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Purple cow employee benefits for sme 2011 (benefits)


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Purple cow employee benefits for sme 2011 (benefits)

  1. 1. 4. B ENEFITS Your SECRET to Financial Security
  2. 2. 1 Purple Cow 2011 Benefits Benefits Overview LIFE – ACCIDENT – HEALTH LIFE 1. LIFE INSURANCE * Total & Perm. Disability Income HEALTH 3. MEDICAL HMO * 21,519 MD, 352 hospitals, 358 clinics 4. DENTAL HMO * 775 dentists, 645 clinics 5. Opt. Annual Physical Exam * 124 hospitals, 241 clinics, 31 mobile 6. Health & Wellness Program * 2x/year; tailored to utilization report ACCIDENT 2. ACCIDENT INSURANCE a. Accidental Death * Murder b. Disability * Assault
  3. 3. 2 Purple Cow 2011 Benefits Benefits Summary LIFE – ACCIDENT – HEALTH 1. Life = 5x MBL 13. 100% Pre-Existing Conditions coverage 2. Total & perm. disability income = 5x MBL 14. 100% Congenital Conditions coverage 3. Accidental death = 5x MBL 15. Benefits on top of Philhealth 4. Murder = 5x MBL 16. Special procedures = 30%/100% of MBL 5. Accidental disability = __% of 5x MBL 17. Opt. Outpatient Reimb. for meds, dental, vision 6. Assault = __% of 5x MBL 18. Dental = HMO (775 dentists / 645 clinics) 7. Medical = HMO (21,519 MD / 352 hospitals / 358 clinics) 19. Dental access to major malls in Metro-Manila 8. Access to Big 5 Hospitals & Healthway 20. 1 permanent filling, 2 oral prophylaxes, etc. 9. Combined inpatient & outpatient limits 21. Opt. APE = designated or mobile clinic 10. Max. Benefit Limits per disability per year 22. Health & Wellness Program 2x/year 11. HMO patient for no-cash-out 23. Same benefits for all Employees 12. Private patient for reimbursement (HMO rate) 24. Same benefits for all Dependents
  4. 4. 3 Purple Cow 2011 Benefits 1. LIFE INSURANCE (worldwide) ASIANLIFE EXCLUSIONS 1. Life 1 5x MBL 1. Suicide within the 1 st year of coverage 2. Total & Perm Disability Income 2 5x MBL +Principals 18yo-65yo; Dependents 30dy-21yo / 18yo-65yo 1 Life insurance = 5x MBL, for death by any cause (suicide covered after 1 year); 2 Total & Permanent Disability Income (TPDI) = 5x MBL, in lieu of the Life benefit, after 6 months of TPD, whether sick or hurt. Example : If MBL = 20T, Life or TPDI = 100,000; If MBL = 40T, Life or TPDI = 200,000; If MBL = 60T, Life or TPDI = 300,000; If MBL = 80T, Life or TPDI = 400,000; If MBL = 100T, Life or TPDI = 500,000. Life benefits are payable on top of Accident and Health benefits
  5. 5. 4 Purple Cow 2011 Benefits 2a. ACCIDENT INSURANCE (worldwide) ASIANLIFE 1. Accidental Death 1 5x MBL 3. Disability 3 _% 5x MBL 2. Murder 2 5x MBL 4. Assault 4 _% 5x MBL +Principals 18yo-65yo; Dependents 30dy-21yo / 18yo-65yo 1 Accidental Death = 5x MBL, for death from any type of accident; 2 Murder = 5x MBL, in lieu of the Accidental Death benefit, for death not due to accident but murder (provoked or not). Example : If MBL = 20T, Accidental Death or Murder = 100,000; If MBL = 40T, Accidental Death or Murder = 200,000; If MBL = 60T, Accidental Death or Murder = 300,000; If MBL = 80T, Accidental Death or Murder = 400,000; If MBL = 100T, Accidental Death or Murder = 500,000. +Principals 18yo-65yo; Dependents 30dy-21yo / 18yo-65yo 3 Disability = __% of 5x MBL, according to a long schedule of disabilities; 4 Assault = __% of 5x MBL, in lieu of the Disability benefit, for disability not due to accident but assault (provoked or not). Example : If MBL = 20T, Disability or Assault = __% of 100,000; If MBL = 40T, Disability or Assault = __% of 200,000; If MBL = 60T, Disability or Assault = __% of 300,000; If MBL = 80T, Disability or Assault = __% of 400,000; If MBL = 100T, Disability or Assault = __% of 500,000. Accident benefits are payable on top of Life and Health benefits
