Quick Guide to 2013 -14 Insurance Benefits Healthy Bytes Page 1 Content Insurance Benefits @SEI Snapshot Enhancements Summarized Enrollment to Insurance Benefits Annexure Insurance Benefits @SEI - Detailed Medical Insurance Accident Insurance Life Insurance Critical Illness Insurance Enrollment to Insurance Benefits Availing Insurance Benefits Medical Insurance Accident Insurance Life Insurance Critical Illness Insurance Retiree Policy How to make most of your benefits? Click on the relevant section for direct navigation Insurance Benefits @SEI - Snapshot Page 3 What are the Insurance Benefits available to me in Schneider? The benefits are renewed with Insurer on annual basis Coverage period for 2013-2014: 1st J uly 2013 till 30th J une 2014 Fresh Enrollment / Validation of Enrollment, along with choice of Top-up Options needs to be made by all employees by 12 th J uly 2013 to avail the benefits Mid-term enrolment changes are not allowed except in case of Marriage or Child birth Schneider Electric offers four Insurance Benefits to employees ! Provides insurance coverage to employees against the risk of death / injury sustained due to an accident Provides life insurance protection to employees 1. Medical Insurance (along with Top-up Option) 2. Accident Insurance 3. Life Insurance (along with Top-up Option) 4. Critical Illness Provides financial support to employees in case of Critical Illness Provides insurance coverage to employees and their family for expenses related to hospitalization due to illness, disease or injury Page 4 Wellness Enhancements under Healthy Bytes - Summarized Medical Insurance Coverage increased from 4L 4.5L / family Enhancement continued from2012 Optionto include 3 rd child in base cover Top-upOptions to extend Hospitalization coverage by 4L or 6L Extension of benefit to Retiringemployees at better than Market discounts Extension of Insurance to HIV cases Accident Insurance Previous cover: J M: INR 15 Lac MM: INR 20 Lac SM: INR 45 Lac Grade 10 onwards 2*FC (enhanced in 2012) New Cover in 2013 2*Fixed Compensation for all, such that minimum of previous benefit applicable for Grade is retained Enhancement in 2013 Life Insurance Previous cover: J M: INR 5 Lac MM: INR 10 Lac SM: INR 15 Lac Grade 10 onwards 2*FC (enhanced in 2012) New Cover in 2013 2*Fixed Compensation for all, such that minimum of previous benefit applicable for Grade is retained Enhancement in 2013 Top-up Options to extend Life Insurance Cover Enhancement continued from2012 Other Wellness Benefits Health Check up benefit @2500/employee being introduced for all employees Enhancement in 2013 (detailed in separate presentation) Deals & Discounts (OPD, IPD and Health check up) in Health care facilities Launch of HealthCamps - Thyroid, Cardiac, Bone Density, Eye Care, Nutrition, Blood Sugar, Yoga, Lung Function, Physiotherapy consultation Enhancement continued from2012 Weekly Health Tips / Communication 5 Insurance Benefits Landscape 2013 Snapshot Health Benefits =>Insurance Benefits Overview Enrollment to Insurance Benefits 7 02 J uly 2013 Make Sure Your Dependents Are Covered You can enrol your spouse, dependant children and dependant parents / parents-in-law (any one set of parents) Make sure you add and / or edit current dependent details online at following website within the enrolment period, failing which you will not be able to cover them till next year Policy period: 1 st July 2013 till 30 th June 2014 URL www.emeditek.com Select E-Enrolment > Schneider Electric option to login Login credentials User ID : Employee Code (8 digit starting with 00) Bridge ID Password : Employee Code (8 digit starting with 00) Bridge ID Annual Enrollment 1st J uly to 12 th J uly 2012. (Please validate the dependants data within the timelines else last year details would be considered. Insurance Companies strictly do not allow mid-term modifications.) Home Page www.emeditek.com Login Page Select your Company name Login Page Enter Employee ID & Password Dependent Addition Page Update Dependent details Available details will appear here 12 02 J uly 2013 How To Enroll? URL www.emeditek.com | Select E-Enrolment > Schneider Electric option to login Login credentials User ID : Employee Code (8 digit starting with 00) Password : Employee Code (8 digit starting with 00) Validate personal details Select Top-up Plans Validate Dependent Details Check Bank Details Update Nominee details Click Save & Sign-off to save details Updated Employee Profile Annexure Insurance Benefits Detailed 14 02 J uly 2013 Insurance Benefits - Detailed 1. Medical Insurance (along with Top-up Option) 2. Accident Insurance 3. Life Insurance (along with