Employee Benefits Manual

October 2013

Client Maxim India Integrated Circuit Design Pvt Ltd

Document No Marsh/TFS/October2013

Start

MARSH 2

Prepared by

Manjula R

Marsh India Insurance Brokers Private Limited

RMZ Millennia, Ulsoor

Bangalore 560008

Copyright © 2013. All rights reserved. No part of this publication may be reproduced, stored in the retrieval system, or be transmitted in any form or by any means, electronic or mechanical, photocopying, recording or otherwise, without the prior written permission of MARSH.

Disclaimer: This manual is intended to be general summary of the benefits offered by your company & should be regarded as guide only.

While Marsh shall make every reasonable effort to ensure the accuracy and validity of the information provided here in this

document. Marsh accepts no liability or responsibility for any errors or omissions in the content or for any loss or damages arising

out of your reliance on information provided here. If there is a conflict in interpretation or benefit applicability, then the terms &

conditions of the policy will prevail.

MARSH 3

Group Medical Provides insurance coverage to employees /dependents for expenses related

to hospitalization due to illness, disease or injury

Program Details

MARSH 4

MARSH 5

Policy Parameter

Insurer The New India Assurance Co Ltd

TPA FHPL

Policy Start Date 07th October 2013

Policy End Date 06th October 2014

Coverage Type Family Floater

Dependent Coverage 1 + 5 – (Employee + Spouse + dependent Children + 2 dependent Parents)

Sum Insured INR 5 lakhs per family (Parental sum Insured restricted to Rs.1.50 lakhs)

Benefits / Extensions

Standard Hospitalization • Yes

Pre existing diseases • Yes

Waiver on 30days & 1st year exclusion • Yes

Pre-Post Hospitalization Exp. • Yes

Maternity benefits • Yes

Ambulance Services • Yes

Baby cover day 1 • Yes

Benefits / Extensions

Baby Expenses during maternity • Yes

Day Care • Yes

Domiciliary Hospitalization • No

Pre & Post natal expenses • Yes

Room Rent Cap • Applicable

Copayment

•Yes, 20% on

parental claims

only only

Medical Benefit – Policy Details

MARSH 6

Medical Benefit – Dependant Coverage

Maximum no of Members insured in a family (Employee

Policy) 1+5

Employee Yes

Spouse Yes

Children Yes (for the first 2 living Children)

Parents Yes

Siblings/ Parents-in-Law No

Others No

Mid Term enrollment of existing Dependents Disallowed

Mid Term enrollment of New Joinees (New employees +their

Dependents) Allowed

Mid term enrollment of new dependents (Spouse/Children) Allowed

Mid term change in the enrolled dependants post window

period

Disallowed

Mid term enrollment of new dependents (Spouse/Children) Allowed

No Individual should be covered as dependent of more than one employee

MARSH 7

Medical Benefit – Policy Period

Existing Employees + Dependents

Commencement Date 07th October 2013

Termination Date 06th October 2014 or last working day whichever is

earlier

New Joinees + Dependents

Commencement Date Date of joining

Termination Date 06th October 2014 or last working day whichever is

earlier

New Dependents (due to Marriage / Birth)

Commencement Date for New dependents due to marriage Date of marriage (additions to be intimated within 30

days from the date of event)

Commencement Date for New dependents due to birth

Date of Birth (additions to be intimated within 30 days

from the date of event)

Termination Date 06th October 2014 or last working day whichever is

earlier

MARSH 8

Medical Benefit – Standard Coverage

• Room and boarding

• Doctors fees

• Intensive Care Unit

• Nursing expenses

• Surgical fees, operating theatre, anesthesia and oxygen and their administration

• Physical therapy

• Drugs and medicines consumed on the premises

• Hospital miscellaneous services (such as laboratory, x-ray, diagnostic tests)

• Dressing, ordinary splints and plaster casts

• Costs of prosthetic devices if implanted during a surgical procedure

• Radiotherapy and chemotherapy

A) The expenses are payable provided they are incurred in India and within the policy period. Expenses will be

reimbursed to the covered member depending on the level of cover that he/she is entitled to.

Inpatient Hospitalization - Covers expenses related to

B) 24 Hours hospitalization not required

Expenses on Hospitalisation for minimum period of 24 hours are admissible in case of an active line of treatment.

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

Hospitalisation Benefit.

