Cashless Pre Auth Request Form         Claim Form            Domiciliary Hospitalisation Claim Form

Checklist for Claim Submission           Day Care                 General Exclusions

List of Non-Payable by IRDA                  Corporate Buffer Claim Form      Domiciliary Treatment List

Scheme Cover, Sum Insured & Coverage

Maternity Benefits

Expenses Covered

Critical Illness

Domiciliary Treatment

Policy exclusions

Claim Process – Cashless

Claim Process – Reimbursement

Documents to be submitted

Other Information

Corporate Buffer

Misc Information

STAFF MEDICAL INSURANCE SCHEME medical

Staff Circular No.6243 dated 18.09.2015, 6263 dated 29.10.2015, 6466 dated 10.10.2016, 6467 dated 10.10.2016, 6472 dated 18.10.2016

Having  regard to the need to extend better coverage and reimbursement of hospitalization  and medical expenses incurred by the officers / employees / dependent family  members, the demand  for full reimbursement of expenses connected with hospitalization and  medical  treatment  including domiciliary hospitalization  and domiciliary treatment was discussed by and between  the parties  and a new  scheme for  reimbursement of medical expenses has been formulated.

The salient feature of the Scheme is as under:-

The scheme shall cover expenses of the officers / employees and dependent family members in cases he / she shall contact any disease or suffer from any illness (hereinafter call DISEASE)  or sustain any bodily injury through accident (hereinafter called INJURY) and if such disease or injury shall require any employee/dependent family member, upon the advice of a duly  qualified Physician / Medical practitioner (hereinafter  called  MEDICAL  PRACTITIONER) or of a duly qualified  Surgeon (hereinafter called SURGEON) to incur hospitalization/domiciliary hospitalization and domiciliary treatment expenses as defined in the Scheme, for medical / surgical treatment at any Nursing Home / Hospital / Clinic (for domiciliary treatment) / Day Care Centre which are registered with the local bodies in India as herein defined (hereinafter called HOSPITAL) as an inpatient or otherwise  as specified as per the Scheme.

Present Policy Number is 5001002817P110716170.

Tenure of the Policy is from 01.10.2018 to 30.09.2019.

Scheme Cover

The Scheme covers Employees + Spouse + Dependent Children + any two of the dependent Parents / Parents-in-law.

    • No age limit for dependent children (including step children and legally adopted children).
    • A child considered dependent if his/her monthly income does not exceed Rs.10,000/- per month.
    • Widowed daughter and dependent divorced / separated daughters, sisters including unmarried/Divorced/abandoned or separated from husband/widowed sisters and Crippled Child shall be considered as dependent for the purpose of this policy.
    • Physically challenged Brother / Sister with 40% or more disability subject to that there individual monthly income does not exceed Rs.10000/-.
    • No age Limits for Dependent Parents. Any two, i.e. either dependent parents or parent-in-law will be covered as dependent.
  • Parents would be considered dependent if their monthly income does not exceed Rs.10,000/- per month or as revised by Indian Banks’ Association In due course, and wholly dependent on the employee as defined in the scheme.

All the existing permanent officers/employees of the Banks which are parties to this Settlement shall be covered by this Scheme from the date of introduction/implementation of this Scheme. All New Officers/employees shall be covered from the date of joining as per their appointment in the bank.

Till the new scheme is made effective and gets implemented, the existing provisions as per Bipartite Settlement / Joint Note dated 27.04.2010 will continue to operate.

The new Scheme as applicable to the officers/ employees in service would be continued beyond their retirement / superannuation / resignation, etc. subject to payment of stipulated premium by them.

The new Scheme would also cover the existing retired officers/employees of the Banks and dependent spouse subject to payment of stipulated premium by them.

In the event of any claim becoming admissible under this scheme, the  Bank will reimburse the amount of such expenses as would fall under different mentioned below and as are reasonable and medically necessary incurred thereof by or on behalf of such employee.

Reimbursement shall cover Room and Boarding expenses as provided by the Hospital/Nursing Home not exceeding Rs.4000/- per day or the actual amount whichever is less.  Intensive Care Unit (ICU) expenses not exceeding Rs.7500/- per day or actual amount whichever is less.  Surgeon, team of surgeons, Assistant surgeon, Anesthetist, Medical Practitioner, Consultants, Specialists Fees, Nursing Charges, Service Charges, IV Administration Charges,  Nebulization  Charges,  Charges, Anesthetic, Blood, Oxygen, operation Theatre Charges, surgical appliances, OT consumables, Medicines & Drugs, Dialysis, Chemotherapy, Radiotherapy, Cost of Artificial Limbs, cost of prosthetic  devices implanted during surgical procedure like pacemaker, defibrillator, ventilator, orthopedic implants, Cochlear  Implant, Intra Ocular Lenses Infra cardiac valve replacements, vascular stents, any other valve replacement, Laboratory diagnostic tests  , X-ray, CT Scan, MRI, any other scan, scopies and such similar expenses that are medically necessary or incurred during hospitalization as per the advice of the attending doctor.

Hospitalization expenses (excluding cost of organ) incurred on donor in respect of organ transplant to officers/employee/dependent also be covered for reimbursement.

Pre and Post Hospitalization expenses payable in respect of each hospitalization shall be the actual expenses incurred subject to 30 days prior to hospitalization and 90 days after discharge.

Sum Insured

Employees – Hospitalization and Domiciliary Treatment coverage as defined in the scheme per annum.

