ALLAHABA BANK PERSONNEL AMINISTRATION EPARTMENT (HUMAN RELATIONS SECTION) Head Office : 2, Netaji Subhas Road, Kolkata 700 001 Instruction Circular. 13993/AMN(HR)/2015-2016/20 ate : 06-11-2015 To ALL OFFICES & BRANCHES C I R C U L A R Medical Insurance Scheme for the existing Officers/Employees in terms of Bipartite Settlement / Joint te dated 25th May, 2015 in lieu of existing Hospitalization Scheme Reference is invited to Head Office Instruction Circular.13942/AMN(HR)/2015-2016/17 dated 30/09/2015 regarding implementation of Medical Insurance Scheme for the existing Officers/Employees in lieu of existing Hospitalization Scheme in terms of 10th Bipartite Settlement / Joint te dated 25th May, 2015. Accordingly, the said medical insurance scheme had been implemented w.e.f 1st October, 2015. The United India Insurance Co. Ltd. has provided blanket coverage (for cashless benefit & claim reimbursement) to all our officers & employees for the period from 1st October, 2015 to 30th September, 2016 and Heritage Health TPA Pvt. Ltd, Kolkata is acting as TPA (Third Party Administrator) for the said scheme. The procedure for lodgment of claims, both for Cashless Hospitalization, omiciliary Hospitalization and Reimbursement claims of Hospitalization/omiciliary treatment will be as under: Intimation of Claim: Officers/ Employees are required to intimate the TPA before date of admission in hospital, in case of planned hospitalization or within seven days from the time of Hospitalization/ omiciliary Hospitalization for all types of Hospitalization claim (Cashless Claim / omiciliary Hospitalization claim/ Reimbursement Claim) over telephone / E-mail / through website of TPA, i.e. http://www.heritagehealthtpa.com for smooth processing/ sanctioning of the claims. For Cashless Benefit: To get the Cashless Hospitalization benefit under the above scheme, the Officers/Employees are required to contact the Insurance esk of the Network Hospital with their Medical Insurance Card/ E-card issued by the TPA. i.e. M/s Heritage Health TPA Pvt. Ltd. The list of Network Hospitals is available on the website of TPA. For Reimbursement claims of Hospitalization / omiciliary Hospitalization/ omiciliary treatment expenses: In case of reimbursement claims of Hospitalization / omiciliary Hospitalization/ or omiciliary treatment expenses under the above scheme, the officers/employees are required to submit the claim application/s on the prescribed Claim format of Heritage Health TPA Pvt. Ltd. (format enclosed) and other requisite documents such as original money receipts, discharge summary, octor s Prescription, hospitalization final bills, reports, medicines bills/vouchers etc. (as per check list enclosed) to their
respective Branches /Offices. Branches /Offices are required to send the claim file to their respective Zonal offices, after keeping a Xerox copy set of the claim file for future reference. Reimbursement claims of Hospitalization expenses should reach the TPA/Insurance Company within 30 days from the date of discharge from the Hospital. Post-hospitalization claims may be submitted separately within 30 days after completion of the Post-hospitalization period. omiciliary hospitalization / omiciliary treatment: Medical expenses incurred in case of the diseases as listed in Appendix I of Annexure IV ( Schedule for reimbursement of Hospitalization expenses Medical Insurance Scheme) of 10 th Bipartite Settlement / Joint te dated 25/05/2015, as circularised vide Instruction Circular. 13764/AMN(HR)/2015-16/04 dated 20/06/2015 and 13765/AMN(HR)/2015-16/05 dated 20/06/2015, which need domiciliary hospitalization / domiciliary treatment as may be certified by the attending medical practitioner and/ or Bank s medical officer shall be deemed as hospitalization expenses and reimbursed to the extent of 100 %. The cost of medicines, investigations and consultations etc. in respect of domiciliary treatment shall be reimbursed for the period stated by the specialist and/or the attending doctor and / or the bank s medical officer, in prescription. If no period stated, the prescription for the purpose of reimbursement shall be valid for a period not exceeding 90 days. Officers/Employees are required to submit Claims for expenses of domiciliary treatment on monthly basis to the branches/offices