Group Mediclaim Insurance Policy Version 1.0
Oct 1, 2014 Wipro – Wipro – For For Internal circulation only Employee Compensation & Benefits Team
Contents
OBJECTIVE ..........................................................................................................................................
3
COVERAGE ..........................................................................................................................................
3
POLICY OVERVIEW .............................................................................................................................
3
POLICY BENEFITS ................................................................................................................................
4
POLICY TERMS & CONDITIONS ........................................................................................................... 5 Co-payment ................................................................................................................................................. 5
Day Care Procedures ................................................................................................................................... 7 Health Insurance Portability ........................................................................................................................ 7 Definition of hospital and nursing home ..................................................................................................... 8 Illness ........................................................................................................................................................... 8 CONTRIBUTION ..................................................................................................................................
8
EXCLUSIONS UNDER MEDICLAIM ......................................................................................................
9
PROCESS FOR CLAIM SUBMISSION ....................................................................................................
9
Claim Documents....................................................................................................................................... 10 Procedure .................................................................................................................................................. 10 E-medical card ........................................................................................................................................... 11 TOP COVER .......................................................................................................................................
12
Summary table of Applicable Annual Premium based on employee’s age & Scope of Cover .................. 13 Top-Up Policy period ................................................................................................................................. 13 Accessing Top-Up Application ................................................................................................................... 13 CONTACTS ........................................................................................................................................
14
AMENDMENT HISTORY ....................................................................................................................
14
OBJECTIVE Group Mediclaim policy provides for reimbursement of hospitalization expenses for illness, disease or injury sustained by employee, spouse and children. Expenses for hospitalization are payable only if a 24 hour hospitalization has been taken. (Except for select day care procedures, which do not require a 24 hour hospitalization). Under the scheme, the 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.
COVERAGE All India based employees of WT, WI, WC and Eco Energy, are covered under the policy.
POLICY OVERVIEW Policy Details
Policy Holder
Wipro Limited
Policy Start & End Date Insurer Third Party Administrator (TPA) Sum Insured
01 October 2014 -30 September 2015 United India Insurance Co. Ltd. Medi Assist India Pvt Limited
Covered Members Total Members Covered per Family (Including Employee) Employee
st
INR 2 Lakhs per Family
Description
Special Condition if any
Employee + Spouse+ Children Covered
This is applicable for all employees in India Payroll only
Covered
Spouse
Child
th
Covered
Incase employee’s spouse is also working in Wipro as a full time employee, please write to
[email protected] to discontinue premium deduction for one of the member No Restriction on number of Children
POLICY BENEFITS Policy Benefits
Standard Hospitalization Pre & Post Hospitalization Expenses
Covered Relevant expenses Covered (30 days & 60 days respectively) maternity benefit for maternity related pre and post limits Covered
Pre-existing & including internal and external congenital Diseases First 30-days & First Year Waiting Period Ambulance Services
Maternity
New Born Baby Cover from Day 1
Day Care Procedures
Dental
Invitro fertilization
Emergency Air Ambulance facility
Covered for a maximum of first 10 cases throughout the year with a limit of INR 100,000 per case in absence of multi-specialty hospital in a radius of 50 KM for named ailments only. (subject to approval of insurer)
Mobility Extension
Covered(INR 5,000 per Employee). Expenses related to external aids used for mobility (like walker, crutches) upon the prescription of the treating doctor and admissibility of the main claim.
Lasik Treatment
Covered, if required for correc tion of power is 6.0D and above
Morbid obesity
Ayurveda
Mental ailment
Treatment for morbid obesity is covered, only if it is life threatening but not cosmetic purpose Ayurvedic Hospitalization is covered for treatment taken in registered hospital with a justified admission In-patient treatment of mental ailment. Latter should be an established ailment - genetic or non-genetic.
