cbs benefits administration awareness session for ... cbs benefits administration – awareness...
TRANSCRIPT
CBS Benefits Administration – Awareness session for
employees & HR team ( Non Exempt )
Policy Year : 1stAugust 2015 to 31st July 2016
Enrollment Process : Have you Enrolled Yourself & dependents?
Step 1 : Employees are required to update their personal information
with dependent details to their Line HR within 1 week post joining
Step 2 : The enrollment window period is open till 1st -20th of every
month on Non Exempt TPA portal, Line HR need to update the details on monthly basis
Step 3 :Employees are required to complete and confirm the
enrollment within the timelines. ***In event of new born baby or
newly wedded spouse, employee is required to update dependent
details within 7 days post occurrence of the event
Step 4 : Medical cards will be made available on the website www.paramounttpa.com by 1st
week of every month. please check your details for name/DOB/ age (in case correction is required contact
and update your HR ) .
Data fields to be reviewed in Employee Self Service :
Personal Information
– Basic Details
– Phone numbers ( Mobile )
– Main Address
– Emergency Contacts
– Dependents Information
– Additional Dependents* and Beneficiary information
– DOB is mandatory for self & dependents
****Dependents’ details shared here is used for Medical Cashless &
Reimbursement Claims also hence please update the details
It’s the employee’s responsibility to check and update the records
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An individual cannot be covered as dependent for more than one employee.
Please notify HR each time you acquire a new dependent i.e. when your family status changes
because of marriage, birth or adoption of a child. It must be declared within 7 days
** Dependent's coverage is subject to their being enrolled in the policy within the
given timelines
Members Covered
Dependents: Employee & As per your Company guideline
Age : 2 children ( (up to the age of 24 years) + 1 set of parents/ in-laws uptill 80 yrs.
Employee & Dependents exceeding 80 years are not covered as per the Health Insurance Policy
Siblings, Others (viz. Grand-parent, Aunt, Uncle, Nephew, Niece, etc.) cannot be covered under policy
Policy at a Glance This insurance policy is to provide insurance coverage to the employees/dependents for expenses related to hospitalization only due to illness, disease or injury.
Policy Type Scope Sum Insured Vendor
Health
Insurance ( Family Floater Policy )
Employee &
declared INR 50,000/-
United India Insurance Co. Ltd
Brokers Aon Global Insurance Brokers Pvt. Ltd.
Third Part Administrator Paramount Health Service (TPA) Pvt. Ltd.
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Maternity Benefit Covered for first 2 living children only,(3rd Covered in case 2nd child
birth is twins only for renewal year )
Maternity sub-limit Normal: INR 25,000/- & Caesarean : INR 35,000/-
Pre and Post natal expenses
Covered upto INR 3500/- within maternity limit only as " in patient
cases " of hospitalization only.( Amount will be deducted from Maternity
sub limit )
Baby Cover Covered from Day 1 up to Family Sum Insured, addition under main
policy need to be updated to HR within 15 days.
Maternity Benefit
Your Health Insurance Policy at a glance
General Hospitalization Benefits
Pre - Existing Ailments Covered
30 days & 1 year waiting period for non -
accidental claims Waived Off
Emergency Ambulance Charges Covered up to INR 1500 /- ( From home to hospital or Hospital
to Hospital cases only )
Domiciliary Hospitalization Not Covered
Day Care Procedures Covered as per named illness share in list, This treatment will
require the prior intimation & approval of the TPA/Insurer.
Pre & Post Hospitalization Pre 30 days and Post 60 days
Diagnostics Expenses Not Covered
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Your Health Insurance Policy at a glance cont...
Terrorism cover Covered,24 hrs. hospitlisation is required
Cataract Surgery
1. Multifocal & Unifocal –Torik type are not covered
2. Only Unifocal / Monofocal are covered
3. Cataract surgery covered as per actual or up to sum insured limit
which ever is less.