immediately after end of the month and Branches/offices are required to send the same to their respective Zonal Office immediately, so that the concerned Zonal Office may be able to lodge the claim to the TPA/Insurance Company within 7 th day of the succeeding month. Action to be taken at Zonal Office Level: On receiving the hard copy of the claim file from the Branches/ Offices, Zonal Offices are required to note all the details of the claim in a register and then upload the same in the module named MEICAL INSURANCE CLAIM LOGE given in the APP Store on Bank s Intranet Site. After uploading, the original claim files are required to be handed over to the representative of TPA i.e. Heritage Health TPA Pvt. Ltd, who will visit the Zonal Offices/ Head Office. Uploading of detailed information for all types of reimbursement claims i.e. reimbursement claims of Hospitalization / omiciliary Hospitalization/ omiciliary treatment expenses in MEICAL INSURANCE CLAIM LOGE module given in the APP Store on Bank s Intranet Site is mandatory for lodgment of claims. The claim amount settled by the TPA/Insurance Company will be remitted to Head Office, which in turn will be credited by Head Office to the Bank account of the concerned Officer /employee directly on the basis of the claim record(s) uploaded in the said Module by the Zonal Offices. Coverage of Officers/ Employees who have retired/ are going to retire during the period from 2 nd October, 2015 to 30th September, 2016 : - Employees who have retired/ are going to retire during the period from 2 nd October, 2015 to 30th September, 2016 and are members of the scheme as existing Officers/Employees will continue to be covered under the scheme for existing employees till 30th September, 2016 with their dependent family members. For becoming a member of the Medical Insurance Scheme for the retired employee from 1 st October,2016 to 31 st October, 2016, they will be required to send the willingness/ consent i.e. duly filled in Annexure-A-1 format along with their ebit Authority ( Annexure-B ) for
prorata Insurance premium of one month, to Sri Subrata Sengupta, Officer, Human Relations Section, Personnel Administration epartment, Head Office,14, India Exchange Place, (4 th Floor) Kolkata-700001 by Regd./ Speed post by 10 th September, 2016. Such section of retired officers/ employees shall also ensure that the amount of premium is debited from their account with Allahabad Bank positively by 15 th September, 2016 to ensure their inclusion in the Medical Insurance Scheme for retired employee for the period from 1 st October, 2016 to 31 st October, 2016. Further they will also be required to renew their membership under the Medical Insurance scheme for retired employees before 1 st vember, 2016 by paying the agreed insurance premium which will be fixed by the Insurance Company at the time of renewal. The Medical Insurance Cards of the officers/employees enrolled as the members of the Medical Insurance Scheme for the existing officers/employees, will be issued by the TPA i.e. M/s Heritage Health TPA Pvt. Ltd. The Medical Insurance E-cards may also be downloaded from the website of Heritage Health TPA Pvt. Ltd as under: Website of Heritage TPA : www.heritagehealthtpa.com : Click on IBA BANK-STAFF : Click on E-CAR : Select ALLAHABA BANK in Bank Option. : Enter PF. (e.g. 31234) in the Emp.I Box & Click on Search. Contact Person of Heritage Health TPA Pvt. Ltd dal Officer : Sri Suraj Pandey, Mob..8334977880 For Reimbursement Claims : Sri Suraj Pandey, Mob..8334977880 For Cashless Claims Related Issues : Sri Sumit eb, Mob..9903315764 Email:- sumitdeb@bajoria.in For any query/guidelines in respect of cashless hospitalization facility, reimbursement of Hospitalization / omiciliary Hospitalization and omiciliary treatment expenses/ claim intimation etc., the TPA, M/s Heritage Health TPA Pvt. Ltd may be contacted at the following address & contact numbers: HERITAGE HEALTH TPA PVT LT. NICCO House, 5 th Floor, 2 Hare Street, Kolkata - 700001 Telephone. 033-4033 4141, Fax. 033-22100837 Toll Free. 1800 102 4547 Email Id:- allahabadbank.heritage@bajoria.in (For Claim Intimation) heritage.complaint@bajoria.in (For Any Complain/Grievance) For any Grievance regarding less payment/ late payment/ non-payment of the Hospitalization claims or claims for domiciliary treatment expenses, complaint may lodged through the Grievances Tab available in the website of TPA, i.e.. http://www.heritagehealthtpa.com The contents of this Instruction Circular should be brought to the notice of all the officers/employees. Hindi version of this Circular will follow. (P. S. Bhatia) General Manager (HR)