Refer
Waived off Covered (INR 1000 per claim for Emergencies only) For Class ‘A’ cities – Normal Delivery: INR 40,000, Caesarian Delivery: INR 40,000. Other cities - Normal Delivery: INR 30,000, Caesarian Delivery: INR 40,000. Pre & Post Natal OPD expenses upto INR 5000 within the Maternity Limit is covered. Maternity benefit is applicable for first two live births only. Any complication rising from pregnancy will not be covered. Within the maternity limit for the normal expenses. Complications which require an admission can be processed under floater. Covered (Only list of select procedures like Dialysis, chemotherapy, radiotherapy and other such specified treatments taken in the hospital/ nursing home where the insured is discharged on the same day. Refer Policy Terms & Conditions for details ). Carries 5 percent copay for all day care treatments Covered (INR 10,000 for surgical treatment per family). Out of this, the sub limit for Root canal treatment is INR 3,000 per tooth inclusive of cost of the crown. (Cosmetic treatment like filling, capping, scaling, polishing, dentures, cleaning & treatment of similar nature are not payable. Detailed prescription, nature of treatment, procedures done, pre-numbered receipts are a must for dental treatment claims. In addition, X-ray reports may be asked for if required for justification of admissibility of claim.) Covered upto INR 40,000
HIV
HIV covered upto sum insured for self, spouse and children
Stem Cell and Cyber Knife treatment
Stem cell therapies and Cyber Knife treatment are covered upto 50% of the sum assured.
POLICY TERMS & CONDITIONS Co-payment The Policy will carry a co-pay from the employee for admissible claim amount over and above INR 10,000 for each and every claim. The Co-pay will be applied on claims above INR10,000 for the portion of claim over and above INR 10,000. If there are multiple claims during the year by an employee, Co-pay will be applied for aggregate claims crossing INR 10,000 for the year. Co-pay essentially means a percentage of the claim amount over and above INR 10,000 will be borne by the employee and the same shall not be reimbursed under any insurance or ancillary in-house medical scheme run by Wipro. No co-pay will be applicable for admissions in GIPSA PPN network hospital for specified GIPSA procedures. List of these procedures vary across hospitals and updated lists are available with the hospitals directly. The policy will carry a co-pay of 5% on all Day Care procedures except in a GIPSA Hospitals for the specified GIPSA procedures Co-Pay limits based on Room Rent categories for non-GIPSA PPN procedures requiring admission: Lower Room Rent Cap
Upper Room Rent Cap
Class A cities: INR 2400, Class B cities: INR 1750
Class A cities: INR 2900, Class B cities: INR 2100
A Standard Co-pay of 10% will apply where the room rent is up to the Lower Room Rent cap. A co-pay of 15% will apply where the room rent is between lower room rent cap and the Upper room rent cap A co-pay of 20% will apply where the room rent exceeds the upper room rent cap ‘A’ class cities includes Metros, Bangalore, Hyderabad, Pune and NCR. Rest of the cities are classified as ‘B’ class cities Sub-limits for Robotics Assisted Surgery
The following ailments are capped with the below mentioned sub-limits (specific to A-type & B-type city). All procedures other than the ones mentioned below are excluded from the policy if performed using robotics. Table 1.1 AILMENTS
Surgery Type
Cataract (Inclusive of Lens) Tonsillectomy
Eye Surgery
Fistula High
General Surgery
Throat Surgery
Description
A Class cities Clouding of vision, common in elderly 25000 people Inflammation and infection of 24000 tonsils/adenoids, glands between mouth, nose and throat Abnormal connection between two 35000 organs, generally between the rectum and vagina/rectum and urinary bladder,
B Class cities 22000 17000
30000
resulting due to injury/surgery
Fisula Low
General Surgery General Surgery
Fissurectomy
Haemorrhoidectomy (Excluding staples & tackers) Thyroidectomy – HEMI – Thyroidectomy TOTAL Arthroscopy
General Surgery
Arthroscopic Surgery
Orthopaedics
Hydroceletomy unilateral
Urology
Hydroceletomy bilateral
Urology
Coronary Angiogram (Including dye)
Cardiology
Hernia repair – open (including mesh)
General Surgery
Hernia repair laparoscopic
–
General Surgery
Appendicectomy open Appendicectomy laparoscopic
–
General Surgery General Surgery
Cholecystectomy open
–
General Surgery
Cholecystectomy laparoscopic
–
General Surgery
–
General Surgery General Surgery Orthopaedics
Hysterectomy – open
Gynecology
Hysterectomy
Gynecology
–