Congenital Internal diseases/
deformity to be covered Only Internal covered
Ayurvedic treatment covered with
following conditions
• Hospitalization is done at a Government Ayurveda hospital, need to
complete 24 hrs. of hospitlisation.
• Claims are restricted to 20% of the sum insured per family.
• Over all policy limit is Rs 1 lakh for Ayurvedic Treatment
•Not pay for allopathic treatment( Cross treatment )
Angiography to be covered if done
under Day Care or OPD basic Covered
General Hospitalization Benefits
Room Rent Limit INR 1000/- for normal per day and No Capping for ICU per day ,
Including Nursing charges
Domiciliary Hospitalization
Benefit Not Covered
Room Rent Restrictions
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Group Medical : Standard Hospitalization
A) The expenses shall be reimbursed 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.
A) Expenses on Hospitalization for minimum period of 24 hours are normally for select day care admissible. However this time limit
will not apply for specific treatments i.e. Dialysis, Chemotherapy, Radiotherapy, Eye surgery, Dental 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 Hospitalization Benefit provided the procedure is approved by the TPA in advance.
If any Insured Person suffers an Illness or Accident during the Policy Period that requires that Insured Person’s
Hospitalization as an inpatient, then the below-mentioned hospitalization expenses will be reimbursed under your
group medical plan.
• Inpatient Treatment
• Room rent and boarding expenses
• Doctors fees (A medical practitioner)
• Intensive Care Unit
• Nursing expenses
• Anesthesia, blood, oxygen, operation theatre charges, surgical appliances,
• Medicines, drugs and consumables (Dressing, ordinary splints and plaster casts)
• Diagnostic procedures (such as laboratory, x-ray, diagnostic tests)
• Costs of prosthetic devices if implanted internally during a surgical procedure
• Organ transplantation excluding the treatment costs of the donor and organ
-Incremental charges are calculated on
charges levied by hospital such as surgeon
charges, anesthesia and anesthetist charges,
Operation room charges, Doctor visits,
investigation charges and all charges
excluding drugs and consumables.
-The deduction charges are proportionate to
the percentage of higher room category
opted
- These charges are not applicable on non
payable items, Medicines & Implants
-Calculation for other incremental charges
will be applicable as per actual Room
Rent charges as per bill per day
- The deduction for incremental charges can
be better understood by the following
example.
Incremental Charges Calculation Sheet
Particular A B
Final
Amount as
per policy
condition
Amount
deducted as
per policy
conditions
Example If
Opted for a
2500 room
Amount
Deducted
Room rent Capping as per
policy per day
1000 1200
Incremental Room rent
Per Day (Excess Room
Rent Per Day)
0.00 200
Percentage of
Incremental
0.00 20%
Room + Nursing for 5
days
5000 0 5000 1000
Registration Charges 500 500
Surgeon Charges 0
Operation Theatre
Charges
0
Anesthesia & Anesthetist
Charges
0
Doctor Visit Charges 2000 0 1600 400
Laboratory Charges 3000 0 2400 600
Imaging charges 1000 0 800 200
Medicines 800 800
Non Payable 40 40
Total 12800 540 12020 2740
Total Bill 13340 1080 14760 5480
What does Incremental Charges mean?
