1. Aker Group Employee Insurance Guide Proceed Click Here Client
[Employee Copy]
Client
Aker Powergas India Pvt LTd.
Remark
Benefit Manual
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2. Proceed Click Here Disclaimer:
This benefit summary will serve as a guide to the benefits provided by “aker Powergas India Pvt Ltd.”. The information contained here is only a summary of the policy documents which are kept by the company. If there is a conflict in interpretation, terms & conditions of the policy will prevail. A copy of the policy is available with Human Resource department.
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Marsh India Insurance Brokers Private Limited
, Tower 2, One Indiabulls Centre, Jupiter Mills Compound, 841, Senapati Bapat Marg, Elphinstone Road (W) Mumbai
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Copyright © 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 the publishers.
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3. Main Menu A. Program Details Click Here B. Definitions & Links
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4. Main Menu 1. Group Mediclaim Click Here Exit Click Here Back
This insurance scheme is to provide adequate insurance coverage of employees for expenses related to hospitalization due to illness, disease or injury
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5. 1. Group Mediclaim 1.1 Benefit Details Click Here
1.2 Enrollment in the program
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1.3 Cashless Hospitalization
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1.4 Non - Cashless Hospitalization
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Contacts
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6. 1.1 Benefit Details Back General Exclusions Policy Parameter Insurer
New India Assurance Company Limited
Service Provider
Paramount Health Group
Policy Start Date
1st January 2017
Policy End Date
31st December 2017
Coverage Type
Family Floater cover
Dependent Coverage
1+3- Employee +Spouse +2 Dependent Children
Sum Insured
INR (unmarried) & Inr (married)
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Benefits covered
Standard Hospitalization
Yes
Pre existing diseases
Waiver on 1st year exclusion
Waiver on 1st 30 days excl.
Baby cover day 1
Pre-Post Hospitalization Exp.
Cataract Limit
No capping
Benefits covered
Ambulance Services
Yes
Domiciliary Hospitalization No
Day Care
Diagnostics
Room Rent
Restricted
Terrorism & Epidemic Break
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General Exclusions

