AESM EMPLOYEE BENEFIT PROGRAM FOR ANGLO EASTERN Senior, Junior, TRAINEE OFFICERS, RATINGS & TRAINEE RATINGS
The Anglo Eastern Ship Management India Private Ltd’s Employee Benefit Program is designed in partnership with Aum Insurance Brokers Pvt. Ltd. This program has been created to better serve and, most importantly, meet the needs of the Officers, Trainee Officers, Ratings & Trainee Ratings and their families.
The Employee Benefit Program comprises Insurance coverage schemes for the Anglo Eastern Officers (Senior & Junior), Trainee Officers, Ratings & Trainee Ratings and their families:
Group Floater Mediclaim Policy: The Policy provides coverage to Self, Spouse and first two dependent children up to 25 years of age and can be availed by any one or any members in the family that are covered in the policy. The Officer’s family is covered for a fixed Sum Insured and anyone in the family can avail the facility till the limit is exhausted.
In order to maximize the benefits under the policy please ensure that all your family members Names & Date of Birth are listed in the Policy. You may get in touch with Welfare Dept. of Anglo Eastern to inquire about the coverage of all your family members.
Group Personal Accident Policy: The Policy covers only the officer, Trainee Officer, Rating & Trainee Ratings. No dependants are covered under this policy. Group Personal Accident policy offers compensation, in case of death to the Insured person’s nominee, directly and solely as a result of an accident.
Policy DETAILS
ITEM / GROUP FLOATER MEDICLAIM POLICY / GROUP PERSONAL ACCIDENT POLICYPolicy Name / Group Floater Mediclaim Policy (GFMP) / Group Personal Accident Policy (GPA)
Insurer / National Insurance Co Ltd. / National Insurance Co Ltd.
Sum Insured / SENIOR OFFICERS INR. 3 Lakhs
JUNIOR OFFICERS INR. 2 Lakhs
TRAINEE OFFICERS INR. 2 Lakhs
RATINGS & TRAINEE RATINGS INR. 2 Lakhs / SENIOR OFFICERS INR. 50 Lakhs
JUNIOR OFFICERS INR. 20 Lakhs
TRAINEE OFFICERS INR. 20 Lakhs
RATINGS & TRAINEE RATINGS INR. 10 Lakhs
Who is covered / Self, Spouse and first two children up to 25 yrs of age / Officer, Trainee Officer, Ratings & Trainee Ratings only on Leave
Policy Number / 240200501610003336 / 240200421610000353
Policy Period / 10th July 2016 to 9th July 2017 / 4th July 2016 to 3rd July 2017
Third Party Administrator / E-Meditek TPA Services Ltd. / NA
The key components of the Group Floater Mediclaim Policy
o Sum Insured of INR. 3,00,000; INR 2,00,000 and INR 2,00,000 respectively for Senior Officers, Junior Officers, Trainee Officers, Ratings & Trainee Ratings along with their Spouse and first Two dependent children upto 25 years on family floater basis.
o New born child covered after the 3rd month subject to intimation to Anglo Eastern
o What is covered?
§ First year Standard Exclusions are covered
§ Pre-existing diseases are covered
§ 30 days waiting period waived (Claims arising from the first day of the inception of policy will get paid)
§ Teeth treatment resulting ONLY out of an Accident are covered
o What is NOT Covered?
§ Maternity and any disease arising or related to maternity
o Availability of the Third Party Administrator (TPA) facility for Claim settlement
o Availability of Cashless and Reimbursement facilities
o Room Charges: For Normal Room 1.5% (Rs. 3000/-) and for ICU 3% (Rs. 6000/-). As per the policy the Hospital Normal Room Charge should not exceed 1.5% of the applicable Sum Insured (e.g. Rs.2 Lakhs), i.e. Rs. 3000 per day. In the event of a person getting admitted in higher category, all other related charges will be pro-rated to the eligibility limit. All other related charges will among other things, include OT Charges, Doctors Charges & Nursing charges and the same will be payable as per room rent entitlement.
Example :
If you are covered for a Sum Insured for Rs. 2 Lakh, therefore you are entitled to a Room Rent (RR) + Associated Charges (AC)= 1.5% of Sum Insured per day, i.e.: 1.5% x Rs.2 Lakh = Rs 3000/day. But if you opt for a higher RR+AC =Rs.4000. In this case the Claim Deduction Calculation will be as follows:
= (Opted R R + AC) – (Entitled R R + AC)*100/ Opted R R + AC
= (4000-3000)*100/4000 = 1000*100/4000 = 25%
o Ambulance Charges :- Rs. 2000/- or actual, whichever is less, in case patient has to be shifted from residence to hospital for admission in emergency ward or ICU or from one Hospital / Nursing Home to another Hospital / Nursing Home by fully equipped Ambulance for Medical Facilities.
o Pre-Hospitalization (30 days before Hospitalization): Doctor consultation fees, medical reports and related medication prescribed 30 days prior to hospitalization can be Reimbursed subject to production of the relevant documents/papers
o Post-Hospitalization (60 days after Hospitalization): Doctor consultation fees, medical reports and related medication prescribed 60 days after hospitalization can be Reimbursed subject production of relevant documents/papers
permanent EXCLUSIONS: What is not covered
4.1 Injury or disease directly or indirectly caused by or arising from or attributable to War Invasion Act of Foreign Enemy Warlike operations (whether war be declared or not) and Injury or disease directly or indirectly caused by or contributed to by nuclear weapons/materials.
