FAQ (FREQUENTLY ASKED QUESTIONS) ON MEDICAL INSURANCE SCHEME FOR RETIRED EMPLOYEES OF PUNJAB & SIND BANK

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Brenda Robbins
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1 FAQ (FREQUENTLY ASKED QUESTIONS) ON MEDICAL INSURANCE SCHEME FOR RETIRED EMPLOYEES OF PUNJAB & SIND BANK 1. What is the definition of family under the scheme? The family of a retired employee includes Self + Dependent Spouse only 2. What is Sum Insured? Hospitalisation Treatment Coverage Officers: Rs.4.00 Lac Award Staff (Clerks and Sub-Staff) : Rs.3.00 Lac 3. What is the date of joining the Scheme: All Retired Employees to be covered from the date of their joining the scheme. Only one time option is being given to Ex-employees / Retirees to join the scheme now. Those who do not opt now, would not be allowed to join later. Once they have joined and subsequently opted out, they cannot rejoin. 4. The Last Date for option letter to reach H.O. PF Department: Although the date of inception of the scheme was , but still, there is an open window kept for accommodating Retirees to join up to three months from the inception of policy i.e. 1st v What is the Age limit for Joining this Scheme: There is no upper age limit for joining the scheme. Retirees of any age may join the scheme. 6. Who is the insurance Company and TPA (Third party Administrator) in the policy: Insurance Company: M/s United India Insurance Co. Ltd. Name & Address of T.P.A MDIndia Healthcare Services (TPA) Pvt. Ltd. 18/13 WEA, Ground Floor, Ganga Plaza, Pusa Lane, Karol Bagh, Near Hanuman Murti, New Delhi Toll Free Customer Care.: Toll Free Cashless.: Contact Person: Abhinandan Dubey (Relationship Manager ):

2 Retired Employees may contact Mr. Abhinandan Dubey of M/s MDIndia Healthcare Services (TPA) Pvt. Ltd. for any of their query related to policy/cards. 7. Room Eligibility : Room Rent Including Room and boarding charges Rs.5000/- per day. ICU Charges Rs.7500/- per day 8. Pre- Post Hospitalization : Expense incurred during the Pre-hospitalization and Post-hospitalization period will be covered for 30 days prior to hospitalization and 90 days after discharge respectively. NOTE : The above information is indicative only and are subject to modification/amendments as per clarifications that may be received from IBA. *******

3 DETAILS OF THE THIRD PARTY ADMINISTRATOR a) Name of TPA / Insurance Company: MDIndia Healthcare Services (TPA) Pvt Ltd b) Toll free phone number: c) Toll free Fax: & PLEASE FAX / SCAN PAGE 1 ONLY REQUEST FOR CASHLESS HOSPITALISATION FOR MEDICLAIM INSURANCE POLICY (To be filled in block letters) TO BE FILLED BY THE INSURED / PATIENT a) Name of the patient: b) Gender : Male Female c) Age: years months d) Date of Birth: e) Contact number: f) Contact number of attending relative g) Insured card ID number: h) Policy number / Name of corporate: i) Employee ID: j) Currently do you have any other Mediclaim / Helath Insurance: Yes Company Name: Give details: k) Do you have a family physician? Yes l) Name of the family physician: m) Contact number, if any: (PLEASE COMPLETE DECLARATION ON THE REVERSE SIDE OF THIS FORM) TO BE FILLED BY THE TREATING DOCTOR / HOSPITAL a) Name of the treating doctor: b) Contact number: c) Nature of illness/ disease d) Relevant clinical findins: with presenting complaints e) Duration of the present ailment: Days i. Date of first consultation: f) Provisional diagnosis: ii. Past history of present ailment, if any i. ICD 10 Code g) Proposed line of treatment: Medical Management Surgical Management Intensive Care Investigation n allopathis Treatment h) If investigation & / or Medical Management, provide details i. Route of drug administration: i) If Surgical, name of surgery: i. ICD 10 PCS Code j) If other treatments, provide details k) How did the injury occur? l) In case of accident: i. Is it RTA? Yes ii. Date of injury: iii. Reported to Police: Yes iv. FIR.: v. Injury / Disease caused due to substance abuse / alcohol consumption: Yes vi. Test conducted to extablish this? Yes (If yes attach reports) m) In case of maternity: G P L A Date of Delivery: Details of the patient admitted Mandatory : Past history of any chronic illness If Yes, since (month / year) a) Date of admission: b) Time: : Diabetes c) Is this an emergency / a planned hospitalization event? Emergency Planned Heart Disease d) Expected no. of days in hospital: Days e) Room Type: Hypertension f) Per Day Room Rent + Nursing & Service Charges + Patient's Diet: Hyperlipidemia g) Expected cost of investigation + diagnostics: Osteoarthritis h) ICU Charges: Asthma / COPD / Bronchitis i) OT Charges: Cancer j) Professional fees Surgeon + Anesthetist Fees + consultation charges: Alcohol or drug abuse k) Medicines + Consumables + Cost of implants (if applicable, please specify), other hospital expenses, if any: l) All inclusive package charges, if any applicable: Any HIV or STD / Related ailments Any other Ailment, give details: m) Sum Total, expected cost of hospitalization: DECLARATION (PLEASE READ VERY CAREFULLY) We confirm having read, understood and agreed to the Declaration on the reverse of this form a) Name of the treating doctor: b) Qualification: c) Registration. with state code: Hospital Seal (must contain hospital ID) Patient / Insured Name & Signature (IMPORTANT: PLEASE TURN OVER)