Same as above Repair of a fissure(a crack or a tear in the lining of an organ),sphincterectomy is the correction of a tear on a sphincter( muscle that helps in contraction of an or gan) Surgical removal of a haemorrhoid( protrusion of the mucous lining of rectum due to constipation) Partial surgical removal of a thyroid gland( usually done when suffering from cancer) Total surgical removal of thyroid gland A procedure done by inserting a fiberoptic tube into the joints to study the nature of condition causing inflammation Done to treat cartilage tears( cartilage is the tissue lining the joints) Removal of hydrocele (collection of fluid around testes), one side. Related to male reproductory organ Removal of hydrocele( collection of fluid around testes), both sides.Related to male reproductory organ An x-ray test done to find out the flow of blood into and out of one's heart( basically to study the nature of blood vessels) Correction of hernia( protrusion of internal organs through weak abdominal muscles) Correction of hernia( protrusion of internal organs through weak abdominal muscles) Removal of appendix by cutting open the abdomen Removal of appendix by laparoscopy( insertion of a laparoscope and removal of appendix by bit by bit, re quires just a small incision on the abdomen) Removal of gall bladder upon finding stone formation( by cutting open the abdomen) Removal of gall bladder upon finding stone formation( by minimal invasion using laparoscope) Removal of uterus due to any complications( by cutting open the abdomen) Removal of uterus due to any
30000 25000
25000 20000
32000
25000
40000
35000
50000
45000
35000
30000
75000
50000
25000
20000
35000
30000
20000
15000
40000
35000
60000
50000
35000
30000
50000
45000
45000
40000
50000
45000
50000
45000
60000
55000
laparoscopic
complications( by laparoscopy)
Day Care Procedures For the purpose of this definition, Specified Treatment means any treatment involving Dialysis, Chemotherapy, Radiotherapy, Eye Surgery, Dental Surgery, Lithotripsy (Kidney stone removal), Tonsillectomy, D&C taken in the Hospital/Nursing Home. Also the treatments as mentioned below will form a part of Specified Treatment: ENT o Myringoplasty o Tympanoplasty o Paracentesis (myringotomy) FESS o Tonsillectomy o Tonsillectomy with adenoidectomy EYE o Operations for pterygium o Operations for cataract o Operations for Glaucoma OPERATIONS ON THE DIGESTIVE TRACT o Surgical treatment of anal fistulas o Surgical treatment of haemorrhoids (piles surgery) GENITAL SURGERY o Operation on a testicular hydrocele o Herniotomy / Hernioplasty o Treatment of a varicocele and a hydrocele o Therapeutic curettage (D & C) OTHER OPERATIONS o Lithotripsy / ESWL
.
Health Insurance Portability Employees will now have an option to carry forward their health insurance policy (with standard benefits) even after leaving the Company/ retirement. Example: In a retail policy from external market, the period during which pre-existing diseases are not covered is referred to as the waiting period. In a normal scenario, in case an employee leaves the Company, s/he will be treated as a new customer and will have to wait for 4 years for getting pre-existing diseases’ coverage. With the feature of portability, an employee will be given an option to carry forward the Policy (with standard benefits) with the insurer, subject to certain conditions. Conditions:
Portability to be offered to an employee only if s/he has spent minimum 2 years in the organization to be eligible for portability.
Example: st Say Ram joined the Company on 1 Oct 2012. He has completed 2 years in the Group Policy. He has quit as of Nov 2014. Ram can therefore continue with the same policy, however he will not get pre-existing benefits for next 2 years (so that he completes 4 years of waiting period). Oct 2016 onwards, he can avail to avail pre-existing coverage. st Say, Krishna joined the Company on 1 Jan 2011. He has completed 4 years in the organization. Krishna decided to separate from the organization as of April 2015. Since he has already completed 4 years in the policy (hence waiting period of 4 years is completed), if he chooses to he will get pre -existing benefits April 2015 onwards. Portable policy will be given at the retail rates approved by the Insurer. Employee opting for retail policy will have to undergo pre-policy medical tests. 50% of medical test expenses subject to a maximum of INR375 would be borne by the insurer when the proposal accepted by the insurance company. Portability cannot be given if employee is suffering from any chronic illness at the time of enrollment in portable policy. Chronic illnesses are conditions or illnesses which are prolonged or recurrent, progressive and may be irreversible i.e. cancer, organ transplant, renal failure, cardiac disease, brain, neurological conditions and etc.
