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UPDATE: 30.12.2015-----Bank's e- Circular dated 28.12.2015-- Group Medical Insurance Policies

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e-Circular
P&HRD.
Sl. No. : 1185/2015 - 16
Circular No. : CDO/P&HRD-PPFG/78/2015 - 16
Monday,December 28,2015.
7 Pausha 1937 (S).
All Branches and offices of
State Bank of India
Madam / Dear Sir,
ADOPTION OF TAILOR MADE FAMILY FLOATER GROUP MEDICLAIM POLICIES:
(I) FOR CONTINUING MEDICAL BENEFITS TO THE EXISTING MEMBERS OF
SBI RETIRED EMPLOYEES MEDICAL BENEFIT SCHEME (SBIREMBS); AND
(II) FOR PROVIDING MEDICAL BENEFITS TO FUTURE RETIREES OF THE BANK
AND EXISTING NON MEMBERS OF SBIREMBS
At present, employees of SBI who retire / retired on superannuation at the
age of 60 years (with certain exceptions) are / were entitled for membership
of SBI Retired Employees’ Medical Benefit Scheme run by SBI Retired
Employees’ Medical Benefit Trust (SBIREMBT) and get medical benefits for self,
spouse and disabled child / children, if any.
2. In view of certain developments in running the SBIREMBS in its present
form and based on feedback from different corners, the Executive
Committee of Central Board of the Bank in its meeting held on 16th
December, 2015 has approved two tailor-made Family Floater Group Health
Insurance Policies (Policy ‘A’ & Policy ‘B’) towards medical benefits of retired
employees.
3. Group Mediclaim Policy ‘A’, will be available to the existing members
of SBIREMBS on the following lines: (details of the policy ‘A’ placed at
page-3 of Annexure-I).
(a) This policy will cover all the existing members of SBIREMBS, their
spouses and disabled child/children, if any.
(b) All the existing members of SBIREMBS will be covered in the policy
with five (5) Basic Annual Sum Insured of Rs. 1.00 lac, 2.00 lac,
3.00 lac, 4.00 lac and Rs. 5.00 lac.
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(c) There will be Corporate Buffer which may be used for any
member whose medical treatment cost exceeds the Individual
Sum Insured limits subject to his entitlement under SBIREMBS and
availability for funds in SBIREMB Trust.
(d) Scheme details for the first year will be as under:
(Rs. in lacs)
REMBS Plans A & A1 B & B1 C & C1 D & D1 E F G H
REMBS Limits (Rs.) 2.00 3.00 4.00 5.00 7.00 10.00 15.00 20.00
No. of existing
Members
24,400 938 633 3,963 32,493 657 139 79
Basic Sum Insured 1.00 1.00 2.00 2.00 3.00 3.00 4.00 5.00
Corporate Buffer 1.00 2.00 2.00 3.00 4.00 7.00 11.00 15.00
Room Rent* (Rs.) 5,000/- 5,000/- 5,000/- 5,000/- 6,000/- 7,000/- 9,000/- 12,000/-
ICU Rent* (Rs.) 7,500/- 7,500/- 7,500/- 7,500/- 9,000/- 10,000/- 12,000/- 15,000/-
Annual Insurance
premium per family
(excluding Service
Tax & Swachh
Bharat Cess) (in Rs.)
3,472/- 4,975/- 6,370/- 7,764/- 9,926/- 12,423/- 15,529/- 18,634/-
* Maximum Ceiling
(e) Under Policy ‘A’ Total Annual limit (Basic Sum Insured + Corporate
Buffer) of a member will not exceed the residual medical Benefit
limit under existing SBIREMBS.
(f) All the existing members of SBIREMBS as on 31.03.2016 will be
shifted to the Policy ‘A’ and the premium will be paid annually
by the SBIREMB Trust to the Insurance Company by debit to
‘SBIREMBT Operation Account’ maintained at Madame Cama
Road Branch. The policy will be renewed annually and will
continue till the medical benefits to members under the scheme
are fully exhausted subject to sufficiency of REMBT corpus.
(g) The Trust will pay the annual insurance premium in advance to
the insurance company to cover all the eligible members.
However, after such payment, if it is found that some members
have expired or they have already exhausted their REMBS limit,
names of such members will be deleted and full premium
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amount will be refunded by the Insurance Company in such
cases.
