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Group Insurance

Draft Agreement for signing up with an insurance broker for managing Employee Benefit Insurance policies.

1.0 OBJECTIVE OF THE SERVICE LEVEL AGREEMENT (SLA):
This SLA underlines the Service Levels, which will be adhered to by ABC, the Insurance Broker, for the specified Insurance Policy availed by XYZ the Client.

2.0 2.0 PARTIES TO THIS AGREEMENT
The parties, which form part of the Agreement, are ABC, and XYZ.

3.0 BACKGROUND
This agreement is effective from 01 April 2016 and meant to govern the service standards to be provided by ABC with respect to the Group Medical Insurance Policy, Group Accident Insurance, Workmen's compensation, Group Term Life insurance policy, Insurance in lieu of EDLI.
The various service parameters associated with Mediclaim Policy, such as issuance of Cashless Cards, Settlement of Claims, Member
Addition-Deletion, Query handling and other similar issues are being addressed by this SLA with specified Turnaround Timelines (TAT) and Mechanism laid out for each activity.

4.0 SCOPE OF THE AGREEMENT
Presented below are the Critical Modules which will cover relevant issues under the scope of this Agreement –

  1. POLICY ISSUANCE AND DUE DILIGENCE
  2. CASHLESS CARDS
  3. EMPLOYEE AWARENESS
  4. QUERY RESOLUTION
  5. CLAIM MANAGEMENT
  6. POLICY ADMINISTRATION
  7. OTHER VALUE ADDITIONS
  8. POLICY REVIEW AND MIS

ABC has the responsibility to coordinate with YYY, the Insurance Company selected for the Programs and Third Party Administrator (TPA).
Co-operation is sought from XYZ in terms of authorizing ABC to take necessary steps to ensure that at each step the interest of delivering a seamless service.

4.01 POLICY ISSUANCE & DUE DILIGENCE

I) Scope of Coverage - The pre-policy policy finalization process will elaborate clearly the scope of the Policy to be logged in and ABC will as the first step of due diligence lay down the “SCOPE of COVERAGE” of the policy before XYZ prior to signing of the contract. Commercial aspects such as Premium per Employee / Family Unit also will be addressed as a part of such due diligence to ensure complete transparency of the contract.

Ii)Data submission by client - ABC expects that the complete data of the members to be enrolled is submitted within 7 working days from the Policy Commencement Date. Any cooperation required on this in terms of collection of dependent data / enrollment forms from the employees will be extended by ABC.

Iii)Policy Issuance - From the date of submission of Complete / Updated data for the logged in policy and payment of all premium due to the insurance company the Policy Document will be delivered to the client within 15 working days. Prior to the issuance of the Policy Document, ABC will ensure that the client possess a risk held letter from the insurer for the affected policy.

Iv)Endorsement Issuance – From the date of submission of Additions/ Deletions by the client, ABC will ensure that Insurance Companies will issue the endorsement within 7 working days. Any expected delay with reasons will be elaborated by ABC to XYZ before 7 days.

V)Due Diligence – Policy/Endorsement once issued will be ratified to confirm adherence to the “SCOPE of COVERAGE” as negotiated for final consideration. Due diligence will involve checking the policy wording elaborating coverage, inclusions, exclusions and correctness of commercial aspects.

4.02 CASHLESS CARDS

I)Timeline for cashless card issuance - Based on the data in the policy, TPA will ensure that the E Cards are issued within 7 working days of the issuance of the policy document and endorsements.

Ii)Rectification of errors in cashless cards – While ABC will ensure that cards are error free, however in the event there are any errors and the same is brought to the notice of ABC Account Manager, correction of cards will be done within 5 days.

4.03 EMPLOYEE AWARENESS

I) Employee Presentation – At the policy inception employee presentations will be conducted to inform employees of the policy scope / coverage and exclusions of such employee benefit insurance policies and the various claim related processes. Dates for such presentations can be decided based on what may be convenient to you.

4.04 QUERY RESOLUTION

Queries on policy coverage, member enrolment status, cashless cards, claim status and similar insurance related the representative will answer queries. All queries will be answered by us within 2 working days (48 hours) from the day of query.

A.Non Cashless Claim Settlement - Claim papers for any non cashless claim will be accepted by ABC representative and follow up for any deficiency in documentation will be done at an individual level with the employee.

B.Online & Offline Query Resolution – The timeline for all types of query resolution, whether online or offline is set at 2 working days, (48 hours).

4.05 CLAIM MANAGEMENT

I) Non-Cashless Claim Settlement – For Non Cashless Claims the timeline is 14 working days from the time complete documents are submitted. Completeness of documentation is subject to submission by the employee of all deficiencies raised by the TPA regarding the claim. If ABC foresees an unavoidable delay, it shall promptly inform the client about the same and provide an indicative date of claim settlement. Claims will be settled with at par cheque payable to the name of the company.

Ii)Timeline for Intimation of Deficiency – Once employee has submitted the claim related papers deficiency if any will be communicated to him / her within 5 working days. An email to this effect will be sent to the concerned employee. If within 7 days of sending the intimation the deficiency is not produced by the employee a reminder mail will be sent to the employee with a cc to HR. However, in certain cases post submission of relevant documents TPA may generate certain deficiencies based on investigations done by the panel of doctors. We will keep HR updated on such cases if any.