Top-up Option) 4. Critical Illness Insurance Page 16 Medical Insurance Benefit Coverage Details Policy Parameter Insurer United India Insurance Company (UIIC) Third Party Administrator E Meditek Sum Insured 4,50,000 INR per family Coverage Type Family Floater Dependent Coverage Employee +Spouse +Children (max 2 children) +2 Parents / Parents in Laws (One set of parents) If there are less than 5 dependents then 3 rd child can also be covered for free else 3 rd child can be covered at additional premium of Rs. 1,124 per year. Note: Enrolments for family needs be done through Emeditek Gateway. Top-up Plans Top-up plans allow you to enhance coverage / benefit limits upon payment of additional premium, at highly discounted prices as compared to Market. Two options are available in Medical insurance: Enhance cover by Rs. 400,000 for an annual premium of Rs. 3,000 Enhance cover by Rs. 600,000 for an annual premium of Rs. 3,600 Note: Enrolments for Top up can be done through Emeditek Gateway by selecting from the drop down. After your authorization, the payments for applicable premium for Top-up plans will be routed through payroll deduction. Co-pay on Claims Applicable for Parent claims only @ 20% Example: If admissible claim value is Rs. 10,000 then insurance plan will pay Rs. 8,000 and remaining Rs. 2,000 has to be paid by you. Page 17 Medical Benefit Coverage Details Contd. Benefits / Extensions Coverage Standard Hospitalization Yes TPA services Yes Pre existing diseases Yes Waiver on 1 st year exclusion Yes Waiver on 1 st 30 days excl. Yes Maternity benefits Yes. INR 50,000 for both Normal & C-section Pre & Post Natal Expenses Yes only for hospitalization. Baby cover day 1 Yes Benefits / Extensions Coverage Day Care Yes HIV / AIDS Yes Room Rent Yes. Up to Rs. 6000 per day Day care Procedures Yes Pre-Post Hospitalization Exp. Yes. 30 & 60 days Ambulance Services Yes. INR 1500 per incident Page 18 Benefits Definition Pre existing diseases 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 Persons first Health Insurance policy with the Insurer First 30 day waiting period 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 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 Baby Cover Day 1 In consideration of additional premium, this policy is extended to cover the new born child of an employee covered under the Policy from the time of birth till 90 days. Not withstanding this extension, the Insured shall be required to cover the newly born children after 90 days as additional member as mentioned elsewhere under this Policy. Pre Hospitalization 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 Members Pre-hospitalization Expenses for up to 30 days prior to his / her Hospitalization. Post Hospitalization If the Insurer accepts a claimunder Hospitalization and immediately following the Insured Members discharge, further medical treatment directly related to the same condition for which the Insured Member was Hospitalized is required, the Insurer will reimburse the Insuredmembers Post-hospitalization Expenses for up to 60 day period. Day Care Day Care Procedure means the course of medical treatment or a surgical procedure listed in the Schedule which is undertaken under general or local anesthesia in a Hospital by a Doctor in not less than 2 hours and not more than 24 hours. Generally 8 aliments (i.e. Dialysis, Chemotherapy, Radiotherapy, Eye surgery, Dental Surgery, Lithotripsy (kidneystone removal), Tonsillectomy, D&C) Benefit Extensions Definitions Page 19 Medical Benefit General Exclusions Any non-medical expenses like registration fees, admission fees, charges for medical records, cafeteria Cost of spectacles, contact lenses, hearing aids Any cosmetic or plastic surgery except for correction of injury Hospitalization 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) Dental treatment. Incidence occurred while under the Influence of intoxicating drink or drugs. 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 Hospitalization for convalescence, general debility, intentional self-injury, use of intoxicating drugs/ alcohol. Venereal diseases . Injury or disease caused directly or indirectly by nuclear weapons (Nuclear radiation or nuclear weapons material) Naturopathy. Aviation other than as a passenger (fare paying or otherwise) in any duly licensed standard type of aircraft any where in the world. Incidence arising out of any breach of law with criminal intent. Insanity Insurance Benefits - Detailed 1. Medical Insurance (along with Top-up Option) 2. Accident Insurance 3. Life Insurance (along with Top-up Option) 4. Critical Illness Insurance Page 21 Group Personal Accident (GPA) Benefit Details This insurance provides compensation/payment up to a financial limit as assigned bythe company, to the insured person or his legal personal representative, if the insuredperson suffers death or disablement due to an accident. The cover is worldwide but payment of claimcanonlybe made in India andin IndianRupees. Policy Parameter Insurer Tata AIG General Insurance Company Policy Start Date 01 st J uly 2013 Policy End Date 30 th J une 2014 Sum Insured 2 times of Fixed compensation (*Enhanced this year) Coverage Details Accidental Death Yes (100% of Capital Sum Insured) Loss of both eyes OR 2 limbs OR 1 limb and 1 eye Yes (100% of Capital Sum Insured) Loss of one eye OR 1 limb Yes (50% of Capital Sum Insured) Permanent Total Disablement from injuries other than those named above Yes (100% of Capital Sum Insured) Page 22 GPA Benefit Details Coverage Details Permanent Partial Disability Yes as per benefit chart Temporary Total Disability (Weekly Benefit- 1% of Sum Insured subject to a maximum of INR 5,000 for 100 weeks) Geographical Limits World wide Terrorism Covered Disappearance Yes, Covered Education benefit* ( Payable in case of Accidental death of an employee ) Yes @10% of sum insured (Max. Rs. 1 Lac) per child for two children up to age of 4 years is payable. Medical Extension ( Payable towards medical expenses for treatment of accidental injury - OPD)* Up to INR 7500 Note: If accident requires hospital admission then your medical insurance can be utilized. Above expenses are available for immediate medical attention Page 23 GPA Details for Various Disability Clauses * Indicative list, Please refer to policy document Insurance Benefits - Detailed 1. Medical Insurance (along with Top-up Option) 2. Accident Insurance 3. Life Insurance (along with Top-up Option) 4. Critical Illness Insurance Page 25 Group Term Life (GTL) Benefit Details Policy Parameter Insurer Kotak Mahindra Old Mutual Life Insurance Company Policy Start Date 01 st J uly 2013 Policy End Date 30 th J une 2014 Sum Insured 2 times of Fixed compensation (*Enhanced this year) Coverage Details Death In the event of death of a member from any cause (natural/accidental), provided that this shall occur while the assurance in respect of such member shall be in force, an amount determined in accordance with the PolicySchedule shall be paid Yes Page 26 26 02 J uly 2013 What is a GTL Top up Cover ? Top up cover is an additional life cover offered to all employees over and above the cover under the company sponsored GTL policy .It is on a pure voluntary basis and the premium for the top- up shall be paid by the individual employee. Features of GTL Top up Cover : It is very quick and hassle free The premium rates under the Top-up plan are substantially lower an individual term plan .Thus top up provides an additional Life cover at a very low cost. It provides tax benefit under Section 80 C of the Income Tax Act, 1961. The premium amount is deducted from employees payroll. Page 27 27 02 J uly 2013 Life Insurance (Top-up Option) A top up plan on Life insurance is a flexible option that increases your total sum insured at a discounted premium as compared to retail / individual insurance plan available in the market. You may select the top up option on the enrolment portal and the premium will be calculated as per the following age band grid. Note: The above values are rounded off. Refer to enrollment portal for actual amount as per your selection Base + Top-up should not be more than 10 x GC. IF it is contact your Admin before selecting Age Band Vs. Options JM MM SM 500,000 1,000,000 1,000,000 2,000,000 1,500,000 3,000,000 18-30 483 966 966 1933 1449 2899 30-35 517 1034 1034 2067 1551 3101 36-40 674 1348 1348 2697 2022 4045 41-45 944 1888 1888 3775 2831 5663 46-50 1472 2944 2944 5888 4416 8831 51-55 2275 4551 4551 9101 6826 13652 56-60 3382 6764 6764 13528 10146 20292 Suicide is not covered under Voluntary Top up. Top up is not available by just authorizing in the portal. Once the medical underwriting is completed and insurers have accepted the case, member will be covered under voluntary top up. In case of any claim arisen during medical underwriting requirement process Top Up Sum insured will not be paid 02 J uly 2013 GTL Top-Up Selection Process Step 1:- Go to emeditek enrolment portal Step 2:- Select your Age bracket and Top up Sum Insured Step 3:- Answer the 4 questions that will appear on the portal under the Voluntary Top up Sum Insured As asked by the insurer either you need to provide the medical details to the Doctor who would call you from and do the tele- underwriting. Or else, need to undergo medical