(h) No employee who retire after 31.12.2015 will be admitted to SBI
Retired Employees’ Medical Benefit Scheme. They will have the
option to join Family Floater Group Health Insurance Policy ‘B’ of
United India Insurance Co. Ltd. However, the employees who
retire on or before 31.12.2015 may be allowed to join SBIREMBS
within the stipulated time schedule as prescribed in SBI Retired
Employees’ Medical Trust (SBIREMBT) Rules and they will be
subsequently covered by Policy ‘A’.
(i) Detailed process of migration of existing members of SBIREMBS to
Group Mediclaim Policy-‘A’, settlement of claims and Role of
TPAs are placed at Annexure-II.
4. Group Mediclaim Policy ‘B’ will be available to future retirees of the
Bank and existing non members of SBIREMBS including spouses of
employees who die/died while in service (details of the policy ‘B’
placed at page-6 of Annexure-I).
(a) This policy will cover permanent employees of the Bank, who
retire on or after 1st January, 2016 / Spouses of employees who
die while in service on or after 1st January, 2016 and existing Non
members of SBIREMBS, their spouses and disabled child / children
if any. There will be no age limit for joining the policy.
(b) All the permanent employees who retire / retired from the Bank
on completion of pensionable service (including VRS optees) will
be allowed to join the policy [excluding those under item (e)
hereinbelow]. Employees who are members of National Pension
System will be allowed to join on completion of 20 years of
confirmed service.
(c) Surviving spouses of deceased permanent employees /
pensioners will be allowed to join the policy.
(d) The policy will also cover the pre-merger retirees / surviving
spouses of pre-merger retirees/ deceased employees of erstwhile
State Bank of Saurashtra (e-SBS), erstwhile State Bank of Indore
(e-SBIN) and e-SBICI.
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(e) However, employees who are / were discharged / dismissed /
removed / compulsorily retired / terminated from service will not
be eligible to join the policy.
(f) The policy will provide Sum Insured, Room rent and ICU rent as
under for the 1st year :
Sum
Insured
(Rs. in lac)
Room Rent
(Max. ceiling)
(Rs.)
ICU Rent
(Max. ceiling)
(Rs.)
Annual Premium per
family (excluding
Service Tax & Swachh
Bharat Cess)
(Rs.)
Scheme
‘A’ ‘B’ ‘C’ ‘D’
A 3.00 lac 5,000/- 7,500/- 5,577/-
B 4.00 lac 5,000/- 7,500/- 7,282/-
C 5.00 lac 7,500/- 9,000/- 9,285/-
D 7.50 lac 15,000/- 18,000/- 12,677/-
E 10.00 lac 15,000/- 18,000/- 16,902/-
F 15.00 lac 15,000/- 18,000/- 25,353/-
G 20.00 lac 15,000/- 18,000/- 33,804/-
H 25.00 lac 15,000/- 18,000/- 42,255/-
(g) New retirees / spouses of deceased employees will be allowed
to join the Policy ‘B’ within three months from the date
retirement / death.
(h) Prospective members can opt for any one of the schemes by
paying the premium from their own sources.
(i) Sum Insured will NOT be reduced by the amount utilized during
the current cover period.
(j) On next year’s renewal they may continue with the same
scheme or change the scheme by paying the applicable annual
insurance premium from their own sources.
5. Contract of Insurance : Both policy ‘A’ and policy ‘B’ will be awarded
to the lowest bidding Insurance Company viz. United India Insurance
Co. Ltd. for a continuous period of 3 years and they will create an
infrastructure at all the Zonal Office Centres for servicing them.
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6. Engagement of Insurance Broker : Bank’s empanelled Insurance Broker
M/s Anand Rathi Insurance Broker Limited (ARIBL) will be engaged as
insurance Broker of the Bank for a period of 3 years for assistance in the
settlement of claims.
7. Maintenance of Record : The select TPAs and M/s Anand Rathi
Insurance Brokers Ltd. (ARIBL) will maintain member wise record of
settlement of claims and provide the data to Bank on exhausted /
outstanding limits of the members on regular basis.
8. Other important instructions :
(a) Onetime option shall be given to eligible past retirees / surviving
spouses of deceased employees / retirees of SBI, e-SBS and
e-SBIN to join the Group Mediclaim Policy-‘B’ during the period
01.01.2016 to 31.03.2016.
(b) Eligible applicants who are willing to join Group Mediclaim
Policy-‘B’ are advised to visit the ‘Portal for SBI Retired
Employees’ and click on ‘Registration for Group Mediclaim
Policy-B’ which will be available w.e.f. 01.01.2016 and apply
online on or before 31.03.2016.
(c) In case the online process is not ready by 01.01.2016, the eligible
applicants shall fill up the application form manually by
downloading the same from ‘Pensioners’ Portal’ or physical
collection and submit to the pension paying branch along with 2
latest joint photographs of self and the spouse.
(d) Details of online / offline process of joining Group Mediclaim
Policy-‘B’, settlement of claims and Role of TPAs are placed at
Annexure-III. Online / Offline admission process for
pre-01.01.2016 retirees/spouses of deceased employees &
pensioners shall remain open till 31st March, 2016. Please note
that the Bank shall not be responsible for any delay in receipt of
the application for whatsoever reasons.
(e) Eligible new retirees / spouses of deceased employees will join
the Policy ‘B’ within three months from the date retirement /
death by paying the premium from their own sources on pro-rata
basis by following the process detailed in Annexure-IV.
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(f) All additions of members and family members would be on
payment of premium on pro-rata basis, In case, some members
join the scheme sometime after the main master policy has been
incepted, they would join by paying the pro-rata premium and
full Sum Insured will be available to the member and his / family
till the expiry of the policy.
(g) Insurance cover for members who pay the premium during
1st day of the month to 14th day of the month will commence
from 16th day of the month. Similarly, insurance cover for
members who pay the premium during 15th day of the month to
the second last day of the month, will commence from 1st day of
the next month.
(h) Premium amount along with service tax for the 1st year and
subsequent renewals will be paid to the United India Insurance
Co. Ltd. by debit to the pension account/other account (in case
of PF optee of e-SBS, e-SBIN & members of NPS) of the applicant.
The applicant shall give mandate / authorization to this effect to
the Bank and maintain sufficient balance in the account till the
premium is debited.
(i) In case of non-payment of premium due to insufficiency of
balance in the account of the applicant / policy holder, the
mandate given by him / her would be treated as lapsed and the
Bank shall not be held responsible under any circumstances for
non inclusion of the concerned individuals in the insurance
policy/ non renewal of the existing policy.
(j) Bank will continue to act as per the authorization given unless the
instruction otherwise is conveyed in writing by such members at
least one month before the due date of premium payment.
(k) The Annual Premium payable is subject to change from time to
time as fixed by the Insurance Company every year.
(l) The terms and conditions of the scheme and benefits available
under the policy are subject to change from time to time as
decided by the Bank every year.
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9. Please arrange to advise all the branches/offices under your control to
make operating staff thoroughly acquainted with the provisions of the
scheme and accept applications for the membership of Group Mediclaim
Policy ‘B’ on the prescribed form from eligible retirees / spouses of deceased
employees and pensioners, to avoid correspondence/complaints at a later
stage.
10. Please also issue necessary instructions to all branches and offices
under your administrative control to prominently display notice in this regard
on the branch / office notice board along with the salient features of the
Scheme for information of the pensioners. Additionally, arrange to
disseminate the contents of the Circular through the office bearers of Circle
Pensioners’ Association so that all the eligible retirees are made aware of the
Scheme.
Yours faithfully,
(Ashwini Mehra)
Deputy Managing Director &
Corporate Development Officer
Encl : Annexure – I, II & III-V


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ANNEXURE-I
FAMILY FLOATER GROUP MEDICLAIM INSURANCE POLICIES FOR RETIRED EMPLOYEES OF
STATE BANK OF INDIA
POLICY – ‘A’ : FOR THE EXISTING MEMBERS OF SBI RETIRED
EMPLOYEES MEDICAL BENEFIT SCHEME (SBIREMBS)
POLICY – ‘B’ : FOR POST 01.01.2016 RETIREES & EXISTING
MEMBERS & NON MEMBERS OF SBIREMBS
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INDEX
Sl
Subject
Page No.