Planned Hospitalization
Approach hospital 48 hrs. prior to admission , produce TPA card and
complete pre-authorization formalities
Fax Pre-Authorization letter to TPA for Approval
If all the documents are in order, TPA will issue authorization letter to hospital
within 3-5 hours
If the case is Declined, Denial Letter will be issued to hospital
(denial of cashless does not mean denial of treatment or claim)
Incase additional information is required, TPA will inform the Hospital /
Employee
Emergency Hospitalization
Admission in Hospital
Pre-Authorization formalities to be completed within 24 hrs and sent to
TPA for Approval
If all the documents are in order, TPA will issue authorization letter to hospital
within 3 hours
If the case is Declined, Denial Letter will be issued
(denial of cashless does not mean denial of treatment or claim)
Incase additional information is required, TPA will inform the Hospital /
Employee
Cashless Hospitalization
Discharge process takes 5-6 hours post all documents are received by TPA, please cross check
that hospital admin team has sent all requirements to TPA
Insured visit non network hospital for treatment
Takes Discharge , pays for treatment
Collects all Original documents, receipts and investigation reports from
Hospital
Submit all Original Hospital documents along with filled claim form within 15 days from date of discharge to
TPA
TPA Helpdesk acknowledges receipt of
claim documents via email and commences claim
process
Incase additional information is required, TPA will inform
the Employee via email with 3 reminders
If Claim Payable, payment will be made to Corporate
via NEFT
If Claim Declined, Denial mail will be sent. If
documents not submitted within 30 days, Claim may
be Declined
Reimbursement Hospitalization
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1.Discharge procedure
You are advised to follow the pre authorization procedure to ensure eligibility for reimbursement of hospitalization expenses from the insurer.
The insured employee shall upon the happening of any event giving rise to a claim under the policy must inform TPA with full particulars prior or within
48 Hours from the date of Hospitalization on below given mail IDs. & format.
Employee will be required to clear the bills and submit the claim within 15 days to TPA through PHS helpdesk for reimbursement. Please ensure
that all necessary documents such as discharge summary, investigation reports, payment receipts, reports etc. are collected in original for submitting
your claim.
Under hospitalization claims, you are also permitted to claim for treatment expenses 30 days prior to hospitalization ,the claim must be submitted within
7 days post discharge and 60 days after the date of Discharge the claim must be submitted within 7 days post completion of treatment
Claims- Reimbursement / Cashless Admission process & Mail Intimation
Please mail details in below format to TPA, HR & Brokers for assisting you. For all claims, members can send an intimation mail
To : [email protected] , [email protected], [email protected]
CC : [email protected] , [email protected] ,[email protected] ,[email protected]
Company Name Contact No. Email ID
TPA
Paramount Health Services
(TPA) Pvt. Ltd.
Account Manager
Mr. Mangesh Jadhav
9322033230
Ms. Rasika R. Mohol 07710078418 [email protected]
Escalation :
Ms. Preeti Dhar
9373091150
Insurance Broker
Aon Global Insurance Brokers
Pvt.Ltd.
( For Escalation )
Mr. Amit Korde 9850862788 [email protected]
Ms. Meriam Ansari 9822071098 [email protected]
CBS :
Cummins India Ltd.
( For Escalation )
Ms. Shibani Dhond 9881711358 [email protected]
Mr. Nilesh P Bhairavkar 9011079702 [email protected]
Claim intimation format
Mail Subject Line : Pre-Intimation for Cashless / Reimbursement for WWID ________, Patient Name ____________
S.No. Details To be filled by Employee ( Below is an example )
1 Employee Name/Insured Name RITESH JHA
2 Employee Code ( WWID ) 22122
3 Company Name Cummins India Ltd.
Entity Name CIL-DBU
TPA Health card ID/Customer ID 20057711
Contact Number 9800011010
4 E-mail ID [email protected], [email protected]
5 Patient Name Gauri Jha
6 Relationship Wife
8 Date of admission 21/12/2015
9 Expected Date of Discharge Not known
10 •Name of the Hospital/Provider Jehangir Hospital
11 •Address of the Hospital for verification purpose 32 , sasoon Road , Pune 411001
12 Ailment for which patient is hospitalized Cataract Left Eye
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Expected cost of treatment /Estimated Cost of Hospitalization
Not known
Submission of hospitalization claim 1.After the hospitalization is complete and the patient has been discharged from the hospital, the claim must be submitted within 15 days from
the date of discharge from the hospital.