tests and questionnaire ,as per the underwriting guidelines at medical centers prescribed by Kotak. (Medical expenses will be borne by Kotak). If No, then your cover would commence after receiving approval from Kotak Life . The applicable premium would be deducted from your payroll. If answer to any of these questions is Yes then you need to undergo medical underwriting : Page 29 GTL Exclusions Service on duty with any armed force Insanity Venereal disease Influence of intoxicating drink or drugs Aviation other than as a passenger (fare paying or otherwise) in any duly licensed standard type of aircraft any where in the world Nuclear radiation or nuclear weapons material 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, detainments of all kings, princes, and people of whatever nation, conditions and qualities so ever Childbirth, pregnancy or other physical causes peculiar to the female sex While committing any breach of law with criminal intent . Insurance Benefits - Detailed 1. Medical Insurance (along with Top-up Option) 2. Accident Insurance 3. Life Insurance (along with Top-up Option) 4. Critical Illness Insurance Page 31 31 02 J uly 2013 Critical Illness Cover Benefit: 2L for J M 3L for MM and SM Diseases covered under Critical Illness: Major Heart Attack (MI) Cancer Stroke Coronary Artery By-Pass Graft Surgery (CABG) Kidney failure Major organ transplant Paralysis Loss of limbs Aorta surgery Major burns Heart valve surgery Blindness Click here for Critical Illness Benefit Details Availing Insurance Benefits 1. Medical Insurance 2. Accident Insurance 3. Life Insurance 4. Critical Illness Insurance Page 33 Cashless / Reimbursement which one to choose Cashless claims process is more easier than Reimbursement: No out of pocket expenditure for employees, except non payable expenses. No requirement for document submission. It saves times for administrative work as TPA directly coordinates with the hospital. Page 34 Availing Medical Benefit Cashless Process Cashless means the Emeditek may authorize upon a Policyholders request for direct settlement of eligible services and its according charges between a Network Hospital and Emeditek. In such case Emeditek 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 coveredunder the Policy. Planned Hospitalization Emergency Hospitalization List of hospitals in the Emeditek network Hospitals list http://www.emeditek.com/NetworkServices.aspx Website : www.emeditek.co.in Contact Customer Service Line 1800-102-3242 +91-124-4466666 (Hotline) customercare@emeditek.com 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. Page 35 35 Emergency Identification via Emeditek Cards. Also carry claimant ID proof Approach Network Hospital. For updated list visit http://www.emeditek.com/NetworkServices.aspx Planned Pre-authorization request to Emeditek TPA from hospital TPA Helpdesk Emeditek TPA Pvt Ltd will verify the documents VERIFIED BY DOCTOR Authorization Issued Pre Authorization Request Denied Queries Raised for further Clarification
Cashless Process Flow Page 36 Member intimates Emeditek of the planned hospitalization in a specified pre-authorization format at-least 48 hours in advance Claim Registered by the Emeditek on same day Follow non cashless process No Emeditek authorizes cashless for planned hospitalization to the hospital Yes Pre-Authorization Completed Pre Authorization Form www. emeditek.co.in Click here for 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 E Meditek Claims Processing & Settlement by Emeditek & Insurer Step 1 Pre-Authorization All non-emergency hospitalisation instances must be pre-authorized with the E Meditek, 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 hospitalisation has been pre-authorized, you need to secure admission to a hospital. A letter of credit will be issued by Emeditek to the hospital. Kindly present your E- card and a photo identity card at the Hospital admission desk. The bills related to treatment will be sent directly to, and settled by Emeditek at the end of the Treatment Planned Hospitalization Page 37 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 E 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 hospitalisation has been pre-authorized the employee is not required to pay the hospitalisation bill in case of a network hospital. The bill will be sent directly to, and settled by E Meditek Member gets admitted in the hospital in case of emergency by showing his E Card Member/Hospital applies for pre-authorization to the Emeditek within 24 hrs of admission Emeditek verifies applicability of the claim to be registered and issue pre- authorization Pre- authorization given by