Officers                 Rs.400000/-

Clerical Staff         Rs.300000/-

Sub Staff               Rs.300000/-

Retirees: Only hospitalization treatment is payable. No expenses related to domiciliary/OPD treatment is payable upto 31.10.2016. Now Renewal for 2016-17 is available with or without Domiciliary Cover is available for retirees with 59 diseases covered with cover of Rs.40000/- with overall sum insured of Rs.400000/-.

*For retirees over and above the limit of Rs.1.25 lacs (life time) available under the Medical Insurance Scheme

Change in sum insured after commencement of policy to be considered in case of promotion of the employee or vice versa.

Salient features & Benefits covered

DEFINITIONS:

ACCIDENT:

An accident is a sudden, unforeseen and involuntary event caused resulting in injury

“Acute condition” – Acute condition is a disease, illness or injury that is likely to respond Quickly to treatment which aims to return the person to his or her state of health Immediately before suffering the disease/illness/injury which leads to full recovery.

“Chronic condition” – A chronic condition is defined as a disease, illness or injury that has one or more of the following characteristics –

  1. It needs ongoing or long-term monitoring through consultations, examination, Check-ups  and/or tests –
  2. It needs on ongoing or long-term control or relief of symptoms.
  3. It requires your rehabilitation or for you to be specially trained to cope with it.
  4. It continues indefinitely
  5. It comes back or likely to come back.

ALTERNATE THERAPY:

Reimbursement of expenses for hospitalization or domiciliary (under clause 3.1) under the recognized system of medicines, viz, Ayurvedic, Unani, Sidha, Homeopathy, Naturopathy, if such treatment is taken in a clinic / hospital registered, by the central and state government.

ALTERNATIVE TREATMENTS:

Alternative treatments are forms of treatment other than treatment “Allopathy” or “modern medicine and includes Ayurveda, Unani, siddha homeopathy and Naturopathy in the Indian context, for Hospitalization only and Domiciliary for treatment only under ailments mentioned under the clause number 3.1 (Ref. 304 Alternative Therapy).

AYURVEDIC TREATMENT:

Hospitalization expenses are admissible when treatment is undergone in a Government Hospital.

ANY ONE ILLNESS:

Any one illness will be deemed to mean continuous period of illness and it includes relapse within 45 days from the date of last consultation with the Hospital / Nursing Home where treatment has been taken occurrence of the same illness after a lapse above will be considered as fresh illness for the purpose of this policy.

CASHLESS FACILITY:

Cashless Facility means a facility extended by the insurer to the insured where the payment of the cost of treatment undergone by the employee and the dependent family members of the insured in accordance with the policy terms and conditions, or directly made to the network provider by the insurer to the extent pre-authorization approved.

COGENITAL ANOMALY:

Congenital Anomaly refers to a condition (s) which is present since birth, and which is Abnormal with reference to form, structure or position.

  1. Internal congenital Anomaly which is not in the visible and accessible parts of the body
  2. External congenital Anomaly which is in the visible land accessible parts of the body

CONTRIBUTION:

The officers/employees shall not be required to share the cost of such benefits under the New Scheme.  However, in the case of officers / employees retiring from the Banks after the scheme is introduced and those who are already retired from the services of the banks and who got to avail the benefits of the scheme, the amount of contribution by such persons shall be decided at the respective Bank level.

DAY CARE CENTRE:

A day care centre means any institution established for day care treatment of illness and/or injuries or a medical setup within a hospital and which has been registered with the local authorities, wherever applicable, and is under the supervision of a registered and qualified medical practitioner AND must comply with all minimum criteria as under:-

  • Has qualified nursing staff under its employment round the clock.
  • Has qualified medical practitioner(s) in charge, round the clock.
  • Has a fully equipped Operation Theatre of its own where surgical procedures are carried out.
  • Maintains daily records of patients and makes these assessable to the insurance company’s authorized personnel.

Day care Treatments:

Covered under the scheme and would refer to medical treatment and or surgical procedure which is

    1. Undertaken under general or local anesthesia in a hospital / day care centre in less than a day because of technological advancement, and
  1. Which would have otherwise required hospitalization of more than a day. Treatment normally taken on an outpatient basis is not included in the scope of this definition.

DOMICILIARY HOSPITALIZATION:

Domiciliary Hospitalization shall be covered under this scheme and would mean medical treatment for an illness/disease/injury which in the normal course would require care and treatment at a hospital but is actually taken while confined at home under any of the following circumstances:

  1. The condition of the patient is such that he/she is not in a condition to be removed to a hospital or
  2. The patient takes treatment at home on account of non-availability of room in a hospital.

HOSPITAL / NURSING HOME:

A Hospital under this scheme would mean any institution established for a in-patient care and day care treatment of illness and/or injuries and which has been registered as a Hospital with the local authorities under the Clinical establishments (Registration and Regulation) Act, 2010 or under the enactments specified under the Schedule of Section 56(1) of the said Act OR complies with all minimum criteria as under:

  • Has qualified nursing staff under its employment round the clock.
  • Has at least 10 in-patient beds in towns having a population of less than 10 lacs and at least 15 in-patient beds in all other places.
  • Has qualified medical practitioner(s) in charge, round the clock.
  • Has a fully equipped Operation Theatre of its own where surgical procedures are carried out.
  • Maintains daily records of patients and makes these assessable to the insurance company’s authorized personnel.

This clause will however be relaxed in areas where it is difficult to find such hospitals and in the case of an emergency. The term “Hospital’/Nursing Home’ shall not include the establishment which is a place of rest, a place for aged, a place for drug-addicts or place for alcoholics, a hotel or a similar place.