2.Under hospitalization claims, you are also permitted to claim for treatment expenses 30 days prior to hospitalization ,the claim must be
submitted within 7 days post discharge and 60 days after the date of Discharge the claim must be submitted within 7 days post completion of
treatment .
This is applicable for both network and non-network hospitalization.
Kindly note: Violation of the above mentioned timelines may result in denial of claims by the Insurer/TPA & any exception will be at the sole
discretion of the Insurer only.
For further assistance /clarification, you can contact PHS Account Manager / Brokers / HR team
1. Signed claim form & cancelled cheque for NEFT payment
2. Original hospital Bill, Payment Receipt and Original Discharge Certificate Card / Summary from the Hospital all need to be
duly signed by the treating doctor and stamped by the hospital.
3.Original Report, Receipt and Pathological Test Report from Pathologist supported by a note from the attending Medical
Practitioner/Surgeon demanding/suggesting such Pathological Test.
4.Original Receipt and Report of X-Ray and ICG of the doctor with a note of doctor suggesting such requirement.
5.Attending Doctor's /Consultant's/Specialist's / Anesthetist's bill, receipt and certificate regarding diagnosis.
6.If operated on, Surgeon's bill and receipt and certificate stating nature of operation performed.
7.Certificate from attending Medical Practitioner/Surgeon that the patient is fully cured .
8.Cash memos from the Hospital /Chemist supported by proper prescription of the Doctor.
9.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.
10. In non- network hospitalization, 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.
Kindly note that claim intimation & claim submission within the specified timelines is a mandatory requirement for
processing the claim. All Documents mentioned are mandatory and have to be submitted in ORIGINAL
Note: Kindly retain photo copies of all the documents. KYC – Government issued Photo ID and Address proof
***The above is an indicative list and additional documents can be requested for to process a claim.
Claim Document Check List
Medical Certificate Discharge Summary
Hospital Bill Payment Receipt
Examples of mandatory documents
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General Exclusions Circumcision, Vaccination, Inoculation Cosmetic treatment, Plastic surgery
Spectacles, Content lenses , Hearing Aids
Convalescence, General weakness, Congenital external disease, Alcohol
Self injury
AIDS
Diagnostic expenses not followed by active treatment for the ailment
Vitamins and Tonics unrelated to treatment
Injuries or diseases caused by nuclear weapons / Expedition / Sports
Voluntary abortion /Family planning Operations (Vasectomy or tubectomy) etc
Any treatment received in convalescent home, convalescent hospital, health hydro, nature care clinic or similar establishments.
The treatment of obesity (including morbid obesity) and other weight control programs, services and supplies.
Genetic disorders and stem cell implantation/ surgery/ storage.
Fertility / Infertility treatment
Homeopathy and naturopathy treatment , unproven procedure/treatment, experimental or alternative medicine/treatment including
acupuncture, acupressure, magneto therapy ,BAMS & BHMS Unani etc.
Any kind of Dental Treatment other than accident
OPD treatments
Any kind of psychiatric treatment
Congenital external diseases or defects/anomalies
Change of treatment from one pathy to other pathy unless being agreed / allowed and recommended by the consultant under whom the treatment
is taken.
Any kind of Service charges, Surcharges, Admission fees / Registration charges etc levied by the hospital.
Doctor’s home visit charges, Attendant / Nursing charges during pre and post hospitalisation period.
Expenses incurred for investigation or treatment irrelevant to the diseases diagnosed during hospitalisation or primary reasons for admission.
Private nursing charges, Referral fee to family doctors, Out station consultants / Surgeons fees etc,.
External and or durable Medical / Non medical equipment of any kind used for diagnosis and or treatment like Prosthetics etc.
Lasik treatment or any other procedure for correction/enhancement of vision is not covered.
Any device/instrument/machine that does not become part of the human anatomy/body but would contribute/replace the function of an organ is
not covered.
Warranted that treatments on trial/experimental basis are not covered under scope of the policy.