Definition of hospital and nursing home Hospital & nursing home where treatment is availed means any institution in India established for indoor care and treatment of sickness and injury which is registered with the local authority having 15 inpatient beds , full equipped operation theatre , fully qualified nursing staff and doctor round the clock.(In class 'C' towns No of beds be reduced to 10). This condition can be waived in case of very s mall towns. The list of network hospitals is dynamic (subject to addition and deletion). It is strongly advisable to check with Medi Assist customer care number or Mediclaim Helpdesk to check the hospital status.
Illness Any one illness will be deemed to mean continuous period of illness and it includes relapse within 45 days from the date of last consultation. Occurrence of same illness after the lapse of 45 days will be considered as fresh illness.
CONTRIBUTION WIPRO pays the annual premium on behalf of the employees; the contribution from the employees towards this premium is accumulated on a monthly basis by way of deduction through salary. The contribution would be based on Marital Status of the employee, as given below: Employee Category
Monthly Premium
Individual (Single)
INR 230
Married (Family)
INR 480
“A nominal amount is collected every month in excess of the medical insurance premium component. The excess will be utilized towards wellness programs and preventive healthcare interventions. Regular communication will be sent out on the available programs and we urge you to make the most out of them.”
EXCLUSIONS UNDER MEDICLAIM
Diseases, illness, accident or injuries directly or indirectly caused by or arising from or attributable to war, invasion, act of foreign enemy, war like operations (whether war be declared or not). Circumcision whether or not necessitated by vaccination or inoculation or change of life or cosmetic or aesthetic treatment of any description, plastic surgery unless necessary for treatment of a disease not excluded by the terms of the policy or as may be necessitated due to treatment of an accident. The cost of spectacles and contact lenses, hearing aids. Convalescence, general debility, run-down condition or rest cure, sterility/family planning surgeries both vasectomy and tubectomy/ infertility, venereal disease, intentional self-injury (whether arising from an attempt to suicide or otherwise) and use of i ntoxicating drugs and/or alcohol. Virus Type III (HTLV –III) or Lymphadinopathy Associated Virus (LAV) or the Mutants Derivative or Variations Deficiency Syndrome or any Syndrome or condition of a similar kind. Charges incurred at Hospital or Nursing Home primarily for diagnostic, X-Ray or laboratory examinations or other diagnostic studies not consistent with or incidental to the diagnosis and treatment of the positive existence or presence of any diseases, illness or injury whether or not requiring Hospitalisation/ Domiciliary Hospitalisation. Expenses on vitamins and tonics unless forming part of treatment for injury or disease as certified by the attending Medical Practitioner. Diseases, illness, accident or injuries directly or indirectly caused by or contributed to by nuclear weapons/materials or contributed to by or arising from ionising radiation or contamination by radioactivity by any nuclear fuel or from any nuclear waste or from the combustion of nuclear fuel. Termination of pregnancy within 12 weeks of the gestational period. Naturopathy treatment, pranic healing, holistic healing, unani, yogic healing etc. Treatment related like hysterolaparoscopy, ovarian drilling , endometriosis, chocolate cyst, diagnostic d and C are not covered IVF Pre and Post or any other infertility related treatment is not covered. Family planning surgeries are not covered. Treatment arising from or traceable to pregnancy, childbirth, miscarriage, abortion or complications of any of these including caesarean section, except abdominal operation for extra uterine pregnancy (Ectopic pregnancy), which is proved by submission of Ultra Sonographic report and Certification by Gynaecologist that it is life threatening one if left untreated
PROCESS FOR CLAIM SUBMISSION Remember to declare your family members at the time of a life changing event like marriage, child birth etc.