7. Applicable Members Back Total No of people Insured 1+ 2 Employee Yes
Spouse
Children
Yes (Maximum 2 dependent children)
Parents No
Parents in Law
Siblings
Others
Mid Term enrollment of Dependents
Disallowed
New Joinees (New employees + Dependents)
Allowed
Acquisition of new dependents (Spouse/Children)
Allowed (Name of new born baby to be given within 30 days of date of birth)
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8. Policy Period Back Existing Employees + Dependents Commencement Date
01st January 2017
Termination Date
30th December 2017 (midnight) or date of leaving the organization whichever is earlier
New Joinees + Dependents
Date of joining
New Dependent (Marriage/Birth)
Date of such event
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9. Coverage Levels Back Sum Insured - Family Floater Family Floater
Employee
Family Floater - Inr for unmarried employees and INR for married employees
Dependents
1+3: Employee + Spouse +2 Dependent Children
Restrictions on sum insured NA
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10. Standard Hospitalization
Reimbursement of expenses related to
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
Organ transplantation including the treatment costs of the donor but excluding the costs of the organ
Internal Congenital diseases
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.
B) Expenses on Hospitalisation for minimum period of 24 hours are 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 hospitalisation Benefit.
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11. √ Pre & Post Hospitalization expenses Applicable Back
Pre-hospitalisation Expenses
Definition
If the Insured Person is diagnosed with an illness which results in his hospitalization and for which the insurer accepts a claim under a) above, the Insurer will reimburse the insured person’s pre-hospitalisation expenses for up to 30 days prior to his hospitalisation as long as the 30 day period commences and ends within the policy period.
Applicable
Yes
Duration
30 Days
Post-hospitalisation Expenses
Definition
If the insurer accepts a claim under a) above and, immediately following the insured person’s discharge, he requires further medical treatment directly related to the same condition for which the insured person was hospitalized, the insurer will reimburse the insured person’s post-hospitalisation expenses
Applicable
Yes
Duration
60 Days
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12. √ √ √ √ Customized Benefits Covered Waived Waived Applicable Back
Pre existing diseases
Definition
Any pre-existing condition or related condition 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
Definition
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
Definition
During the first year of the operation of the policy the expenses on treatment of diseases such as Cataract, Benign Prostatic Hypertrophy, Hysterectomy for Menorrhegia or Fibromyoma, Hernia, Hydroceie, 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
Baby Cover Day 1
Definition
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 after 90 days as additional member as mentioned elsewhere under this policy. √
Applicable
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13. √ Ambulance services Applicable Back Ambulance Services 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.
Amount restriction
Rs per claim for shifting of insured to hospital upon written advices of attending doctor
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14. Domiciliary HospitalizationX
Not Applicable
Domiciliary Hospitalization
Definition
Domiciliary hospitalization 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
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
Note: When treatment such as Dialysis, Chemotherapy, Radiotherapy is taken in the Hospital/Nursing Home/Clinic and the insured is discharged the same day the treatment will be considered to be taken under Hospitalisation Benefit section.
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15. √ √ √ Customized Benefits Applicable – pre authorization required
Day Care
Day Care Procedure means the course of medical treatment or a surgical procedure listed in the schedule which is undertaken under general or local anesthesia in a hospital by a doctor in not less than 2 hours and not more than 24 hours. √
Dental Treatment
Definition
Any dental treatment or surgery of a corrective, cosmetic or aesthetic nature unless it requires hospitalisation; is carried out under general anesthesia and is necessitated by illness or accidental bodily injury. √
Restricted
Vision & Hearing aid
Definition
The cost of spectacles, contact lenses and hearing aids covered if it requires hospitalisation; is carried out under general anesthesia and is necessitated by illness or accidental bodily injury. √
Restricted
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16. Diagnostic Expenses X Not Applicable Back
Diagnostics Expenses
Definition
Charges incurred at hospital or nursing home primarily for diagnostic, X-Ray or laboratory examinations or other diagnostic studies not consistent with or incidental to the diagnosis and treatment of the positive existence of presence of any ailment, sickness or injury for which confinement is required at a hospital/nursing home or at home under domiciliary hospitalization as defined
Stand Alone Diagnostics will not be covered under the policy. However if diagnostic tests are in line with
hospitalization/ line of treatment, it will be paid for.
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Solvay Specialities India Pvt. Ltd.
Emerson Process Management Pvt Ltd.

17. Room Rent √ Restricted Back Room Rent
Room rent restricted max. 1% of the sum insured for normal & 2% for ICU. Incase an employee opts for the higher room rent then his eligibility propionate deduction will be applicable. Please note propionate deduction will not be applicable for medicines.
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18. General Exclusions
Treatment for injuries arising out of an act of War.
Circumcision unless necessary for treatment of a disease due to an accident or as a part of any illness.
Routine eye examinations and cost of glasses, contact lenses and hearing aids and all external aids.
Any cosmetic, plastic surgery, or aesthetic procedure, change of sex surgery.
Any treatment received outside India.
Naturopathy treatment.
Use of intoxicating drugs / alcohol and the treatment of alcoholism, solvent abuse, drug abuse or any addiction and medical conditions resulting from, or related to, such abuse or addiction.
Any stay in hospital for any domestic reason or where there is no active regular treatment by a specialist. Dental treatment or surgery of any kind unless requiring hospitalisation arising out of an accident.
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Solvay Specialities India Pvt. Ltd.
Emerson Process Management Pvt Ltd.

19. General Exclusions (Contd)
Convalescence, general debility, "Run-down" condition or rest cure
Congenital external disease
Venereal diseases, AIDS/HIV
Intentional self-injury and use of intoxicating drugs/alcohol.
Any fertility, infertility, sub-fertility or assisted conception operation, treatment for sterility.
Charges incurred in the hospital purely for diagnostic purpose.
Injury or Disease directly or indirectly caused by or contributed to by nuclear weapons/materials or radioactive contamination.
Expenses on vitamins and tonics unless forming part of treatment for injury or disease as certified by the attending Physician.
Voluntary termination of pregnancy
Any routine or preventative examinations, vaccinations, inoculation or screening.
Treatment taken in Outpatient department (OPD)
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Solvay Specialities India Pvt. Ltd.
Emerson Process Management Pvt Ltd.

