Health Insurance Cell

HEALTH & ACCIDENT INSURANCE SCHEME OF AMC
(OCTOBER 2007 – SEPTEMBER 2008)

Tailor made group insurance product for members and their families.

Main Features:-

  • Our H & A scheme requires NO medical examinations for joining at any age.
  • Entry into Standard Mediclaim is not easily available for people above the age of 60 years and requires medical check up after 45 years for joining.
  • Our H.& A policy age limit is 80 years even for new starters. The policy can then be continued for life of the individual provided there is no break in continuity in the policy.
  • Pre-existing Diseases and illness are excluded in the first year, but are covered later with specific restrictions as mentioned below.
  • Costly investigation like MRI, Thallium test and day care surgery can be done as an OPD procedure. Hospitalization, is not essential for reimbursement.
  • Congenital diseases having a functional disability will also be considered after 1 year of insurance.
  • The scrutiny of all claims is by the H & A Committee of AMC, whose decision is final and binding on The Oriental Insurance Co.Ltd who are our official insurers.
  • Family members are permitted to join the scheme.
  • Hospital stay charges allowed per day will be restricted to 1% of capital sum insured in wards/rooms and 2% of capital sum insured in ICU. However if the member takes room of higher class, other charges reimbursable is also as per the class of room charges he is eligible. If a member fails to produce the other charges as per his class of eligibility then 25% of other charges will be deducted if member takes bed charges double than this eligibility and 50% of other charges will be deducted if member takes bed charges four times more than his eligibility.
  • AMC Service charge of Rs. 200/- per person will be extra.

TPA for cashless service is compulsory and it will be charged at 6% of premium. PHM is our official TPA.

SPECIAL TERMS IN THE H & A POLICY FROM 1.10.07 TO 30.09.08
The salient features of our H & A policy is being tabled below along with our latest premium table.

1.) Domiciliary Hospitalization, and Domiciliary Physiotherapy etc is not reimbursable.

2.) All claimants will NOW pay a 15% compulsory deductible of their reimbursable claim while the remaining 85% of the claim will be paid by insurer.

3.) Treatment and investigation of
   (1) Cataract
   (2) Heart ailment
   (3) Joint replacement
   (4) Fracture neck femur
   (5) Hysterectomy

will not be covered in the initial 2 years of joining the scheme or for the enhanced value of the Capital Sum Insured, if any. From the 3rd year onwards 50% reimbursement and from 4th year full reimbursement of the reimbursable claims will become payable. (first 12 months of joining insurance scheme and for enhancement of CSI, no payment is done for ANY pre-existing disease / ailments).

Health premium chart (in Rupees) for Rs. 1 lac of Capital Sum Insured (CSI).
(Inclusive of TPA Cash Less Charges 6% and service tax of 12.36%)
All rates for CSI to 5 lacs to be calculated in multiples of 1 lac.

Premium Table for CSI of 1 Lac.

  Age in Completed years Up to 35 years 35yrs +1 day up to 45 yrs 45yrs + 1 day up to 55 yrs 55 yrs +1 day up to 60 yrs 60 yrs +1 day up to 70 yrs 70 yrs + 1 day upto 75 yrs 75yrs + 1 day and above
TABLE 1 Basic Revised Premium
(incl 12.36% tax & 6% Cash Less)
1414 2080 3366 4361 5140 5433 5874
TABLE 2 Bonus rate only applicable to renewals without claims or previous loadings.
(incl 12.36% tax & 6% Cash Less)
1343 1976 3197 4143 4883 5161 5580
TABLE 3 Basic revised premium for dependants above 45 years.
(incl 12.36% tax & 6% Cash Less)
---- ---- 4016 4642 5340 5829 7108

PREMIUM FOR PERSONAL ACCIDENT COVER

Sum Insured in Rupees

Premium with weekly benefit
cover incl. S.tax in rupees

Premium without weekly
benefit cover incl. S.tax in rupees

1,00,000

190

130

N.B.: ALL PREMIUM RATES FOR CSI UPTO 5 LACS TO BE CALCULATED IN MULTIPLES OF 1 LAC

Minimum CSI for all NEW ENTRANTS above 18 years of age is 1 lac. Only below 18 years of age one can take CSI of minimum Rs. 50,000/- or above.

Previous insurance year implies

1.10.05 to 30.09.06

Current insurance period implies

1.10.06 to 30.09.07

Next (Renewal insurance period implies)

1.10.07 to 30.09.08

4. Loading of premium will apply to all those who have made more than one reimbursable claim in the last 5 years.
Formula of loading % as follows:
If CSI (current) 1.10.06 – 30.09.2007 is 1 lac and claim reimbursed is 10000.

Claim reimbursed Rs.10000/-                  
------------------------------------------X 200  = 20%
           CSI 100000                                

This is the loading which will be applied ON the RENEWAL PREMIUM of 1.10.07 – 30.09.08 (TABLE - 1)
Any previous loading amount of the earlier 2 or 3 years WILL be added to this newly loaded premium.

Those members in this scheme who have had no claims for 5 continuous years before making a claim will not be charged any loading FOR THE FIRST CLAIM only.

