Maharashtra Building Construction WWB.ppt

Healthcare / insurance deign features for a Government scheme for construction workers

1. Maharashtra Building Construction & Other
Workers Welfare Board
Presenting: Credentials, Capabilities & Value Proposition for the beneficiaries of

2. Company Structure: About us
Almondz Group
 is one of India’s leading Financial Services providers with interest across Merchant Banking, Infrastructure
Advisory, Debt Portfolio Management, Retail & Distribution, Insurance, Equity and Commodity Broking.
The Almondz Group comprises the following entities:
Almondz Global Securities Ltd.
- Trading and clearing members for equities and derivatives with NSE and BSE
- SEBI Registered Merchant Bankers
- Depository participant with CDSL
- Corporate Finance
- Debt Portfolio Management
- Distribution
Almondz Commodities Pvt. Ltd.
- Memberships of MCX and NCDEX
Almondz Insurance Brokers Pvt. Ltd.
- Registered with IRDA as Insurance broker
- Risk Management
- Insurance Broking
- Employee benefit consulting
- Claims Management
Almondz Insurance Brokers Pvt. Ltd.
 
Almondz Capital and Management Services Ltd.
- Holding Company of Almondz Group

3. Diversification of Insurance Practice at Almondz

4. Employee Benefits Team at Almondz
Naveen K Midha is the Employee Benefits practice leader for Willis in India. Naveen’s career spans senior positions with
various insurance entities within and outside India. During his tenure of more than a decade in the Indian Insurance
industry, Naveen has gained experience and expertise in areas of benefits design consulting, product design, strategic &
operational experience in healthcare management and other critical domains of employee benefits. In his current role with
Willis, Naveen is responsible for strategizing the development and implementation of Employee benefits activities – design,
placement, negotiation & servicing – for key corporate clients.
 Naveen has received his Bachelor of Business Studies from University of Delhi and is also a qualified Cost & Works
Accountant (ICWA), India. He has also done his MS in Risk Management from The School of Risk Management, Insurance &
Actuarial Science, St. John’s University, New York, and has yet another Masters degree in Finance from Delhi University,
India.
Naveen Kumar Midha
Sudip Indani is the Employee Benefits leader for North, West & East India. Sudip always been an Insurance professional, with
nearly 9 years of experience in the Indian Insurance industry, Sudip has gained experience and expertise in areas of benefits
design consulting, product structuring and implementing large and tricky employee benefits programs. Sudip also lead the
Expatriate Employee Benefits for All India Clients.
 
Sudip has received his Bachelor in Computer Science from DAVV University, India & MBA in Insurance & Risk Management
from Birla Institute of Management and Technology India.
  He has also completed his Associate from Insurance Institute of
India.
Sudip Indani

5. Value Proposition for MBCWWB – Services:

6. Pre-Placement Services
Policy Benchmarking: Designing a product
• A thorough analysis of Insurance Policy within the similar;
•Peer Group Analysis
•Industry wise benchmarking
•Cost Benefit analysis & identifying a sustainable product
Claims Benchmarking: Defining a price & other critical factors
• A thorough analysis of Insurance Product within the similar product range to
understand;
•Average Claim cost
•Ailments & Hospital wise benchmarking
•Forecasted utilization & Inflation

7. Pre-Placement Services – a Sample Product
Generic / Standard Product
•Hospitalization coverage for up to Rs 30,000 per annum for a family of five on a floater basis which includes
transportation allowance of 100/ hospitalization to maximum of Rs 1,000
•Cashless treatment through biometric smart cards with across- the- country portability
•Insurance cover to pre-existing diseases
•No age restrictions for enrollment
•The unorganized sector worker and his family (unit of five) will be covered
•Cashless attendance to all covered ailments
•Hospitalization expenses, taking care of most common illnesses including maternity benefits.
•Transportation costs (actual with maximum limit of Rs. 100 per visit) within an overall limit of Rs.1000
Eligibility Criteria
• The member should be aged between I8 and 59 years
• The member should be the head of the family or one earning member in the family
Accident Benefits Amount in / Family
On natural death 30,000
On death due to accident/ on permanent total disability due to accident 75,000
On partial disability due to accident 37,500
Scholarship Benefits to two children/ eligible family studying in 9th to 12th standard 1,200/Child

