MARSH EMPLOYEE HEALTH & BENEFITS

OPD PROPOSAL & CI COVER-

RPG GROUP

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• Introduction & Advantage of OPD

• OPD proposal

A G E N D A

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MARSH EMPLOYEE HEALTH & BENEFITS

I N T R O D U C T I O N

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S T E P S T O H E A L T H

4

What can we do to keep

the these 90% people feel

satisfied and 100% of

population engaged in

Healthcare

TYPICALLY JUST 1 IN 10 EMPLOYEES

UTILIZE HOSPITALISATION BENEFIT

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Aware and alert employees

Providing for Diagnostics and outcome based treatment keeps employees

both alert and active on path of a healthy state.

Early control saves money

Presently, more than 70 % of the claims are made for diseases related to lifestyle

disorders. Having an OPD cover along with other preventive measures might control

the progression of disease and prevent the hospitalization in about 44.3% of cases*.

Act as Guide

OPD data can be utilized to understand linkages with various factors and predict the

pattern of hospitalization.

Reduction in Unwanted admissions

It’s a well known fact that in many cases of hospitalization ,primarily focus is

investigation. With OPD covers, these investigations can be done at a much

lower cost without the burden of hospitalization.

What can OPD cover do ?

T H E S O L U T I O N

O P D C O V E R A G E

*Source : Ficci Study on OPD and Preventive Care Dec 2015

WHAT IS OPD?OPD is a health services which does not require Stay/ confinement in a hospital/clinical establishment apart

from the procedural times. It can include doctor consultations, Minor procedures, diagnostics, Exhaustive Health

Checks, Pharmacy etc.

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E M P L O Y E R C H A L L E N G E S

Large numbers and multiple

types of claims

A D M I N I S T R AT I V E

C H A L L E N G E S

N O N AV A I L A B I L I T Y

O F C A S H L E S S

Reimbursement entails submission of

documents and follow ups

P R O M O T I N G S E L F -

M A N A G E M E N T

Wellness and positive intervention are

the path to health.

P R O G R A M

D E S I G N

What all should be the contents

of an ideal program

R O L E O F

E M P L O Y E R

Benefit Owner

to Benefit Facilitator

P E R S O N L I Z E D

A P P R O A C H

Smart & Personalized approach

desired in this era.

MARSH EMPLOYEE HEALTH & BENEFITS

O P D P R O P O S A L

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O P D P R O P O S A L

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On Selection Basis

Option I

Family Definition Employee+ Spouse + 2 Children

Sum Insured INR 10000

Net Payable Premium (incl. GST)/Per Employee INR 8400

Doctor Consultations -General Physician, Specialist, Super Specialist, Prescribed diagnostics, Health Check ups, all prescription medicines, physiotherapy, and all treatments on OPD Basis. Cosmetic treatment not covered

INR 4000

Dental –covers general diagnostics, preventive check ups, Extraction, filling root canal, RCT, Scaling, polishing, braces, oral surgery, orthodontics for children. Cosmetic treatments not covered

INR 4000

Vision-Prescription lens/ Vision check-up done by optometrist /optician, cost of consultation andtreatment. Cosmetic treatment not covered

INR 2000

• Minimum 15% participation

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OPD Coverage & exclusions :

1.) Consultation fees –

Consultations: General Physician, Specialist, Super Specialist, including Dentist and Ophthalmologist.

Not to cover non-allopathic treatments. Not to cover Optometrist charges unless prescribed. Home Visit not covered. All consultation documents to have Doctors

Registration Number and to be duly signed and stamped along with a stamped receipt of consultation fee. The procedures which are covered by the insurer under

day care are not covered.

2.) Dental Treatment –

Dental Treatment means a treatment related to teeth or structures supporting teeth including examinations, fillings (where appropriate), extractions ,excluding

Cosmetic treatment.

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O P D C O V E R A G E S A N D E X C L U S I O N S

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C R I T I C A L I L L N E S S C O V E R - P R O P O S A L

Critical Illness – Benefit Cover On Selection Basis

Option I

Family Definition Employee+ Spouse

Sum Insured Per Person INR 300,000

Net Payable Premium (incl.GST) Per Person INR 1570

• Being a Benefit cover, it is payable on 1st diagnosis for the defined ailments only basis document submission to the TPA and approval by the insurer• Minimum 20% participation• Waiting period of 90 days is applicable from the inception of the policy and 30 days survival period is mandatory

Ailment List under CI Illness Benefit Cover

1. Myocardial Infarction(First Heart Attack of Specific severity) 6. Permanent Paralysis of Limbs

2. Cancer of Specified Severity 7. Loss of Limbs

3. Stroke resulting in Permanent symptoms 8. Third Degree Burns

4. Kidney Failure requiring Regular Dialysis 9. Blindness

5. Major Organ / Bone Marrow Transplant 10. Coma of specified severity

11. Benign Brain Tumor 12. Loss of Speech

13. Motor Neuron Disease with Permanent Symptoms

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I M P O R T A N T P O I N T S U N D E R C R I T I C A L I L L N E S S B E N E F I T

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Coverage to be offered only for third degree burns and not major burns as requested( Ailment No 8).

The plan requires minimum 20% participation

Only employee and spouse to be covered. Children and parents are not covered.

Parkinson's disease and Aorta Surgery is not agreed.

• List of documents to be submitted shall include

o Duly filled Claim form

o Treating Physician's certificate

o Original/Attested copy of Discharge summary

o Original/Attested copies of all lab/radiological/Histopathological/investigation reports

o Original/Attested copies of Indoor case papers(If needed)

o Original/Attested copies of all the medical bills

o Any other document (e.g. Disability Certificate, Dialysis records etc.)

deemed necessary at the time of claim investigation for a specific CI condition

• The following are excluded -

o Tumours showing the malignant changes of carcinoma in situ & tumours which are histologically

described as pre-malignant or non invasive, including but not limited to: Carcinoma in situ of breasts,

o Cervical dysplasia CIN-1, CIN -2 & CIN-3.

o Any skin cancer other than invasive malignant melanoma

o All tumours of the prostate unless histologically classified as having a

o Gleason score greater than 6 or having progressed to at least clinical

o TNM classification T2N0M0.........

o Papillary micro - carcinoma of the thyroid less than 1 cm in diameter

o Chronic lymphocyctic leukaemia less than RAI stage 3

o microcarcinoma of the bladder

o All tumours in the presence of HIV infection.

MARSH EMPLOYEE HEALTH & BENEFITS

The information contained in this publication provides only a general overview of subjects covered, is not intended to be taken as advice regarding any individual situation, and should not be relied upon as

such. Insured should consult their insurance, legal and other advisors regarding specific coverage issues. All insurance coverage is subject to the terms, conditions, and exclusions of the applicable individual

policies. Statements concerning financial, regulatory or legal matters should be understood to be general observations based solely on our experience as risk consultants and may not be relied upon as

financial, regulatory or legal advice, which we are not authorized to provide. All such matters should be reviewed with appropriately qualified advisors in these areas. Marsh cannot provide any assurance that

insurance can be obtained for any particular client or for any particular risk.

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Brokers Pvt Ltd is JV Company of Marsh LLC, a global leader in risk management, risk consulting, insurance broking.

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