aesm employee benefit program

AESM EMPLOYEE BENEFIT PROGRAM

AESM EMPLOYEE BENEFIT PROGRAM

Brief about the Program

Anglo Eastern Ship Management India Pvt. Ltd. offers many facilities and benefit programs to seafarers sailing with them. This is one among such benefit Programs through which the seafarers along with their family members are insured where by the expenses incurred on hospitalization by the seafarers and their family members are reimbursed.

To ensure that the benefits program runs successfully, Anglo Eastern Ship Management India Pvt. Ltd has appointed Aum Insurance Brokers Pvt. Ltd. to oversee the successful execution of the benefit program with United India Insurance Co. Ltd and Health India TPA Services Pvt. Ltd.United India Insurance Co. Ltd. is the insurer and the Health India TPA Services Pvt. Ltd. is health claim settlement agency.

There are two policies specifically taken for seafarers by Anglo Eastern Ship Management India Pvt. Ltd. These policies are

1. Group Health Insurance Policy

Under this policy, seafarers along with their family members are insured and any one of them or all can take advantage of the insurance policy. The policy reimburses the cost of hospitalization.

2. Group Personal Accident Policy

Under this Policy, the seafarers are insured against the risk of death.The detailed note on these policies is provided below.Benefit ProgramThe Anglo Eastern Ship Management India Private Ltds Employee Benefit Program is designed in partnership with Aum Insurance Brokers Pvt. Ltd. This program has been created to better serve and, most importantly, meet the needs of the Officers and their families.

The Employee Benefit Program comprises two Insurance coverage schemes for the Anglo Eastern Officers and their families:Group Floater Mediclaim Policy: The Policy provides coverage to Self, Spouse and first two children and can be availed by any one or any number of members in the family that are covered in the policy. The Officers family is covered for a fixed Sum Insured and anyone in the family can avail the facility till the limit is exhausted.Group Personal Accident Policy: The Policy covers only the officer. Group Personal Accident policy offers compensation in case of death to the Insured persons nominee, directly and solely as a result of an accident.

Policy DETAILS

ITEMGROUP FLOATER MEDICLAIM POLICYGROUP PERSONAL ACCIDENT POLICY

Policy NameGroup Floater Mediclaim Policy (GFMP)Group Personal Accident Policy (GPA)

InsurerUnited India Insurance Company Ltd.United India Insurance Company Ltd.

Sum InsuredINR. 2 LakhsINR. 20 Lakhs

Who is coveredSelf, Spouse and first two childrenOfficer only

Policy Number120700/48/11/41/00000228120700/42/11/05/00000080

Policy Period14th June 2011 to 13 June 201214th June 2011 to 13 June 2012

Third Party AdministratorHealth India TPA ServicesNA

The key components of the Group Floater Mediclaim Policy Sum Insured of INR. 2,00,000 for self, Spouse and first Two children Family floater for self, spouse and first two children

New born child covered after the 3rd month

What is covered?

First year Standard Exclusions are covered Pre-existing diseases are covered 30 days waiting period (Claims arising from the first day of the inception of policy will get paid)

Eye and Teeth treatment resulting ONLY out of an Accident are covered

What is NOT Covered?

Maternity

Availability of the Third Party Administrator (TPA) facility for Claim settlement

Availability of Cashless and Reimbursement facilities

Room Charges: As per the policy the Hospital Room Charge should not exceed 1% of the Sum Insured (Rs.2 Lakhs), i.e. Rs 2000 per day. Additional Room charges over Rs.2000 per day and associated charges thereof are payable by the Claimant (Insured)

Pre-Hospitalization (30 days before Hospitalization): Doctor consultation fees, medical reports and related medication issued 30 days prior to hospitalization can be Reimbursed subject to production of the relevant documents/papers

Post-Hospitalization (60 days after Hospitalization): Doctor consultation fees, medical reports and related medication issued 60 days after hospitalization can be Reimbursed subject production of relevant documents/paperspermanent EXCLUSIONS: What is not covered4.4.1 War, Invasion, Act of foreign enemy, War like operations, Nuclear weapons, lionizing Radiation, contamination by Radioactive material nuclear fuel or nuclear waste.

4.4.2 Circumcision, cosmetic or aesthetic treatment, plastic surgery unless required to treat any injury or illness.

4.4.3 Vaccination & Inoculation.

4.4.4 Cost of braces, equipment or external prosthetic devices, non-durable implants, eyeglasses, Cost of spectacles and contact lenses, hearing aids including cochlear implant and durable medical equipment.

