CENTRAL OFFICE CIRCULAR ON MEDICLAIM FAMILY FLOATER POLICY

LIFE INSURANCE CORPORATION OF INDIA

CENTRAL OFFICE

Department: Personnel/ER

Yogakshema, Jeevan Bima Marg, Mumbai-400021

Circular No. CO/Per/ER-A/066/2014
28th April 2014

ALL OFFICES OF THE CORPORATION

Re: Premium rates for family floater policy & option for increased cover

under Groups Mediclaim  Scheme.

This is further to CO circular no.CO/PER/ER-A/058/2014 dated 04/03/2014 on revision in limits of cover under Group Mediclaim Scheme.

Our Group Mediclaim Policy covering in-service employee, retired employees and their dependents has been renewed for the year 2014-2015. Employees/Retired Employees and their family are covered by Family Floater coverage w.e.f. 01/04/2014.  The compulsory Family Floater Sum Insured and corresponding benefit category are as under:-

There is also provision of optional increased sum insured in which an employee can opt for increased sum insured (on floater basis) for Rs.4 lacs, 5 lacs, 6 lacs, 8 lacs, 10 lacs, 12 lacs, 15 lacs & 20 lacs (inclusive of the limits set out in Table above).

Sharing of premium between in-service/retired employees and the Corporation shall be only for compulsory family floater mediclaim cover.  While in case of in-service employee, sharing of premium will be for the employee, spouse and two dependent children, for a retired employee sharing of premium will be for retired employee, spouse and dependent disabled children.

1. Option for Additional Family Floater Cover.

This option for additional  floater sum insured is subject to the following conditions:

1.   It may be noted that in no case can total floater sum insured (compulsory + additional) exceed Rs.20 lakh.

2.    The last date for exercising option by employees/retired employees shall be 31^st May 2014. Option Form for increased Floater cover is enclosed.

3.    Risk under additional Floater cover (in excess of compulsory Floater sum insured) will start from 01/07/2014.

4.    The entire premium for the additional Floater cover shall be borne in full by the concerned employee/retired employee.

5.    The additional Floater sum insured shall also be applicable to the entire unit of family (employee/retired employee and family members covered under compulsory Family Floater cover).

6.    Employees/Retired Employees who were already covered for additional sum insured or employees/retired employees who have opted for additional sum insured from the policy year 2014-15 or desire to opt for additional cover are required to exercise the option afresh for Additional Floater cover with the desired cover clearly stated in the option form.

7.    In case of change in category of the in-service employees because of change in their Basic Pay, the additional floater sum insured can be reduced but total floater sum insured (compulsory + additional) shall not be reduced from total floater sum insured available in previous policy year.  For example: An employee falls under category II and having total floater coverage of Rs.10 Lakh (compulsory : Rs.4 Lakh + additional: Rs.6 Lakh).  On next renewal he/she will fall under category I because of change in his/her Basic Pay.  Then he/she shall be covered for compulsory and additional floater cover of Rs.6 Lakh and Rs.4 Lakh respectively.

8.    The option for increased Floater sum insured shall be available once in a period of three policy years.  To clarify, those employees/retired employees who do not opt for increased Floater sum insured will not be eligible to exercise the option for increased Floater mediclaim coverage in the next two renewals of Mediclaim Policy.

9.    Once an employee/retired employee opts for increased Floater sum insured, he/she will not be allowed to lower the total Floater sum insured.  However, he/she can reduce the total Floater sum insured proportionately to the next available total  Floater sum insured on exit of any member by way of death/ineligibility but compulsory Floater sum insured will remain same.  For example: if any family of four members is covered for total Floater sum insured of Rs.20 Lakh and one member exits  due to his/her ineligibility on next  renewal, employee can reduce total Floater cover from 20 Lakh to 15 Lakh.  For the same coverage if number of members is 5 then proportionate reduction in total Floater cover on exit of one member will be Rs. 4 Lakh but cover for Rs.16 Lakh is not available.  Therefore, employee will have to go for next available total Floater cover of Rs.20 Lakh.

You are advised to ensure that retired employees and spouse of deceased employees/retired employees are informed about the premium rates and availability of the option for increased Floater sum insured.

2.  Premium – Family Floater Mediclaim Cover.

The annual premium chargeable per person for various age bands and total Family Floater sum insured for the policy year 2014-2015 in Table A & B are as follows:

Premium for additional Floater cover (in excess of compulsory Floater sum insured) is to be calculated and collected from employees/retired employees for 09 months on pro rata basis.  In case of in-service employees, deduction for the premium of additional Floater cover shall start from the salary for the month June 2014.

Illustrations for calculating premium.

1.  Total premium of a family which is covered for compulsory Family Floater sum insured of Rs.4 Lakh and subsidy in premium are given below in Table:

2. An employee and his/her family is covered for compulsory and Optional additional Floater cover for Rs.600000/- and Rs. 900000/- respectively.  Therefore, increased Family Floater Cover will be Rs. 15 Lakh.  Calculation of total premium and subsidy in premium are given below.

3.  A retired emplkoyee and his/her family  is covered for compulsory and Optional additional Floater cover for Rs.300000/- and Rs.1700000/- respectively.  Therefore, increased Family Floater Cover will be Rs.20 Lakh.  Calculation of total premium and subsidy in premium are given below:

3. Mediclaim Data and statements.

The data of all beneficiaries as on 01/04/2014 is essential for finalization of the premium.  All the Zonal Offices are required to provide the updated data of the beneficiaries for Compulsory Floater Cover as on 01/04/2014 in enclosed Excel formats (Annexure – I) and consolidate the same in (Annexure – A) and submit the same to Central Office by 24/05/2014.  The data of beneficiaries, who have opted for increased floater cover, needs to be submitted separately in the same Excel format (Annexure – I and  Annexure – A) by 16/06/2014.

3. Claims Data

In addition to this, all the Divisional Offices are required to maintain records for claim payments in enclosed Excel format (Annexure – II).  Data for claim paid and pending (soft copy) is to be sent to the respective Zonal Office.  The Zonal Office will consolidate the data for all the offices under its jurisdiction and submit it to Central Office as follows:

It is to be brought to the notice of all the members of scheme that intimation of claim should without fail reach the office within 7 days of admission to hospital and the claim must be filed within 20 days of discharge from the hospital.