the E Meditek 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 the E Meditek Non cashless Hospitalization Process Yes Page 38 Dos and Don'ts Cashless Claims Produce your IDcardto the hospital authorities at the time of admission. In case of non-photo ID card, please also carry any other Photo ID Proof with you andsubmit a photo copyof the same to the hospital. Please informTPA well in advance (at least 48 Hours before admission) about the hospitalization (Within 24 hours of admission, in case of Emergency Hospitalization). This ensures that the authorization for cashless is provided well before the patient reaches hospital and the admissionwould be hassle free. Make sure to fill upthe mobile number in pre-authorizationform Non-payable items and co-payment charges have to be borne by the Insured Page 39 Emergency Approach To Non Network Hospital Planned Intimate within 72 Hrs. from time of admission or before Intimate within 24 Hrs. from time of admission Emeditek TPA
Submit documents within 15 days from date of discharge from the hospital Availing Medical Benefit Reimbursement Process: Non Network Hospital Page 40 Reimbursement Claims Please intimate TPA about the hospitalization before the admission (within 24 hours from time of admission in case of Emergency hospitalization), even if the hospital is not in network or you do not wish to avail cashless facility. Please ensure that the hospital meets the requirement as per the definition provided in the policy. Please collect and preserve Discharge summary, Reports, Prescriptions, Bills and receipts in Original. Please note that All Bills, cash memos and diagnostics should be supported by the doctors prescription. Submit all the documents along with a duly filled in claim form within 15 days from the date of discharge from the hospital (within 60 days if the claimincludes Post Hospitalization expenses). Page 41 Indicative list of documents to be submitted for Reimbursement Process 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 (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 doctors registration number in Hospital letterhead and get the same signed and stamped by the hospital, if required. Claims Form www.emeditek.co.in Click here for Claim Form *Please retain photocopies of all documents submitted Click here for Checklist of Documents Page 42 Things to remember Always carry your TPA card with Government identity proof while going to the hospital Maintain all bills relating to hospitalization, including pre and post in original Remember to take the bills fromyour family / consulting doctor Before hospitalization, clarify whether the particular disease is covered under your policy terms and conditions or not Request the hospital authorities to send the necessary papers to the TPA at the earliest, without which, claim cannot be processed &cashless cannot be granted Feel free to consult TPA claims team anytime for any issues. It is advisable to store TPA helpline numbers in your mobile phone and also give it to your family members. Page 43 E meditek Contact Points Southern Region Commercial Sales Offices : 1 st Point of Contact : Shivshankar 9620552223 shivshankar@emeditek.com Ramesh 9845081848 In.medicalhelpdeskbanglore@schneider-electric.com. Sundarrajan 8861005057 Helpdesk.apc@emeditek.com. Escalations : Vikas Anupam 8861005056 vikash.anupam@emeditek.com. Dr Sujit Paul 9686957788 drsujit.paul@emeditek.com. Northern Region Commercial Sales Offices : 1 st Point of Contact : Shatrunjay 9958793092 in.medicalhelpdeskgurgaon@schneider-electric.com, smishra@emeditek.com Amit Kumar 9958086222 amitkumar.raman@emeditek.com. Escalations : Dr Faisal Khan 9910029560 drfaisal.khan@emeditek.com. Page 44 E meditek Contact Points Western Region Commercial Sales Offices : 1 st Point of Contact : Tushar Shoni 9737150883 emslbaroda@emeditek.com. Sanjay Pawar 9594083185 Sanjay.pawar@emeditek.com, in.medicalhelpdeskmumbai@schneider-electric.com. Escalations : Dr Kadam 9867330175 skadam@emeditek.com. Nishchint Kumar 9594567878 nischint.kumar@emeditek.com. Eastern Region Commercial Sales Offices : 1 st Point of Contact : Ayan Mitra 9830333702 Ayan.mitra@emeditek.com, in.medicalhelpdeskkolkatta@schneider-electric.com. Escalations : Parthe Sarkar 9831013691 partha.sarkar@emeditek.com. Page 45 Medical Benefit Local Admin Contact Points Sourthern Region Commercial Sales Offices : Secundrabad Mr. Dennis Edwin Bangalore Mr. Palani G. Chennai Mr. Unni Krishnan Eastern Region Commercial Sales Offices : Kolkata Ms. Shampa Dutta J amshedpur Mr. Amit Deshpande Plants : Hyderabad Plant Mr. Ravindra Adavadkar Nasik Plant Mr. Rajendersinh Bhandari Vadodara