All /any Expenses are only payable subject to policy terms and conditions

Note the list above is not exhaustive and the policy document to be referred for further details

MARSH 9

Post-hospitalisation Expenses

Definition

• If the Insurer accepts a claim under Hospitalization and immediately following

the Insured Member’s discharge, further medical treatment directly related to the

same condition for which the Insured Member was Hospitalized is required, the

Insurer will reimburse the Insured member’s Post-hospitalisation Expenses for up

to 60 day period.

Covered • Yes

Duration • 60 Days

Pre & Post Hospitalization Expenses

Pre-hospitalisation Expenses

Definition

• If the Insured member is diagnosed with an Illness which results in his / her

Hospitalization and for which the Insurer accepts a claim, the Insurer will also

reimburse the Insured Member’s Pre-hospitalisation Expenses for up to 30 days

prior to his / her Hospitalization.

Covered • Yes

Duration • 30 Days

Note: Pre and post hospitalization expenses are payable only if the expenses are related to the ailment of the main hospitalization claim. Also if there is a hospitalization in the pre/post period with no active line of treatment the room rent would not be payable however the related diagnostics would be payable.

MARSH 10

Maternity Benefits

• These benefits are admissible in case of hospitalisation in India.

• Covers first two children only. Those who already have two or more living children will not be eligible for this benefit.

• Expenses incurred in connection with voluntary medical termination of pregnancy during the first 12 weeks from the

date of conception are not covered.

•Medical termination of pregnancy post 12 weeks would be covered with in the maternity limit

Benefit Details

Benefit Amount • INR 50,000 for normal & INR 75,000 for C-Sec within the Family

Floater Sum Insured

Restriction on no of children • Restricted to the first 2 children

9 Months waiting period • Waived off

Pre-Post Natal Expenses • Incurred on an out patient basis upto 5% of the maternity sub-limit

specified in the table below or Rs.5000 whichever is lower

Baby Expenses

•Up to 5% of the maternity Sub-limit or Rs.5000 whichever is lesser

MARSH 11

Day Care Procedures

HOSPITALISATION means admission in any Hospital/Nursing Home in India upon the written advice of a Medical

practitioner for a minimum period of 24 consecutive hours. Day care procedures as below which does not require 24 hour

hospitalization would be covered under the policy OR any other Surgeries / Procedures agreed by TPA/COMPANY which

require less than 24 hours hospitalisation due to subsequent advancement in Medical Technology.

Anti Rabies Vaccination Hysterectomy

Appendectomy Inguinal/Ventral/Umbilical/Femoral Hernia repair

Coronary Angiography Lithotripsy (Kidney Stone Removal)

Coronary Angioplasty Parenteral Chemotherapy

Dental surgery following an accident Piles / Fistula

Dilatation & Curettage (D & C) of Cervix Prostate

Eye surgery Radiotherapy

Fracture / dislocation excluding hairline fracture Sinusitis

Gastrointestinal Tract system Stone in Gall Bladder, Pancreas, and Bile duct

Haemo-Dialysis Tonsillectomy

Hydrocele Urinary Tract System

MARSH 12

Room rent

Room rent Cap per Day – 1% of SI for normal & 2% of SI for ICU

Sum Insured – INR 5 lacs • INR 5000 for normal & INR 10000 for ICU

IMPORTANT NOTE : In The Event Of A Member Occupying A Room Higher Than The Above Limits, All The

Related Expenses Like Doctor’ S Fees, Surgery Charges, Nursing Charges, Etc Will Be Scaled Down In

Proportion To The Eligible Room Charges

MARSH 13

Ambulance Services

Ambulance Expenses

Definition

•The Insurer will pay for Emergency ambulance road transportation by a

licensed ambulance service to the nearest Hospital where Emergency Health

Services can be rendered. Coverage is only provided in the event of an

Emergency.

Covered

•The Policy will cover Ambulance charges in connection with admitted claim

incurred to shift the insured person from Residence/accident site to Hospitals in

emergency cases and from one Hospital/Nursing Home to another

Hospital/Nursing Home/Diagnostic centre for better care/diagnosis,

Amount Restriction •1% of the sum insured or Rs.2000 which ever is lower

MARSH 14

Benefits Definition Coverage Limit

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

Person’s first Health Insurance policy with the Insurer

Covered

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

Waived

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

Waived

Benefit Extensions – Definitions

MARSH 15

Benefits Definition Coverage Limit

Dental & Vision

Treatment

Any dental treatment or surgery of a corrective, aesthetic nature

unless it requires Hospitalization; is carried out under general

anesthesia and is necessitated by Illness or Accidental Bodily Injury.

