To: All Affiliates/Office Bearers/Central Committee Members Dear Sir/Madam,

Size: px

Start display at page:

Download "To: All Affiliates/Office Bearers/Central Committee Members Dear Sir/Madam,"

Dorthy Barton
5 years ago
Views:

ALL INIA CANARA BANK RETIREES FEERATION (Regd.) (Affiliated to All India Bank Retirees Federation) A.K.Nayak Bhavan, 2 nd Floor, 14, Second Line Beach, Chennai 600001.

1 ALL INIA CANARA BANK RETIREES FEERATION (Regd.) (Affiliated to All India Bank Retirees Federation) A.K.Nayak Bhavan, 2 nd Floor, 14, Second Line Beach, Chennai Ref No:97:2015 November 11, 2015 Chairman A.K.Bansal To: All Affiliates/Office Bearers/Central Committee embers ear Sir/adam, President V.K..Varma Vice President A.N.Balasubramanian T.T.Raman.V.Subba Rao.C.Katiyar General Secretary S.V.Srinivasan Joint Genl Secretary K.R.anohar Secretary K.Shanmugam.Krishnappa.Balasubramanian B.S.Joshi.K.Saha K.P.Prasad Anil Sood Organising Secretary EICAL INSURANCE SCHEE -- OWNLOAING E-CAR FOR CASHLESS FACILIT AN HOSPITALISATION AN OBSERVANCE OF PROCEURES FOR AVAILING BENEFITS UNER EICAL INSURANCE SCHEE We are happy to share with you that on account of our sustained campaign by way of mass meetings and explanations provided to the retirees across the country, Officers, 5537 Clerical Staff and 463 Subordinate Staff in our Bank have opted and remitted premium for joining the scheme. aster Policy No: /48/15/41/ issued for the retirees of Canara Bank commenced from and will be in force till For the purpose of Hospitalization and claiming cashless facility, retiree requires E- Cards which can be downloaded by accessing the link provided in the web portal of TPA The access to the portal will allow the retired employees to send claim intimation, track claim status in real-time, view e-card and also access claims history / medical records in digital format, submission of claim for reimbursement etc. The retired employees can also upload the latest photo of self and spouse before generating E Card with photograph. For an easy access of portal, a link is also provided at the penultimate line in the bottom of Home Page of Canara Bank Website i.e. ww.canarabank.com under the head Employees/Ex-employees -- ediclaim Login. R.Sudalaimuthu.Venugopalan A.P.Raveendranath S.adusoodananpillai P.Giridharan B.Venkatrao B.S.A.Rao S.K.adan Treasurer A.B.Kasturirangan Assistant Treasurer P.hanaram Also, edi Assist India TPA Pvt. Ltd. has uploaded the complete data of the Canara Bank Retired Employees in their computerised system and created the login details to access their system for downloading E-Card through Android application in Smart obile Phone or through ordinary mobile phone with internet facility. Also, retirees can upload the latest photo of self and spouse before generating E Card with photograph by clicking Beneficiary etails. For accessing the above the login I and initial Password details are as under: Login URL- Login I- staffnumber@iba (For example: 75118@iba) efault Password: OB in dd/mm/yyyy format. In cases, where reimbursement of hospitalization expenses is sought, the fact of getting hospitalized shall be informed to TPA at the earliest, in any case, not later than 7 days of hospitalization. As processing of retirees claims has been centralised at Bengaluru, all claims in the duly filled Ph (O) LL: obile: E-ail: aicbrf2010@gmail.com Website: 1

2 up prescribed format should be accompanied by relevant documents, bills, certificates etc., and should be submitted directly to TPA within 30 days from the date of discharge from the Hospital to the following Address: edi Assist India TPA Pvt. Ltd. Tower, 4th Floor, IBC Knowledge Park 4/1 Bannerghatta Road Bangalore (Toll free Number: ) In this regard, our Bank has since issued Circular No.538 dated enumerating procedural aspects governing the Scheme and the same has also been uploaded in our website. Further, please remember that the present Scheme has been introduced in our bank as part of industry level initiatives in terms of Clause 20 of 10th BPS/ as per edical Insurance Scheme detailed in Schedule IV of the Settlement for serving employees and also as per Clause 10 of the 7th Joint Note dated for Officers as per Scheme contained in Annexure IV. We request all our Functionaries to get themselves familiarised with intricate aspects/procedures involved in the edical Insurance Scheme, by referring to the Scheme Annexures circulated by us and uploaded in our website earlier, so that our retirees are properly guided while preferring claims for deriving maximum benefit from the Scheme. With Warm Greetings, ours Sincerely, Enclosure: 1. Specimen of Reimbursement Claim Form 2. Specimen of Cashless Facility Form (S.V.SRINIVASAN) GENERAL SECRETAR 2