Should you wish to decrease your CSI this year for any reason the loading %age (calculated on your current year CSI) will apply only for the reduced CSI.

i.e. If current year (1.10.06 – 30.09.07) you had CSI of 5 lacs, and you made a reimbursable claim of 50 thousand then your loading will be 20 %.

Now this year you decrease your CSI to 2 lacs, 20 % loading will apply to renewal premium on CSI of 2 lacs only.

Loading does not apply to

  • New Entrants
  • Enhancement of CSI

N.B. : Since the premium WILL BE COLLECTED by the 1st September 07 it is likely that some insured may institute a claim for the remaining period of the current insurance (till 30.09.07). If such an insured has availed of a) bonus and b) reduction of loading for the next renewal, this amount will have to be refunded to the AMC, along with the actual increase in the newly loaded premium.

This refund + actual excess premium to be paid must be sent to AMC office within 15 days of receipt of such a fresh notice seeking payment.

Those claimants, who have claimed AN AVERAGE of between 90-100% of CSI over the last 3 years, will be allowed only 50% of the average CSI of last 3 years. E.g. If A has claimed

3 lacs on CSI of 3 lacs in 2004-2005
3 lacs on CSI of 3 lacs in 2005-2006
3 lacs on CSI of 3 lacs in 2006-2007

Total Claims in 3 years is Rs.9 lacs and Total CSI in 3 years is Rs 9 lacs i.e. average claim is 100%

The total CSI which will permitted by us would be 50% of the average CSI of these 3 years i.e. 3/2 = 1.5 lacs. We will not permit such an insured to avail of 3 lacs CSI but only permit him a CSI of 1.5 lacs.

If the following year claims are again between 90-100% of CSI, this amount will be reduced by a further 50% and so on.

For those having claims between 50-90% averages over 3 years CSI will be permitted to the extent of 75% of average of those last 3 years. If the following year he claims again more than 50% then CSI will be reduced further by 25%.

By this system, we are reducing the claim ratio in future years, while at the same time not totally excluding the need for health insurance.


N.B. : This above average of claims and CSI will only be relevant for a maximum of the last 3 continuous years of the H & A policy.

Most claims are settled without dispute. However some claims which are considered excessive, unreasonable or out of range by the H & A Committee, will be called in for scrutiny; the claimant would have to justify the fairness of the claim and abide by the decision of the professional colleagues in the H & A Cell.

When an insured or his dependents are treated for any illness or disease in one’s OWN FAMILY INSTITUTION OR SETUP, For Doctor himself or blood relatives taking treatment in their own hospital 50% of all the hospital bills will be reimbursed. No professional charges of Doctors treating their own family or close relatives will be allowed even if treated else where. Other doctor’s bills, outsourced investigations and medicine bills will be completely reimbursed. Since it was found some of our members are disregarding this limitation, the decision of H & a cell will be final regarding any claim approval.

Dependents who can avail of our scheme include children, grand children, and parents of spouse, son-in-law and daughter-in-law.

N.B. : CSI of any dependent cannot exceed the CSI of main member of group.
CSI of parents of Non member spouse can be equal to or less than the CSI of the concerned spouse.

Deposits payable at hospitals where Paramount Healthcare Management becomes applicable.

N.B.: 15% compulsory deductible applies on all claims.
Our H & A policy is just another product available to you. It is tailor made to meet our requirements and provide cover for dependents. Its not just an insurance, it is social security insurance, where the consultant community looks after the health needs of its members and their dependents to the maximum extent feasible.

Detailed terms of H & A policy will be available at AMC office or with approved agents of AMC.


CAUTION
  • Members must understand ours is a group health insurance and NOT standard mediclaim. If we make higher claims, the total claims made by our members will go up more than the premium paid by us in that year. If this happens all of us have to pay higher premium next year. Hence it is in OUR INTEREST that the hospital bills claimed by us are fair and reasonable to prevent rise in premium next year to enable us to reduce the claims and thus keep our costs down. We request you all to go to tertiary care hospitals only for major illnesses; For other illness please take treatment in smaller hospitals to reduce the claim amount.
  • If scrutinizing committee of H & A Cell feels the bills submitted are inflated or unreasonable then H & A Cell decision will be final regarding approval of claims.

1. Dr. S.S.Rao – Chairman TEL:C-26843030 Cell : 98200 25201
2. Dr. Suhas Kate – Convenor TEL:C-25110272 Cell : 93222 80305
3. Dr. P. N. Rao – Member TEL:R-26200041 Cell : 98200 42957
4. Dr. Jayesh Shah – Member TEL:C-26131803 / 2614538
5. AMC Office (10 a.m.- 6p.m.) TEL : 26836019 Telefax : 26821109
(Contact Person : Mrs.Reena Desai + Mrs. Pushpa - Office Supt.)

Dr Smita Sharma
President - Amc

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The Association of Medical Consultants - Mumbai or AMC as it is popularly known, was established in 1972 by a small group of energetic active and concerned medical consultants from distant suburbs who often assembled and animatedly discussed their common problems.

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