HRMD CIRCULAR NO Medical Insurance Scheme for Retired Officers/Retired employees Operational Guidelines

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1 Human Resources anagement ivision (Hospitalisation Cell), Head Office: New elhi Phone No FAX arch 11, 2016 TO ALL OFFICES HR CIRCULAR NO. 300 edical Insurance Scheme for Retired Officers/Retired employees Operational Guidelines etails of the edical Insurance Scheme were circulated vide Annexure/ Schedule-IV to PA Circular No.271 dated and HR Circular No.694 dated However, details of operational guidelines containing instructions for seeking reimbursement / availing benefits under the scheme for retired Officers/retired employees are being circulated herewith as Annexure. All concerned are advised to go through the provisions of the joint note dated for complete details and bring this circular to the notice of retirees drawing pension from their branches and place a copy of this circular on the notice board. (INESH SAXSENA). GENERAL ANAGER

2 ANNEXURE BRIEF ETAILS OF EICAL INSURANCE SCHEE FOR RETIRE EPLOEES Policy Period to Plan Type Group Health Policy Beneficiary Retired employee + Spouse Sum insured (Annual cover amount) Critical illness Cadre at the time of Sum insured () retirement Officers 4,00,000/- Clerical & Sub Staff 3,00,000/- All diseases are covered from day one. Coverages 1(i) Inpatient Hospitalisation expenses (all diseases are covered which require hospitalization) (ii) Pre/Post hospitalization expenses covered Pre-hospitalization for 30 days Post Hospitalization for 90 days: 2. Listed ay Care Procedures 3. omiciliary Hospitalization is covered- It means medical treatment for an illness/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:- o The condition of the patient is such that he/she is not in a condition to be removed to a hospital. o The patient takes treatment at home on account of non availability of room in a hospital. Room Rent - Room Rent upto to 5,000/- per day. - ICU charges upto 7,500/- per day. Ambulance Charges - Ambulance charges upto 2500/- per trip. - Taxi and Auto in actual maximum up to 750/- per trip Congenital internal / external diseases / defects/ anomalies Pre-existing diseases coverage Alternative therapy Covered in the policy. Covered in the policy. Reimbursement of expenses due to hospitalization under the recognized system of medicine, viz Unani, Sidha, Homeopathy, Naturopathy, if such treatment is 1 P age

3 taken in a clinic/hospital registered by the central/state government. Ayurvedic Treatment Hospitalization expenses are admissible only when the treatment has been undergone in a Government Hospital or in any institute recognized by the Government and/or accredited by Quality Council of India/National Accreditation Board on Health. Nursing Charges The following charges in the scheme are payable:- Nursing Charges, Service Charges, IV Administration Charges, Nebulization Charges, RO charges,anesthetic, Blood, Oxygen, Operation Theatre Charges, surgical appliances, OT consumables, edicines & rugs, ialysis, Chemotherapy, Radiotherapy, Cost of Artificial Limbs, cost of prosthetic devices implanted during surgical procedure like pacemaker, efibrillator Ventilator, orthopedic 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, RI, any other scan, scopies and such similar expenses that are medically necessary, or incurred during hospitalization as per the advice of the attending doctor. iscellaneous o Expenses for treatment of Congenital internal/external diseases,defects anomalities are covered. o Expenses for treatment of psychiatric and psychosomatic diseases be payable with or without hospitalization. o Treatment taken for Accidents can be payable even on OP basis in hospital upto sum insured. o Treatment for Genetic isorder and stem cell therapy is covered under the scheme. o Treatment for Age Related acular egeneration treatment such as Roptational Field Quantum magnetic Resonance, enchanced external Counter Pulsation etc are covered under the scheme, Treatment for all neurological/macular degeneration disorder shall be covered under the scheme. 2 P age