  6. 6. 5 Purple Cow 2011 Benefits 2b. ACCIDENT INSURANCE… SCHEDULE OF DISABILITIES 1. Life (same as Accidental Death) 100% 14. Middle finger 6% 2. Both hands or feet or sight of both eyes 100% 15. Ring finger 5% 3. One hand and one foot 100% 16. Little finger 4% 4. Either hand or foot and sight of one eye 100% 17. Metacarpals 1 st /2 nd - 3 rd/ 4 th /5 th 3% - 2% 5. Injuries resulting in being perm. bedridden 100% 18. Leg at or above knee 60% 6. Any other injury causing Total Perm. Disab. 100% 19. Leg below knee 50% 7. Arm at or above elbow 70% 20. One foot 50% 8. Arm between elbow and wrist 50% 21. All toes on one foot 25% 9. One hand 50% 22. Big toe 5% 10. Four fingers and thumb of one hand 50% 23. Any toe other than big toe (each) 1% 11. Four fingers 35% 24. Sight of one eye 50% 12. Thumb 15% 25. Hearing - both ears 50% 13. Index finger 10% 26. Hearing - one ear 25% +Multiple losses from 1 accident will be limited to the highest loss, not to exceed 100%. If a member suffered the loss of 1 hand/foot/eye prior to coverage, the benefit for a subsequent loss of the same will be ½. Losses refer to total and permanent loss of use or complete severance
  7. 7. 6 Purple Cow 2011 Benefits 2c. ACCIDENT INSURANCE… EXCLUSIONS 1. Bodily or mental infirmity, hernia, ptomaine, bacterial or viral infection (except pyogenic infection occurring with and through an accidental cut or wound) 12. War, invasion, act of foreign enemy or warlike operation (whether declared or undeclared), mutiny, strikes, demonstrations, riots, civil commotion, conspiracy, military takeover, state of siege, or any weapon or instrument employing atomic fission or radioactive force whether in time of peace or war 2. Disease, sickness, parasite, or disorder of the body/ mind 3. Poison, gas or fumes voluntarily or involuntarily taken 4. Insect bites 13. Serving in the armed forces of any country, or international authority, whether in war or peace 5. Earthquake, volcanic eruption or tidal wave 6. Atomic explosion, nuclear fission, or radioactive gas 14. Entering, operating, servicing, ascending or descending from any aerial or submarine device or conveyance, except as provided under a passenger aviation provision 7. Pregnancy, childbirth, miscarriage or any complications 8. Accident occurring while or because the Insured is under the influence of alcohol or any drug 15. Hunting, motorcycling or pillion riding, mountaineering which necessitates the use of ropes or pitons, racing of any kind, other than on foot, ice or winter sports, water-ski jumping and tricks, yachting beyond 5 km. off a coastline, underwater activities involving the use of underwater apparatus, or using woodworking machinery driven by mechanical power other than portable tools, applied by hand and used solely for private purposes without reward 9. Suicide or any attempted threat while sane or insane, or any intentionally self-inflicted injury 10. Participation in any brawl, or committing any crime or felony 11. Provoked murder / assault or attempted threat [waived]
  8. 8. 7 Purple Cow 2011 Benefits 3a. MEDICAL HMO (nationwide) ASIANLIFE (21,519 MD / 352 hospitals / 358 clinics) TERMS & CONDITIONS 1. Combined inpatient & outpatient limits 1. Instant rates, regardless of size 2. Max. Benefit Limits per disability per year 2. No franchising required 3. HMO patient for no-cash-out 3. No utilization report required 4. Private patient for reimbursement (HMO rate) 4. No individual applications required 5. Access to Big 5 Hospitals and Healthway 5. Minimum group size = 10 6. 100% Pre-Existing Conditions coverage 6. Minimum mode of payment = monthly 7. 100% Congenital Conditions coverage 7. Pooled Employee utilization to spread risk 8. Benefits on top of Philhealth 8. Separate Dependent utilization to reduce cost 9. Special Procedures = 30%/100% of MBL 9. Buy now, pay later 10. Opt. Outpatient Reimb. for meds, dental, vision 10. 1 st year Virgin promo rate, if applicable +Principals 18yo-65yo; Dependents 30dy-21yo / 18yo-65yo +Same rates for Dependents in 2011 Medical HMO benefits are covered on top of Life and Accident benefits