CHECK LIST (for submission of reimbursement claims of Hospitalization, omiciliary treatment and omiciliary Hospitalization) 1. Claim Intimation Copy duly received by Policy Issuing Office/TPA within 7 ays from ate of Admission 2. Reason for elay in submission of documents/intimation copy, if not submitted timely as per Policy T/C 3. uly filled in Claim Form, With Claimant Signature mentioning Exact Claim Amount, Contact etails, E Mail I etc. 4. Hospital ischarge Certificate in original with ate & Time, etails of Treatment 5. All the Prescriptions, Money Receipts/Cash Memo, Investigations Reports, Hospital requisitions and other supporting documents, in original. 6. Advice for Admission and First Prescription with clinical notes, in original 7. Hospital Bill with detailed break up along with Money Receipts in original 8. In case of Implant Sticker & Tax Invoice with money receipt in original (For Cataract, Patient Lens Identification Card Mandatory) 9. In accidental cases Self Statement/FIR/Medico Legal Report 10. Investigation Reports along with plates, in original 11. Any other relevant documents pertaining to claim. N.B. ----- Photocopies & Scanned Copies not acceptable. All original documents required.
CLAIM FORM FOR HEALTH INSURANCE POLICIES OTHER THAN TRAVEL AN PERSONAL ACCIENT - PART A TO BE FILLE IN B THE INSURE The issue of this Form is not to be taken as an admission of liability IRAI License. 008 ETAILS OF PRIMAR INSURE: (To be filled in block letters) a) Policy : b) Sl../Certificate : c) Company/TPA I : d) Name : e) Address : City : Pin Code : ETAILS OF INSURANCE HISTOR: a) Currently covered by any other Mediclaim/Health insurance: c) If yes, company name : Sum Insured () iagnosis : f) If yes, Company Name : ETAILS OF INSURE PERSON HOSPITALIZE: a. Name : e) Relationship to Primary Insured: f) Occupation: Service g) Address (if different from above) : City : Pin Code : ETAILS OF HOSPITALIZATION: a) Name of Hospital where Admitted : es Self Self Employed b) Room Category occupied : ay care c) Hospitatization due to : Injury e) ate of Addmission : vi. Others : State : Phone : Email I : es b) ate of commencement of first insurance without break: Policy. d) Have you been hospitalized in the last four years since inception of the contract? es Spouse es ETAILS OF PRIMAR INSURE S BANK ACCOUNT : a) PAN c) Bank Name and Branch : d) Cheque/ Payable details : Child Homemaker State : Phone : Email I : Father Student Mother Retired e) Previously covered by any other Mediclaim/Health Insurance: Other Other (Please Specify) (Please Specify) i) If injury give cause : Self inflicted Road Traffic Accident Substance Abude /Alcohol Consumption i) If Medico legal: ii) Reported to police : ETAILS OF CLAIM a) etails of the treatment expenses claimed : i. Pre-Hospitalization Expenses : iii. Post-Hospitalization Expenses : v. Ambulance Charges : vii. Pre-Hospitalization period : b) Claim for omiciliary Hospitalization : c) etails of Lump sum / cash benefit claimed: i. Hospital aily Cash iii. Critical illness Benefit: v. Pre/Post Hospitlaization Lump sum benefit ETAILS OF BILLS ENCLOSE : SL.. 1 2 3 4 5 6 7 8 9 10 S U R N A M E S U R N A M E Single occupancy Twin sharing 3 or more beds per room Illness Maternity d) ate of injury/ate isease first detected/ate of elivery ate: f) Time : H H g) ate of ischarge : h) Time : H H ays F I R S T N A M E F I R S T N A M E b) Gender: Male Female c) Age : ears Months d) ate of Birth : iii) MLC Report & Police FIR attached ii. Hospitalization Expenses : iv. Health-Check up Cost : vi. Others (code) : viii. Post-Hospitalizatio n period : ii. Surgical Cash: iv. Convalescence : Total Total es ays (If yes, provide details in annexure) j) System of Medicine es es Claim ocuments Submitted - Check List : Claim Form uly signed Copy of the claim intimation, if any Hospital Main Bill Hospital Break-up Bill Hospital Bill Payment Receipt Hospital ischarge Summary Pharmacy Bill Operation Theatre tes ECG octor s request for investigation Investigation Reports (including CT/MRI/USG/HPE) octor s Prescriptions Bill. ate Issued by Towards Amount (Rs) b) Account Number : e) IFSC Code: Hospital Main Bill Pre-hospitalization Bill: Others s. Post-hospitalization Bill: s. Pharmacy Bills M I L E N A M E M I L E N A M E (IMPORTANT:PLEASE TURN OVER) SECTION A SECTION B SECTION C SECTION SECTION E SECTION F SECTION G