4 OPERATIONAL GUIELINES TPA CAR i. The scheme is being operationalised by United India Insurance Company through Raksha TPA and all the claims under the scheme are to be processed by the TPA. ii. Each retiree and their spouses are to be issued separate TPA I card containing the photo of the insured. iii. Circle Offices obtained photographs on the format prescribed for the purpose of issuing TPA I cards. In the meantime the TPA I card without photograph can be downloaded through website (rakshatpa.com) and / or through mobile app as below iv. For downloading TPA I Card through website, the retirees are advised to follow the path >> visit Raksha TPA web site >> click on IBA >> click PNB. System will ask you to fill the I card No. where the following is to be filled:- UIC545(Employee PF Number) PNBR eg. If PF number is 12345, the text to be filled shall be UIC PNBR >> click on search button. New screen will appear with all details. If details are correct, click PRINT E-CAR and save the same for records and future reference. For downloading TPA I card through mobile app, use smart mobile phone for the facility. ownload the obile App. Raksha TPA, on the application. System will show many options, click on Request E-card and enter the particulars as advised above, then click on search button. New screen will appear with all details. If details are correct, click PRINT E-CAR and save the same for record and future reference. INTIATION OF CLAI IN CASE OF ALL HOSPITALISATION (CASHLESS OR OTHERWISE) i. The reimbursement claims are required to be intimated to Raksha TPA within 24 hours of hospitalization and original documents are to be submitted within 30 days of discharge from the hospital. ii. In case of planned hospitalization, the TPA is to be informed at least two days before hospitalization, but in any case within 24 hours of hospitalization. iii. Intimation has to be sent along with the following particulars:- a. ember I b. Patient s Name c. Name and address of the Hospital d. isease / ailment and Treatment given e. ate of admission f. Requested amount 3 P age

5 iv. Intimation can be sent by the insured / relatives / through any of the following methods:- a. Through to Raksha TPA at id helpiba@rakshatpa.com, claimintimation@rakshatpa.com b. Through phone by calling any of the following 24 hours toll free No./Call Center and providing above information a) elhi b) elhi c) umbai d) Bangalore c. On line Registration by following the undernoted procedure: 1. login to 2. click on claim intimation link 3. Punch in desired details like ember id, date of admission, name of hospital etc. 4. Acknowledgement No. (i.e. your claim no.) shall be reflected, a copy of which may be retained SUBISSION & PAENT OF EICAL BILLS (OTHER THAN ON CASHLESS BASIS) PROCEURE & TIE SCHEULE FOR SUBISSION OF EICAL CLAIS HOSPITALISATION CLAIS - (CASHLESS BASIS) i. All claims are to be submitted on the prescribed format of the insurance company. Proforma of the claim form is enclosed. ii. Retirees may also lodge claim direct to Raksha TPA or any Circle Offices or Head Office-Hospitalisation cell. iii. Circle Offices and HR ivision HO (Hospitalisation Cell) will submit these bills to TPA on daily basis, after keeping proper record. iv. All reimbursements shall be credited in Retirees Bank account directly. All supporting documents in original, i.e ischarge Card, edical Prescription, edicine Bills, related Reports, X-rays, ECG strips, CT scan pictures and other documents relating to the claim must be submitted with the claim form within 30 days from the date of discharge from the hospital. In case of post-hospitalization treatment (limited to 90 days), all claim documents should be submitted within 30 days after completion of such treatment. i. The benefit of cashless hospitalisation facility is available in many hospitals on provider s network. The list of such hospitals can be accessed on Raksha TPA s website. 4 P age

6 EERGENC HOSPITALISATION IF HOSPITAL IS NOT IN THE APPROVE LIST OF TPA ii. Retirees are advised to contact TPA counter of the hospital along with TPA I Card and a Govt. Photo I proof of the patient for seeking cashless hospitalization claim. iii. On production of I card, the TPA desk of the hospital shall inform the TPA, the requisite particulars of employee, the patient admitted, reason for hospitalization etc. and seek initial approval of the estimated hospitalization expenses. iv. Some hospitals have a policy of seeking an advance for treatment to start. The same is refundable once the cashless approval is received. v. After treatment, the hospital s TPA desk will submit the bills to the TPA and on receipt of sanction, the patient shall be discharged. Claim amount shall be paid by Insurance Company through TPA directly to the hospital concerned. vi. Any amount not admissible under the scheme and not sanctioned by the TPA shall have to be paid by the retiree to the hospital at the time of discharge of patient. vii. In case of post-hospitalisation treatment, all claim documents should be submitted within 30 days after completion of such treatment. In case of an emergency admission to a hospital which is not in PP Network, the officers / employees can approach the TPA for cashless treatment by intimating the Third Party Administrator, call centre number ( , (elhi), (umbai), (Bangalore), mentioning his I card No. and name. The hospital authorities would fax / mail the details of hospitalisation to the Third Party Administrator, who would again revert by fax / mail a confirmation to the hospital to proceed with the claim. Wherever the hospital is not in the approved list of Third Party Administrator, the Third Party Administrator will take necessary action for considering addition of such hospital on their network hospital list in consultation with bank. In an emergency the claim payment would be made to the hospital and empanelment of the hospital would be considered. 5 P age