4.4.5 All types of Dental treatment except arising out of an accident.

4.4.6 Convalescence, general debility, Run-down condition or rest cure, obesity treatment and its complications, congenital external disease/defects or anomalies, treatment relating to all psychiatric and psychosomatic disorders, infertility, sterility, use of intoxicating drugs/alcohol, use arising of tobacco leading to cancer.

4.4.7 Bodily injury or sickness due to willful or deliberate exposure to danger (except in an attempt to save a human life), intentional self-inflicted injury, attempted suicide and arising out of non-adherence to any medical advice.

4.4.8 Treatment of any bodily injury sustained whilst or as result of active participation in hazardous sports of any kind.

4.4.9 Treatment of any Bodily injury sustained whilst or as a result of participation in any criminal act.

4.4.10 Sexually transmitted diseases, any condition directly or indirectly caused due to or associated with Human Lymphotropic Virus Type III (HTLB-III) or Lymphotropathy Associated Virus (LAV) or the Mutants Derivative or Variation Deficiency Syndrome or any syndrome or condition of a similar kind commonly referred to as AIDS.

4.4.11 Diagnostic, X-Ray or Laboratory examination not consistent with or incidental to the diagnosis of positive existence and treatment of any ailment, sickness or injury, for which confinement is required at a Hospital/Nursing Home.

4.4.12 Vitamins and tonics unless forming part of treatment for injury or disease as certified by the attending physician.

4.4.13 Treatment arising from or traceable to pregnancy, childbirth, miscarriage, abortion or complication of any of these including caesarean section, except abdominal operation for extra uterine pregnancy (Entopic Pregnancy), which is proved by submission of Ultra Sonographic Report and Certification by Gynecologist that it is life threatening one if left untreated

4.4.14 Any Naturopathy Treatment.

4.4.15 Instrument used in treatment of Sleep Apnea Syndrome (C.P.A.P.) and Continuous Peritoneal Ambulatory Dialysis (C.P.A.P.) and Oxygen Concentrator for Bronchial Asthmatic condition.

4.4.16 Genetic disorders and stem cell implantation / surgery.

4.4.17 Any Domiciliary Hospitalization/Treatment.

4.4.18 Treatment taken outside India.

4.4.19 Experimental Treatment and Unproven treatment (not recognized by India Medical Council).

4.4.20 Change of treatment from one system of medicine to another unless recommended by the Consultant/Hospital under whom the treatment is taken.

4.4.21 All non-medical expenses including convenience items for personal comfort such as telephone, television Ayah, Private Nursing/Barber or beauty services, diet charges, baby food, cosmetics, tissue paper, diapers, sanitary pads, toiletry items and similar incidental expenses.

4.4.22 Services charges or any other charges levied by hospital, except registration/admission charges.

MEDICLAIM MANAGEMENTTypes of Hospitalization and hospitals

TYPES OF HOSPITALIZATION

PLANNEDIndividual is aware of hospitalization 72 hours in advance EMERGENCYIndividual meets with an accident/suffers from about of illness that requires immediate hospital admission

TYPES OF HOSPITALS

TPA NETWORKHospitals which the TPA has partnered with (more than 3000 hospitals covered) and Cashless Service can be availed. NON NETWORKNot included in the TPA network of hospitals and Reimbursement service can be availed

Types of Claims

REIMBURSEMENT CASHLESS

The hospital is not under the TPAs network hospitals or at his/her own liberty the individual chooses a non-network hospital, orThe insured need not pay money at the time of admission or discharge

Cashless is DeniedAvailed only at TPA Nework Hospitals

Bill is settled after hospitalization and subsequently makes a claimPayment is subject to deductibles and Sum Insured as specified in the policy

Claim Intimation Requirements

A Claim Intimation E-mail should be sent to Aum Insurance Brokers Pvt. Ltd. ([email protected]) with the following information: Companys Name

Crew Name

Company Crew ID and Rank Name of the Patient, Age and Relationship

Nature or Illness/Accident Hospital Details, Doctors Name, Hospital Admission and Discharge date Personal Contact information (Address and Number) Commencement date of symptom of the disease in case of an illness

Accident Case : Date and time, location of accident, FIR Report.Claim Intimation Requirements

Given below are the requirements for your information, which are a must while submitting the claims (Reimbursement and Cashless facility) for a particular Ailment along with other essential Claim relevant documents:Cataract Surgery : 'A' Scan report & IOL Sticker (If lens above Rs. 10,000 then Purchase Invoicerequired)

Fractures: X-ray reports with Plates (Including Hip & Knee Replacement)Accidents: MLC / FIR / Self-declaration from patient/Family Angiography: Final Report with DiagramImplants in Bones/Hernia Mesh: If it is above Rs. 10,000 then Purchase Invoice required.

