Saturday, June 8, 2013

NEW STAFF GROUP MEDICLAIM POLICY

Dear friends,
We are happy to inform you that a new Floater policy is introduced from July 1st of 2013.
The above policy has got some advantages and also the Premium rate is higher. The policy cover is increased to 20 lakhs but on floater basis. Our EC has discussed the for and against points yesterday and we are sending letters to GIPSA and all the four companies regarding the above policy. The main features of the present policy compared with the new policy is given down below. for your perusal. Please opt for a higher sum insured before June 30th.

Revision in Group Mediclaim Policy for Serving & Retired
Employees of our Company w.e.f 1st July 2013

The Group Mediclaim Policy (GMC Policy) covering our serving and retired employees and their family members which is
in force now, has undergone modifications with effect from 1.07.2013. For ready reference, some important features
are outlined below :-

Current Provision
Revised Provision
Company’s Contribution towards Premium in case of Serving Employees (for employee, spouse & two dependent children) :-
Class I – 2/3rd premium + loading, if any,
-       up to Eligible S.I + Service Tax
Class II/III/IV- 3/4th premium + loading, if any,
-        up to Eligible S.I + Service Tax
Company’s Contribution towards Premium in case of Serving Employees (for employee, spouse & two dependent children) :-
75% of the premium payable (including loading on account of applicable TPA fees and Service Tax)
- up to the Eligible Sum Insured.
Company’s Contribution towards Premium :-
For Retired Employees :-
-       Loading portion of premium up to Eligible S.I + Service Tax

For Spouse of Deceased Employee/ Spouse of Retired & Deceased Employee :-
-       Loading portion of premium up to Eligible S.I + Service Tax

Company’s Contribution towards Premium :-
For Retired Employees :-
- 75% of the premium payable for retired employee &
  spouse (including loading on account of applicable TPA fees & Service Tax) - up to the Eligible Sum Insured.
For Spouse of Deceased Employee/ Spouse of
Retired & Deceased Employee :-
- 75% of the premium payable for spouse (including loading on account of applicable TPA fees & Service Tax)
                       - up to the Eligible Sum Insured.
Employees’ Contribution towards Premium in case of Serving Employees :-
For employee, spouse & two dependent children :-
Class I – 1/3rd premium + loading, if any,
-       up to Eligible S.I + Service Tax
-       the entire differential premium for differential higher Sum Insured opted by Employee over & above the Eligible Sum Insured + Service Tax
Class II/III/IV- 1/4th premium + loading, if any,
-        up to Eligible S.I + Service Tax
-       the entire differential premium for differential higher Sum Insured opted by Employee over & above the Eligible Sum Insured + Service Tax
For dependent ineligible children/dependent parents/ dependent parents-in-law/independent children & their family members :-
-       the entire cost of premium for opted Sum Insured + Service Tax
Employees’ Contribution towards Premium in case of Serving Employees :- (Class I/II/III/IV) –
For employee, spouse & two dependent children :-
- 25% of the premium payable + TPA fees + Service Tax
                                - up to the Eligible Sum Insured.

- the entire cost of premium payable for dependent
  ineligible children and dependent parents + TPA Fees +
  Service Tax

- the entire cost of premium payable for dependent
  parents-in-law, independent children and their family
  members, in the applicable cases + TPA Fees +
  Service Tax

- the entire differential premium payable for differential
   higher Sum Insured opted by Employee over & above
   the Eligible Sum Insured for self, spouse & two
   dependent children + TPA Fees + Service Tax

                                                                                                                                                                
Current Provision
Revised Provision
Employees’ Contribution towards Premium in case of Retired Employees :-
For self, spouse & two dependent children :-
-the entire cost of premium for opted Sum Insured + Service Tax (except Loading portion of premium up to Eligible S.I + Service Tax)


For dependent ineligible children/independent children & their family members :-
-the entire cost of premium for opted Sum Insured + Service Tax
Premium Contribution by Spouse in case of Spouse of Deceased Employee/ Spouse of Retired & Deceased Employee :-
-the entire cost of premium for opted Sum Insured + Service Tax (except Loading portion of premium up to Eligible S.I + Service Tax)


