Ashok Leyland ltd Employee benefit program 2021-22 - PowerPoint Presentation

1. Ashok Leyland ltd Employee benefit program 2021-22

2. 2Group Mediclaim -2021-22Benefit DetailsGeneral Def. & Policy Conditions Claims Process Contacts & Escalations Exit

3. GROUP MEDICLAIM - Benefit Details3

4. Policy details– Employee policy 4FeaturesTerms & ConditionsPolicy TypeFamily FloaterFamily MembersSelf + spouse + children + dependent siblings, restricted to Self+5 dependents Sum Insured4 LacsDefinition of Family Members - Children Natural set of children – no limits on numbersLegally Adopted Children are considereddisabled(mentally or/and physically) / unemployable dependent children Children earning less than INR10,000 per month considered dependent.Siblings Dependent Brothers (unemployed below 25 years)Dependent Sisters (Unemployed & Unmarried)Sibling earning less than INR10,000 per month considered dependent.Age LimitNo Age Limit 1st ,2nd,3rdand 4th year exclusionsWaived offFirst 30 days waiting periodPre-Existing Ailments waiting periodPre & Post Hospitalization30 & 60 days respectively( not applicable for maternity claims)Maternity Benefit (* Benefit is available only for Self & Spouse)Normal delivery INR 50,000, C section INR 75,000Pre & Post Natal expensesCovered upto a limit of INR 5,000/- over and above the maternity sum insuredTwin/Multiple baby delivery For any complication in delivery, limit up to sum insured is available 9 Months Waiting Period for MaternityWaived offBaby day one CoverCovered from day 1 within Family Floater SIRoom RentSingle AC non sharing room subject to a cap of 1.5 % of Sum Insured per day.ICU - Actuals Proportionate deduction in case of higher room.Waived offAmbulance ChargesActuals (not applicable for maternity claims)Day Care ProceduresSpecific list of day care procedures covered , for all other procedures 24hrs hospitalization is a must. Domiciliary HospitalisationCovered subject to general domiciliary preconditions

5. 5Policy details– Employee policyFeaturesTerms & ConditionsCongenital Internal & ExternalCovered, except for cosmetic surgeriesDental Cover due to accidentsCoveredEmergency Air Evacuationcovered : AOA:AOY - 5 Lacs : 15 LacsOrgan Donor expensesHospitalisation expenses covered upto Sum Insured. cost of organ not coveredOral ChemotherapyCoveredStem Cell SurgeryCovered upto 50% of Base Sum InsuredCyber – Knife SurgeryCovered upto 50% of Base Sum InsuredArtificial life support Hemodialysis /RadiotherapyCoveredAyurvedic or Homeopathic treatmentCovered (provided treatment is taken in Govt. approved hospitals on Pre Authorisation)Ayush Treatment - Covered as per IRDA guidelines . Naturopathy and yoga excludedHospitalisation Expenses for Ailments with No Active Line of treatmentCovered provided there is 24hrs hospitalization. Hospitalization for General check ups and diagnostic tests are not covered.Fracture / Injury covered under day care procedures Fracture / Injury due to accident which does not warrant 24 hrs. Hospitalization to be covered under day care with a limit of 10,000 per claim. POP usage is also coveredMid Term Inclusion of dependents Allowed for (I) newly married spouse (II) Newborn baby (III) Newly adopted child, to be declared within 15th of the succeeding month. Subject to overall family size of 1+5.Claim IntimationWithin 30 days from DOAClaim SubmissionWithin 30 days from date of discharge(DOD). For Pre-post within 60 days from DOD.Deficiency docs within 30 days from Date of Deficiency LetterTreatment for Psychiatric ailmentsTo be covered upto 50,000 subject of max. of 500,000 - Only through Reimbursement modeNew JoineesDay one cover subject to premium / CD balance as on effective date of cover and to be declared within 20th of the succeeding monthInfertility TreatmentCovered upto INR. 50,000/- within maternity Sum insuredDeath claims - 100% Payment In case of death claim,100% of the Hospitalisation expenses claimed to be paid without any deductions