  9. 9. 8 Purple Cow 2011 Benefits 3b. MEDICAL HMO… PRE-EXISTING CONDITIONS (Dreaded) PRE-EXISTING CONDITIONS (Non-Dreaded) 1. Blood dyscrasias 1. Asthma, pleural effusion or other chronic airway obstruction conditions 2. Benign / malignant new growths 2. Benign cyst / tumor and malignant conditions 3. Chronic cardiac / cardio-vascular diseases 3. Chronic gynecologic conditions 4. Collagen / connective diseases 4. Hemorrhoids and other chronic colonic and ano-rectal illnesses 5. Diseases of the immune system 5. Diseased tonsils requiring surgery, cataracts & other opthalmo-otolaryngologic conditions 6. Chronic hepatobiliary diseases 6. Pathological abnormalities of nasal septum and turbinate 7. Neuro-surgical / neurological conditions 7. Sinus condition requiring surgery 8. Chronic pulmonary diseases 8. Chronic neurologic conditions 9. Chronic genito-urinary diseases 9. Calculus cholecystitis / cholelithiasis and/or urolithiasis 10. Chronic gynecological conditions 10. Chronic conditions of the genitourinary system 11. Chronic gastrointestinal conditions 11. Polyps, ulcers, liver cirrhosis and other chronic gastrointestinal diseases 12. Endocrine abnormalities 12. Endocrine illnesses 13. Antibiotic / chemotherapy-resistant diseases / bactemia / septicemia 13. Seizure disorders 14. Chronic opthalmo-otolaryngologic diseases 14. Moderately to far advanced tuberculosis 15. Chronic musculo-skeletal diseases 15. Chronic musculo-skeletal malignancies 16. Pathological / accidental fractures 16. Malignancies of the blood and bone marrow 17. Illnesses / injuries necessitating the use of isolation room / ICU or other IC facilities 17. Hypertension, coronary artery disease / myocardial ischemia, cerebrovascular accident and other chronic cardiac diseases 18. Accidental injuries 19. Second and third degree burns 18. Collagen / connective tissue diseases 20. Surgical procedures requiring application / use of prosthesis for immediate treatment 19. Diseases of the immune system 21. PEC (except congenital ones) subject to the provision on ‘PEC’ in this Agreement [waived] All Dreaded & Non-Dreaded PEC are covered 100% to MBL
  10. 10. 9 Purple Cow 2011 Benefits 3c. MEDICAL HMO… SPECIAL PROCEDURES – 30% of MBL SPECIAL PROCEDURES – 100% of MBL 1. Lithotripsy 1. Dialysis 2. Arthroscopic procedures 2. Chemotherapy 3. Laparoscopic procedures 3. Radiation oncology / therapeutic radiology 4. Laser therapy (excludes use for correcting vision) 4. Sclerotherapy 5. Nuclear / radioactive isotope scans 5. Physical & speech therapy 6. Cost of artificial limbs, joint prosthesis and heart valve prosthesis 6. Angiography 7. Nuclear technologies 7. Other new modalities of treatment for conditions with established etiologies and used as alternatives to conventional or traditional procedures 8. Thallium scintigraphy 9. CT scan / MRI 10. Pulmonary perfusion scan For the above special procedures, the remaining 70% of your Maximum Benefit Limit per disability per year can be used for conventional treatment of the same condition (unlike other HMO’s which exclude conventional treatment after a special procedure, and limit special procedures to 1x/year). 11. Endoscopy 12. Bone densitometry scan 13. Anti-nuclear anti-body (ANA) 14. C-reactive protein (rheumatic & complications) 15. Lupus cell exam 16. Sleep therapy
  11. 11. 10 Purple Cow 2011 Benefits 3d. MEDICAL HMO… Optional OUTPATIENT REIMBURSEMENT EXCLUSIONS 1. Rx Medicines 1. Vitamins, supplements and/or non-BFAD approved medicines, herbal medicines, and other medicines that have no legal BFAD-approved therapeutic claims 2. Dental 3. Vision 2. Dental procedures not included in the dental HMO plan +Outpatient Reimbursement for Rx Meds, Dental & Vision benefits within 15 working days of receipt of all documents. +Reimbursement for Rx Meds covers treatment for any covered sickness or accident. +Reimbursement for Dental covers the same schedule of benefits as the dental HMO, but with your choice of dentist for full reimbursement up to your aggregate limit. +Reimbursement for Vision covers tests for visual acuity and prescription lenses. +The annual aggregate limit for all Rx meds, dental and vision benefits together = 1/10 th your Max. Benefit Limit. 3. Non-prescription lenses and frames Rx Medicines, Dental & Vision are covered on top of Medical & Dental HMO benefits