Plant Ms. Swati Mehta Ambattur Plant Ms. Renuka Devi / Mr.Sukhesh Gopalan Conzerv Ms. Anju Mathew (HRBP) Meher Mr. Arun Shetty Western Region Commercial Sales offices : Mumbai Mr. Antony Raj Pune Mr. Pankaj J ain Vadodara Mr. Rajesh Thakore Ahmedabad Mr. Haresh Patel Northern Region Commercial Sales offices : Gurgaon Ms. Manisha Kala Mr. Sachin Chauhan Ludhiana Mr. Mohit Khurana Chandigarh Mr. Shahab Naqvi J aipur Mr. Om Pandey Lucknow Mr. Rahul Srivastava GTCI & GSC : Bangalore Office Mr. J ayaram Govindaiah Administration of the insurance related benefits will be handled by Administration department. Location specific admin SPOC points are given below: Local Helpdesk / Impant are also provided across major locations : Gurgaon , Bangalaore , Mumbai , Kolkatta , Hyderabad , Nashik and Baroda. The contact details of person and schedule will be separately circulated on regional basis Page 46 Medical Benefit Central Contact Point Schneider SPOC: Providers Ms Manisha Kala Phone: +91 858885693 E Meditek: www.emeditek.co.in Marsh: www.marsh.com Escalation Mr. Shatrunjay Misra Phone: +91 9958793092 Email: smishra@emeditek.com Mr. Rajiv Joshi Phone: +91 8588835007 Email: rajiv.joshi@marsh.com Mr Surendra Bisht Phone: +91 9711157768 Availing Insurance Benefits 1. Medical Insurance 2. Accident Insurance 3. Life Insurance 4. Critical Illness Insurance Page 48 48 02 J uly 2013 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 Page 49 GPA Claims Document Checklist 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 Click here for GPA Claim Form Page 50 50 02 J uly 2013 GPA Contact Details Providers: Tata AIG General Insurance Company Claims Intimation / Registration Claim Intimation mail should go to General.claims@tata-aig.com, A&H.delhi@tata-aig.com; Ankur.jain@tata-aig.com With a cc to : Respective HRBP and Manisha.Kala@schneider-electric.com Claims can also registered directly on Toll free no: 18002267780 / 1800119966 with policy no. Contact Person Name : Ankur Jain Mobile:+91 999931608 Email : Ankur.jain@tata-aig.com Availing Insurance Benefits 1. Medical Insurance 2. Accident Insurance 3. Life Insurance 4. Critical Illness Insurance Page 52 52 02 J uly 2013 GTL Claims Process Claimant / Assignee notifies HR, who in turn would intimate Insurer and submit required claim documents within <<3 days>> of the event On obtaining all relevant documents, Insurance Co. will begin processing the claims Claim Investigation and Review within <<7 Days>>of submission of all the required documents Is claim payable? Cheque sent to Employer (HR) within <<10 working days>, from where it is given to the Claimant/ Assignee Insurer provides a valid reason for the rejection to HR/Claimant/ Assignee No Yes Page 53 Claim form with authorized signature & stamp of client (as per Annexure A) Active Employment Letter Original Death Certificate Proof of age of the life insured Last attending doctor's death certificate Guardian details for minor beneficiary Driving license (Accidental claim) First information report (Accidental & dismemberment claim or any police case in natural death) Post mortem report (Accidental or any police case in natural death) Police case closure report (Accidental or any police case in natural death) Viscera Report (Accidental or any police case in natural death, if applicable) Nomination Declaration from policyholder (as per Annexure B) Nominee bank details & ID proof Cause of death certificate GTL Document Checklist Page 54 54 02 J uly 2013 GTL Contact Details Providers: Kotak Life Insurance Company Claims Intimation Claim Intimation mail should go to chaturvedi.akansha@kotak.com Charu.gosain@kotak.com With a cc to : Respective HRBP and Manisha.Kala@schneider-electric.com Contact Person Name : Charu Gosain Mobile:+91 9818335173 Email : Charu.gosain@kotak.com Availing Insurance Benefits 1. Medical Insurance 2. Accident Insurance 3. Life Insurance 4. Critical Illness Insurance Page 56 56 02 J uly 2013 Critical Illness Claims Process Notification of Claim All critical Illness claims must be submitted in writing to KLI within 30 days from the claim event date along with the primary documents Submission of diagnosis reports /medical reports Employee should submit complete treatment papers from diagnosis till date of discharge along with medical questionnaire Claim Investigation and Review within <<7 -10 Days>>of submission of all the required documents Is claim payable? Insurer provides a valid reason for the rejection to HR/Claimant/ Assignee No Cheque sent to Employer (HR)/ employee within <<10-12 working days. Yes Critical illness claim is payable only when a doctor prescribes a claimant