Not Covered

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 within 30 days as

additional member as mentioned elsewhere under this Policy.

Covered

Benefit Extensions – Definitions

MARSH 16

Benefits Definition

Domiciliary

Hospitalization

(NOT

COVERED)

DOMICILIARY HOSPITALISATION BENEFIT means Medical treatment for a period

exceeding three days for such illness/disease/injury which in the normal course would

require care and treatment at a hospital/ nursing home but actually taken whilst

confined at home in India under any of the following circumstances, namely:

– The condition of the patient is such that he/she cannot be removed to the

hospital/nursing home or

– The patient cannot be removed to the hospital/nursing home for lack of

accommodation therein

Benefits not

covered under

Domiciliary

Treatment

• Expenses incurred for pre and post hospital treatment, and

• Expenses incurred for the treatment for any of the following diseases:

– Asthma

– Bronchitis

– Chronic Nephritis and Nephritic Syndrome

– Diarrhea and all types of dysentries including Gastroenteritis

– Diabetes Mellitus and Insipidus

– Epilepsy

– Hypertension

– Influenza, Cough, and Cold

– All Psychiatric or Psychosomatic disorders

– Pyrexia of unknown origin for less than 10 days

– Tonsillitis and upper respiratory tract infection including Laryngitis and

Pharyngitis

– Arthritis, Gout and Rheumatism

Benefit Extensions – Definitions

X

Not Applicable

MARSH 17

Medical Benefit – General Exclusions

• Injury or disease directly or indirectly caused by or arising from or attributable to War or War-like situations

• Circumcision unless necessary for treatment of disease

• Congenital external diseases or defects/anomalies

• HIV and AIDS

• Hospitalisation for convalescence, general debility, intentional self-injury, use of intoxicating drugs/ alcohol.

• Venereal diseases

• Injury or disease caused directly or indirectly by nuclear weapons

• Naturopathy

• Any non-medical expenses like registration fees, admission fees, charges for medical records, cafeteria charges, telephone

charges, etc

• Cost of spectacles, contact lenses, hearing aids

• Any cosmetic or plastic surgery except for correction of injury

• Hospitalisation for diagnostic tests only

• Vitamins and tonics unless used for treatment of injury or disease

• Infertility treatment

• Voluntary termination of pregnancy during first 12 weeks (MTP)

• OPD Claims

• Claims (of high value) submitted without prescriptions/diagnosis

• Health foods

• Costs incurred as a part of membership/subscription to a clinic or health centre

• Naturopathy

• Cost of appliances, spectacles, contact lenses, hearing aids

• Non-medical expenses like Hospital surcharge, telephone bills, cafeteria bills

MARSH 18

Medical Policy – Policy Change for 2013-14

Policy Terms Existing Coverage Renewal Coverage

Pre Existing Covered Covered

Maternity Covered Covered

Ailment Capping Not Applicable Not Applicable

Room Rent Eligibility

INR 5000 for normal and INR

10000 for ICU INR 5000 for normal and INR 10000 for ICU

Co payment No Co-payment 20% Co-pay on parental claim

MARSH 19 Health Administration Team

PROCEDURE FOR CARD ISSUANCE FOR NEW EMPLOYEE / ADDITIONS

IN FAMILY

1. Declaration of Employee with family details through H.R within 30 days of Joining Period

2. Data sent for cards issuance to the TPA/Insurer.

3. New cards issued within 15 working days of receipt of data from HR .

• IN THE INTERIM PERIOD TILL THE CARDS ARE ISSUED,IN CASE OF ANY MEDICAL EMERGENCY,EMPLOYEE

CAN AVAIL OF CASHLESS BENEFIT BY QUOTING HIS EMPLOYEE NUMBER.

• Newly wedded spouse & new born children need to be declared within 30 days of marriage and 30 days of

birth respectively

• For seamless transactions of cashless please contact the FHPL SPOC

MARSH 20

Process for e-card

Click on www.fhpl.net

Click on e-card

Select “Maxim India ” from “corporate” drop down menu.

Enter your User ID and Password ( User Id and password will be communicated to you by FHPL

shortly)

Login successful – Click on individual name, welcome message will appear and than click on e-card to

view and download the e-card. You may retain print copy of this at your home and office.

