CIRCULAR LETTER NO.06/2016 DATED REG: GROUP MEDICAL INSURANCE SCHEME (IBA) FOR RETIREES

Transcription

1 CIRCULAR LETTER NO.06/2016 DATED REG: GROUP MEDICAL INSURANCE SCHEME (IBA) FOR RETIREES : We are pleased to inform that our Association successfully held the seminar on Group Medical Insurance Scheme for retirees on at KPG Memorial Hall, Sealdah, Kolkata, as declared earlier through our Circular Letter, SMS and website notice. The seminar was attended by local Authorities of both United India Insurance Company and Raksha TPA and more than 160 members of our association. During the seminar lots of queries were raised by our members and the Insurance Company and TPA personnel gave their clarifications to the satisfaction of everybody. On the basis of the discussions, deliberations and also clarifications on domiciliary expenses, received from PNB Hospitalisation Cell, HO, New Delhi, as per their Notice dated , as available in PNB PARIVAR ( the following hand out has been prepared as a guidance paper to our members. However, all these information are subject to verification from the original policy. Sl. Question / Answer No. Q.1 From the scheme it is amply clear that domiciliary hospitalization and domiciliary treatment are two separate aspects. For Domiciliary hospitalization either of the two conditions, i.e. (a) the condition of the patient is such that he cannot be removed to a hospital or (b) the patient takes treatment at home on account of non-availability of room in a hospital has to be qualified, whereas eligibility for Domiciliary treatment is only for specified diseases. Again, it is mentioned that Domiciliary treatment shall also be covered under this scheme for treatments taken for specified 59 diseases which may or may not require hospitalization. Under such circumstances, what will be the scope of availing domiciliary treatment benefit by a member? Domiciliary treatment is different from domiciliary hospitalization. Expenses of medicines, Doctor s consultation and disease related investigations only for 59 specified diseases (as per list given below) will be available under domiciliary treatment. Pre-existing diseases will also be covered under this policy. Further, in case of hospitalisation for less than 24 hours for treatment of domiciliary diseases, room rent is not payable as per policy. Q.2 Domiciliary hospitalization is an alternate of hospitalization, which is a compelling necessity under two situations explained above. Whether the total limit for hospitalization is available for the expenses incurred under domiciliary hospitalization? Domiciliary hospitalization, i.e. when either of the two conditions is fulfilled, will be considered under normal limit. Q.3 This year domiciliary expenses limit has been set at 10% of the total insured limit.

2 Please confirm that these limits are interchangeable, i.e. one can use the unutilized portion of the domiciliary expenses limit for hospitalization within the overall limit of insurance. Domiciliary limit is a sub-limit within overall limit of Rs.4 lac / Rs.3 lac. Any unutilised portion of domiciliary limit will be available for hospitalization expenses. Q.4 What is the periodicity for submitting claim for domiciliary treatment expenses, monthly, quarterly, till the limit is exhausted? What will be the forms for submission of such claim and what is the procedure? Domiciliary claim should be submitted quarterly within 7 days from the close of the quarter. For larger amount it should be submitted monthly. It should be submitted on same claim form part A and should be marked as DOMOCILIARY CLAIM FROM. TO at the top of the form. All bills / money receipts / reports / prescriptions have to be original copies. Xerox copy of prescription, duly attested by BM (clearly mentioning name, designation and branch), can also be submitted. A cancelled cheque (if name is printed thereon) or a Xerox copy of the pass book (Account details portion at the back of cover) has to be submitted. Q.5 It is mentioned that expenses on hospitalization for minimum period of a day are admissible. However, this time limit shall not be applied to 37 specific treatments named in the circular / scheme. All these treatments can be done on day care basis. Whether these expenses will be treated under the normal limit or the domiciliary treatment limit? Day care treatments do not fall under domiciliary treatment. Expenses for the 37 diseases (as per given list) on day care basis, would be considered under the normal limit. Q.6 Is it mandatory to make a prior intimation to the TPA / Insurance Company for Domiciliary treatment, like in hospitalization scheme? Not necessary. Q.7 Whether a patient taking regular Haemo Dialysis will be eligible under this scheme of hospitalization? Yes, as stated in item 5. This is included in the list of 37 diseases. Q.8 In case of diseases which require continuous treatment i.e. Diabetes, Hypertension, Blood sugar, Thyroids etc., what will be the guidelines for the insured to follow for lodgment of claim? All the named diseases are included in the list of 59 diseases eligible for domiciliary treatment. Q.9 In such cases, as it is a regular treatment, how the doctor s prescription should be prepared and submitted? If no period is mentioned on the prescription, by the treating doctor, regarding up to what period the medicine is to be taken then that prescription is valid for 90 days. If doctor has prescribed medicine for the period 180 or above, then that prescription is valid for maximum period of 180 days only. After 180 days, fresh prescription is required to be taken from the treating doctor. Q.10 In case of hospitalization, medical expenses incurred up to 90 days from the date of discharge are admissible to retirees. Can these claims be made at monthly intervals for 3 months, to avoid financial crunch? These expenses are not definitely to be treated as of Domiciliary Treatment. For both pre-hospitalisation (30 days) and post-hospitalisation (90 days) expenses, a single claim should be made. A grace period of 30 days for submission of the claim is