Note: Above exclusions are only indicative, please refer Insurance Company Policy Copy for complete Standard Exclusions
Exclusions
General Exclusions list
Non Medical Expenses
Your health insurance policy pays for reasonable and necessary medical expenditure. There are several items that do
not classify as medical expenses during hospitalization. These items will not be payable and expenditure towards such
items will have to be borne by you. Some common examples of non-medical expenses are listed for your reference:
• Telephone expenses
• Food for patient attendant
• Toiletries such as soap, razor, shaving cream, comb, etc.
• Double occupancy - two hospital beds occupied for one patient
• Rehabilitative aids such as crutches, braces, slings,walker, orthopaedic belts, collar, etc.
• Water bed
• Registration charges
• Documentation charges
• Administrative expenses
• Admission fee
• Complan, Horlicks, Viva, Bournvita, Spert etc. that come under the category of food supplements
• Boroline, Boroplus , Borocalendula, any other perfumed antiseptic cream.
• Any kind of shampoo, hair cream, hair oils, hair vitalizers, medicated soaps and powders, vitaminized oils, olive oils,
cosmetic creams, dental cream etc.
• Baby cream, baby powder, baby oil, baby shampoo and any other related items
• Water purifiers such as Zeoline etc.
• Thermometer
• Admission kit
• Tissue paper/Diaper/Sanitary pad
• Spectacles even if prescribed
• Nebulizer kit
• Oxygen cylinder
• Urine can / commode
• C.D/Video cassette
• Expenses for newborn infants unless authorized.
• Vaccinations of any kind even for the new-born
• Medication/ treatment not pertaining to the illness for which hospitalized
Download Medical E-Card How Can I view my E-card using WWID ?
Step 1 : Log on to. www.paramounttpa.com
Step 2 : Click on INSTANT E card.
Step 3 : In the drop down box select Insurance Company name :- “ United India Insurance Company Ltd.”
Step 4 : In the pick box select “Employee ID”,enter your unique WWID no. in the check box
Step 5 : Enter “Group code” as per your Corporate name
Step 6 : Click “ submit “
1st step
2nd step Medicards
3rd ,4th,5th,6th step Corporate Group Coding's
Coding Corporate Name Entity type
TCU TATA CUMMINS LTD.
Non Exempt
CUMI CUMMINS INDIA LTD.
Non Exempt
CGTL CUMMINS GENERATOR
TECHNOLOGIES INDIA LTD
Non Exempt
CMTL CUMMINS TECHNOLOGIES
INDIA LIMITED Non Exempt
TPA Mobile App. For your 1st hand information
PHS TPA Mobile app is for GMC – Corporate policies for Android Mobiles. You all can search it in Play Store by
"Paramount TPA
Steps / Procedure to avail the benefit of Mobile App as follows :
1)Go To Play Store in your Android Mobile
2)Search for “Paramount TPA” in app store
3)Click on Install
4)Follow user registration process with either of below option –
5)Corporate Employee – Group Mediclaim Policy
a) PHS Id And Insurance Company
Or
b) Employee No + Group Code + Insurance Company
6)Individual Policy Holder
a) PHS Id And Insurance Company
Or
b) Policy Number And Insurance Company
After successful registration, login credentials will be shared on user’s registered mobile number and email id by auto SMS
and email respectively
8)User can login to PHS Mobile app using credentials received on your mobile & email.
9)It is a onetime login process until user clears his/her mobile data / cache for Paramount TPA app.
10)In case any login / registration problem user can use Raise Query Option available on main screen of Mobile app or can
write Paramount on [email protected]
11)In case any issue with internal options available such as enrollment information, claim details etc. same Raise Query
Option can be used with selecting appropriate service option from list or can write Paramount on
12)While writing mail on [email protected], kindly quote your "PHS ID" and Mobile type e.g. :
"Android/iPhone/Blackberry/Windows" in subject line.
Plan Wise. Live Healthy
THANK YOU