4.2 Circumcision unless necessary for treatment or a disease not excluded hereunder or as may be necessitated due to an accident, vaccination or inoculation or change of life or cosmetic or aesthetic treatment of any description, plastic surgery other than as may be necessitated due to as accident or as part of any illness.
4.3 Surgery for correction of eye sight cost of spectacles, contact lenses, hearing aids etc.
4.4 Dental treatment or surgery-corrective, cosmetic or aesthetic procedure, filling of cavity, root canal, wear & tear unless arising due to an accident and requiring hospitalisation.
4.5 Convalescence general debility `Run Down’ condition or rest cure, congenital external disease or defects or anomalies, sterility, infertility/sub fertility or assisted conception procedures, venereal disease, intentional self-injury, suicide, all psychiatric & psychosomatic disorders/diseases, accidents due to misuse or abuse of drugs/alcohol or use of intoxicating substances.
4.6 All expenses arising out of any condition directly or indirectly caused to or associated with Human T-Cell Lymphotrophic Virus Type III (HTLB-III) or Lymphadinopathy Associated Virus (LAV) or the Mutants Derivative or variations Deficiency Syndrome or any Syndrome or condition or a similar kind commonly referred to as AIDS, complications of AIDs and other sexually transmitted diseases(STD).
4.7 Expenses incurred primarily for evaluation/diagnostic purposes not followed by active treatment during hospitalization.
4.8 Expenses on vitamins and tonics unless forming part of treatment for injury or disease as certified by the attending physician.
4.12 Treatment arising from or traceable to pregnancy/ childbirth including caesarean section, miscarriage, abortion or complications there of including changes in chronic conditions arising out of pregnancy.
4.13 Naturopathy, unproven procedure/treatment, experimental or alternative medicine/treatment including acupuncture, acupressure, magneto-therapy etc.
4.14 Expenses on irrelevant investigations/treatment; private nursing charges, referral fee to family physician, outstation Doctor/Surgeon/ consultants’ fees etc.
4.15 Genetical disorders/stem cell implantation/surgery
4.16 External/ durable medical/Non-medical equipment of any kind used for diagnosis/treatment including CPAP, CAPD, infusion Pump etc., ambulatory devices like walker/ crutches/ belts/ collars/caps/ splints/ slings/ braces/ stockings/ diabetic foot-wear/ glucometer/ thermometer & similar related items & any medical equipment which could be used at home subsequently.
4.17 Non-medical expenses including personal comfort/ convenience items/ services such as telephone/ television/ aya/ barber/ beauty services/ diet charges/ baby food/ cosmetics/napkins/ toiletries/ guest services etc.
4.18 Change of treatment from one pathy to another unless being agreed/allowed & recommended by the consultant under whom treatment is taken.
4.19 Treatment for obesity or condition arising there from (including morbid obesity) and any other weight control program/services/supplies.
4.20 Arising from any hazardous activity including scuba diving, motor racing, parachuting, hand gliding, rock or mountain climbing etc. unless agreed by insurer.
4.21 Treatment received in convalescent home/hospital, health hydro/nature care clinic & similar establishments.
4.22 Stay in hospital for domestic reason where no active regular treatment is given by specialist.
4.23 Out-patient diagnostic/medical/surgical procedures/treatments, non-prescribed drugs/ medical supplies/ hormone replacement therapy, sex change or any treatment related to this.
4.24 Massages/Steambath/ Surodhara & alike Ayurvedic treatment.
4.25 Any kind of service charges/surcharges, admission fees/registration charges etc. levied by the hospital.
4.26 Doctor’s home visit charges/attendant, nursing charges during pre & post hospitalization period.
4.27 Treatment which the insured was on before hospitalization and required to be on after discharge for the ailment/disease/injury different from the one for which hospitalization was necessary.
MEDICLAIM MANAGEMENT
Types of Hospitalization and hospitals
TYPES OF HOSPITALIZATIONPLANNED
Individual is aware of hospitalization 72 hours in advance / EMERGENCY
Individual meets with an accident/suffers with illness that requires immediate hospital admission
TYPES OF HOSPITALS
TPA NETWORK
Hospitals which the TPA has partnered with (more than 3000 hospitals covered) and Cashless Service can be availed. / NON NETWORK
Not included in the TPA network of hospitals and Reimbursement service can be availed
Hospital/Nursing Home‚ means any institution in India established for indoor care and treatment of sickness and injuries and which
Either
(a)Has been registered either as a hospital or Nursing Home with the local authorities and is under the supervision of the registered and qualified medical practitioner
OR
(b)Should comply with minimum criteria as under:
I. It should have at least 15 inpatient beds. In Class "C" towns condition of number of beds may be reduced to 10
II. Fully equipped Operation Theatre of its own wherever surgical operations are carried out.
III. Fully qualified nursing staff under its employment round the clock
IV. Fully qualified Doctor(s) should be in charge round the clock
2.4.1 The term‚ `Hospital/Nursing Home’‚ shall not include an establishment which is a place of rest, a place for the aged, a place for drug addiction or place of alcoholics, a hotel or a similar place.