Iii) Troubleshooting for Cashless Claim Settlement – Claims in Network hospitals are settled cashless by TPA. For the same, members have to follow the process set for Cashless Claim Authorisation. TPA has a TAT of 5 hours within which they process the claim and send the authorization letter either allowing the claim to be passed cashless or denial of cashless authorisation. In case a member does not have the reply from the TPA within the set TAT he/she may contact the ABC representatives and ABC thereon will take up the responsibility to have a confirmation. Also, in cases where a member needs early authorisation for any emergency case he/she is free to contact the ABC representative in advance and place a request. ABC will expedite the processing by coordinating with TPA to facilitate an early confirmation in such special cases.

4.06 POLICY ADMINISTRATION

i) Addition – Deletion – Data for addition-deletion of employee is expected within 15 days of the employee joining or leaving the company.

a. Based on the data sent by the client Endorsements will be passed subject to availability of float premium. Copies of such passed endorsements will be sent to the client in 5 working days.

B.If endorsements are not possible because of data inadequacy or non availability of floating premiums, intimation to the client will be sent on a priority. The timeline within which such an intimation will be sent to the client is 2 working days (48 hours).

Ii)Float Accounting - The float available with the insurance company for the particular policy will be monitored by ABC. A threshold level will be determined and on approaching the threshold limit a trigger will be sent to the client requesting replenishment of the float. Such a trigger will be generated within two working days (48 hours) of such a situation arising.

Iii)Premium Accounting Statement – Before the 10th of every month the monthly account statement of the preceding month will be sent to the concerned authorities in your organization. This statement will elaborate on the endorsements passed in the policy and the resultant consumption and refund of premium and therefore the Float Status.

Iv)Data Mapping – To ensure correctness of database in terms of coverage of all eligible members and deletion of all members who have left the company we undertake to map the complete database available with us & Insurer against your master database. This activity will be done in the last week of every quarter.

4.07 Other Value Additions

ABC will coordinate with other vendors appointed by client in rendering Employee wellness services like Employee assistance program, Doctor on call, Doctor on visit, onsite wellness talks. The calendar for the same can be frozen at the start of this contract.

4.08 POLICY REVIEW & MIS

I) Monthly MIS Reports – On the 5th of every month ABC will generate an MIS elaborating

A. Monthly Claim Tracker – A Monthly Claim tracker which will give details of all Cashless and Non Cashless claims filed during the month with updates on status of pending claims and details of passed claims will be sent to HR. Break up of claims made by Employee and Dependents will be presented along with Claim Ratio. After the policy is logged in, we will take your inputs on the template we have on the same and have the same ratified by you to accommodate any changes you may suggest.

II)Policy Review Meeting – 5th of every month, MIS Report will be presented by the ABC over a meeting with concerned authorities in your organization. The primary agenda of the meeting will be to understand areas of improvement, deficiencies, if any and value additions ABC needs to make to ensure seamless service.

III) Monitoring Set TAT – Presented below is the summary of the various timelines quoted in this SLA :

Activity Agreed TATs

Presentation of “Scope of Coverage” - Before policy log in

Data submission of insured members by the Client. Within 15 working days of Commencement of Policy

Policy Issuance 10 working days from date of submission of complete data and payment of all premiums due.

Cashless Cards Issuance for Day 1 & New Joinees -7 working days from date of policy issuance / endorsement.

Reissuance of Duplicate / Rectified Cards - 5 days from the date of endorsement

Employee Presentations - Monthly once

Query Resolution (all types) - Within 2 working days (48 hours)

Non Cashless Claim Settlement - Within 14 working days from the date of submission of all relevant documents.

Deficiency Intimation on Claims - Within 5 working days post submission of relevant documents for the case.

Deficiency Reminder - On the 7th day post the first deficiency intimation if deficiencies are not submitted.

Addition-Deletion Data to be submitted by the Client - For employees and dependents, within 15 days of an employee joining the organization

Data inadequacy / Non availability of Float Premium for Endorsements - Within two working days (48 hours) after such a situation has arisen.

Premium Accounting Statement - 10th day of every month

Data Mapping - Once every quarter

Monthly MIS Report submission - Claim Tracker 5th of every month

The details of the persons who are responsible for servicing the needs of the clients are presented hereunder in the escalation matrix:

Mr.aaaa – Director, Operations.

If any deviation is noticed by the client from the set TAT they are free to contact persons as above.

4.09 COST STRUCTURE

For the services highlighted in the SLA client does not have to pay any extra fees.

4.10 VALIDITY OF THE SLA DOCUMENT

The SLA will be valid unless it is terminated in writing by either party, giving a 30 days notice period to the other party.

The SLA agreement shall be effective upon all the parties signing the same and the insurance policy commencing for the client.

5.0 Mid Term Additions of Dependents

Mid-term additions of dependents is not allowed by insurers unless same is on account of natural additions like addition of a newly born baby and newly married spouse.

6.0 COMPLIANCE

The parties to this Service Level Agreement are independent and shall be liable to render its respective services/ obligations within the agreed terms & conditions of present SLA and in accordance with policy and above all, in compliance with IRDA regulations. In the event of any compliance matter, the policy shall always prevail over SLA.


XYZ

Address

Signature

Place: Location

ABC

Address

Signature

Date: __________