to be critically ill as per diseases mentioned and a claimant is able to survive for the next 30 days. The claimant also needs to produce sufficient documents to avail this claim. Click here for Critical Illness - Documents checklist Page 57 57 02 J uly 2013 For Critical Illness Contact Providers: Kotak Life Insurance Company Claims Intimation / Submission All Claims should should be submitted to chaturvedi.akansha@kotak.com Charu.gosain@kotak.com With a cc to : Respective HRBP and Manisha.Kala@schneider-electric.com Contact Person Name : Charu Gosain Mobile:+91 9818335173 Email : Charu.gosain@kotak.com Retiree Policy 1. Coverage Details 2. Retiree Policy Process 3. Contact Details Page 59 Retiree Policy Coverage Details Policy Parameter Insurer United India Insurance Company (UIIC) Third Party Administrator To be decided by United Insurance Sum Insured INR 450,000 if desired Family Definition Self & Spouse Benefits / Extensions Coverage Standard Hospitalization Yes Copayment Copay of 20% would applicable as per retail policy. Pre existing diseases PED coverage subject to stipulated claim free years, this is subjected to certificate from the TPA as per the format .There is a waiting period of 4 years under normal individual cover. If you have had 4 claims free years and this is being certified by the TPA then PE would be covered from day one. Pre & Post Hospitalization Covered for 30 & 60 days for Hospitalization on disease / illness / injury subject to maximum of 10 % of Sum Insured. Room Rent Capping 1 % of Sum Insured per day for normal and 2 % of Sum Insured per day for ICU. Maternity benefits Not Applicable Cataract Capped at 10% of SI subject to maximum of INR.25,000 Hernia Capped at 15% of the SI subject to maximum of INR.30,000 Hysterectomy Capped at 20% of the SI subject to maximum of INR.50,000 Page 60 Benefits / Extensions Coverage Major Surgeries related to Cancer Surgery / Cardiac surgery / Brain Tumor surgeries / Pacemaker Implantation / Knee J oint / For sick, sinus syndrome / Hip replacement Capped at 70% of the SI subject to maximum of INR4 Lac First 2 year exclusion clause During the first two years 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 disease, Fistula in anus, piles, Sinusitis and related disorders, Gall Bladder Stone removal, Gout & Rheumatism, Calculus Diseases, J oint Replacement due to Degenerative Condition and age-related Osteoarthritis & Osteoporosis are not payable. Retiree Policy Coverage Details Contd. Policy guidelines of individual retail policies would be applicable. All other benefits would be strictly as per retail policy. Page 61 Conitnuity certficate from employer and photographs are talso required o be submitted for taking policy. 02 J uly 2013 Retiree Policy Process Step 1:- The concerned employee should have four claim free years under mediclaim policy. Step 2:- The intimation to this effect (Date of exit) should come a month before to Schneider Admin/ Manisha Kala to register this with UNITED Insurance Company Step 3:- UNITED Insurance Company would ask TPA to provide claims and policy details for concerned employee in attached TPA certificate format Step 5:- The concerned employee would submit this proposal form duly completed in all respects and contact the designated office which will be issuing an Individual Mediclaim policy by charging the applicable premium as per the retail policy. Step 4:- Basis the details provided in TPA certificate UNITED insurance company would issue a proposal form to concerned employee. Page 62 Provider : United India Insurance Company Admin SPOC Schneider Electric Name : Ms Manisha Kala Phone: +91 858885693 Email : manisha.kala@schneider-electric.com Contact Person United Insurance Name : Mr. Manjeet Singh Phone : 011-23414357 / 011-23415322 Mobile : 9810074632 Email : manjeetsingh@uiic.co.in Office Address : United India Insurance Co. Ltd., Branch Office,K 31,Connaught Place, New Delhi-110001 For Retiree Policy Contact details 63 02 J uly 2013 How to make most of your benefits? Make an informed choice of hospitals, when the hospitalization is planned and non critical in nature. In case of any planned hospitalization, approach the TPA sufficiently in advance (at least 48 hrs) and request pre authorization this enables TPA to facilitate smooth hospitalization admission & discharge process and negotiate better prices / package rates / room rent. Try to negotiate discounts with the hospital if opting for reimbursement as the bill is settled directly you. 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 bill amount Ask WHY & WHAT is billed to you (as a consumer, you have the right to know) We Care!