Ear Surgery: Audiometry reportPneumonia: X-ray Chest reportPre-existing Disease: Detailed History with durationof Ailments like Diabetes, Hypertension, Asthma, Fits/Epilepsy, Heart Diseases, Kidney Stones, Arthritis, TBParalysis: CT scan / MRI ReportReimbursement Reimbursement of the Claim can be availed, wherein: The hospital is not included in the TPAs network of hospitals, The individual chooses a non-network hospital as his/her liberty ,or

Cashless is DeniedIMPORTANT:

1. All the Original Claim documents, bills and reports from Hospitalization and 30 days Pre-hospitalization must be couriered to Aum Insurance Brokers Pvt. Ltd. Address :- C/8, Amul Commercial Premises Co. Op. Soc. Ltd., 2nd Floor, 1st Road, Opp. BMC Office, Chembur (E), Mumbai 400 071 immediately after the discharge of the patient, in any case within 7 days from the discharge of the patient.2. All bills accrued 60 days Post-hospitalization can be reimbursed within 90 days of hospitalization3. Maintain a personal Photocopy of all the Claim relevant documentReimbursement CLAIM PROCESS CLAIM INTIMATIONSend AUM a Claim Intimation via an e-mail ([email protected]) on knowledge of Hospitalization CLAIM INTIMATIONE-mail should contatin all the Claim Intimation Requirements & AUM will forward the claim to the TPA to check if Claimable or not

CLAIM LODGEOn receipt of claim intimation, AUM will lodge the claim & e-mail a list of Reimbursement Documents CLAIM SETTLEMENTDuring Hospital discharge, settle all the hospital bills & collect the Original documents, bills and reports

CLAIM SETTLEMENTReimbursement Documents must be completed and couriered to AUM within 7 days to effectuate the claim CLAIM SETTLEMENTIn case of incomplete document/ reports a Deficiency e-mail will be sent to individual to fulfill the requirement, until which the claim will be put on hold

CLAIM SETTLEMENTClaim will be processed and reimbursed by the TPA, Health India subject to terms, conditions, exclusions and limitations of the policy. CLAIM CHEQUEAUM sends the Claim cheque within 2 weeks to the claimants address after claim settlement.

Reimbursement CLAIM DOCUMENTS

The following Original Reimbursement Documents must be completed and couriered to Aum Insurance Brokers Pvt. Ltd within 7 days of discharge from the Hospital for claim settlement: Completed Claim form signed by the claimant. Hospital discharge card

Inpatient hospital bills signed by the insured to authenticate the amount

Payment receipt of hospital bills

The doctors consultation bills with consultation notes

Doctors prescriptions with the chemist bills

Investigation reports with their bills

Details of consumables and disposables used for medical and procedures (detailed break up)

Photocopy of indoor case papers/operative notes

Completed Annexure 'A' (to be filled, signed & sealed by the treating Doctor)

Complete contact details

Self declaration letter on behalf of the patientCashless

Cashless is a service wherein the insured is not required to pay any money at the time of admission or discharge from the hospital. Non-Medical expenses and expanses falling outside the scope of the policy are payable by the Insured, for which a Security Deposit is required by the Hospitals Intimate Aum Insurance Brokers Pvt. Ltd. about the need for Cashless within 24 hours of an emergency case and a minimum of 4 days prior to planned hospitalization

Cashless facility can be availed only at the TPA, Health Indias network hospitals

The TPA, Health Indias network hospitals can be accessed from Health Indias website www.healthcare-india.com The individual is required to sign the final bill at the time of discharge and the TPA will pay the hospital for the treatment undertaken by the insured Subject to the authorization being taken from the TPA, the bills will be settled directly with the hospital according to the terms and conditions under the policy Maintain a Photocopy of all Claim Documents, reports and bills

IMPORTANT : Always carry an ID Proof with the E-Card.