  12. 12. 11 Purple Cow 2011 Benefits 3e. MEDICAL HMO… EXCLUSIONS 1. Expenses that should be taken care of by any government programs such as Philhealth 13. Illnesses / injuries attributable to the plan member’s own misconduct / gross negligence / immoral habits, and willful and unnecessary exposure to danger or health hazards 2. Services rendered or supplies provided free of charge 3. Additional hospital charges and/or professional fees resulting from a plan member taking a room accommodation more than his R&B limit (excesses and/or incremental costs) 14. Self-inflicted injuries including, but not limited to, any form of suicide attempt 4. Maternity and maternity-related conditions and/or complications except those benefits that may be provided by the (optional) Maternity benefit 15. Sexually transmitted disease, AIDS, rehabilitative treatment for alcoholism and drug abuse 5. Sterilization of either sex or reversal of such, artificial insemination, sex change, consultation/confinement regarding fertility 16. Acquisition of prosthetic appliances, artificial aids, durable equipment, surgically implanted devices and external prosthetic devices except those that are explicitly covered and enumerated in the ‘Special Procedures or New Modalities of Treatment’ provision of this agreement 6. Non-recommended confinement, convalescent / domiciliary / custodial care, rest cures 7. Dental-related cases except those that may be provided by the Dental Benefits and to the extent that are necessary for the repair or alleviation of damage caused solely by accidental injury sustained (and not caused by the plan member) 17. Organ transplant-expense relating to organ donation of the donating party/parties 18. Executive check-ups, unless explicitly provided in the master policy, and/or confinements purely for diagnostic purposes, as well as non-recommended confinements 8. Circumcision, cosmetic / aesthetic procedures except re-constructive surgery to treat functional defects due to a covered disease and/or accidental injury 9. Psychiatric disorders, psychosomatic conditions, treatment for any mental or nervous disorders, illness / injury / condition / complication arising from the plan member’s excessive alcohol intake and/or use of regulated/prohibited drugs 19. Take-home medicines, unless optional ‘Reimbursement of Prescribed Medicines’ benefit is provided, and vaccines, except for first doses of either anti-venom, anti-rabies or anti-tetanus used for emergency treatment 10. Illnesses and/or injuries arising from the plan member’s participation in brawls, riots, commission of a crime, violation of ordinances, or the like 20. Medico-legal fees including the cost of Medical Certificates that a plan member may require for any purpose it may serve him or her 11. Illnesses / injuries resulting from conditions of war or sustained from combat-related activities 21. Congenital disease / deformity that is evident to the plan member at birth and/or can be clinically determined to be congenital [waived] 12. Illnesses / injuries resulting from the plan member’s active participation in hazardous activities such as, but not limited to, bungee jumping, hang-gliding, scuba diving, mountain/wall climbing, and professional sports 22. Medical / surgical procedures and/or diagnostic tests that are experimental in nature and/or not generally accepted by the medical profession such as, but not limited to, iridology, chiropractic services, and acupuncture