7 Advisory Efforts have been made for issuance of TPA photo I cards to all the retirees alongwith their spouses. It is understood that some of the application forms are still lying in the branches, where these have submitted. These should be sent to nearby Circle Offices so that these are forwarded to TPA. In the meantime I cards without photo shall be honoured by TPA. GRIEVANCE RERESSAL EX-staff to ensure providing of photos of self and spouse to concerned Circle Offices so that next time i.e. Policy period to , Photo I Cards are issued by TPA. 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 6 P age

8 CLAI FOR - PART A' to 'CLAI FOR FOR HEALTH INSURANCE POLICIES OTHER THAN TRAVEL AN PERSONAL ACCIENT - PART A ETAILS OF PRIAR INSURE: TO BE FILLE B THE INSURE The issue of this Form is not to be taken as an admission of liablity (To be Filled in block letters) a) Policy No.: b) Sl. No/ Certificate no. c) Company/ TPA I No: d) Name: S U R N A E F I R S T N A E I L E N A E e) Address: City: State: Pin Code Phone No: I: ETAILS OF INSURANCE HISTOR: a) Currently covered by any other ediclaim / Health Insurance: es No b) ate of commencement of first Insurance without break: c) If yes, company name: Policy No. Sum insured () d) Have you been hospitalized in the last four years since inception of the contract? es No ate: iagnosis: e) Previously covered by any other ediclaim /Health insurance : : es No SECTION A SECTION B f) If yes, company name: ETAILS OF INSURE PERSON HOSPITALIZE: : a) Name: S U R N A E F I R S T N A E I L E N A E b) Gender ale Female c) Age years onths d) ate of Birth e) Relationship to Primary insured: Self Spouse Child Father other Other (Please Specify) f) Occupation ETAILS OF HOSPITALIZATION: : ETAILS OF CLAI: ETAILS OF BILLS ENCLOSE: Sl. No. Bill No. ate Issued by Towards Amount (Rs) City: Service g) Address (if diffrent from above) : Pin Code Phone No: I: a) Name of Hospital where Admited: ETAILS OF PRIAR INSURE S BANK ACCOUNT:: Self Employed b) Room Category occupied: ay care Home aker Student Retired State: Other (Please Specify) Single occupancy Twin sharing 3 or more beds per room c) Hospitalization due to: Injury Illness aternity d) ate of injury / ate isease first detected /ate of elivery: e) ate of Admission: f) Time H H H g) ate of ischarge: h) Time: H H : H I) If injury give cause: Self inflicted Road Traffic Accident ii) Reported to Police a) etails of the Treatment expenses claimed I. Pre -hospitalization expenses iii. Post-hospitalization expenses v. Ambulance Charges: iii. LC Report & Police FIR attached Substance Abuse / Alcohol Consumption es No ii. Hospitalization expenses iv. Health-Check up cost: vi. Others (code): j) System of edicine: vii. Pre -hospitalization period: days viii. Post -hospitalization period: days b) Claim for omiciliary Hospitalization: es No c) etails of Lump sum / cash benefit claimed: i. Hospital aily cash: iii. Critical Illness benefit: v. Pre/Post hospitalization Lump sum benefit: a) PAN: c) Bank Name and Branch: d) Cheque / Payable details: Total (If yes, provide details in annexure) ii. Surgical Cash: iv. Convalescence: vi. Others: Total b) Account Number: Hospital main Bill Pre-hospitalization Bills: Post-hospitalization Bills: Pharmacy Bills Nos Nos e) IFSC Code: I) If edico legal es No Claim ocuments Submitted - Check List: Claim form duly signed Copy of the claim intimation, if any Hospital ain Bill Hospital Break-up Bill Hospital Bill Payment Receipt Hospital ischarge Summary Pharmacy Bill Operation Theater Notes ECG octor s request for investigation Investigation Reports (Including CT / RI / USG / HPE) octor s Prescriptions Others SECTION C SECTION SECTION E SECTION F SECTION G (IPORTANT: PLEASE TURN OVER)