HOSPITALIZATION:

Hospitalization would mean admission in a Hospital/ Nursing Home for a minimum period of 24 consecutive hours of inpatient care except for specified procedures/ treatments where such admission could be for a period of less than a day.

ID CARD:

In terms of the scheme arrived at between the Banks and insurance companies, ID Cards would be issued to all the officers / employees / dependent family members / retired officers / employees / their dependents for purpose of availing cashless facility in network hospitals.

ILLNESS:

Illness means a sickness or a disease or pathological condition leading to the impairment of normal physiological function which manifests itself during the policy period and requires medical treatment.

INJURY:

Injury means accidental physical bodily harm excluding illness or disease which is verified and certified by a medical practitioner. However, all types of Hospitalization is covered under the Scheme.

IN PATIENT CARE:

In Patient Care means treatment for which insured person has to stay in a hospital for more than a day for a covered event.

INTENSIVE CARE UNIT:

Intensive care unit means an identified section, ward or wing of a Hospital which is under the constant supervision of a dedicated medical practitioner(s) and which is specially equipped for the continuous monitoring and treatment of patients who are in a critical condition, or require life support facilities and where the level of care and supervision is considerably more sophisticated and intensive than in the ordinary and other wards.

MATERNITY EXPENSES:

Maternity expenses /treatment shall include:-

  1. Medical Treatment expenses traceable to childbirth (including complicated deliveries and caesarean sections incurred during hospitalization
  2. Expenses towards medical termination of pregnancy during policy period.
  3. Complications on Maternity would be covered upto the Sum Insured plus the Corporate buffer.

MEDICAL ADVICE:

Any consultation or advice from a medical practitioner/doctor including the issue of any prescription or repeat prescription.

MEDICAL EXPENSES:

Medical Expenses means those expenses that an insured person has necessarily and actually incurred for medical treatment on account of illness or accident on the advice of a medical practitioner, as long as these are no more than would have been payable if the insured person had not been insured.

MEDICALLY NECESSARY:

Medically Necessary treatment is defined as any treatment test, medication or stay in hospital or part of a stay in a hospital which

  • Is required for the medical management of the illness or injury suffered by the insured.
  • Must not exceed the level of care necessary to provide safe, adequate and appropriate medical care in scope, duration or intensity.
  • Must have been prescribed by a medical practitioner.
  • Must confirm to the professional standards widely accepted in international medical practice or by the medical community in India.

MEDICAL PRACTITIONER:

Medical Practitioner is a person who holds a valid registration from the Medical Council of any state or Medical Council of India or Council for Indian Medicine or the homeopathy set up by the Government of India or a State Government and is thereby entitled to practice medicine within its jurisdiction; and is acting within the scope and jurisdiction of his license.

The term Medical Practitioner would include physician, specialist and surgeon. (The Registered practitioner should not be the insured or close family members such as Parents, parents-in-law, spouse and children.)

NETWORK PROVIDER:

Network provider means hospitals or health care providers enlisted by an insurer or by a Third party Administrator and insurer together to provide medical services to an insured on payment by a cashless facility.

The list of network hospitals is maintained by and available with the THIRD PARTY ADMINISTRATOR and the same is subject to amendment from time to time.

NEW BORN BABY:

A new born baby means baby born during the Policy Period aged between one day and 90 Days, both days inclusive.

NET WORK:

Any hospital, day care centre or other provider that is not part of the network.

NOTIFICATION OF CLAIM:

Notification of claim is the process of notifying a claim in the Bank, insurer or Third Party Administrator as well as the address / telephone number to which it should be notified.

OPD TREATMENT:

OPD Treatment is one in which the insured visits a clinic/hospital or associated facility like a consultation room for diagnosis and treatment based on the advice of the medical practitioner. The insured is not admitted as a day care in-patient.

PRE EXISTING DISEASE:

Pre Existing Disease is any condition, ailment or injury or related condition(s) for which you had signs or symptoms, and/or were diagnosed, and/or received medical advice/treatment, prior to the first policy issued by the insurer. Preexisting Diseases would be covered for reimbursement under the scheme.

PRE HOSPITALISATION MEDICAL EXPENSES:

Medical expenses incurred immediately 30 days before the insured person is hospitalized will be considered as part of a claim provided that such medical expenses are incurred for the same condition for which the insured person’s hospitalization was required.

POST HOSPITALIZATION MEDICAL EXPENSES:

Relevant medical expenses incurred immediately 90 days after the employee / dependent / retirement employee is discharged from the hospital provided that such medical expenses are incurred for the same condition for which the Insured Person’s Hospitalization required.

QUALIFIED NURSE:

Qualified Nurse is a person who holds a valid registration from the Nursing Council of India or the Nursing Council of any state in India and/or who is employed on recommendation of the attending medical practitioner.

REASONABLE AND CUSTOMARY CHARGES:

Reasonable Charges means the charges for services of supplies, which are the standard charges for the specific provider and consistent with the prevailing charges in the geographical area for identical or similar services, taking into account the nature of illness/injury involved.

ROOM RENT:

Room Rent shall mean the amount charged by the hospital for the occupancy of a bed on per day basis.

SUBROGATION:

Subrogation shall mean the right of the insurer to assume the rights of the insured person to recover expenses paid out under the policy that may be recovered from any other source.  It shall exclude the medical/accident policies obtained by the insured person separately.

SURGERY:

Surgery or surgical procedure means manual and/or operative procedures(s) required for treatment of an illness or injury, correction of deformities, relief of suffering or prolongation of life, performed in a hospital or day care centre by a medical practitioner.