Reasonable and Customary Expenses: means reasonable and customary surgical/medical treatment expenses within the scope of cover of this policy to treat the condition for which the insured person was hospitalised.
Types of Claims
REIMBURSEMENT / CASHLESSThe hospital is not under the TPA’s network hospitals or at his/her own liberty the individual chooses a non-network hospital, or / The insured need not pay money at the time of admission or discharge other than what is not covered by the policy
Cashless is Denied / Can be availed only at TPA Nework Hospitals
Bill is settled after hospitalization and subsequently makes a claim / Payment is subject to deductibles and Sum Insured as specified in the policy
Claim Intimation Requirements
A Claim Intimation E-mail should be sent to Aum Insurance Brokers Pvt. Ltd. () with the following information:
Insured’s (Seafarer) NameInsured’s Crew ID / Designation
Name of the Patient / Age of the patient with DOB Proof (for dependents only)
Nature or illness/ Accident / Relationship of patient with the employee
Hospital Details
Doctor’s Name / Hospital Admission Date
Hospital’s Name / Hospital Discharge date
Personal Postal Address / Personal Contact No.
Commencement date of symptom of the disease in case of an illness / Remarks (if Any)
Accidental Case
Date and time of Accident / FIR Report
location of accident / MLC Report
Claim Intimation Requirements
Given below are the requirements for your information, which are a must while submitting the claims (Reimbursement and Cashless facility) for a particular Ailment along with other essential Claim relevant documents:
Cataract Surgery : 'A' Scan report & IOL Sticker is must. If sticker not available than invoice shall be needed
Fractures: X-ray reports with Plates (Including Hip & Knee Replacement)
Accidents: MLC / FIR / Self-declaration from patient/Family
Angiography: Final Report with Diagram
Implants in Bones/Hernia Mesh: If it is above Rs. 10,000 then Purchase Invoice required/Bar Code or any other supporting document for the use of Implant/Mesh.
Ear Surgery: Audiometry report
Pneumonia: X-ray Chest report
Pre-existing Disease: Detailed History with durationof Ailments like Diabetes, Hypertension, Asthma, Fits/Epilepsy, Heart Diseases, Kidney Stones, Arthritis, TB
Paralysis: CT scan / MRI Report
Reimbursement
Reimbursement of the Claim can be availed, wherein:
o The hospital is not included in the TPA’s network of hospitals,
o The individual chooses a non-network hospital as per his/her liberty ,or
o Cashless is Denied
IMPORTANT:
1. All the Original Claim documents, bills and reports from Hospitalization and 30 days Pre-hospitalization must be couriered to Aum Insurance Brokers Pvt. Ltd. Address :- 603, 6th Floor, Shubham Atlanta, Opp. Basant Park Chembur Police Station, Chembur (E), Mumbai – 400 071 immediately after the discharge of the patient, in any case within 7 days from the discharge of the patient.
2. Form – C must also be couriered and the same shall be provided by the Hospital/Nursing Home on demand. This is not required in case of cashless hospitalisation
3. All bills accrued 60 days Post-hospitalization can be reimbursed within 67 days from the date of hospitalization
4. Maintain a personal Photocopy of all the Claim relevant document
Reimbursement CLAIM PROCESS
• CLAIM INTIMATIONSend AUM a Claim Intimation via an e-mail () on knowledge of Hospitalization / • CLAIM INTIMATION
E-mail should contain all the Claim Intimation Requirements & AUM will forward the claim to the TPA to check if Claimable or not
• CLAIM LODGE
On receipt of claim intimation, AUM will lodge the claim & e-mail a list of Required Documents / • CLAIM SETTLEMENT
At the time of discharge from hospital, settle all the hospital bills & collect all the Original documents, bills and reports, cash memos etc.
• CLAIM SETTLEMENT
Reimbursement Documents must be completed and couriered to AUM within 7 days to effectuate the claim. If all documents are not available with you, please send available documents within 7 days / • CLAIM SETTLEMENT
In case of incomplete document/ reports a Deficiency e-mail will be sent to individual to fulfill the requirement, until which the claim will be put on hold
• CLAIM SETTLEMENT
Claim will be processed and reimbursed by the TPA, E-Meditek subject to terms, conditions, exclusions and limitations of the policy. / • RTGS/CLAIM CHEQUE
TPA shall reimburse the settled claim amount to the insured through RTGS or cheques.
Reimbursement CLAIM DOCUMENTS
The following Original Reimbursement Documents must be completed and couriered to Aum Insurance Brokers Pvt. Ltd within 7 days of discharge from the Hospital for claim settlement: