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Leadership, Knowledge, Solutions…Worldwide.
Employee Benefits Manual
Client JLL (India)
Document No JLL/2017/EBM
2
Prepared by
Marsh India Insurance Brokers Private Ltd.
21/3, DLF Square, DLF City, Phase - II, M-Block, Jacaranda Marg,
Gurgaon, Haryana, India 122002.
Copyright © 2010. All rights reserved. No part of this publication may be reproduced, stored in
the retrieval system, or be transmitted in any form or by any means, electronic or mechanical,
photocopying, recording or otherwise, without the prior written permission of MARSH.
Disclaimer:
This manual is intended to be general summary of the benefits provided by JLL & should be regarded as guide only.
While HR shall make every reasonable effort to ensure the accuracy and validity of the information provided here in
this document. HR accepts no liability or responsibility for any errors or omissions in the content or for any loss or
damages arising out of your reliance on information provided here. If there is a conflict in interpretation or benefit
applicability, then the terms & conditions of the policy will prevail.
3
Group Medical
Program Details
FAQs & Common Definitions
Provides insurance coverage to employees for expenses related to hospitalization due to illness, disease or injury
Frequently Asked Questions & Common Definitions
Group Personal Accident Provides insurance coverage against the risk of death / injury during the policy period sustained due to an accident caused by violent, visible and external means
4
5
Medical Benefit
General Exclusions
GMC Contact Details
Coverage Details (Employee)
Claims Process
Claims Document List
Prudent Utilization of Benefit
Cashless Process
Non-Cashless
Benefits Extensions – Definitions
6
Medical Benefit – Coverage Details For Employee Policy
Policy Parameter
Insurer The New India Assurance Company Limited
TPA MediAssist Insurance TPA Pvt. Ltd.
Policy Start Date 27th January’2017
Policy End Date 26th Januray’2018
Coverage Type Family Floater (1+3) Max 4. Employee, Spouse, Children and Parents.
Dependent Coverage Employee , Spouse, Children, Parents (Max 4)
Sum Insured Graded - 1.5 L- upto Sr. Manager, 2.5L for Above Sr. Manager, For IFM –UHG INR 2 Lacs and for IFM –N.T – INR 5 Lacs
Benefits / Extensions Coverage
Domiciliary Hospitalization Not Covered
Pre-Post Hospitalization Exp. 30 days and 60 days
Pre and Post Natal INR 2500 within maternity limit
Well Baby Expenses INR 2500 within maternity limit
Room Rent Capping Normal – INR 2000 and as per actuals for ICU.
Deductible and Copay Non Medical and 10% Copay for admissible claim amount
Benefits / Extensions Coverage
Standard Hospitalization • Yes
TPA services • Yes
Pre existing diseases • Yes
Waiver on 1st year exclusion • Yes
Waiver on 1st 30 days excl. • Yes
Maternity benefits • Normal – 30K and C-Sec
– 50K
Baby cover day 1 • Yes
Ambulance Services • As Per actuals
(Emergency only)
7
Medical Benefit – Dependant Coverage
*No Individual should be covered as dependent of more than one employee
Next
Maximum no of Members insured in a family 1 + 3 (Max 4)
Employee Yes
Spouse Yes
Children Yes
Parents Yes
Parents-in-Law Yes
Siblings No
Others No
Mid Term enrollment of existing Dependents Disallowed
Mid Term enrollment of New Joinees (New employees +their
Dependents) Allowed
Mid term enrollment of new dependents (Spouse/Children) Allowed
8
Medical Benefit – Policy Period
Existing Employees + Dependents
Commencement Date 27th January’2017
Termination Date 26th Januray’2018
New Joinees + Dependents
Commencement Date Date of joining
Termination Date 26th Januray’2018
New Dependents (due to Marriage / Birth)
Commencement Date Date of such event
Termination Date 26th Januray’2018
9 Employee Benefits Manual
Medical Benefit – Standard Coverage
A) The expenses are payable provided they are incurred in India and within the policy period. Expenses will be
reimbursed to the covered member depending on the level of cover that he/she is entitled to.
Covers expenses related to
B) Expenses on Hospitalisation for minimum period of 24 hours are admissible.
However this time limit will not apply for specific treatments i.e. Dialysis, Chemotherapy, Radiotherapy, Eye
surgery, Lithotripsy (kidney stone removal), Tonsillectomy, D & C taken in the Hospital/Nursing home and the
insured is discharged on the same day of the treatment will be considered to be taken under Hospitalisation
Benefit.