ECLARATION B THE INSURE: 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 & authorise 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 SECTION H ate : Place Signature of the Insured a) Policy. Enter the policy number As allotted by the insurance company b) SI../Certificate. Enter the social insurance number of the certificate As allotted by the organization number of social health insurance scheme c) Company TPA I. Enter the TPA I. License number as allotted by IRA and printed in TPA documents d) Name Enter the full name of the policyholder Surname, First name, Middle 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 Indicate whether currently covered by another Tick es or Mediclaim / Health Insurance? Medicliam / Health Insurance b) ate of Commencement of first insurance without break Enter the date of commencement of first insurance Use dd-mm-yy format c) Company Name Enter the full name of the insurance company Name of the organization in full Policy 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 Indicate whether hospitalized in the last four years Tick es or inception of the contract? ate Enter the date of hospitalization User mm-yy format iagnosis Enter the diagnosis details Open Text e) Previously Covered by any other Indicate whether previously covered by another Tick es or Mediclaim / Health Insurance? mediclaim / Health Insurance 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, Middle name b) Gender Indicate Gender of the patient Tick Male 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 Enter the phone number of patient Include ST code with telephone number i) E-mail I Enter e-mail address of patient Complete e-mail address SECTION - ETAILS OF HOSPITALIZATION a) Name of Hospital where admitted Enter the name of hospital Name of hospital in full b) Room category occupied Indicate the room category occupied Tick the right option c) Hospitalization due to Indicate reason of hospitalization Tick the right option d) ate of Injury / ate isease first detected Enter the relevant date Use dd-mm-yy format / ate of elivery 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 Indicate cause of injury Tick the right option If Medico legal Indicate whether injury in medico legal Tick es or Reported to Police Indicate whether police report was filed Tick es or MLC Report & Police FIR attached Indicate whether MLC report and Police FIR attached Tick es or j) System of Medicine Enter the system of medicine followed in treating the patient Open Text SECTION E - ETAILS OF CLAIM a) etails of Treatment Expenses Enter the amount claimed as treatment expenses In rupees (o not enter paise values) b) Claim for omiciliary Hospitalization Indicate whether claim is for domiciliary hospitalization Tick es or c) etails of Lump sum/cash benefit claimed Enter the amount claimed as lump sum /cash benefit In rupees (o not enter paise values) d) Claim ocuments Submitted-Check List Indicate which supporting documents are submitted Tick the right option Indicate which bills are enclosed with the amounts in rupees GUIANCE FOR FILLING CLAIM FORM - PART A (To be filled in by the insured) ATA ELEMENT ESCRIPTION FORMAT SECTION A - ETAILS OF PRIMAR INSURE SECTION F - ETAILS OF BILLS ENCLOSE SECTION G - ETAILS OF PRIMAR INSURE S BANK ACCOUNT a) PAN Enter the. permanent account number As allotted by the Income Tax department b) Account Number Enter the bank account number As allotted by the bank c) Bank Name and Branch Enter bank name along with the branch Name of the bank in full d) Cheque/ payable details Enter the name of beneficiary the cheque/ Name of the individual/organization in full should be made out to e) IFSC Code Enter the IFSC code of the bank branch IFSC code of the bank branch in full SECTION H - ECLARATION B THE INSURE Read declaration carefully and mention date (in dd:mm:yy format), place (open text) and sign.