Login Failure – Please contact FHPL respective zone account manager for immediate assistance

MARSH 21

Medical Benefit – Cashless Process

Cashless means the TPA may authorize upon a Policyholder’s request for direct settlement of eligible services and it’s

according charges between a Network Hospital and the TPA. In such case the TPA will directly settle all eligible amounts with

the Network Hospital and the disallowed amount would be paid by the insured member

List of hospitals in the FHPL network eligible for cashless process

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.

Please check for the updated Network Hospital list on the FHPL https://www.fhpl.net/NetworkHospitals/NWHospitals.aspx (New India

Assurance company Limited)

MARSH 22

Hospitalization in Network Hospitals

• EMERGENCY ADMISSIONS – In FHPL Network Hospitals

– Admission of Patient

– Starting of Treatment

– Provide Hospital Administration your Health Identity card

– Pre Authorization form to be filled up by treating Doctor and Hospital Admin to Fax it to FHPL

– FHPL to confirm validity of Person Covered to Hospital for Cashless

– On Discharge:

– 1.Employee to Sign on Claim form and Hospitalization Bills provided from Hospital.

MARSH 23

• PLANNED ADMISSIONS – Empanelled Hospitals

– Pre Authorization Letter to be filled up by the treating Doctor and the Hospital has

to send it to FHPL 48 hrs before admission.

– FHPL to confirm the validity of employee insured and preauth will be processed as per policy terms and conditions.

– Patient gets admitted.

Hospitalization in Network Hospitals

MARSH 24

Eligibility

Covered

Not

Covered

Pre-authorization Process for Cashless

Hospital sends

Intimation to

FHPL

Authorization as

per eligibility

Out of Pocket

payment

TAT : less than 2 hrs for routine cases

Regularization within 24 Hrs

Process of cashless authorization is decentralized

List of network hospital visit our website.

Member

approaches

Hospitals with

FHPL ID Card

Cashless treatment

at NWH

MARSH 25

FHPL processes claims

Settle the Claim in 15 working days

FHPL verifies the documents submitted

In case of incomplete documents

recovery of documents for scrutiny

Member avails treatment at any hospital and intimates FHPL with in 24

hours & takes an intimation No. and flashes at time submitting the claim

Member submits bills to FHPL within 15 days of discharge

Protocol for Availing Treatment in Non Network Hospital

MARSH 26

Procedure for Reimbursement

Pay and settle the bills & collect the following documents from the hospital. Submit the same to FHPL

representative within 15 days of discharge :

1. NIA claim form, duly filled & signed by the claimant.

2. Discharge Summary

3. Final Bill with breakup

4. Receipts for the payment made.

5. All Laboratory investigation reports

6. In case of surgical packages – detail breakup of the package.

7. Medicine bills with prescriptions.

8. In case of maternity, gravida status to be mentioned in discharge summary.

9. Cancelled cheque.

30 Days pre & 60 Days Post hospitalization.

1. NIA claim form, duly filled & signed by the claimant.

2. Original investigation reports along with bills & receipts.

3. Consultation receipts.

4. Medicine bills with prescriptions.

Please Note: All the documents should be submitted in Original and please retain copy of all the documents for

further references

MARSH 27

Call Centre

Dedicated member helpline 24 x 7

Nationwide Toll free 1800 – 425 - 4033

24 X 7days accessible

Electronically supported systems

Managed by professionally skilled manpower

Assistance in information on

Network hospitals

Enrollment status

Support services in an Emergency

Coverage eligibility

Claims- documentation support, query handling

General information on health plan

MARSH 28

Important

Always keep a copy of FHPL ID card in your wallet and remember your UHID (FHPL ID card number). Without FHPL e-card

/UHID you cannot avail cashless benefits and claiming for benefits.

While contacting FHPL personnel, please introduce yourself by your name, UHID and corporate you are working for.

Always remember 5 – 6 FHPL network hospitals near to your work location and residence.

In case of any emergency in odd hours, kindly contact our 24/7 toll free number (1800-425-4033)

For downloading e-card(s), claim forms, network hospital list, kindly follow the link www.fhpl.net

For e-card queries or resetting your e-card login password, please write to csblr@fhpl.net

MARSH 29

Escalation Matrix

FHPL

Level of Contact Contact Person Contact no: E-mail ID

Ist Level Suresh. P 9243479820 sureshp@fhpl.net

IInd Level Mr. Rahul Krishnan 9243468395 rahul.krishnan@fhpl.net

IIIrd Level Mr. Jom George 9243353882 jom.george@fhpl.net

MARSH 30