6. 6Policy details– Parents policyFeaturesTerms & ConditionsPolicy TypeFamily FloaterFamily MembersOne Set of Parents/Single Parent And / Or One Set of Parents-in-laws/Single Parent-in-lawSum InsuredINR 3 lacs , applicable to each set of Parent/Parent-in-laws. Eg: father and/or mother will be one set and father-in-law and/or mother-in-law will be another set.Age LimitNo Age Limit1st ,2nd,3rdand 4th year exclusionsWaived off First 30 days waiting periodPre-Existing Ailments waiting periodPre & Post Hospitalization30 & 60 days respectivelyRoom RentSingle AC non sharing room subject to a cap of 1.5 % of Sum Insured per day ICU - ActualsProportionate deduction in case of higher room.Waived offAmbulance ChargesActualsDay Care ProceduresSpecific list of day care procedures covered , for all other procedures 24 hr hospitalisation is a must.Domiciliary HospitalisationCovered , subject to general domiciliary preconditionsMid Term Inclusion of dependents Allowed for parents and/or parents-in-laws of new joinee to be declared within 15th of the succeeding monthCongenital Internal & ExternalCovered, except for cosmetic surgeries.Dental Cover due to accidentsCoveredOrgan Donor expensesHospitalisation expenses covered upto Sum Insured. cost of organ not coveredEmergency Air EvacuationCovered : AOA:AOY - 5 Lacs : 15 LacsOral ChemotherapyCoveredStem Cell SurgeryTo be covered upto - 50% of Base Sum InsuredCyber – Knife SurgeryTo be covered upto - 50% of Base Sum Insured

7. 7Policy details– Parents policyFeaturesTerms & ConditionsArtificial life support Haemodialysis/CoveredRadiotherapyAyurvedic or Homeopathic treatmentCovered (provided treatment is taken in Govt. approved hospitals on Pre Authorisation)Ayush Treatment - Covered as per IRDA guidelines . Naturopathy and yoga excludedHospitalisation Expenses for Ailments with No Active Line of treatmentCovered provided there is 24hrs hospitalization. Hospitalization for General check ups and diagnostic tests are not covered.Fracture / Injury covered under day care procedures Fracture / Injury due to accident which does not warrant 24 hrs. Hospitalization to be covered under day care with a limit of INR10,000 per claim. POP usage is also covered.Cataract, Hernia, HysterectomyCovered with NO SUBLIMITTreatment for Psychiatric ailmentsCovered upto INR 50,000 subject of max. of INR 5 lacs during the policy periodClaim Intimationwithin 30 days from DOAClaim SubmissionWithin 30 days from date of discharge(DOD). For Pre post within 60 days from DOD.Deficiency docs within 30 days from Date of Deficiency LetterNew JoineesDay one cover subject to premium / CD balance as on effective date of cover and to be declared within 20th of the succeeding monthPost Hospitalisation expenses For critical Accident cases, on HR discretion , expenses beyond 60 days of hospitalization to be payable Death claims - 100% Payment In case of death claim ,100% of the hospitalization expenses claimed to be paid without any deductions

8. 8CoversTop Up Option 1Top Up Option 2 Top Up Option 3 Top Up Option 4 Sum Insured Top up SI : 6lacs Base SI : 4 lacsTotal SI : 10 lacsTop up SI : 8 lacs Base SI : 4 lacsTotal SI : 12 lacsTop up SI : 11lacs Base SI : 4 lacsTotal SI : 15 lacsTop up SI : 15lacs Base SI : 4 lacsTotal SI : I9 lacsRoom Rent1% of the TOTAL Sum Insured (base SI + top up SI)1% of the TOTAL Sum Insured (base SI + top up SI)At Actuals At Actuals Proportionate deduction in case of higher room rent.waived offwaived offwaived offwaived offRest all terms as per base employee policyTOP UP– employee policyTop up rates Top UpOption 1Top Up Option 2 Top Up Option 3 Top Up Option 3 Top up Sum Insured Rs. 6 lacs Rs. 8 lacsRs. 11 lacs Rs. 15 lacs Rates incl.taxRs. 4378Rs. 5270Rs. 7295Rs. 10213

9. 9CoversTop Up Option 1Top Up Option 2 Top Up Option 3 Top Up Option 4 Sum Insured Top up SI : 2 lacs Base SI : 3 lacsTotal SI : 5 lacsTop up SI : 4 lacs Base SI : 3 lacsTotal SI : 7 lacsTop up SI : 6 lacs Base SI : 3 lacsTotal SI : 9 lacsTop up SI : 10 lacs Base SI : 3 lacsTotal SI : 13 lacsRoom Rent1% of the TOTAL Sum Insured (base SI + top up SI)1% of the TOTAL Sum Insured (base SI + top up SI)At Actuals At Actuals Proportionate deduction in case of higher room rent.waived offwaived offwaived offwaived offRest all terms as per base Parents policyTOP UP– Parents/PARENTS-IN-LAW policyTop up rates for each set of parentTop UpOption 1Top Up Option 2 Top Up Option 3 Top Up Option 3 Top up Sum Insured Rs. 2 lacs Rs. 4 lacsRs. 6 lacs Rs. 10 lacs Rates incl taxRs. 7086Rs. 9648Rs. 13192Rs. 18469