3 permissible. Q.11 Whether a retiree not opting for Domiciliary Treatment expenses cover, would be eligible to opt for the facility in the next or subsequent years and vice-versa? As per UIIC rules, it is permissible, but this should be as per Bank s circular issued from time to time. Q.12 As per the scheme alternative system of treatments including Ayurveda, Unani, Siddha, Homeopathy, Naturopathy are permissible. How these claims will be made as in such system, stay in the hospital or clinic is usually not necessary, but taken on day care basis. Whether Ayurvedic treatments and others are permitted under domiciliary facilities? As per policy these alternative systems are eligible under the scheme. However, no confirmation could be given for domiciliary treatments. We feel, if the disease is included in the list of 59 diseases, then domiciliary claim can be submitted as a test case. Q.13 When submitting the claim, while all the documents will be submitted in original, whether duly attested copy of the prescription can be submitted instead of the original? No. Q.14 The premium for current year s medical insurance has increased by more than 130% (inclusive of domiciliary expenses). For serving employees, the premium is paid by the Bank, but the retirees have paid the same out of their pockets in individual capacities. We strongly feel that in that case retirees are entitled for income tax relief under section 80D. Please let us know as to how we shall obtain the money receipt for the premium. The Insurance Company representatives agreed to our view. They have assured us that money receipts for the premium would be issued on approaching them properly. All members are advised to contact Association office for the same. Q.15 Why names of hospitals not allowing cashless treatment are still being displayed in the list of hospitals displayed by TPA, thus causing harassment to the members? The TPAs are in the process to update the list. However, we request the members to verify the same over phone from the hospital before proceeding. Q.16 The Insurance Policy copy is not available? Can you please provide us one? We think we are entitled to have the copy after paying the premium. The Insurance Company has agreed to provide us a soft copy of the policy. This would be circulated by us, once it is available. Q.17 Why the same premium is being charged from the single beneficiary i.e. in case of family pensioners or widower / bachelor retirees? We feel it should be halved. This aspect is considered at the time of negotiation with IBA. Q.18 A number of members are yet to receive their ID cards. In many cases, photos are not displayed, even though photos were given to the TPA. A list of such few cases has already been handed over to the TPA. The TPA agreed to amend / provide the ID cards, as the case may be. Members are requested to contact Association office to register their cases, to enable us to take up with the TPA. Q.19 In the UIIC, DO-IV, 2, Brabourne Rd., Kolkata letter dated ; our Association was given an offer for Top-up cover for health insurance with additional premium. The matter was further discussed on with the DO at his office and we were asked to ascertain the number of possible participants in the Top-up scheme. While we are on the job, we would request you to please confirm that the Top-up facility