Annexure to Instruction Circular.13993/AMN(HR)/2015-2016/20 dated 06/11/2015. To The Asstt. General Manager (HR) Allahabad Bank Head Office, 14, India Exchange Place, (4th Floor) Kolkata- 700001 ANNEXURE - A-1 Willing to join in the Medical Insurance Scheme for the Officers/Employees of IBA Member Banks which are parties to the Bipartite Settlement/ Joint te dated 25th May,2015 by payment of agreed Insurance Premium I am a retired employee of the Bank. I retired from Bank s service as a/an. (Officer/Clerk/Sub-staff) on from..branch. I am presently drawing Pension through our. Branch [Br. Code.. ] under.. Zone through my SB A/C. I have gone through and understood the terms of the 10 th Bipartite Settlement / Joint te dated 25.05.2015. I am willing to join in the Medical Insurance Scheme for the Officers/Employees of IBA Member Banks which are parties to the Bipartite Settlement/ Joint te dated 25th May, 2015 which is extended to the existing retirees subject to payment of agreed Insurance Premium by me. The detail information of myself and dependent spouse are as under: Sl.. Full Name of Self/ ependent Spouse. ate of Birth (/MM/) Relationship Monthly Income Gender Photograph 1. Photograph of Self 2. Photograph of Spouse I also understand and accept that the Bank is in no way responsible for payment of any amount under the scheme except what is admissible /payable by the Insurance Company. a) Name of the retired Employee:.. b) PF. c) Address for Correspondence :..PIN Code b) Mobile./Ph.... c) E-mail I:.. ate :.. Place:.. (Signature of the Retired Officer/Employee)
Annexure to Instruction Circular.13993/AMN(HR)/2015-2016/20 dated 06/11/2015. Annexure-B [ebit Authority for the Officers/ Employees who have retired or going to be retired from 2 nd October, 2015 to 30 September, 2016] To The Asstt. General Manager (HR) Allahabad Bank Head Office, 14, India Exchange Place, (4th Floor) Kolkata- 700001 ear Sir, Re: ebit Authority for membership of the Medical Insurance Scheme for Retired Officers/Employees from 01 st October, 2016 to 31 st October, 2016. I request you to kindly debit the prorata premium of one month from my / our Savings Bank Account.towards the Insurance Premium for joining the Medical Insurance Scheme for Retired Officers/ Employees in terms of 10 th Bipartite Settlement / Joint te dated 25th May, 2015 and take necessary action for coverage under the Medical Insurance Scheme for Retired Officers/Employees from 01 st October, 2016 to 31 st October, 2016 I shall renew my membership under the scheme w.e.f. 1 st vember, 2016 separately by depositing the premium amount as fixed by the Insurance Company within the stipulated time.. ate: ours faithfully, ------------------------------------------ (Signature of the Retired Officer /Employee) Name: PF. ate of Birth: Mobile. Last date of submission at Head Office is 10 th September, 2016 with filled in Annexure-A-1