Claim Documents In the event of a claim, you would be required to furnish the following for or in support of a claim: a) Duly completed claim form b) Bills, receipts and discharge certificate/card from the Hospital c) Bills from Chemists supported by proper prescription. d) Test reports and payment receipts.
st
For any claims effective 1 Oct 2013, please use the claim form available in myWipro My Information Source People Practice India Policies My Financial Mediclaim Medical Insurance Claim form. You will need to fill the form and drop the supporting documents in Wividus Drop box, please write to
[email protected] for claims processing or for any clarification.
Please refer the portal for the detailed checklist ailment wise: www.mediassistindia.com
Procedure Depending on the need and condition of hospitalization, employee can go for 3 forms of hospitalization:
(i). Planned Hospitalization : In the case of a planned admission, doctor must have been consulted first and would in turn have advised on the probable date of hospitalization. In such a case, employee must apply for an approval of the estimated hospital expenses directly with the TPA at least 4-5 days prior to the date of hospitalization. Employee needs to fill ‘Pre-Authorization form for Cashless Claim’(Available in Section 10, Forms). This would help you get the best services, room and rate with help of TPA. Below process can be followed for registering claim incase of a planned hospitalization (Cashless if approved by TPA):
Employee to call up TPA to plan the hospitalization
Employee Approaches the Hospital with medical ID
Sto
Hospital Intimates TPA and sends Pre-Authorization Request with approximate cost of the treatment
TPA issues letter of credit (for cashless) with approval for partial amount as per Eligibility and Coverage to the hospital
TPA send the final approval to hospital which allows the employee to get discharged by
At the time of Discharge hospital sends the final bill and the discharge summary for the final
(ii). Emergency Hospitalization : In case of emergency hospitalization, hospital will take up your case on a fast track basis with your TPA and is likely to receive approvals within 4 hours during any working day. For cashless treatment it is mandatory for the hospital to have an approval from your TPA. Incase of delay in receiving the approval or when you cannot wait for receiving the approval owing to medical urgency you can undertake
the
treatment
by
paying
the
necessary
cash
deposit.
If you receive approval from your TPA after paying the cash deposit, you are entitled for refund of the cash deposit (as per reimbursement process mentioned in point (iii)). registering claim incase of an emer gency hospitalization:
Below process can be followed for
Member get admitted in the hospital in case of emergency by showing his
Member / Hospital applies for pre-authorization to the TPA within 24 hrs of
Hospital sends complete set of claims documents for processing to the TPA
Member gets treated and discharged after paying all non entitled benefits like
TPA verifies applicability of the claim to be registered and issue pre-
Yes
Preauthoriza
No
Claims Processing by TPA & Insurer
Release of payments to the hospital
Employee will be him/herself to the hospital and claim reimbursement from Insurer through TPA.
Stop
(iii). Reimbursement: Incase any hospital does not accept cashless facility, employee can register the claim as reimbursement. Below mentioned documents for or in support of a claim need to be submitted within 30 days of hospitalizatio: a) Duly completed claim form b) Bills, receipts and discharge certificate/card from t he Hospital c) Bills from Chemists supported by proper prescription. d) Test reports and payment receipts. Please refer the portal for the complete document checklist on ailment wise: www.mediassistindia.com
a) You would need to log the claim in myWipro under My Financials MAS, Health Check, Medi-cards & Insurance claim (WISH) b) All relevant documents along with the claim form need to be dropped in the nearest Wividus drop box. c) Documents must be submitted within 30 days of completion of hospitalization treatment. Any late submission shall not be considered. d) Medi-Assist will process and settle the claim within 14 working days of receipt of complete documents.
E-medical card You can print yours & your family’s e-card yourself on the link provided below:
myWipro
My Financials
MAS, Health Check, Medi-cards & Insurance claim (WISH)
Medicard.
Do remember to print the card(s) and share with family right away as medical contingency hits unplanned most of the time.
TOP COVER Top up Cover Policy Features
Top Up Cover offers you an option to increase your Mediclaim Insurance for furthering your financial protection benefit under this plan.
Employee can increase sum insured upto INR 100,000, INR 200,000, INR 300,000, INR 500,000, INR 700,000 OR INR 1,000,000 over and above the existing sum insured. A one-time premium would be deducted from payroll in the month this additional coverage is opted for.
Please note that it is important to top-up your cover in case you have a chronic pre-existing ailment, failing which CMAP benefit may not be released by the Company.