10. 10No medical tests requiredPremium rate is much lower than retail market.Exhaustive coverage as in master mediclaim policy of Ashok Leyland No waiting period for pre-existing diseases or any ailment.Employees can take coverage for both sets of Parents and Parents-in-laws. Sum insured and premium will be applicable for each set of parents/ parents-in-law. Eg., father and/or mother will be one set and father-in-law and/or mother-in-law will be one set.Prorata/proportionate premium is chargeable for new joinees from the date of joining till policy period for Parents and top up policyMid-term addition allowed only for new-joinees and their dependants or newly married spouse/parent-in-laws. Premium paid by the employee can be claimed as deduction in Income Tax u/s 80D-Premium Details will be automatically captured by payroll teamScheme advantages and key points

11. 11CoversOption 1Option 2 Option 3 Option 4 SUM INSUREDFAMILY DEFINITIONRs.3 LACS (Per family premium incl GST)Rs. 5 LACS (Per family premium incl GST)Rs.7 LACS (Per family premium incl GST)Rs.10 LACS (Per family premium incl GST) Family Size (1+3)Rs. 10516Rs. 12198Rs 14640Rs.20497 Family Size (1+5)Rs. 21034Rs. 25870Rs. 30835Rs. 43168Covid policyNote : Annual premium is chargeable for COVID policy, irrespective of the date of joining.

12. 12Scheme advantages and key pointsFeaturesTerms & ConditionsProduct TypeFamily FloaterType of CoverCovid-19 Hospitalization CoverWaiting Period15 days/30 days waiting period Waived offPolicy Period1 year from the date of payment of premiumFamily DefinitionSelf, Spouse, 2 Children (1+3)Self, Spouse, 2 Children, 2 Parents/Parents-in-Law (1+5)AgeNo Age LimitRoom RentActualsPre & Post Hospitalization30 days & 60 daysHome Care TreatmentCosts of treatment incurred by the Insured Person on availing treatment at home maximum up to 14 days per admission including pre-hospitalisation expenses for a period of 15 days and post hospitalisation expenses for a period of 30days, subject to a maximum of Rs.20,000/-.

13. 13Scheme advantages and key pointsFeaturesTerms & ConditionsAmbulanceRs. 2,000/- per hospitalizationCo-MorbiditiesAny Co-morbid condition triggered due to Covid-19 shall be covered during the hospitalizationPersonal Protective Equipment (PPE) KitsActualsAYUSH CoverageMedical expenses incurred on hospitalisation for Covid under AYUSH Treatment in Govt recognised hospitalMidterm inclusion of New Joinees & Deletion Spouse & Baby InclusionCovered from the Date of Birth / Date of Marriage within the Covid-19 policy Family Floater Sum Insured, subject to intimation with the insurer within 30days of such eventInstitutional Isolation/QuarantineCovid-19 Tested positive and should be prescribed to be in Isolation for more than 24 hoursInstitutional Isolation ChargesInstitutional isolation charges are inclusive of room rent and patient food.Hospital Daily CashNot CoveredBaby Day oneCovered from Day one within the Covid-19 policy Family Floater Sum InsuredDomiciliary HospitalisationCovered provided the following 3 conditions of Domiciliary are met:a). Insured's condition would ordinarily require treatment at hospital, AND b). Insured is not in a condition to be moved to a hospital ORc). Insured takes treatment at home on account of non-availability of a room in a hospital.

14. GROUP MEDICLAIM – General Def. & Policy Conditions 14

15. 15general exclusions in Mediclaim 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 Dental treatment other than due to accidents HIV and AIDS related treatments 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 Naturopathy Treatment, acupressure, acupuncture, magnetic therapies, experimental and unproven treatments/therapies. Treatment including drug experimental therapy which is not based on established medical practice in India, is treatment experimental or unproven. Voluntary termination of pregnancy during first 12 weeks (MTP)Any cosmetic or plastic surgery except for correction of injuryTreatment for Genetic disorders.Treatment for Age Related Muscular Degeneration (ARMD), treatment such as Rotational Field Quantum Magnetic Resonance (RFQMR), Enhanced External Counter Pulsation (EECP), etc.Hospitalization for General check ups and diagnostic tests.