Employees’ Contribution towards Premium in case of Retired  Employees :-
For self & spouse :-
- 25% of the premium payable + TPA fees + Service Tax
                                - up to the Eligible Sum Insured.
- the entire differential premium for differential higher Sum Insured opted by Employee over & above the Eligible Sum Insured for self & spouse + TPA Fees + Service Tax
For dependent children/ dependent parents :-
-the entire cost of premium payable for opted Sum Insured
  +TPA Fees + Service Tax

Premium Contribution by Spouse in case of Spouse of Deceased Employee/ Spouse of Retired & Deceased Employee :-
- 25% of the premium payable for spouse + TPA fees
   + Service Tax - up to the Eligible Sum Insured.
- the entire differential premium for differential higher Sum
  Insured opted over & above the Eligible Sum Insured +
  TPA Fees + Service Tax
Eligible Sum Insured :-
Basic less than – Rs.22,731          Rs.   70,000/-
Between Rs. 22,731 & Rs. 29,000 - Rs. 1,00,000/-
Rs. 29,001 & above                   –  Rs. 1,55,000/-
Eligible Sum Insured :-
Basic less than – Rs.22,731          Rs. 3,00,000/-
Between Rs. 22,731 & Rs. 29,000 - Rs. 4,00,000/-
Rs. 29,001 & above                   –  Rs. 5,00,000/-
Maximum Optional Sum Insured :-
Rs. 5,00,000/- per member
Maximum Optional Sum Insured :-
Rs. 20,00,000/- on floater basis

Who can be covered :-
Serving Employees :-
Spouse, Dependent Children
Dependent ineligible children
Dependent Parents/ Parents-in-law
Independent Children/their family members



Retired Employees :-
Spouse, Dependent Children
Independent Children/their family members

Who can be covered :-
Serving Employees :-
Spouse, Dependent Children
Dependent ineligible children
Dependent Parents
Independent Children/their family members &
Parents-in-law can be continued to be covered provided
they are already covered – but no fresh inclusion from
1.04.2013.
Retired Employees :-
Spouse, Dependent Children
Dependent Parents
Other provisions :-

Ambulance Charges – Not payable
Other provisions :-

Ambulance Charges (cumulative actual charges
                                          per policy period) –
Distance up to 50 Km.   - Rs. 1,500/- maximum
Distance beyond 50 Km.- Rs. 3,000/- maximum
         (payable against hospitalization claim only)
                                                              










Current Provision









Revised Provision
Other provisions :-

Room rent Charges – no sub-limits









No Medical Check-up facility


Cover to Infant-after 3 months from date of birth
Pre-existing diseases  covered
Maternity Benefits (for two living children) –
-        Rs. 50,000/- maximum

Other provisions :-

Room rent charges 
Actual room rent charges per day shall be limited to an amount which is equal to the sum of :-
-1% of S.I. up to Rs. 5 lacs + 0.5% of S.I.> Rs. 5 lacs
which shall not exceed -
7,000/- per day maximum in Metro/ A Class Cities
4,500/- per day maximum in B Class Cities
4,000/- per day maximum in C Class Cities
Stay in ICU/CCU :- Maximum reimbursement limit per day shall be double that of above room rent entitlement.
Medical Check-up facility-
Once in 04 claim-free years (w.e.f 1.07.2013) :-
                                   - Rs. 5,000/- maximum
Cover to Infant -  from Day 1.
Pre-existing diseases clause  - stands waived.
Maternity Benefits (for two living children) -
Rs.25,000/- maximum per child for normal delivery
Rs.50,000/-maximum per child for caesarian delivery
Being a single master policy for all the employees (serving & retired) along with all the covered members, data relating to collection of premium and claims paid are kept collectively for Class I to Class IV. Percentage of loading of premium was decided on the basis of Incurred Claim Ratio as a whole.
 Now, policies shall be underwritten separately for –
a)Class I, b) Class II and c) Class III & IV. Therefore, data relating to collection of premium and claims paid should be kept from 1.07.2013 on the basis of the above classes separately and send the class-wise data to HO Fund Department on quarterly basis.

the above points will guide you about the policy. we are also giving you the method of calculation of premium with some examples down below.