• Room and boarding- Normal –INR 2000 and as per actuals for ICU
•Doctors/Medical Practitioner fees
• Intensive Care Unit
• Nursing expenses
• Surgical fees, operating theatre, anesthesia and oxygen and their administration
• Drugs and medicines consumed on the premises
• Hospital miscellaneous services (such as laboratory, x-ray, diagnostic tests)
• Costs of prosthetic devices if implanted during a surgical procedure
• Radiotherapy and chemotherapy
10
Post-hospitalisation Expenses
Definition
• If the Insurer accepts a claim under Hospitalization and immediately following the
Insured Member’s discharge, further medical treatment directly related to the same
condition for which the Insured Member was Hospitalized is required, the Insurer will
reimburse the Insured member’s Post-hospitalisation Expenses for up to 60 day
period.
Covered • Yes
Duration • 60 Days
Pre & Post Hospitalization Expenses
Pre-hospitalisation Expenses
Definition
• If the Insured member is diagnosed with an Illness which results in his / her
Hospitalization and for which the Insurer accepts a claim, the Insurer will also
reimburse the Insured Member’s Pre-hospitalisation Expenses for up to 30 days prior
to his / her Hospitalization.
Covered • Yes
Duration • 30 Days
*Any One Illness: A claim is considered as a single illness if it has a continuous period of illness or results in a relapse within 45 days of the earlier treatment.
11 Employee Benefits Manual
Maternity Benefits
• These benefits are admissible in case of hospitalisation in India.
• Covers first two children only. Those who already have two or more living children will not be eligible for this benefit.
• Expenses incurred in connection with voluntary medical termination of pregnancy during the first 12 weeks from the date of
conception are not covered.
Benefit Details
Benefit Amount • INR 30,000 for Normal & C-section., INR 50,000
Restriction on no of children • Maximum of 2 children
9 Months waiting period • Waived off
Pre and Post Natal • INR 2500 within maternity limit
Well Baby Expenses •INR 2500 within maternity limit
12
Medical Benefit – Cashless Process
Cashless means the Administrator may authorize upon a Policyholder’s request for direct settlement of eligible
services and it’s according charges between a Network Hospital and the Administrator. In such case the
Administrator will directly settle all eligible amounts with the Network Hospital and the Insured Person may not
have to pay any deposits at the commencement of the treatment or bills after the end of treatment to the extent
as these services are covered under the Policy.
Hospitals in the network (please refer to the website for the updated list)
For Updated List visit to Mediassist link as below:
https://network.medibuddy.in/
You can find network hospitals list in bottom of the webpage.
Note : Patients seeking treatment under cashless hospitalization are eligible to make claims under pre and post hospitalization expenses. For all such
expenses the bills and other required documents needs to submitted separately as part of the claims reimbursement.
Emergency Hospitalization Planned Hospitalization
13
P
R
O
C
E
S
S
Emergency Hospitalization & Process
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.
Relatives of admitted member
should inform the call centre within
24 hours about the hospitalization &
Seek pre authorization. The
preauthorization letter would be
directly given to the hospital. In
case of denial member would be
informed directly
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 Mediassist
Member gets admitted in
the hospital in case of
emergency by showing his
ID Card
Member/Hospital applies
for pre-authorization to
Mediassist within 24 hrs of
admission
Mediassist verifies
applicability of the claim to
be registered and issue pre-
authorization
Pre-
authorization
given by
Mediassist
No
Member gets treated and
discharged after paying all
non medical expenses like
refreshments, etc.
Hospital sends complete set
of claims documents for
processing to Mediassist
Yes
Non cashless
Hospitalization
Process
14
Member intimates Mediassist of the
planned hospitalization in a
specified pre-authorization format
at-least 48 hours in advance
Claim
Registered by
Mediassist on
same day
Follow non cashless
process
No
Mediassist authorizes
cashless as per SLA for
planned hospitalization to
the hospital
Yes
Pre-Authorization
Completed
Pre – Authorization Form
Member produces 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
Mediassist
Claims Processing &
Settlement by
Mediassist & Insurer
Step 1 Pre-Authorization
All non-emergency hospitalization
instances must be pre-authorized
with Mediassist, as per the
procedure detailed below. This is
done to ensure that the best
healthcare possible, is obtained,
and the patient/employee is not
inconvenienced when taking
admission into a Network Hospital.
Step 2 Admission, Treatment &
discharge
After your hospitalization has been
pre-authorized, you need to secure
admission to a hospital. A letter of
credit will be issued by Mediassist
to the hospital. Kindly present your
ID card at the Hospital admission
desk. 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
Mediassist
Planned Hospitalization
15
Non-Cashless
Admission procedure
• In case you choose a non-network hospital you will have to liaise directly with the hospital for admission.