THIRD PARTY ADMINISTRATOR:

Third Party Administrator means a Third Party Administrator who holds a valid license from Insurance Regulatory and Development Authority to act as a THIRD PARTY ADMINISTRATOR and is engaged by the Company for the provision of health services as specified in the agreement between the Company and Third Party Administrator.

UNPROVEN / EXPERIMENTAL TREATMENT:

Unproven / Experimental Treatment is treatment, including drug experimental therapy, which is not based on established medical practice in India.

Maternity Benefit

The Hospitalization expenses in respect of the new born child can be covered within the Mother’s Maternity expenses.  The maximum benefit allowable under this clause will be up to Rs.50,000 for normal delivery and Rs.75,000 for Caesarean Section.

Special conditions applicable to Maternity expenses benefit Extension:-

    1. 9 months waiting period under maternity benefits will be waived from the policy.
  1. Pre-natal & post-natal charges in respect of maternity benefit are covered under the policy up to 30 days and 60 days only, unless the same requires hospitalization.
  2. Missed abortions, miscarriage or abortions by accidents are covered under the limit of Maternity.
  3. Complications in Maternity including operations for extra uterine pregnancy ectopic pregnancy would be covered in the up to the Sum Insured + Corporate Buffer.
  4. Expenses incurred for Medical Termination of Pregnancy.
  5. Claim in respect of delivery to be given irrespective of the number of children.

Baby day one cover

New born baby is covered from day one. All expenses incurred on the new born baby during maternity will be covered in addition to the maternity limit and up to `20,000/-. However, the baby contacts any illness the same shall be considered in the Sum Insured + Corporate buffer.  Baby to be taken as an additional member within the normal family floater.

Expenses on Hospitalization for minimum period of a day are admissible.  However, this time limit shall not be applied to specific treatments, such as:-

1 Adernoidectomy 19 Haemo dialysis
2 Appendectomy 20 Fissurectomy /  Fistulectomy
3 Auroplasty not cosmetic in nature 21 Mastoidectomy
4 Coronary angiography/Renal 22 Hydrocele
5 Coronary angioplasty 23 Hysterectomy
6 Dental Surgery 24 Inguinal/ventral/umbilical/femoral hernia
7 D & C 25 Parenteral Chemotherapy
8 Excision of cyst / granuloma / lump / tumor 26 Polypectomy
9 Eye Surgery 27 Septoplasty
10 Fracture including hairline fracture/ dislocation 28 Piles/fistula
11 Radiotherapy 29 Prostate surgeries
12 Chemotherapy including parental chemotherapy 30 Sinusitis surgeries
13 Lithotripsy 31 Tonsillectomy
14 Incision and drainage of abscess 32 Liver aspiration
15 Varicocelectomy 33 Sclerotherapy
16 Wound suturing 34 Varicose Vein Ligation
17 FESS 35 All scopies along with biopsies
18 Ascitic Pleural tapping 36 Lumbar puncture
37 Operations/Micro surgical operation on the nose, middle ear / internal  ear, tongue, mouth, face, tonsils & adenoids, salivary glands & salivary ducts, breast, skin & subcutaneous tissues, digestive tract, female / male sexual organs

This condition will also not apply in case of stay in hospital of less than a day provided the treatment is undertaken under General or Local Anesthesia in a hospital/ day care centre in less than a day because of technological advancement and which would have otherwise required hospitalization of more than a day.

Critical Illness

To be provided to the employee only subject to a sum insured of Rs.1,00,000/-. Cover starts on inception of the policy. In case an employee contracts a Critical Illness as listed below, the sum of Rs.1,00,000/- shall be paid. This benefit shall be provided on first detection/diagnosis of the Critical Illness.

  • Cancer including Leukemia
  • Stroke
  • Paralysis
  • By pass surgery
  • Major Organ Transplant/Bone marrow transplantation
  • End Stage Liver Disease
  • Heart Attack
  • Kidney failure
  • Heart Valve Replacement Surgery

Hospitalization is not required to claim this benefit. Further the employee can claim the cost of Hospitalization on the same from the Group Mediclaim Policy as cashless / reimbursement of Expenses for the treatment taken by him.

Ambulance Charges:

Ambulance charges are payable up to `2,500 per trip to hospital and/or transfer to another hospital or transfer from hospital to home if medically advised.  Taxi and Auto Expenses in actual maximum upto `750/- per trip will also be reimbursable.

Ambulance charges actually incurred on transfer from one center to another center due to non-availability of medical complication shall be payable in full.

Congenital Anomalies:

Expenses for treatment of Congenital Internal / External diseases, defects anomalies are covered under the scheme.

Psychiatric diseases:

Expenses for treatment of psychiatric and psychosomatic diseases shall be payable with or without hospitalization.

Advanced medical treatment:

All new kinds of approved advanced medical procedures for e.g. Laser Surgery, stem cell therapy for treatment of a disease is payable on hospitalization / day care surgery.

Treatment taken for Accidents can be payable even on OPD basis in Hospital.

Taxes and other charges:

All Taxes, Surcharges, Service Charges, Registration Charges, Admission charges, Nursing and Administration charges to be payable.

Charges for diapers and sanitary pads are payable, if necessary, as part of the treatment.

Charges for Hiring a nurse / attendant during hospitalization will be payable only in case of recommendation from the treating doctor in case ICU/CCU, Neo natal nursing care or any other case where the patient is critical and requiring special care.

Treatment for Genetic Disorder and stem cell therapy shall be covered under the scheme.

