 days, please send it to this address:- Kind Attention - Mr. RAHUL KUMAR Medi Assist India TPA P Ltd B-20, Sector-2, Near Noida Sector-15, Metro Station. Opp HCL Comnet, Noida U.P-201301 Ph# 0120 4628200/4628201 ; Fax # 0120-4628250


Please follow the below mentioned steps to download the insurance cards for you and your family:

LOGON TO WWW.MEDIASSISTINDIA.COM

In the homepage under the "LOGIN" tab click on "Corporate Employee "

User ID would be your "EMP-ID@BAXTER"

Password would be "BAXTER"

Please change the password after your first login. Once you enter you will be able to view the list of members covered.

Click on the link e cards where you can download & save it.

Claims status can also be viewed similarly. Please enter the username and password as mentioned below Username : Employee ID@baxter Password : baxter You can also login at www.mediassistindia.com anytime to access the following information:- a) Claim Forms b) Pre-authorization request note (for cashless hospitalization) c) Status of any pending claims submitted with the TPA d) Updated list of networked Hospitals which provides cashless treatment based on pre-

authorization.

india_insurance policy- apr' 14.pdf

Documents

policy effective

group medical policy

current policy

single policy

group insurance policy

personal accident policy

group medical mediclaim

applicable policy period