Main Details of the Policy.

Existing                                               Revised                        Co's Contribution
Eligible S.I.                                         Eligible S.I.                  75% of Premium Payable
70,000                                                  3,00,000                       up to Eligible Sum Insured
1,00,000                                                4,00,000                      ( for employee &spouse )
1,55,000                                                5,00,000                      plus TPA Fees &Service Tax

                                               If you take Sum insured for 10 lacs
                                               

Members                      Relation                       Age (Years)                  Amount
(Rs.)
A                                  Self                              63                                 17,358
B                                  Spouse                        55                                  6,702
C                                  Dep.Child 1                  24                                 3,003
D                                  Dep.Parent                   85                                 14,792

Yearly Premium-                      Total :              41,855
                                                     (plus TPA Fees &S/Tax)

                                                Eligible S.I. - 3 lakh                             

Members                      Relation                       Age (Years)      Amount         
                                                                                                 (Rs.)            Co's Contribution
A                                  Self                              63                     8,274
B                                  Spouse                        55                     3,205           75% of PremiumPayable
C                                  Dep.Child 1                  24                     1,408           up to EligibleSumInsured
D                                  Dep.Parent                   85                     6,769          (for employee &spouse)

             19,656  plus TPA Fees &ServiceTax
   

Co's Contbn.-      75% of 11,479 
             (i.e 75%of A & B)               8,609

Emp's Contbn.-                                    Yearly -                        11,047         ( For S.I.-Rs. 3 lakh)
                 
                  (19,656 - 8,609)
                 (plus TPA Fees & S/Tax)



Emp's Contbn.-                                    Yearly -                        33,246          (For S.I. - Rs. 10 lakh)                                                                              
       (41,855 - 8,609)
(plus TPA Fees & S/Tax)


















RETIRED EMPLOYEE
Example for Calculation of Premium underStaff Mediclaim Policy on Floater Basis 
Sum Insured - Rs. 10 lak
 Eligible sum ins.4 lakh

Members          Relation           Age (Years)                  Amount(Rs.)                 Co's Contribution

A                      Self                   63                                11,292
B                      Spouse             55                                4,365                75% of Premium Payable
C                      Dep.Child 1       24                                1,913                up to Eligible Sum Insured
D                      Dep.Parent       85                                  9,213               ( for employee & spouse )

26,783 plus TPA Fees & Service Tax

Co's Contbn.-               75% of 15,657
(i.e 75%of A & B)          11,743

Emp's Contbn.-            Yearly -                        15,040.00              ( For S.I.-Rs. 4 lakh)
        (26,783-11,743)
  (plus TPA Fees & S/Tax)

Emp's Contbn.-            Yearly -                        30,112                   (For S.I. - Rs. 10 lakh)
        (41,855 - 11,743)
   (plus TPA Fees & S/Tax)

                                            IF YOU TAKE 10 LAKHS AND ELIGIBLE SUM INSURED 
                                                                      5LAKHS

Members          Relation           Age (Years)                  Amount(Rs.)                 Co's Contribution
A                      Self                  63                                 13,446
B                      Spouse            55                                 5,192                75% of Premium Payable
C                      Dep.Child 1      24                                 2,327                up to Eligible Sum Insured
D                      Dep.Parent       85                                 11,459              ( for employee & spouse )
            
32,424  plus TPA Fees & Service Tax
Co's Contbn.-               75% of 18,638
(i.e 75%of A & B)          13,978

Emp's Contbn.-            Yearly -                        18,446.00            ( For S.I.-Rs. 5 lakh)
       
          (32,424-13,978)
          (plus TPA Fees &ServiceTax)

Emp's Contbn.-            Yearly -                        27,877                 (For S.I. - Rs. 10 lakh)
          (41,855 - 13,978)
          (plus TPA Fees & ServiceTax)






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