• However you are advised to follow the pre authorization procedure to ensure eligibility for reimbursement of
hospitalization expenses from the insurer.
Discharge procedure
• In case of non network hospital, you will be required to clear the bills and submit the claim to Mediassist for
reimbursement from the insurer. Please ensure that you collect all necessary documents such as – discharge
summary, investigation reports etc. for submitting your claim.
Submission of hospitalization claim
• You must submit the final claim with all relevant documents within 30 days from the date of discharge from
the hospital.
16
Non-Cashless Claims Process
Member intimates Mediassist
before or as soon as
hospitalization occurs
Insured admitted as per hospital
norms. All payments made by
member
Claim registered by Mediassist
after receipt of claim intimation
Insured Submits relevant
documents the Help desk
within 30 days of discharge
Is document
received
within 30 days
from
discharge
Claim Rejected
No
Mediassist performs medical
scrutiny of the documents
Is claim
payable?
Yes
Mediassist checks document
sufficiency
No
Yes
Is
documentatio
n complete
as required
Claims processing done as per
SLA
Receives mail about deficiency
and document requirement A
A
Payment to be Employee at the
help desk. The discharge
voucher and copy of payment
receipt to be sent to HR. Yes
No
•Insured will create the
summary of Bills (2 copies)
and attach it with the orignal
bills
•The envelope should
contain clearly the
Employee ID & Employee e-
17
Claims Document List
Completed Claim form with Signature
Hospital bills in original (with bill no; signed and stamped by the hospital) with all charges itemized and the original receipts
Discharge Report/Certificate/card (original)
Attending doctors’ bills and receipts and certificate regarding diagnosis (if separate from hospital bill)
Original reports or attested copies of Bills and Receipts for Medicines, Investigations along with Doctors prescription in Original and Laboratory
Follow-up advice or letter for line of treatment after discharge from hospital, from Doctor.
Provide Break up details including Pharmacy items, Materials, Investigations even though it is there in the main bill
In case the hospital is not registered, please get a letter on the Hospital letterhead mentioning the number of beds and availability of doctors and nurses round the clock.
In non- network hospital, you may have to get the hospital and doctor’s registration number in Hospital letterhead and get the same signed and stamped by the hospital, if required.
*Please retain photocopies of all documents submitted
Claims Form
18
Benefits For
Marsh Definition
Pre existing diseases
Covered Any Pre-Existing ailments such as diabetes, hypertension, etc or related ailments for which care, treatment or advice was recommended by or received from a Doctor or which was first manifested prior to the commencement date of the Insured Person’s first Health Insurance policy with the Insurer
First 30 day waiting period
Waived Off
Any Illness diagnosed or diagnosable within 30 days of the effective date of the Policy Period if this is the first Health Policy taken by the Policyholder with the Insurer. If the Policyholder renews the Health Policy with the Insurer and increases the Limit of Indemnity, then this exclusion shall apply in relation to the amount by which the Limit of Indemnity has been increased
First Year Waiting period
Waived Off During the first year of the operation of the policy the expenses on treatment of diseases such as Cataract, Benign Prostatic Hypertrophy, Hysterectomy for Menorrhagia or Fibromyoma, Hernia, Hydrocele, Congenital Internal Diseases, Fistula in anus, Piles, Sinusitis and related disorders are not payable. If these diseases are pre- existing at the time of proposal they will not be covered even during subsequent period or renewal too
Benefit Extensions – Definitions
X
X
√
19
Medical Benefit – General Exclusions
• Injury or disease directly or indirectly caused by or arising from or attributable to War or War-like situations
• Circumcision unless necessary for treatment of disease
• Congenital external diseases or defects/anomalies
• HIV and AIDS
• Hospitalisation for convalescence, general debility, intentional self-injury, use of intoxicating drugs/ alcohol.
• Venereal diseases
• Injury or disease caused directly or indirectly by nuclear weapons
• Naturopathy
• Any non-medical expenses like registration fees, admission fees, charges for medical records, cafeteria charges, telephone
charges, etc
• Cost of spectacles, contact lenses, hearing aids
• Any cosmetic or plastic surgery except for correction of injury
• Hospitalisation for diagnostic tests only
• Vitamins and tonics unless used for treatment of injury or disease
• Infertility treatment
• Voluntary termination of pregnancy during first 12 weeks (MTP)
• OPD Claims
• Claims (of high value) submitted without prescriptions/diagnosis
• Health foods
• Costs incurred as a part of membership/subscription to a clinic or health centre
• Naturopathy
• Cost of appliances, spectacles, contact lenses, hearing aids
• Non-medical expenses like Hospital surcharge, telephone bills, cafeteria bills
20
Extra Dependent Policy
WHAT THIS POLICY COVERS
This would cover the dependents of an employee who are not included in the Main policy (i.e. 1+3)
ADVANTAGES
the premium as compared to last year has been reduced by 10%.
Nomination for Extra Dependent policy is done once a year and not in between policy period, except for new joiners
The coverage is identical to the main medical policy terms and conditions
Employee will get S.I value as per the employee designation(refer to below table)
The extra dependent coverage will discontinue once the employee resigns
Extra dependents would include only parents, spouse and upto two kids
In laws and siblings are not covered
Maternity claims are not allowed as part of this policy
Employee gets a tax benefit on the premium paid towards the policy
Levels Sum Insured Premium per life (Inclusive of Taxes)
Up-to Senior Managers 100000 5015
Associate Director & above 150000 5712
21
Top Up Medical Plan
WHY EVALUATE A TOP UP MEDICAL PLAN
Healthcare costs are rapidly rising with medical inflation being in the range of 15% to 20%. In such a situation, an employee may feel that his or her insured amount in the group health insurance is inadequate. Top up provides an additional coverage to employees over and above the company sponsored limit.
The premium rates are lower as compared to employee purchasing an additional retail insurance policy
The premium as compared to last year top up policy has been reduced by 9-10%
ADVANTAGES
Coverage is identical to main medical policy
Employee can choose the said sum insured as per his/her needs
The main medical plan and the top up plan can be claimed together for the same hospitalization.
Employee gets a tax benefit on the premium paid towards the top up plan.
22
Enrollment Period for New Joinees for Voluntary Program
The new joinees can declare their dependents for the voluntary program with 15 days from their date of joining.
Post the declaration window closes, no request for enrollment shall be entertained.
23
Top Up Medical Plan
OPERATIONAL ASPECTS
The sum insured is INR 1Lac, 2 Lacs, 3 Lac, 4 Lac, 5 Lac and 10 Lac
The top up plan is placed with the same insurer and TPA who underwrites the Group Medical Policy for operational efficiency
Nomination for top up policy is done once a year & not in between the policy period except for the new joinees
When the main medical plan sum insured is exhausted, only then the top up plan pays for the claim (amount over and above it).
The top up sum insured could be utilized for ailments, except for Maternity
Additional Sum Insured Premium (Inclusive of Taxes)
INR 1,00,000 6875
INR 2,00,000 8938
INR 3,00,000 12833
INR 4,00,000 16821
INR 5,00,000 19938
INR 10,00,000 40975
24
Prudent Utilization of Benefit
Health Insurance is a benefit for the employee and their dependents. One has to utilize the benefit with utmost caution and prudence.
The ever increasing cost for the benefits require a proactive involvement from all of us.
The following steps are recommended, ensuring the benefits is prudently utilized by the employee and dependents
Please ensure to crosscheck the final bill sent to the TPA for the following:
You are Billed only for the services utilized for e.g. category of room, diagnostics undergone ,
medicines consumed
Total of the bill
In case of any planned hospitalization, approach the hospital in advance(48 hrs) and request pre
authorization- this enables TPA to further negotiate the rates
To approach hospitals with caution – most expensive is not necessarily the best.
To cross check the tariff with the Bench Mark Rates provided- the benchmark rates would give an idea
the general spend for the treatment or procedure.
Try to negotiate
Ask WHY & WHAT is billed to you ( as a consumer , we have the right to know)
25
Medical Benefit – Contact Details
Provider List
Primary Contact - Endorsements Escalation Point - Endorsements and Claims
Insurer
The New India Assurance Co Ltd
Mukta Kansal (Relationship Manager)
Mob: 9871717872
Email: [email protected]
Rita Bawa (Sr. Divisional Manager)
Mob: 9911656060
Email: [email protected]
26
Escalation Matrix
Medi Assist India TPA Pvt. Ltd.
Tower D, 4th Floor, IBC Knowledge Park, 4/1
Bannerghatta Road, Bangalore – 560029
JLL Toll Free No : 1800 208 1038.
Level- 1
Mr. Chandra Shekhar - JLL HD
Mob: 7022034727
Email id – [email protected]
Escalation Matrix for TPA
27
Marsh India Insurance Brokers Pvt. Ltd.
Registered office at 1201-02, Tower 2,
One Indiabulls Centre, Jupiter Mills Compound,
Senapati Bapat Marg, Elphinstone Road (W), Mumbai 400 013 .
ESCALATION 1
Vikas Chauhan
Email id: [email protected]
Mob: 9643315133
ESCALATION 2
Sapna Bedi
Email id: [email protected]
Contact Details – Marsh India Insurance Broker
28
29
Group Personal Accident Policy
Policy Details
Benefit extension
Claims Procedure
General Exclusions
Contact Details
Document Check List
30
GPA – Benefit Details
All employees will be provided with a Personal Accident insurance policy through- New India Assurance Co. Ltd, based on company rules (you may contact your HR for further details). This insurance provides compensation/payment up to a financial limit as assigned by the company, to the insured person or his legal personal representative, if the insured person suffers death or disablement due to an accident. The cover is worldwide but payment of claim can only be made in India and in Indian Rupees.
Policy Parameter
Insurer Religare Health Insurance Company Ltd
Policy Start Date 27-Jan-2017
Policy End Date 26-Jan-2018
Coverage For Employees Only
Sum Insured Graded – Executive and Sr. Executive – INR 3 Lac, Asst Manager and
Manager – INR 5 Lac, Sr. Manager and Associate Director – INR 15 Lac,
Local Director and above – INR 30 Lac
Accidental Death Yes
Permanent Total Disability Yes
Permanent Partial Disability Yes
Temporary Total Disability Yes, upto 104 weeks. 1% of Sum Insured subject to maximum of INR 5K
per week, which ever is lower
Medical Extension 10% of SI or 40% of admissible claim or actuals, whichever is less
Terrorism Yes
Geographical Limit world wide
MARSH
Benefit Extensions
This policy covers the following benefits-
• Permanent Total Disability (PTD)
• Permanent Partial Disability (PPD)
• Temporary Total Disability (TTD)- up to 104 weeks. 1% of Sum Insured subject to
maximum of INR 5K per week, which ever is lower
• Medical Extension-10% of SI or 40% of admissible claim or actuals, whichever is
less
• Coverage operates world wide on 24 hours basis.
• Terrorism cover.
• Education benefit @ 10% of SI or INR 100,000 which ever is lower
• Repatriation of remains & cremation charges INR 5000
• Coverage for adventure sports
32
GPA – Claims Process
Claimant / Nominee notifies HR, who in turn would intimate Insurer and submit
required claim documents within 30 Days of the event
On obtaining all relevant documents, Insurance Co. will begin processing
the claims
Claim Investigation and Review of submission of all the required
documents
Is claim payable?
Cheque is sent to Employer (HR), from where it is given to the Claimant/ Assignee
Insurer provides a valid reason for the rejection to HR (death) no death
(Claimant)
No
Yes
33 Employee Benefits Manual 33 14 February 2017
Group Personal Accident – Claims Document Checklist
GPA Claim Form
Weekly Benefit Claims
1. Completed Claim form
2. Doctor's Report
3. Disability Certificate from the
Doctor, if any
4. Investigation/ Lab reports (x-ray
etc.)
5. Original Admission/discharge
card, if hospitalized
6. Employers Leave Certificate &
Details of salary
Death Claims
1. Completed claim form
2. Attending Doctor's report
3. Death Certificate
4. Post Mortem/ Coroner's report
5. FIR ( First Information Report)
6. Police Inquest report, wherever
applicable
Dismemberment/ Disablement
Claims 1. Completed claim form
2. Doctor's Report
3. Disability Certificate from the
Doctor
4. Investigation/ Lab reports (x-ray
etc.)
5. Original Admission/ discharge
card, if hospitalized.
6. Police Inquest report, wherever
applicable
34 Employee Benefits Manual
GPA – General Exclusions
1. Service on duty with any armed force
2. Insanity
3. Venereal disease
4. AIDS
5. Influence of intoxicating drink or drugs
6. Aviation other than as a passenger (fare paying or otherwise) in any duly licensed standard type of
aircraft any where in the world
7. Nuclear radiation or nuclear weapons material
8. Any consequence of war, invasion, act of foreign enemy, hostilities (whether war be declared or
not), civil war, rebellion, revolution, insurrection, mutiny, military, or usurped power, seizure,
capture, arrest, restraint, detainment’s of all kings, princes, and people of whatever nation,
conditions and qualities so ever
9. Childbirth, pregnancy or other physical causes peculiar to the female sex
10. While committing any breach of law with criminal intent
35
FAQ’s & Common Definitions
Documents and links
FAQ’s
Definitions
IRDA (Insurance Regulatory and Development Authority)
http://www.irdaindia.org/
36
Thank You!