4 would also be eligible for cash-less hospitalization like the main limit. We are in the process of ascertaining the possible number of participants. The Insurance company will give their quote of premium on that basis. However, they have confirmed that cash-less hospitalization is available under Topup facility also. Members interested for Top-up limit may please contact our Association office. Q.20 When any of our members moves out of state, whether he will have to submit the claim to the local office of TPA or to their Kolkata office? The claim can be lodged with any local branch of the TPA. Q.21 In case a single insured dies during treatment either in hospital or at home, how to lodge a claim by the legal heirs and what are the documents the TPA will require to settle the claim? In that case the legal heirs can make the claim as per normal procedure, but additionally they will have to submit proof of legal heirship through documents. Q.22 Settlements, non-admitted expenses and queries are informed through TPA s website. Whether this can be intimated to the insured by letter also, since most are not accustomed to websites? If the member wants communication in his or by letter, he should mention that while submitting the claim. Q.23 When the medical expenses incurred are beyond the limit insured and consequently not allowed, can the same be claimed from any other TPA / Insurance company, whose policy is also held by the insured simultaneously and vice-versa? One claim can be covered under multiple policies, if the limit is exhausted. In that case the documents have to be duly certified by the 1 st. TPA before submission it to the 2 nd. TPA. If both the TPAs are same, no such formality is required. Q.24 Whether this limit of Rs.4 lac or Rs.3 lac is for both, employee and spouse together or for each of the member? The total limit is for both together. Q.25 When the bill covers the expenses incurred in the last month of first year and first month of next year of the policy, say October and November, then whether the bill will be considered under limits of both the years or will it be passed only for expenses incurred up to the first year? In that case whether the expenses incurred in the first month of the next year can be claimed subsequently again, submitting copies of the bills already submitted? The basis of deciding the period of the claim is the date of admission. So if the date of admission is in the first year and limit is available for the expense, it will be covered under that only. No overlapping is allowed. Q.26 Why the hospitals are charging heavily under cash-less system, thus exhausting the limit quickly? Have you done anything to stop such practice? The Insurance company is looking into the matter. Q.27 Whether the existing employees I cards will be valid even after retirement? No, the card will be replaced by the TPA. Q.28 What is the grievance redressal mechanism available to the insured? In the event of any grievance relating to the insurance, the insured Person may raise query and grievance in writing to the TPA, through its website link online grievance. The insured person may also submit in writing to the Policy Issuing Office or Grievance Cells at the Regional Office of the United India Insurance on link online complaint.

5 LIST OF 59 DISEASES ELIGIBLE FOR DOMICILIARY TREATMENT Sl. No. Treatments Sl. No. Treatments 1 Cancer 31 Malaria 2 Leukemia 32 Non-Alcoholic Cirrhosis of Liver 3 Thalasemia 33 Purpura 4 Tuberculosis 34 Typhoid 5 Paralysis 35 Accidents of serious nature 6 Cardiac Ailments 36 Cerebral Palsy 7 Pleurisy 37 Polio 8 Leprosy 38 All Strokes leading to Paralysis 9 Kidney Ailments 39 Haemhorrages caused by Accidents 10 All Seizure Disorders 40 All animals / reptiles / insects bite or sting 11 Parkinson s Diseases 41 Chronic Pancreatitis 12 Psychiatric Disorder including 42 Immuno Suppressants Schizophrenia and Psychotherapy 13 Diabetes and its complications 43 Multiple Sclerosis / Motorneuron Disease 14 Hypertension 44 Status Asthamaticas 15 Hepatitis - B 45 Sequalea of Meningitis 16 Hepatitis - C 46 Osteoporosis 17 Hemophilia 47 Muscular Dystrophies 18 Myasthenia Gravis 48 Sleep Apnea syndrome (not related to obesity) 19 Wilson s Disease 49 Any Organ related (chronic) condition 20 Ulcerative Colitis 50 Sickle Cell Disease 21 Epidermolysis Bullosa 51 Systemic Lupus Erythematous (SLE) 22 Venous Thrombosis (not caused by 52 Any connective Tissue Disorder smoking) Aplastic Anaemia 23 Psoriasis 53 Varicose Veins 24 Third Degree Burns 54 Thrombo Embolism Venous Thrombosis / Venous Thrombo Embolism (VTE) 25 Arthritis 55 Growth Disorders 26 Hypothyroidism 56 Graves Disease 27 Hypothyroidism expenses incurred 57 Chronic Pulmonary Disease on Radiotherapy and Chemotherapy in the treatment of Cancer and Leukemia 28 Glaucoma 58 Chronic Bronchitis 29 Tumor 59 Physiotherapy and Swine Flu shall be considered for re-imbursement under Domiciliary treatment 30 Diphtheria

6 TPA ADDRESS: Usha Martin Building, 2nd floor,2a, Shakespeare Sarani, Ward No. 63, Kolkata Phone No , Fax No. Cashless , Others IN CASE OF EMERGENCY, INTIMATION WILL HAVE TO BE GIVEN TO THE TPA, AT THE TIME OF HOSPITALISATION OR WITHIN 24 HOURS OF IT. INTIMATION CAN BE GIVEN BY (web site: www. rakshatpa.com, then go to CLAIM INTIMATION [6 th. box on the top] and fill it and post) and save a copy OR BY PHONE / SMS to Shri Prasanta Ghosh (phone no / land line ). Date : A. K. Mondal S.N. Samanta Place : Kolkata. General Secretary President Visit our website