8. Pre-Placement Services – TPA Evaluation
Sr. No.Name of TPA
1License Number
2Whether Renewed for the current year
3Onwership Details
4Location/s and reach
5Current Client Details (Insurance Companies)
6Past Client Details (Insurance Companies)
7Range of Services provided
8Are fixed benefit products handled by TPA
9Management Details
aName and details of Director
bIndustry Experience of TPA
cQualifications and Experience of claims personnel
dNumber of Claims personnel
eAny Legal and Medical Consultants for expert opinion
10Claims Philosophy
11Claims Management processes
aEnd to End Reminburement and Pre authorization Process
bClaims Authority Limits
cSupport provided to Insurer in Reconsideration and Litigation cases
12Investigation Process
13Follow up Mechanism
14Claims Workloads
aNumber of claims received per month for the last 2 years
bValue of claims received per month for the last 2 years
c% of Claims processed within one month
15Service Standards (Average TAT per service)

9. Pre-Placement Services – TPA Evaluation (Contd…)
a
End to End TAT from Claim Intimation to Final Communication Letter
bTAT from receipt of last requirement to Final Communication Letter
16Systems
aIs system available in all locations (Also list down the Locations)
bIs Branch having all access that HO has
cAre Policy terms and conditions available on system
dAre proposal details available on system
eAre Underwriting details available on system
fIs ICD 10 coding used to determine the diagnosis
gIs PCS coding used to determine the Line of treatment
hShare all the fields captured in the system
iIs the system updated on realtime basis
jIs the insurer having access to TPA system
kIf yes, to what extent
17Monitoring of performance, how is it measured?
18Audit process
19Are the hospitals codified based on their Reg No., No, of beds and address
20Service Provider Network
aNumber of hospitals empanelled
bSpread of hospitals empanelled
cLevel of discount agreed upon with Hospitals
dProcess of auditing of hospitals
21Communications
aType of communication channels used with insureds, insurer and hospitals
b
Samples of all communication Letters( Notification Letter, Reminder Letters, Closed Letters, Payment and Rejection letters, Pre
authorization Form, Claim Form
22Type of analysis can be provided
23Remuneration

10. Pre-Placement Services – Insurer Evaluation & Defining
Sustainability
Standard Parameters: understanding the market standing
• A thorough analysis of Insurance companies to identify;
•Premium Underwritten - Overall
•Premium Underwritten - Health
•Loss Ratios – To understand their Claims Psychology
•Sustainability
•Years into existence
Service Differentiators: understanding the dynamism
• A thorough analysis of Insurers services w.r.t;
•Preferred TPA’s
•Clients handled
•Turn Around Time (Endorsement, Add-Del, Dedicated Resources)

11. Pre-Placement Services – Insurer Evaluation & Defining
Sustainability
Policy Parameters & Technology: understanding the product offering
• A thorough analysis of Insurance companies to identify;
•Innovation in Product & Customization
•Experience in handling similar policies
•Policy Benefits & Coverage in standard domain
•Platforms, ERP, MIS - Single-Window / SWISS / e-BOW etc,
Claims Psychology: understanding the efficiency
• A thorough analysis of Insurers Claims Psychology w.r.t;
•Clinical Guidelines
•Claimed Amount Vs Paid Amount (Within similar policy parameters)
•Customer Loyalty & Vintage

12. Placement Services – Pricing & Negotiation
RFQ: understanding the price factor
•Designing a comprehensive RFQ
•Preliminary Quotes
•Short listing – For subsequent Negotiations
•Comparison Chart & Trends with Critical Indicators
•Negotiation on Value-Adds
Policy Issuance & Signoffs: Due Deligence
A Comprehensive Exercise to evaluate the following;
•Terms & Conditions (as mentioned in the RFQ)
•Policy Issuance & Benefits Mapping Review
•Sign-offs
•Service Level Agreements
•Orientation

13. Service par’ Excellence – Overview

14. Service par’ Excellence – Onsite Support: Presence
Service Partners Presence in
Major location like;
1.Mumbai
2.Pune
3.Nashik
4.Ahmadnagar
5.Aurangabad
6.Kolhapur
7.Nanded
8.Nagpur

15. Service par’ Excellence – Onsite Support: Organogram
Considering a 45 Member Dedicated Employee Benefit team with Pan-India Presence, the scalability and sustainability of Best-In-
Class Services is assured
Onsite Services:
1.Enrollment
2.Feedback
3.Escalation
4.Coordination
5.Insurance Payment
6.TAT’s