5 edi Assist a) Policy No.: c) Company / TPA I (A I)No: R REIBURSEENT CLAI FOR TO BE FILLE B THE INSURE The issue of this Form is not to be taken as an admission of liablity ETAILS OF PRIAR INSURE: b) Sl. No/ Certificate no. (To be Filled in block letters) 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 CLAI: ETAILS OF BILLS ENCLOSE: Sl. No. Bill No. ate Issued by Towards Amount (Rs) City: Service g) Address (if diffrent from above) : Self Employed Home aker Student Retired State: Other ETAILS OF PRIAR INSURE S BANK ACCOUNT: b) Account Number: (Please Specify) Pin Code Phone No: I: ETAILS OF HOSPITALIZATION: a) Name of Hospital where Admited: b) Room Category occupied: ay care 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 Substance Abuse / Alcohol Consumption I) If edico legal es No ii) Reported to Police iii. LC Report & Police FIR attached es No j) System of edicine: a) etails of the Treatment expenses claimed I. Pre -hospitalization expenses iii. Post-hospitalization expenses v. Ambulance Charges: ii. Hospitalization expenses iv. Health-Check up cost: vi. Others (code): Total vii. Pre -hospitalization period: days viii. Post -hospitalization period: days b) Claim for omiciliary Hospitalization: es No (If yes, provide details in annexure) c) etails of Lump sum / cash benefit claimed: i. Hospital aily cash: ii. Surgical Cash: iii. Critical Illness benefit: iv. Convalescence: v. Pre/Post hospitalization Lump sum benefit: vi. Others: Total a) PAN: c) Bank Name and Branch: d) Cheque / Payable details: Hospital main Bill Pre-hospitalization Bills: Post-hospitalization Bills: Pharmacy Bills e) IFSC Code: ECLARATION B THE INSURE: Nos Nos 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 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. ate Place: Signature of the Insured SECTION C SECTION SECTION E SECTION F SECTION G SECTION H (IPORTANT: PLEASE TURN OVER)

6 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 Enter the full postal address Include Street, City and Pin code SECTION B -ETAILS OF INSURANCE HISTOR a) Currently covered by any other ediclaim / Health Insurance? Indicate whether currently covered by another ediclaim / Health Insurance 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 Enter the total sum insured as per the policy In rupees d) Have you been Hospitalized in the last four years since Inception of the contract? Indicate whether hospitalized in the last four years 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 Indicate whether previously covered by another mediclaim / Insurance? 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, if others, please specify f) Occupation indicate occupation of patient. If others, please specify. g) Address Enter the full postal address Include Street, City and Pin code h) Phone No Enter the phone number of patient Include ST code with telephone number 1) I Enter address of patient SECTION - ETAILS OF HOSPITALIZATION Complete address a) Name of Hospital where admited Enter the name of hospital Name of hospital in full b) Room category occupied indicate the room category occupied c) Hospitalization due to indicate reason of hospitalization d) ate of injury/ate isease first detected / ate of elivery Enter the relevant date Use dd-mm-yy format e) ate of admission Enter date of admission Use dd-mm-yy format f) Time Enter time of admission Use hh-mm- format g) ate of discharge Enter date of discharge Use dd-mm-yy format h) Time Enter time of discharge Use hh-mm- format I) If injury give cause If edico legal Reported to Police LC Report & Police FIR attached indicate cause of injury indicate whether injury is medico legal indicate whether police report was filed indicate whether LC report and Police FIR attached Tick es or No Tick es or No Tick es or No j) System of edicene Enter the system of medicine followed in treating the patient SECTION E - ETAILS OF CLAI Open Text a) etails of Treatment Expences Enter the amount claimed as treatment expences In rupees (o not enter paise values) b) Claim for omiciliary Hospitalization indicate whether claim is for domiciliary hospitalization Tick es or No c) etails of Lump sum/ Cash benifit claimed Enter the amount claimed as lump sum / cash benefit In rupees (o not enter paise values) d) Claim documents Submitted-Check List indicate which supporting documents are submitted Indicate which bills are enclosed with the amount in rupees SECTION F - ETAILS OF BILLS ENCLOSE SECTION G - ETAILS OF PRIAR INSURE s BANK ACCOUNT a) PAN Enter the permanent account number b) Account Number Enter the Bank account number c) Bank Name and Branch Enter the Bank name along with the branch c) Cheque/ payable details Enter the name of the beneficiary the cheque / should be made out to c) IFSC Code Enter the IFSC code of the Bank branch SECTION H - ECLARATION B THE INSURE Read declaration carefully and mention date (in dd:mm:yy format), place (open text) and sign. 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