20. GPA Benefits

21. Group Personal Accident Policy Enrollment in the program
Benefit Details
Enrollment in the program
Claims Procedure
Document Checklist
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22. GPA – Benefit Details General Exclusions Policy Parameter
This insurance provides compensation/payment up to a financial limit as assigned by the company, to the insured person or his legal personal representative, if the insured person suffers death or disablement due to an accident. The cover is worldwide but payment of claim can only be made in India and in Indian Rupees.
Policy Parameter
Insurer
HDFC ERGO General Insurance Company Limited
Policy Start Date
1st January 2017
Policy End Date
30th January 2017
Sum Insured
INR
Coverage Details
Accidental Death
Yes (100% of Capital Sum Insured)
Permanent Total Disablement
Permanent Partial Disability
Yes as per the chart
Temporary Total Disability
Weekly benefit – 1% of Sum Insured subject to a maximum of INR 5,000 per week for weeks.
Geographical Limits
World wide
Burns due to Accidents
Covered
Terrorism
Yes
Under In-Hospital Medical Expenses- Accident only Section
Least of the following 1) Actual basis 2) 25% of the accidental Death Section Sum Insured 3) 40% of the admissible Disablement Claim
General Exclusions

23. * Indicative list, Please refer to policy document
GPA – Details for PPD
* Indicative list, Please refer to policy document

24. GPA – Enrollment
All existing employees are covered under the policy from 1st January The policy ends on 31th December 2017
For new employees, enrollment data must reach the Insurer within 30 days of your joining. Please contact your HR.
The policy ends on 31th December 2017 or Date of Leaving the Organization whichever is earlier

25. GPA – Claims Process
Claimant / Assignee notifies HR, who in turn would intimate Marsh / Insurer and submit required claim documents within 30 days of the event
Is claim payable?
Cheque is sent to Employer (HR) within 30 days, from where it is given to the Claimant/ Assignee
Yes
On obtaining all relevant documents, Insurance Co. will begin processing the claims No
Insurer provides a valid reason for the rejection to HR/Claimant/ Assignee
Claim investigation and review within 15 days of submission of all the required documents

26. GPA – Claims Document Checklist
Weekly Benefit Claims
Death Claims
Dismemberment/ Disablement
Claims
Completed Claim form
Doctor's Report
Disability Certificate from the Doctor, if any
Investigation/ Lab reports (x-ray etc.)
Original Admission/discharge card, if hospitalized
Employers Leave Certificate & Details of salary
Completed claim form
Attending Doctor's report
Death Certificate
Post Mortem/ Coroner's report
FIR ( First Information Report)
Police Inquest report, wherever applicable
Completed claim form
Doctor's Report
Disability Certificate from the Doctor
Investigation/ Lab reports (x-ray etc.)
Original Admission/ discharge card, if hospitalized.
Police Inquest report, wherever applicable
Solvay Specialities India Pvt. Ltd.

27. GPA – General Exclusions
Service on duty with any armed force
Insanity
Venereal disease
AIDS
Influence of intoxicating drink or drugs
Aviation other than as a passenger (fare paying or otherwise) in any duly licensed standard type of aircraft any where in the world
Nuclear radiation or nuclear weapons material
Any consequence of war, invasion, act of foreign enemy, hostilities (whether war be declared or not), civil war, rebellion, revolution, insurrection, mutiny, military, or usurped power, seizure, capture, arrest,, restraint, detainment’s of all kings, princes, and people of whatever nation, conditions and qualities so ever
Childbirth, pregnancy or other physical causes peculiar to the female sex
While committing any breach of law with criminal intent

28. Thank You