16. Service par’ Excellence – Offline Support
Portal: tracking & monitoring
• A dedicated White Labeled Portal to;
•Get real-time updates
•Policy Overview
•Tracking of Claims
•Feedback & Complaints
Monitoring Performance: Effectiveness of services
• A periodic review with Insurer & TPA to understand;
•Adherence to SLA’s
•Payment of Claims
•Utilization review
•Hospital experience

17. Service par’ Excellence – Offline Support
Claims Review: understanding the trends w.r.t;
•Relation Wise Claims
•Status & Relation Wise Claims
•Gender & Cashless Vs. Reimbursement
•Age Band Wise Claims
•Amount Band Wise Claims
•Hospital Wise Claims
•Disease/ Ailments Wise Claims
•Location Wise Claims
•Rejected Claims
•Outstanding : Month-wise TAT
•Settled : Month-wise TAT
Demographics:
•Relation & Gender Wise Demographics
•Average Age Wise Demographics
•Age Band Wise Demographics

18. Service par’ Excellence – Offline Support: Reports

19. Service par’ Excellence – Communication: Wallet Cards
Wallet Cards: Consolidating the benefits
•Mediclaim Policy Terms
•Personal Accident Policy Terms
•General Info
•Emergency Contact Numbers
•Health Tips

20. Service par’ Excellence – Communication: EB Portal
EB Portal: Creation of dedicated, Almondz-managed portal that streamlines the entire process for Group
Health Insurance, Group Personal Accident, Group Life Policies purchased by Employer for their employees.
EB Portal Link : http://www.almondz-ebportal.com

21. Service par’ Excellence – Communication: Call Centre
Call Centre – Multi-Lingual (English, Hindi, Marathi)
Toll Free Call-in Lines for all Employees/members
Priority Service with Staff Trained around your policy
White labeled Service
“Welcome to Maharashtra Labour Helpline”;
“म
हाराष्ट्र के श्रम हेल्पलाइन में आपका स्वागत है
”;
“म
हाराष्ट्र कामगार हेल्पलाईन स्वागत आहे
”;
Capability of Automatic Call Distribution System (ACD) providing Online
Reporting on
Abandoned Calls, Call Drops, Alert Time-outs, Holding Time, etc.
Regular Reporting with Call Centre Metrics
VIP Identification & Service Delivery
VIP Tagging & Caller Line Identification
SMS Facility @ time of Pre-Authorization Fax Receipt & Response Fax out
Dedicated Desk for Rejections managed by experienced Medico

22. Service par’ Excellence – Communication: Operations
Systematic Work Flow with In-house Developed IT Application and EB Portal
Dedicated Team of agents on MBCWWB Policy
TAT < 7 Days for Re-imbursement claim
Option of EFT to Workers & linking to DIRECT CASH TRANSFER scheme
account for Reimbursement Claims
Handholding Employees for Reimbursement Claims/ OPD Claims
Workers Manual with Wallet Cards, Posters, Flyers
Call Centre Assistance 24/7*365 - DEDICATED
Help Desk Agents Trained in 8 Districts
Strong Document Recovery Team
IT Enablement: Automated e-Reminders with Escalation Option
Call out and sms options as alternate communication mode
Use of Helpdesks for Aiding Employees
Regular Trainings with Documents Processes & Manuals

23. Service par’ Excellence – Communication: Offline
Sample
Customized Designing of Communication materials:
•Posters & Flyers
•Standees at Enrollment Locations in Regional Languages
•Brochures at District offices for Easy-to-Explain approach
•Do’s & Dont’s at Most utilized Hospitals

24. Service par’ Excellence – Communication: Mobile Application
Mobile Applications: This can be used by the administrators to;
•Monitor Claims status
•Track Hospitals
•Wellness tips
•Policy Benefits & Coverage

25. Service par’ Excellence – Other Critical Aspects
 Tracking of Fradulent Claims
 Usage of Miliman Guidelines for Clinical Assessment
 Emphasis on ICD 10 Coding
 Standardization of Tariffs & Rates
 Periodic Investigations at Hospitals & Subsequent black-listing
 Feedback Mechanism: Random checks of the services w.r.t;
 Cashless / Reimbursement Experience
 Hospital Staff & Friendliness
 Approvals & Follow-ups
 Call Centre Support
 Enrollment Services
The Reports are made available to the Board / Committee / Assignee with the
overall satisfaction scores

26. Questions?
?