Treatment for Age related Macular Degeneration (ARMD), treatment such as Rotational Field Quantum magnetic Resonance (RFQMR), Enhanced External Counter Pulsation (EECP), etc. are covered under the scheme. Treatment for all neurological/macular degenerative disorders shall be covered under the scheme.

Rental Charges for External and or durable Medical equipment of any kind used for diagnosis and or treatment including CPAP, CPAD, Bi-PAP, infusion pump etc. will be covered under the scheme.  However purchase of the above equipment to be subsequently used at home in exceptional cases on medical advice shall be covered.

Ambulatory devices i.e. walker, crutches, belts, collars, caps, Splints, Slings, Braces, Stockings, elastocrepe bandages, external orthopedic pads, sub cutaneous insulin pump, Diabetic foot wear, Glucometer (including Glucose Test Strips) /Nebulizer / prosthetic devise / Thermometer, alpha / water bed and similar related items etc., will be covered under the scheme.

Physiotherapy charges:

Physiotherapy charges shall be covered for the period specified by the Medical Practitioner even if taken at home. All claims admitted in respect of any/all insured person/s during the period of insurance shall not exceed the Sum Insured.

************************************

Expenses Covered

Room and Boarding expenses as provided by the Hospital/Nursing Home not exceeding Rs. 4000 per day or the actual amount whichever is less.

Intensive Care Unit (ICU) expenses not exceeding Rs.7500/- per day or actual amount whichever is less.

  • The difference of the room rent will be borne by the employee.

Surgeon, Team of Surgeons, Assistant Surgeon, Anaesthetist, Medical Practitioner, Consultants, Specialist Fee.

Nursing Charges, Service Charges, IV Administration Charges, Nebutization Charges, RMO Charges, Anaesthetic, Blood, Oxygen, Operation Theatre Charges, Surgical Appliances, OT Consumables, Medicines & Drugs, Dialysis, Chemotherapy, Radiotherapy, Cost of Artificial Limbs, Cost of Prosthetic Devices Implanted during Surgical procedures like Pacemaker, Defibrillator, Ventilator, Orthopaedic Implants, Cochlear Implant, Any other implant, Intra-Ocular Lenses, Infra Cardiac Valve Replacements, Vascular Stents, Any other Valve Replacement, Laboratory / Diagnostic Tests, X-Ray, CT Scan, MRI, Any other Scan, Scoples and such similar expenses that are medically necessary, or incurred during hospitalization as per the advice of the attending doctor.

Hospitalization expenses (excluding cost of organ) incurred on donor in respect of organ transplant to the insured.

All Taxes, Surcharges, Service Charges, Registration charges, Admission Charges, Nursing, and Administration charges to be payable.

Charges for diapers and sanitary pads are payable if necessary as part of the treatment.

Charges for hiring a nurse/attendant during hospitalization will be payable only in case of recommendation from the treating doctor in case ICU/ICCU.

Expenses incurred 30 days prior to admission & 60 days post discharge are covered under the policy Terms & Conditions

    • Consultation bills – should be supported with consultation note / papers of the doctor
  • Investigation / Pathological / Radiological test bills – should be supported along with Reports & advice for the same
  • Chemist bills – should be supported with respective prescriptions for the same
  • Copy of Discharge Card of the Hospitalization
  • All Pre & Post documents should be submitted within 7 days from completion of 60 days of post hospitalization period

Note: Only expenses relating to hospitalization will be reimbursed as per the policy taken. All non-medicalexpenses (As per IRDA list) will not be reimbursed.

Domicillary Treatment

Covered for treatment of specified ailments which may or may not require hospitalisation.

domiciliary-treatment

Policy exclusions

  • War like Operations: Injury/disease directly or indirectly caused by or arising from or attributable to War, invasion, Act of Foreign enemy and War like operations (whether war be declared or not).
  • Circumcision unless necessary for treatment of a disease not excluded hereunder or as may be necessitated due to an accident.
  • Vaccination or inoculation.
  • Cosmetic Surgeries: Change of life or cosmetic or aesthetic treatment of any description is not covered.
  • Plastic surgery other than as may be necessitated due to an accident or as part of any
  • Cost of spectacles and contact lenses, hearing aids.
  • Dental treatment or surgery of any kind which are done in a dental clinic and those that is cosmetic in nature.
  • Convalescence, rest cure and General debility.
  • Obesity treatment and its complications including morbid obesity.
  • Treatment for Venereal disease.
  • Intentional self-injury.
  • Use of intoxication drugs / alcohol.

Vitamins and Tonics: Expenses on vitamins and tonics unless forming part of treatment for injury or disease as certified by the attending physician.

Non-Medical Expenses: Charges for telephone, television, /barber or beauty services, food charges (other than patient’s diet provided by hospital), baby food, cosmetics, tissue paper, toiletry items and similar incidental expenses.

Claim Process – Cashless

claim-process-cashless

Cashless Facility is a benefit extended by the Insurance Company through Paramount TPA wherein the insured has the option to get admitted to a Network hospital without the burden of payment of the Hospital Bill. The network hospital list is available on the website (www.paramounttpa.com/iba) The bill is settled directly by the insurance company subject to terms and conditions of the policy.

Cashless can be availed by;
    1. A) Directly Approaching the Network Hospital. Cashless facility will only be available in a network hospital.
  1. B) Reimbursement: Intimate TPA of the hospitalization, Get admitted to the hospital, take treatment and pay the bill after collecting all the original documents from the hospital.
    • Insured can get admitted in any hospital (Network / Non Network).
    • Claim documents to be submitted to Help Desk, Bank Regional Office.
  • The claim is processed on the basis of the terms and conditions laid down in the policy, and NEFT will be done directly to the employee.