9 ECLARATION B THE INSURE: I hereby declare that the information furnished in the claim form is true & correct to the best of my knowledge and belief. If I have made any false or untrue statement, suppression or concealent of any material fact with respect to questions asked in relation to this claim, my right to claim reimbrusement shall be forfeited, I also consent & authorize TPA / Insurance Company, to seek necessary medical information / documents from any hospital / edical 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. SECTION H ate Place: Signature of the Insured GUIANCE FOR FILLING CLAI FOR - PART A (To be filled in by the insured) ATA ELEENT ESCRIPTION FORAT SECTION A - ETAILS OF PRIAR INSURE a) Policy No. Enter the policy number As allotted by the Insurance Company b) Sl. No/ Certificate No. Enter the social Insurance number or the certificate number of social health insurance scheme As allotted by the oraganization c) Company TPA I No. Enter the TPA I No. Licence number as allotted by IRA and printed in TPA documents. d) Name Enter the full name of the policyholder Surname, First name, iddle name e) Address a) Currently covered by any other ediclaim / Health Insurance? Enter the full postal address SECTION B -ETAILS OF INSURANCE HISTOR Indicate whether currently covered by another ediclaim / Health Insurance Include Street, City and Pin code Tick es or No b) ate of commencement of first Insurance without break Enter the date of commencement of first Insurance Use dd-mm-yy-forrmat c) Company Name Enter the full name of the Insurance Company Name of the organization in full Policy No. Enter the policy number As allotted by the Insurance Company Sum insured d) Have you been Hospitalized in the last four years since Inception of the contract? Enter the total sum insured as per the policy Indicate whether hospitalized in the last four years In rupees Tick es or No ate Enter the date of Hospitalization Use mm-yy format iagnosis Enter the diagnosis details Open Text e) Previously covered by any other ediclaim / Health Insurance? Indicate whether previously covered by another mediclaim / Health Insurance Tick es or No f) Company Name Enter the full name of the Insurance Company Name of the organization in full SECTION C -ETAILS OF INSURE PERSON HOSPITALIZE a) Name Enter the full name of the patient Surname, First name, iddle name b) Gender Indicate Gender of the patient Tick ale or Female c) Age Enter age of the patient Number of years and months d) ate of Birth Enter ate of Birth of patient Use dd-mm-yy format e) Relationship to primary Insured Indicate relationship of patient with policyholder Tick the right option, if others, please specify f) Occupation indicate occupation of patient Tick the right option. If others, please specify. g) Address Enter the full postal address Include Street, City and Pin code h) Phone No 1) I Enter the phone number of patient Enter address of patient SECTION - ETAILS OF HOSPITALIZATION Include ST code with telephone number Complete address a) Name of Hospital where admited Enter the name of hospital Name of hospital in full b) Room category occupied c) Hospitalization due to d) ate of injury/ate isease first detected / ate of elivery e) ate of admission f) Time g) ate of discharge h) Time I) If injury give cause If edico legal Reported to Police LC Report & Police FIR attached j) System of edicene a) etails of Treatment Expences b) Claim for omiciliary Hospitalization c) etails of Lump sum/ Cash benifit claimed d) Claim documents Submitted-Check List Indicate which bills are enclosed with the amount in rupees a) PAN b) Account Number c) Bank Name and Branch c) Cheque/ payable details c) IFSC Code indicate the room category occupied indicate reason of hospitalization Enter the relevant date Enter date of admission Enter time of admission Enter date of discharge Enter time of discharge indicate cause of injury indicate whether injury is medico legal indicate whether police report was filed indicate whether LC report and Police FIR attached Enter the system of medicine followed in treating the patient SECTION E - ETAILS OF CLAI Enter the amount claimed as treatment expences indicate whether claim is for domiciliary hospitalization Enter the amount claimed as lump sum / cash benefit indicate which supporting documents are submitted SECTION F - ETAILS OF BILLS ENCLOSE SECTION G - ETAILS OF PRIAR INSURE s BANK ACCOUNT Enter the permanent account number Enter the Bank account number Enter the Bank name along with the branch Read declaration carefully and mention date (in dd:mm:yy format), place (open text) and sign. Enter the name of the beneficiary the cheque / should be made out to Enter the IFSC code of the Bank branch SECTION H - ECLARATION B THE INSURE Tick the right option Tick the right option Use dd-mm-yy format Use dd-mm-yy format Use hh-mm- format Use dd-mm-yy format Use hh-mm- format Tick the right option Tick es or No Tick es or No Tick es or No Open Text In rupees (o not enter paise values) Tick es or No In rupees (o not enter paise values) Tick the right option As allotted by the Income Tax epartment As allotted by the Bank Name of the Bank in full Name of the individual / organization in full IFSC code of the Bank branch in full

ID: Yes. Yes. /No. months. b) Date of Birth: Spouse. Service Self Employed Homemaker Student Retired Other. ID:

ID: Yes. Yes. /No. months. b) Date of Birth: Spouse. Service Self Employed Homemaker Student Retired Other. ID: INSURANCE TPA SERVICES (I) PVT.LT. 6B, Paul ansions, Bishop Lefroy Road, Kolkata 700 020, West Bengal, India ETAILS OF PRIAR INSURE (To be filled in block letters) a) Policy b) Company/ TPA I CLAI FOR