  13. 13. 12 Purple Cow 2011 Benefits 4. DENTAL HMO (nationwide) HP DENTAL (775 dentists / 645 clinics) EXCLUSIONS 1. (1) permanent filling 1. Dental procedures not included in the dental HMO plan 2. (2) oral prophylaxes 1 +No reimbursements allowed (unless you get the optional Outpatient Reimbursement Plan for Rx Medicines, Dental & Vision). +Discounts of up to 20% available on procedures not included in the dental HMO plan. +Dental card and booklet provided, as well as an orientation and an annual utilization report. 3. Unlimited consultations 4. Simple tooth extractions if indicated 5. Temporary fillings when indicated 6. Gum treatment except for alveolectomy/gingivectomy 7. Simple adjustment of dentures 8. Re-cementation of fixed bridges/crowns/jackets/inlays/onlays 9. Treatment of pain/lesions/wounds/burns 10. Emergency dental procedures if necessary +By appointment only (unless emergency) Dental HMO benefits are covered on top of Medical HMO benefits
  14. 14. 13 Purple Cow 2011 Benefits 5. Optional Annual Physical Exam ASIANLIFE (241 designated clinics, 31 mobile clinics) EXCLUSIONS 1. Physical examination 1. APE procedures not included in the Basic 5 APE plan 2. Chest X-Ray +You can add additional procedures to your Basic 5 APE: call GRA to help design, source, price, and schedule your APE anytime during your plan year. +Nationwide (241 clinics, 31 mobile) or Metro Manila-wide (114 clinics, 24 mobile) APE also available to companies with multiple locations, at roughly triple or double the cost respectively (reflecting their average cost of a Basic 5 APE). Otherwise, individual clinics are best, whether designated or mobile. 3. CBC Basic 5 only 4. Urinalysis 5. Fecalysis +The Annual Physical Exam (APE) is a diagnostic tool, not a cure for sickness or accident. Results can serve as a baseline for referral to specialists who can authorize tests and/or prescribe further treatment. +By appointment only, 30 days in advance. +Pay as you go, so you don’t lose it if you don’t use it (don’t pay in advance, as payment is not transferable). Basic 5 Cost +/- P300 (for designated or mobile clinics). APE benefits are covered on top of Medical HMO benefits
  15. 15. 14 Purple Cow 2011 Benefits 6. Health & Wellness Program ASIANLIFE EXCLUSIONS 1. Comprehensive Wellness Program (2x/year) 1. Cost of vaccines <ul><li>+A company’s corporate wellness program is a key component of company success. Based on a company’s health and wellness needs/wants, AsianLife has developed the CWP that can motivate and maintain good health. AsianLife brings corporate wellness programs to the client’s location and implements a wellness program that suits the client’s actual health profile to achieve their unique needs and goals. </li></ul><ul><li>To effectively manage healthcare costs, organizations must include programs that proactively help employees maintain and improve their health. The road to better health (and fewer preventable health claims) is paved with small decisions we make every day. The result of doing nothing is continued skyrocketing health-care costs, rising absenteeism, and lower employee productivity. </li></ul><ul><li>Wellness Bottom Line: gains can include: </li></ul><ul><li>Improved employee health; </li></ul><ul><li>Increased workforce productivity; </li></ul><ul><li>reduced health insurance premiums; </li></ul><ul><li>lower workers compensation claims. </li></ul>+The Comprehensive Wellness Program is customized to meet your health & wellness needs through the following services: HEALTH RISK ASSESSMENTS: Comprehensive written assessment and detailed CUR (current utilization report) are provided which gives the employee and the employer the information needed to set wellness goals. HEALTH PROMOTION & DISEASE MANAGEMENT SEMINARS: Pooling from a wealth of resources and expertise available through the medical partners, numerous presentations and seminars are available for the client’s workforce to promote Wellness. HEALTH SCREENINGS: Periodic onsite health screenings such as blood pressure and body fat analysis are available in the program in addition to more extensive screenings such as blood analysis. HEALTH PROTECTION MEASURES: Scheduled vaccine administration program can be done within company premises. The vaccine may vary depending on the need/requirement of the company. Health & Wellness Program benefits are covered on top of Medical HMO benefits