Procedure to be followed for Cashless directly with the Network Hospital

Cashless can be availed at the network hospital list updated in the web site www.paramounttpa.com/iba. The procedure mentioned below needs to be followed while availing Cashless at hospitals.

  • Choose network Hospital from updated network list of hospital on the website (www.paramounttpa.com/iba).
  • Show Paramount TPA ID card and collect Pre-Authorization form from the hospital. Fill up personal details and the rest to be filled up by the hospital treating doctor along with contact number.
  • Hospital will send cashless request form to Paramount TPA.
  • The Paramount TPA shall process the claim as per policy terms and conditions and send an approval letter to the hospital.
  • Get admitted, take treatment and get discharged without payment of bill except for non-payable items. Please ensure final bill is signed, before discharge.

Payment will be made to the Hospital/Nursing Home directly by United India Assurance Co.

For planned cashless hospitalization

Insured has to arrange for the Pre-Authorization (Pre-Auth) form to be sent via email or fax from respective network hospital TPA desk before 48 hours of admission to Paramount (PHS).

  • E-mail ID – al.request@paramounttpa.com
  • Contact No. – 022-66620808
  • Fax No. – 022-66444755/ 754

It is mandatory for Insured to thoroughly check the Pre-Auth form (to ensure that all required details are furnished & holds true to the best of their knowledge) & duly signing it as a confirmation. Please note that the PHS ID should be mentioned on the Pre- Auth. In case an employee does not have his PHS ID he should provide his corporate name along with his employee code

For emergency cashless hospitalization

Insured should get admitted and start the treatment. Pre-Auth to be followed within 24 hours of admission

  • At the time of discharge If the bill amount exceeds the limit of indemnity, insured/member will have to settle the additional amount on their own
  • Prior to discharge insured should verify the Final Bill & duly sign the same
  • Cases wherein the claim is denied for cashless benefit, the claimant/ Insured can send all claim documents for reconsideration in reimbursement along with claim form

Note: A security deposit of a minimum of Rs.10,000/- or more may be collected from the empanelled hospitals which may be reimbursed fully or partially post deduction of non-admissible expenses and once cashless settlement is done by the TPA

Claim Process – Reimbursementclaim-process-reimbursement

Reimbursement Hospitalization

  • Employees need to ensure that the treatment is done in a Registered Hospital /nursing home to get coverage under the policy in case of admission to Non-Network Hospital

Reimbursement claims need to be submitted to below mentioned address within 30 days from Date of Discharge. Please fill the claim form (claim form provided in your employee portal) and submit the same along with claim documents (all documents to be in original) to the following address.

Note: please keep a photo copy of all the submitted documents for your records before submitting the originals

Claim Intimation

Claim Intimation is to be given prior to the Hospitalization or in case of emergencies immediately upon hospitalization but prior to discharge.

1) Telephonically: 022 66629814

2) E-mail: claim.intimation@paramounttpa.com

3) Online intimation: www.paramounttpa.com/iba

Time period for claim intimation

    • Planned: Prior to admission to hospital
  • Emergency: Within 7 days of admission to hospital

Time period for Submission of Claim Documents

Pre- Hospitalization: Pre – Hospitalization means relevant medical expenses incurred like consultations, diagnostic tests, 30 days prior to hospitalization and related to the hospitalization claim.

Post – Hospitalization: Post – Hospitalization means relevant medical expenses incurred up to 90 days from the date of discharge and related to the hospitalization claim.

Documents required to avail Cashless facility

Cashless facility is available only in network hospitals. The following documents will be required before issuing cashless Authorization Letter.

  • Duly filled, signed & stamped Pre Authorization Form from the hospital.
  • Investigation reports & previous consultation papers (if any).
  • Photo ID proof.
  • Health ID number/policy number/employee number (Please mention on the AL form and provide a copy of Health ID card).

Cashless hospitalization does not mean that the treatment is free of cost.
Any expenses that are not payable under the insurance policy will not be authorized during hospitalization and the same will have to be borne by the patient.

Charges for telephone, television, barber or beauty services, food charges, baby food, cosmetics, tissue paper, toiletry items and similar Non Medical items are not payable. All the other charges related to the treatment are covered as per the terms & conditions of the policy.

CHECK LIST FOR CLAIM SUBMISSION

  1. In-patient Treatment / Day Care Procedures
  • Duly filled, signed Claim Form with mobile no. & e-mail id.
  • Photocopy of ID card / Photocopy of current year policy.
  • Address proof along with photo ID for any claim more than 1 Lac.
  • Original Detailed Discharge Summary / Day care summary from the hospital.
  • Original consolidated hospital bill with breakup of each item, duly signed by the insured.
  • Original Payment Receipt of the hospital bill.
  • First Consultation letter and subsequent prescriptions.
  • Original bills, original payment receipts and Reports for investigation.
  • Original medicine bills and receipts with corresponding Prescriptions.
  • Original Invoice / bills for implants (viz. Stent / PHS Mesh / IOL etc.) with original payment receipts.
  1. Road Traffic Accident
  • In addition to the in-patient treatment documents.

In Medico Legal cases

  • Copy of the First Information Report from Police Department / Copy of the Medico Legal Certificate
  • Copy of Post Mortem Report & Death Certificate.