16. 16Few non payables as per policyCost of spectacles, contact lenses and hearing aidsRegistration fees, admission fees, Service charges, Surcharges, charges for medical records, cafeteria charges, telephone charges, Luxury tax etc.,Vaccination or inoculationExternal and or durable Medical / Non-medical equipment of any kind example - Infusion pump, Oxygen concentrator i.e., walker, crutches, Belts, Collars, Caps, Splints, Slings, Braces, Stockings, bandages, external orthopaedic pads, Diabetic foot wear, Glucometer/Thermometer, related items etc.. and so onVitamins and tonics unless used for treatment of injury or diseaseconvenience items for personal comfort such as charges for telephone, television, ayah, private nursing/barber or beauty services, diet charges, baby food, cosmetic, tissue paper, diapers, sanitary pads, toiletry items and similar incidental expenses.

17. Group Mediclaim - Claims process17

18. 18FHPL Cashless processFHPL receives the fax, check the eligibility, tariff & coverage.Hospitalization Planned and Emergency.Member approaches the hospital with the printout of the E-card(FHPL) 2 days in advance & get the preauth form filled Hospital send fax to FHPL.Member approaches the hospital tell the hospital that he is covered under FHPL. Hospital starts the treatment, relative of member to fill the preauth form and send to FHPL within 24 hrs of Hospitalization.Query letter sent to the hospital, Member gets the requirement fulfilled from the treating doctor.After getting the querry fulfilled hospital fax the letter to FHPL.Case authorized and approval letter sent to the hospital.Denial letter sent to the hospital. with the justification for denying the cashless to hospital. END STARTMember is intimated via sms & mail about the receipt of requestMember is intimated via sms & mail about the denial of requestMember is intimated via sms & mail about the pendencyTAT : less than 120 min for routine casesProcess of Authorization is Decentralized with central electronic monitoring.Member is intimated via sms & mail about the approval of requestEmergencyPlannedQueryRejectedApproved

19. 19FHPL Reimbursement process STARTMember submits the claim at the helpdeskScrutiny of the claim for documents by helpdesk personnel.Claim returned to the member with intimation to the local Hr to get the required documents and submit the claim in the next helpdesk.Complete documents in Claim, claim collected by helpdesk personnel for further processing.Claim submission to FHPL office for processing the claim.query letter sent to the individual member by e-mail with a copy to HR.Payment advise to Bank (NEFT or Cheque).Payment credited to Members account and a automated mail is sent to memberMail sent to the employee with justification for denialReminder 1 SMS & e-mail.Reminder 2 SMS & e-mailFinal reminder SMS & e-mail sent to member with a cc to HR.Member submits the required documents at the helpdesk. DAY 1 counting starts from this day.member not able to submit the required documents case is closed.Mail sent to the member, Local HR, Corporate HR, & Broker, with proper justifications for rejection or closing the claim.ENDMedical Scrutiny, Billing, Audit, Verification, Investigationsdone to control cost Complete DocumentsIncomplete DocumentsRejectedApprovedQuery

20. 20Mandatory documents for reimbursement claimsSigned claim form - FHPLMain hospital bills in original (with bill no; signed and stamped by the hospital) with all charges itemized and the original receipts with pre numbered payment detailsDischarge summaryAttending doctors’ bills and receipts and certificate regarding diagnosis (if separate from hospital bill)Original lab reports with payment bills and receipts for medicines, investigations along with doctors prescription in originalDetailed bill break ups for the Total amount paid to hospital or Main Bill (Item wise break ups)Accidents – FIR/MLC – Medico Legal Certificate/AR (Accident Report) copyReimbursement claim documents to be submitted within 15 days from the date of discharge to Howden Helpdesk at ALCOB Chennai

21. GROUP MEDICLAIM – Escalation Matrix 21

22. 22HELPDESK details – TPA SPOC  DetailsParticularsNameMobile NoMail IdCustomer RelationshipMr. Sathyanarayanan 9952337064support.ashokleyland@fhpl.netAccount ManagerMr. Nisar Ahmed 9282329403nisarahmed@fhpl.netII Level EscalationMr. Karthika9962202273Karthika.l@fhpl.net

23. 23Howden HELPDESK detailsHierarchyNameDesignationE-MailContactLevel - ISangamalinihelp deskalhealthclaims@howdenindia.com+917397237336Level – IISrividhya VAsst Vice Presidentsrividhyav@howdenindia.com+918754484224 Level – IIIAnanth Prabhu President & Regional Head ananth.prabhu@howdenindia.com+919791079774

24. 24Thank you