Employees will have option of buying a top-up cover over and above the floater cover at their own expense. st
th
Top up is a limited period offer and available from 1 Oct to 15 Nov in 2014.
Critical Illness Cover (Please note – it is important to top-up your cover in order to be eligible for this
benefit):
Amount of cover – INR 2 lacs (over and above sum insured and top up)
This benefit is for the employee only
The critical illnesses covered are as below:
Cancer of specified severity
First Heart Attack
Coronary artery surgery open chest (CABG)
Heart valve replacement
Coma of specified severity
Kidney Failure
Stroke resulting in permanent symptoms
Major organ/Bone marrow transplant
Multiple Sclerosis
Motor Neuron disease with permanent symptoms
Permanent paralysis of limbs
Loss of Pay Cover (Please note – it is important to top-up your cover in order to be eligible for this benefit):
This benefit is for employees only
Amount – INR 5000 per week
This benefit will commence immediately on the day ‘Loss of Pay’ (due to medical exigencies) begins and will be paid till employee returns to work or for 52 weeks, whichever is earlier
New Employees have to opt for top-up cover within 45 days from the date of joining or on returning from abroad. The premium payable calculated will be proportionate to the number of months the policy will be effective.
The top-up cover can be utilized only after exhausting the main cover.
The Top up policy is applicable from 1 October 2014 to 30 September 2015 if applied during the window
st
th
mentioned above.
st
For new joinees/Long Term assignee return cases, top up is applicable from 1 of the following month in which you choose Top up Cover in myWipro.
myWipro Top up Coverage application will be accessible from the 1st to the 20th of every month (only for a new joinee / returnee from Long term onsite assignment).
To choose Top up Cover, please log onto myWipro My Financials Top Up Cover.
Top up option, once selected on myWipro c annot be cancelled.
The Top up Cover lapses in the event of Separation due to resignation / Termination from the company as in the case of default coverage. There will be no refund of Top up premium paid in such event.
Summary table of Applicable Annual Premium based on employee’s age & Scope of Cover Unmarried Amount
Below 35 Years
36 - 45 Years
Married Above 45 Years
Below 35 Years
36 - 45 Years
Above 45 Years
INR 100,000
450
490
700
950
1030
1260
INR 200,000
850
930
1320
1790
1940
2400
INR 300,000
1110
1200
1710
2320
2520
3590
INR 500,000
1399
1512
2155
2923
3175
4523
INR 700,000
1678
1814
2586
3508
3810
5428
INR 1000,000
2014
2177
3103
4209
4572
6514
Top-Up Policy period th
The Top up policy is applicable from 1st October 2014 to 30 September 2015. You have an option to apply for st
Top up from 1 Oct 2014 to 15th Nov 2014 only. For a new joinee / returnee from Long term onsite assignment, the top up window will be open for 45 days from date of joining / date of return. The premium payable calculated will be proportionate to the number of months the st
policy will be effective. Top up is applicable from 1 of the following month in which you choose Top up Cover in myWipro.
Accessing Top-Up Application myWipro Top Up Cover module will only be accessible from the 1st to the 20th of every month (only for a new joinee / returnee from Long term onsite assignment).
To choose Top up Cover, please log onto myWipro My Financials MoreTop up Cover. Please refer to the Editorial section for further information on how to raise a request on myWipro.
CONTACTS For any further information with regards to the Policy,
E-mail Id's
First point of contact for all enquiries and Cashless claims:
Contact No.
Timings
080 32413698
Wipro Working hours
+91 9341625893
24 / 7
[email protected]
First level of escalation:
[email protected]
+91 9379260825 and 7022969803
24 / 7
Final level of escalation:
[email protected]
+91 9739519191
Working hours and for emergencies 24X7
Visit myWipro My Information Sources People Practices India Other Benefits services to know about the existing offers across the network of hospitals/ clinics.
Healthcare
Visit Channel W Fit for Life to take proactive care of your health! Top
AMENDMENT HISTORY Amendment Dat
Policy Version
Author
Approved By
Oct 1, 2014
1.0
C&B Team
Head – C&B
Nature of Changes Renewed Policy for year 2014-15
Top