In Non Medico Legal cases

  • Treating Doctor’s Certificate giving details of injuries (How, When and Where injury sustained)
  • Copy of Post Mortem Report & Death Certificate.
  1. For Death Cases
  • In addition to the in-patient treatment documents.
  • Original Death Summary from hospital
  • Copy of the Death Certificate from treating doctor or the hospital authority
  • Copy of the Legal Heir Certificate, if the claim is for death of the principle insured.
  1. Pre and Post hospitalization expenses
  • Duly filled, signed Claim Form with mobile no. & e-mail id.
  • Photocopy of ID card / Photocopy of current year policy.
  • Original medicine bills, original payment receipts with Prescriptions.
  • Original investigation bills, original payment receipts with Prescriptions and report.
  • Original consultation bills, original payment receipts with Prescriptions. Copy of the discharge summary of the main claim.
  1. Organ Donation / Transplantation
  • In addition to the documents of general hospitalization.
  • Organ Function Test / Blood Test proving organ failure.
  • Treatment Certificate issued by the Transplant Surgeon of the hospital concerned.
  1. Ambulance Benefit
  • Duly filled and signed claim form with mobile no. e-mail id.
  • Photocopy of ID card / Photocopy of current year policy original bill with original receipt.
  • Treating Doctor’s consultation prescription indicating Emergency Hospitalization.
  • Paid receipt.
  1. Maternity Expenses
  • In addition to the in-patient treatment documents.
  • Obstetric History (USG Report, Gravida, Para, Living Children Abortions) from treating doctor.
  1. Critical Illness Benefit
  • Duly filled and signed claim form with mobile no. e-mail id.
  • Photocopy of ID card / Photocopy of current year policy.
  • Investigation reports / other related documents reflecting the critical illness diagnosis.
  • A medical certificate confirming the diagnosis of critical illness from a doctor not less qualified than MD / MS.
  1. Expenses for Intra-Ocular Lenses and Cochlear Implant
  • Duly filled and signed claim form with mobile no. e-mail id.
  • Photocopy of ID card / Photocopy of current year policy.
  • Prescription of the Treating Doctor.
  • Original Invoice / bills, Original payment receipts of the device, appliances, lens etc.
  1. NEFT Details
  • Mobile No. & Email ID.
  • Cancelled Cheque with the name printed of the employee.

You may visit the website for checklist for claim submission     –    www.paramounttpa.com/iba.

All the documents need to be submitted within 30 days of discharge.

Other important information

Services offered by TPA to the insurer

As the authorized TPA servicing the policy following services are offered:

    • A personalized Identity Card will be issued to each member and dependents to avail of Cashless facilities in all the network hospitals of TPA.
    • Cashless service facility at network hospitals up to the authorized limit as per policy terms & conditions.
    • Claims processing of reimbursement claims.
    • 24 X 7 Call Centre service through toll free number 18002667008.
  • Website (www.paramounttpa.com/iba) giving online facility for generation of E-card, claim intimation, and tracking of claims and Payment Status.

Procedure to generate e-card

Step 1: go to www.paramounttpa.com/iba

Step2: then click on instant e-card option

Step3: enter employee no

Step4: select union bank retired from group code drop down list

Step 5: submit

It will generate e-card.

Procedure to upload the photos on e-card

Step 1: Go to www.paramounttpa.com/iba site.

step2: click on union bank’s logo and it will show login page.

Step3: type your PF number in user name and date of birth as a password
Step 4: Put your Pf No in User name and your Date of Birth in Password in proper format.

Step 5: After login it will ask you to change your password, Change accordingly.
Step 6: Then in next step update your Mobile No and Email Id.
Step 7: In next step it will take you upload photos window, just upload yours and your spouse’s photo there.

Step 8: Take the printout of E card and keep it with you for reference.

As an identity proof PAN card, Aadhar Card or voter ID card may be carried along with the medicard.

For modification of personal details viz name, date of birth etc.

kunal.waghmare@unionbankofindia.com – Please put a mail with the required changes.

Hospital Network List

You may visit the website www.paramounttpa.com/iba for hospital network list. You may also view the list from “FORMATS” appearing in OUR WEBSITE.  

To view Cashless Network List of Hospital

Log on to https://www.paramounttpa.com/ProviderNetwork/ProviderNetwork.aspx

  • From the drop down boxes select: –
    • State
    • City
    • Insurance Company: UNITED INDIA INSURANCE COMPANY
    • Category: Hospital/ Nursing home / All

Claims forms are available at www.paramounttpa.com, one could download the related forms from this site. You may also view the list from “FORMATS” appearing in OUR WEBSITE. 

Put a mail from your registered mail id to contact.phs@paramounttpa.com for reset of password.

CONTACT DETAILS OF PARAMOUNT REPRESENTATIVES

First level SPOC
1. Mr. Abhishek Kokate — Mobile 7710067734; abhishek.kokate@paramounttpa.com
2. Mr. Varsha Vora — Mobile 9320167512; varsha.vora@paramounttpa.com
Landline: 022-22896298, IP- 116255
Second Level SPOC
Ms. Namrata Anjarlekar — Mobile 9322987115; namrata.anjarlekar@paramounttpa.com
First Level Escalation
Mr. Suresh Ghadi — Mobile 7718874260; suresh.ghadi@paramounttpa.com
Escalation
Mr. Nilesh Saha– 7498425305; nilesh.saha@paramounttpa.com

CONTACT DETAIL OF UNION BANK MEDICAL INSURANCE TEAM CENTRAL OFFICE

  1. Mr. Pankaj Gupta — 022-22896255, IP 116253, pankaj.gupta1@unionbankofindia.com, staffmediclaim@unionbankofindia.com
  2. Mr. Anshul Jain — 022-22896255, IP 116253, anshul.jain@unionbankofindia.com, staffmediclaim@unionbankofindia.com
  3. Mr. Kiran Chawak — 022-22896255, IP 116252, kiran.chawak@unionbankofindia.com, staffmediclaim@unionbankofindia.com