4 PAGE 2: NOT TO BE FAXED/SCANNED DECLARATION BY THE PATIENT / REPRESENTATIVE 1. I agree to allow the hospital to submit all original documents pertaining to hospitalization to the Insurer/T.P.A after the discharge. I agree to sign on the Final Bill & the Discharge Summary, before my d 2. Payment to hospital is governed by the terms and conditions of the policy. In case the Insurer / TPA is not liable to settle the hospital bill, I undertake to settle the bill as per the terms and conditions of 3. All non-medical expenses and expenses not relevant to current hospitalization and the amounts over & above the limit authorized by the Insurer/T.P.A not governed by the terms and conditions of the policy will be paid by me. In case any clarification is needed on admissibility of a particular item I shall contact T.P.A at the Toll Free Number on the reverse of this form. 4. I hereby declare to abide by the terms and conditions of the policy and if at any time the facts disclosed by me are found to be false or incorrect I forfeit my claim and agree to indemnify the Insurer / T 5. I agree and understand that T.P.A is in no way warranting the service of the hospital & that the Insurer / TPA is in no way guaranteeing that the services provided by the hospital will be of a particular q 6. I hereby warrant the truth of the forgoing particulars in every respect and I agree that if I have made or shall make any false or untrue statement, suppression or concealment, my right to claim 7. I agree to indemnify the hospital against all expenses incurred on my behalf, which are not reimbursed by the Insurer / TPA. a) Patient s / Insured s Name: b) Contact number: d) Patient s / Insured s Signature: HOSPITAL DECLARATION 1. We have no objection to any authorized TPA / Insurance Company official verifying documents pertaining to hospitalization. 2. All valid original documents duly countersigned by the insured / patient as per the checklist below will be sent to TPA / Insurance Company within 7 days of the patient's discharge. 3. All non medical expenses, OR expenses not relevant to hospitalization or illness, OR expenses disallowed in the Authorization Letter of the TPA / Insurance Co, OR arising out of incorrect information in the pre-authorisation form will be collected from the patient. 4. WE AGREE THAT TPA / INSURANCE COMPANY WILL NOT BE LIABLE TO MAKE THE PAYMENT IN THE EVENT OF ANY DISCREPANCY BETWEEN THE FACTS IN THIS FORM AND DISCHARGE SUMMARY or other documents. 5. The patient declaration has been signed by the patient or by his representative in our presence. 6. We agree to provide clarifications for the queries raised regarding this hospitalization and we take the sole responsibility for any delay in offering clarifications. 7. We will abide by the terms and conditions agreed in the MOU. Hospital Seal Doctor's Signature DOCUMENTS TO BE PROVIDED BY THE HOSPITAL IN SUPPORT OF THE CLAIM 1. Detailed Discharge Summary and all Bills from the hospital 2. Cash Memos from the Hospitals / Chemists supported by proper prescription. 3. Receipts and Pathological Test Reports from Pathologists, supported by note from the attending Medical Practitioner / Surgeon recommending such pathological Tests. 4. Surgeon's Certificate stating nature of operation performed and Surgeon's Bill and Receipt. 5. Certificates from attending Medical Practitioner / Surgeon that the patient is fully cured.

5 DETAILS OF PRIMARY INSURED : PUNJAB AND SIND a) Policy no: c) MDIndia ID : Emp Name: CLAIM FORM - PART A TO BE FILLED IN BY THE INSURED The issue of theis form is not to be taken as admission of liability ZONAL OFFICE / REGIONAL OFFICE: b) BOM Employee ID f) BOM Emp Branch Location (To be filled in block letters) e) Address: City: a) Currently covered by any other Mediclaim/ Health Insurance: Sum Insured (): Pin Code: DETAILS OF INSURANCE HISTORY Yes Diagnosis: e) Previously covered by any other Mediclaim/ Health Insurance : Yes f) If yes, Company Name : DETAILS OF INSURED PERSON HOSPITALIZED a) Name : e) Relatuionship to Primary Insured: Self Spouse Child f) Occupation: Service Self Employed Homemaker g) Address (if different from above): Phone : c) If yes, company name: Policy : b) Gender : Male Female c) Age: years months d) Have you been hospitalized in the last four years since inception of the contract? Father Mother State: d) Date of Birth: Other Student Retired Other ID: b) Date of commencement of first insurance without break: Yes (Please specify) (Please specify) Date: SECTION A SECTION B SECTION C City: State: DETAILS OF HOSPITALIZATION a) Name of Hospital where Admitted: Pin Code: Phone : ID: b) Room category occupied: Day Care Single occupancy Twin sharing 3 or more beds per room c) Hospitalization due to: Injury Illness Maternity d) Date of injury/ Date Disease first detected/ Date of Delivery: e) Date of Admission: f) Time: : g) Date of Discharge: h) Time: : i) If injury, give cause: Self inflicted Road Traffic Accident Substance abuse / Alcohol Consumption i. If Medico Legal: ii. Reported to police: Yes iii. MLC Report & Police FIR attached: Yes j) System of medicine: DETAILS OF CLAIM a) Details of treatment expenses claimed i. Pre Hospitalization Expenses iii. Post Hospitalization Expenses v. Ambulance Charges vi. Others (code): vi. Pre hospitalization period: days vii. Pre hospitalization period: days b) Claim for Domiciliary Hospitalization: c) Details of Lump sum / cash benefit claimed: Yes Yes Claim Documents Submitted- Check List: Implants - Invoices / BarCode Stickers i. Hospital Daily Cash: ii. Surgical Cash: ECG, USG, X Ray Etc iii. Critical Illness Benefit: v. Pre/Post hosp. Lump sum benefit: vi. Others: Investigation Reports (including CT / MRI / Report CD's / HPE) Total Doctor's Prescription of Medicines DETAILS OF BILLS ENCLOSED Sl.. Bill. Date DECLARATION BY THE INSURED (if yes, provide details in annexure) Issued By ii. Hospitalization Expenses iv. Health Check up Cost Total iv. Convalescence: Towards Hospital Main Bill Pre hospitalisation Bills: s Post hospitalisation Bills: s Pharmacy Bills: Claim FormDuly signed Hospital Orginal Bill & Paid Receipts Hospital Break-up bill Hospital Discharge Summary Pharmacy Bill & Cash Memo Operation Theatre tes Doctor's request for investigation Others: MLC/FIR: I hereby declare that the information furnished in this claim form is true & correct to the best of my knowledge and belief. If I have made any false or untrue statement, suppression or concealment of any material fact with respect to questions asked in relation to this claim, my right to claim reimbursement shall be forfeited. I also consent & authorize TPA / insurance company, to seek necessary medical information / documents from any hospital / Medical Practitioner who has attended on the person against whom this claim is made. I hereby declare that I have included all the bills / receipts for the purpose of this claim & that I will not be making any supplementary claim except the pre/post-hospitalization claim, if any. Amount () SECTION D SECTION E SECTION F SECTION H Date: Place: Signature of the insured:

6 DETAILS OF HOSPITAL CLAIM FORM - PART B TO BE FILLED IN BY THE HOSPITAL The issue of theis form is not to be taken as admission of liability Please include the original preauthorization request form in lieu of PART A (To be filled in block letters) a) Name of the Hospital: c) Hospital ID: d) Name of the treating doctor: e) Qualification: DETAILS OF PATIENT ADMITTED a) Name of Patient: b) IP Registration.: c) Gender : Male Female d) Age: years months e) Date of Birth: f) Date of Admission: g) Time: : h) Date of Discharge: i) Time: : j) Type of Admission: Emergency Planned Day Care Maternity l) Status at time of discharge: Discharged to home Discharged to another hospital Deceased m) Total claimed amount DETAILS OF AILMENT DIAGNOSED (PRIMARY) a) ICD 10 Codes Description b) i. Primary Diagnosis : ii. Additional Diagnosis : iii. Co-morbidities : iv. Co-morbidities : c) Pre authorization obtained: Yes d) Pre-authorization number: e) If authorization by network hospital not obtained, give reason: f) Hospitalization due to injury: Yes ii. If injurydue to Substance abuse / alcohol consumption, Test Conducted to establish this: v. FIR. vi. If not reported to police, give reason: DETAILS IN CASE OF NON NETWORK HOSPITAL (ONLY FILL IN CASE OF NON NETWORK HOSPITAL) a) Address of the hospital: City: Phone : Hospital Registration : Yes (if yes, attach reports) iii. If Medico Legal: Yes iv. Reported to Police: Yes d) Hospital PAN e) Number of inpatient beds Facilities available in the hospitai i. OT: Yes ii. ICU: Yes g) Does Hospital Maintains Daily Records of Patients & Makes them Accesible to Insurance Company's Authorized Personanel Yes DECLARATION BY THE HOSPITAL i. If yes, give cause Self inflicted Road Traffic Accident Substance abuse / alcohol consumption State: c) Type of Hospital: Network n Network (if non network, fill Section E) f) Registration. with state code: k) If Maternity: i. Date of Delivery: i. Procedure 1 : ii. Procedure 2 : iii. Procedure 3 : iv. Details of Procedure : Pin Code: ICD 10 PCS g) Phone. Reg Authority: ii. Gravida Status: Description Local or State Government Licensed (Please read very carefully) We hereby declare that the information furnished in this Claim Form is true & correct to the best of our knowledge and belief. If we have made any false or untrue statement, suppress or concealment of anu material fact, our right to claim under this claim shall be forfeited. Seal & Signature of the Hospital Authority Name & Signature of the Insured Date: SECTION A SECTION B SECTION C SECTION D SECTION E Place:

7 DETAILS OF PRIMARY INSURED : PUNJAB & SIND BANK a) Policy no: DOMICILIARY TREATMENT - CLAIM FORM TO BE FILLED IN BY THE INSURED (The issue of this form is not to be taken as admission of liability) ZONAL OFFICE / REGIONAL OFFICE: b) BOM Employee ID (To be filled in block letters) c) MDIndia ID : f) BOM Emp Branch Location Emp Name: e) Address: City: State: Pin Code: Phone : ID: DETAILS OF INSURED PERSON HOSPITALIZED a) Name : b) Gender : Male Female c) Age: years months d) Date of Birth: e) Relatuionship to Primary Insured: Self Spouse Child Father Mother Other (Please specify) f) Occupation: Service Self Employed Homemaker Student Retired Other (Please specify) DETAILS OF CLAIMS a) Name of Treating Doctor: b) Commencement of Treatment: Date (DD/MM/YYYY) c) Treatment End Date: (DD/MM/YYYY) c) Domiciliary Treatment For: Claim Documents Submitted- Check List: Claim FormDuly signed Total Number of Claim Documents Submitted: Select the Number as below in lieu of the documents submitted Illness Certificate by Treating Doctor with Duration Members are requested to submit the Illness Certificate by Treating Doctor with detailed duration of the illness for which the treatment would be done. Pharmacy Prescriptions by Treating Doctor Pharmacy Bills Cash Memo Investigation Prescriptions by Treating Doctor Investigation Bills Cash Memo Investigation Reports Treating Doctor Consultancy Charges Cash Receipts DETAILS OF BILLS ENCLOSED: Sl.. Bill. Date Issued By Towards - Pharmacy, Investigations or Consultancy Charges Amount () DECLARATION BY THE INSURED In case more than 10 Bills are to be submitted then attach separate annexure using the same above format: I hereby declare that the information furnished in this claim form is true & correct to the best of my knowledge and belief. If I have made any false or untrue statement, suppression or concealment of any material fact with respect to questions asked in relation to this claim, my right to claim reimbursement shall be forfeited. I also consent & authorize TPA / insurance company, to seek necessary medical information / documents from any hospital / Medical Practitioner who has attended on the person against whom this claim is made. I hereby declare that I have included all the bills / receipts for the purpose of this claim & that I will not be making any supplementary claim except the pre/post-hospitalization claim, if any. Date: Place: Signature of the insured:

8 IC NAME-OIC/UIIC/NIC/NIA INSURED NAME BANK A/C NO Sheet1 POLICY NO.- PATIENT NAME: BANK NAME & ADDRESS CCN: MOBILE: PHONE (STD) CLAIM DOCUMENT CHECK LIST DOCUMENT TYPE: CASHLESS/REIMBURSEMENT/ADDTIONAL/ADR/PRE/POST S.no STATUS 1 Intimation Yes / / NA 2 Date of Intimation 3 Mode of Intimation Mail/Call/Letter 4 Date of receiving of claim 5 Photo ID Proof(PAN Card,Voter ID) Yes / / NA 6 Policy Schedule ( Onl Reimbursement Claim) Yes // NA 7 Claim Form ( Only Reimbursemt Claims & Yes // NA additional Payment Claims ) 8 Reports Yes / / NA 9 Prescription Yes / / NA 10 Original/Attested Discharge Card (Cashless Yes / / NA or Reimbursement Claim only ) 11 Authentic Final Hospital bill. ( Cashless or Yes / / NA Reimbursement Claim only 12 Final Bill Detail Breakup Yes / / NA 13 Original Receipts of Deposit Payment Yes / / NA 14 Chemist Bills Yes / / NA 15 Indoor Case Papers Yes / / NA 16 Farmercy Bills Yes // NA 17 Is FIR/MLC available (RTA cases ) Yes / / NA 18 USG Film Yes / / NA 19 MRI Films Yes / / NA 20 ECG Yes / / NA 21 X-Ray Films Yes / / NA 22 Claim Lodged Amount (As Per Claim Form in Yes / / NA Reimbursement & Add Payment Claims ) 23 Delay in Submission from Date of Discharge in Yes / / NA Cashless & Reimbursement Claims) 24 Consent letter Yes / / NA 25 Report of Investigation Yes / / NA 26 Hospital Registration Certificate Yes / / NA 27 ECS Form With canceled Cheque Yes // NA 28 Total no of papers submitted CHECK LIST FOR CLAIM ACKNOWLEDGEMENT/SUBMISSION MDI INTERNAL REMARK Please ensure that the claim document are arranged in the sequence of Policy Schedule=>64 VB=> Claim Form=> Discharge Card=> Final Hospital Bill=> Final Hospital Bill Reciept=> All Other Prescriptions, Bills, Reciepts & Reports In Chronological Sequence Page 1

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National Insurance Company Limited

National Insurance Company Limited DETAILS OF THE THIRD PARTY ADMINISTRATOR a) Name of TPA / Insurance Company: b) Toll free phone number: c) Toll free Fax: CIN No. - U10200WB1906GOI001713 IRDA Regn. No. - 58 PLEASE FAX / SCAN PAGE 1 ONLY