NOTE: Aum Insurance Brokers Pvt. Ltd. is a Coordinator between the Claimant and the TPA, on behalf of Anglo Eastern Ship Management India Pvt. LTD.Cashless procedure

CLAIM INTIMATION

Send Aum Brokers an intimation via an e-mail ([email protected]) on knowledge of hospitalizationCLAIM INTIMATIONE-mail should contain the claim intimation requirements & Aum Brokers forwards the claim to TPA to check if claimable or not.

PRE-AUTHORIZATION

Claimant approaches TPA Dept. of Network Hospital with a Heath India e-card and ID Proof to obtain a cashless request form or Pre-authorization form.

PRE-AUTHORIZATION

Aum Brokers informs the claimant if claimable or not and sends list of TPAs Network Hospital in claimants area.

PRE-AUTHORIZATION

Claimant completes the form with the help of treating Doctor and hands over the form along with mandatory investigation reports to the hospitals TPA dept.

PRE-AUTHORIZATION

The network Hospitals TPA dept. faxes/emails the cashless request form to Health India and claimant intimates Aum Brokers to co-ordinate with TPA

AUTHORIZATION

Health India issues and authorization letter to Hospitals TPA dept. with an initial payable amount and claimant is informed.

TPA VERIFICATION

Health India will scrutinize the request & in case of deficiency, requirements will be informed to the Hospital. The claimant must constantly co-ordinate with the Hospitals TPA Dept.

HOSPITAL DISCHARGE

On discharge from the hospital, claimant hands over the discharge report & final hospital bill to the Hospitals TPA dept.

FINAL CLAIM AMOUNT

Health India will sanction the final amount. Non-medical expenses to be paid by the claimant

Cashless Service DeNIAL

A request for Cashless authorization may be denied under the following circumstances:

1. Inadequate information is provided and the TPA is unable to get further access to information

2. In case of doubt in the coverage of the treatment of the present ailment under the policy

3. The disease/condition for which hospitalization is required is not covered by the insurance policy

4. The person does not have adequate insured amount left to cover the hospitalization costs

5. The request for authorization is not received by the TPA on time

IMPORTANT: Denial of Cashless Service should NOT be construed as a denial of treatment. In such a case the insured is advised to file the claim for reimbursement and the TPA will settle the claim subject to the policys terms and conditions

TPA, HEALTH INDIAS CONTACT FOR Cashless Service

Dr. Nitin Devkar: 022 4247 1904

Dr. Pravin Khurade: 022 42471904 Cashless/Call Centre Executive: 4247 1902/21/20.

HEALTH INDIA online: E-Card and claim status

The insured can access the E-Card or Claim Status with the following:

1. Log on to www.healthcare-india.com 2. Select category Employee3. Select Username crewID@AESM (Crew code varies for each member)4. Select Password AESM

5. Select Policy Number Enter current year policy number

6. Click on E-Card and Claim Info on the left hand side of the webpage. Here one can view the names of all his dependants.

7. Click on View block adjacent to that particular name.8. On clicking View, the page will display 2 Blue circles namely, E-Card & Claim.9. On clicking E-card, the E-card will Pop-up.

10. Then you can click on the PRINT option for printing the E-card.TPA HEALTH INDIAS NETWORK Hospitals

The TPA Health Indias hospitals in its network can be accessed with the following:

1. Log on to www.healthcare-india.com2. Select General Health Insurance

3. Select State and City

CONTACT INFORMATION

TPA Health India

Main contact - Dr. Vrushali Surve E-mail: [email protected] Contact Number: 022-42471967 Secondary contact Dr. Kamlesh Ghadge E-mail: kamleshghadge@ healthcare-india.com Contact Number: 022-42471908

Corporate Executive Ms. Durga Tripathi E-mail : corporate@ healthcare-india.com Contact Number: 022-42471923

Website www.healthcare-india.com Insured can check their online claim status and generate E-Cards

Address Anand Commercial Co. Compound, 103-B, L.B.S Marg, Gandhinagar, Vikhroli West, Mumbai 400 083

Fax: (022) 42471911

Aum Insurance Brokers Pvt. Ltd.

Main contact Mr. Rajesh Singh Dedicated E-mail:- [email protected] Dedicated Phone: +91 8655 437 589

Secondary Contact Mr. Abhijeet Samanta E-mail: - [email protected] Phone: + 91 22 2529 2552 Standby Contact Mr. Sushant Kadam

E-mail: - [email protected] Phone: + 91 22 2529 2552

Address: - C/8, Amul Commercial Premises Co. Op. Soc. Ltd., 2nd Floor, 1st Road, Opp. BMC Office, Chembur (E), Mumbai 400 071.

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