Escalation:

Mrs. Shilpa Sharma Sarkar– 022-22896235, IP 116250, shilpasarkar@unionbankofindia.com, staffmediclaim@unionbankofindia.com

Super Top-up in Medical Insurance

Policy under Super Top-up in existing policy effective from 07.12.2017 to 30.09.2018 is circulated vide staff circular no.6759 dated 01.03.2018. Policy no. is 5001002817P113761150

  • Sum Insured for Group Mediclaim on Family Floater basis for Officer is `500000/- & Clerks and Subordinate staff is `400000/-
  • Any claim under this policy shall be payable
  • It is in respect of Covered Expenses specified in policy
  • The aggregate of Covered Expenses in respect of hospitalization of insured person in case of Family Policy exceeds the Threshold Level and
  • All limits of reimbursement under any other Health Insurance Policy / Reimbursement Scheme available to the insured person have been exhausted.

To provide more transparency in the procedure of claim processing and also real time update of past / present claims, access to the aforementioned portal has now been extended to all the insured existing and retired employees. Important detail and New Features are as follows:-

URL –        https://www.paramounttpa.com/UNIONBANK/

Log in Credentials  –        Username                      –        Employee Number

Password (by default) –        DOB in DD/MM/YYYY

On first login, there will a prompt to modify Password. New password thus chosen by the insured ensures exclusive access to the portal. Annexure I is attach with the circular.

Cashless Assistance        –        A new feature of “Cashless Assistance” has been provided in the home page. This tab provides for instant “Cashless Assistance” to the insured initiating this request, ensuring processing of cashless request on top priority saving precious time of the patient / family. This tab when clicked prompts for mobile number. Upon providing the required details, mail and sms will be triggered to the nominated TPA representative for a given region to attend to the request. The nominated representative will call back immediately for assistance. Cashless assistance will be available round the clock. Annexure II & III are attached with the circular.

After log in, the home page have tabs for Policy & Claim Status, Online Claim Intimation, Escalation Matrix and Contact Information. The home page also have menus for Instant E-cards, Hospital List, Downloads, Mobile App PPT and FAQ as per Annexure II attached with the circular.

Policy & Claim Status procedures are as per Annexure IV & Annexure V attached with the circular.

Claim Intimation     –        This tab provides the raising specific intimation of claim for self and dependants. Detailed procedure is in Annexure VI and Annexure VII attached with the circular.

List containing contact details and addresses of TPA representatives, allocated region wise, is available under tabs “Escalation Matrix” and “Contact US”. Annexure VIII and Annexure IX.

Menu      –        Generation of E-Card, Tie up hospital list, claim forms for domicialiary and hospitalisation, ppt for mobile app and FAQs are available under “Menu” in homepage. Annexure X – XVI.

For further clarification and guidance regarding the portal, insured may contact on below mentioned contact number of TPA officials:-

Shri Harshal Ghorpade                 –        7718806684

Shri Rupesh Palve                           –        022-66620757

Corporate Buffer

Policy on Corporate Buffer (Medical Assistance) – Staff Circular No.20.09.2016

Corporate buffer may be appropriated as per the premium of the bank. If the corporate buffer of one bank is exhausted, the remaining amount can be claimed from the unutilized corporate buffer of the other banks. Corporate buffer can be authorized by the management, through an authorized person / committee as decided by IBA / Bank, and informed directly to the THIRD PARTY ADMINISTRATOR by keeping the insurance company in the loop.

In the event of any claim becoming admissible under this scheme, the company will pay through Third Part Administrator to the hospital / nursing home or insured the amount of such expenses as would fall under the different heads mentioned below and as are reasonably and medically necessary incurred thereof by or on behalf of such insured but not exceeding the sum insured in aggregate mentioned in the schedule hereto.

To Claim from Corporate Buffer

HR:MEDICAL:068:16 dated 16.06.2016

All employees who have exhausted their sum insured may apply for financial assistance from Corporate Buffer. A claim form has been devised for claim of financial assistance from Corporate Buffer.

For seeking financial assistance from Corporate Buffer the following documents are required to be submitted:-

  • The details of claim, in the given form. To be filled by the employee.
  • Original bills with the claim form.
  • A recommendation from the vertical head.

For claim under Corporate Buffer following points are to be noted:-

  • Domiciliary is not covered for claim under Corporate Buffer.
  • The balance amount claimed should be more than Rs.10000/-
  • Corporate Buffer to be claimed only upon exhaustion of sum insured.
  • Ailments not covered under the Medical Insurance Scheme are out of the purview of Corporate Buffer.
  • Corporate Buffer can be sanctioned to existing employees only.
  • Reimbursement of inadmissible expenses is not permitted under Corporate Buffer.
Where to submit the claim

For cashless:

  • Employee/Dependent to fill up the Corporate Buffer Claim Form. Recommendation by Vertical Head/DGM in the given field.
  • Submit the claim form to Medical Insurance Division, HR Department, Central Office, Mumbai.

For reimbursement

    • Employee/Dependent to fill up the Corporate Buffer Claim Form. Recommendation by Vertical Head/DGM in the given field.
    • All original bills, against which claim is raised, need to be attached.
    • The reimbursement form, given in SC 6263 dated 29.10.2015 should be filled in by the employee.
  • All bills and forms to be submitted to Medical Insurance Division, HR Department, Central Office, Mumbai.