1
Details of Policy ‘A’
3 to 5
2
Details of Policy ‘B’
6 to 7
3
Discount & Loading under both the Policies
8
4
Definitions for both the Policies
9 to 15
5
Coverage under both the Policies
16 to 26
6
Exclusions under both the Polices
27 to 28
7
Management of claims under both the Policies
29 to 31
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DETAILS OF POLICY-‘A’
1. Coverage
All existing members of SBI Retired Employees Medical Benefit Scheme (SBIREMBS), their spouses and disabled child / children, if any. There is no age limit for joining the policy.
2. Duration of cover : 1 year
3. Sum Insured / Room rent / ICU rent :
Hospitalization and Domiciliary Treatment coverage as defined in the scheme and maximum ceiling of Room Rent / ICU Rent under the policy will be as under:
Sl
Category
Medical Benefit Limit under existing REMBS
‘A’
Basic Sum Insured (Rs. in lacs)
‘B'
Corporate Buffer*
(Rs. in lacs)
‘C’
Total Annual Entitlement subject to cap of life time REMBS Plan limit
(Rs. in lacs)
‘D’
Room Rent
(Max. ceiling)
(Rs.)
‘E’
I.C.U Rent
(Max. ceiling)
(Rs.)
‘F’
1
REMBS Plan A / A1
2.00 lac
1.00 lac
1.00 lac
2.00 lac
5,000/-
7500/-
2
Plan B / B1
3.00 lac
1.00 lac
2.00 lac
3.00 lac
3
Plan C / C1
4.00 lac
2.00 lac
2.00 lac
4.00 lac
4
Plan D / D1
5.00 lac
2.00 lac
3.00 lac
5.00 lac
5
Plan-E
7.00 lac
3.00 lac
4.00 lac
7.00 lac
6,000/-
9,000/-
6
Plan-F
10.00 lac
3.00 lac
7.00 lac
10.00 lac
7,000/-
10,000/-
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Plan-G
15.00 lac
4.00 lac
11.00 lac
15.00 lac
9,000/-
12,000/-
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Plan-H
20.00 lac
5.00 lac
15.00 lac
20.00 lac
12,000/-
15,000/-
* In case the basic sum insured is getting exhausted.
4. Corporate Buffer :
The separate buffer will be provided for the members which can be used as per the TPA decision. This buffer will take care of any additional cost which may be required by the members in case of exceeding the individual sum insured limits subject to his entitlement under SBIREMBS and availability of funds.
5. Maximum Sum Insured
Total annual entitlement (Basic Sum Insured + Corporate Buffer) of a member under any circumstance shall not exceed the corresponding balance medical benefit limit under existing REMBS Plan as per column ‘A’ in the above table.
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6. Payment of Annual Premium
 All the existing members of SBIREMBS will join the policy and the premium will be borne by the SBI Retired Employees’ Medical Benefit Trust (SBIREMBT)for them. The Trust will continue to pay premium for a member till his lifetime REMBS Medical Benefit limit is fully exhausted.
 Basic sum insured and Corporate Buffer will be fixed based on actual outstanding amount in the REMBS accounts of individual members as on 31.03.2016.
Example (A):
 Mr. X is a member of plan ‘A1’ (Medical Benefit limit of Rs. 2.00 lac) under the existing REMBS.
 Residual balance in his REMBS account is Rs. 1.00 lac on the date of joining the Mediclaim Policy.
 In the 1st first year he will be admitted to the policy with basic sum insured of Rs. 1.00 lac (no benefit of corporate buffer will be available).
 At the end of the first year if he utilizes the full sum insured of Rs. 1.00 lac, his entitlement under REMBS will be fully exhausted and Bank’s liability to pay further premium will be over.
 The member will have an option to join the separate Group Mediclaim Policy for retirees of SBI by paying the annual insurance premium from his own sources.
Example (B):
 Mr. Y is a member of Plan-‘F’ with lifetime REMBS medical benefit limit of Rs. 10.00 lac.
 Residual balance in his REMBS A/c is Rs. 9.00 lac on the date of joining the Mediclaim Policy.
 In the 1st first year he will be admitted to the policy with basic sum insurance of Rs. 3.00 lac (Rs. 6.00 lac will be available from Corporate Buffer).
 At the end of the first year if he utilizes 2.00 lac, on next year’s renewal will be admitted to the policy with sum insurance of Rs.3.00 lac (Rs. 4.00 lac will be available from Corporate Buffer).
 At the end of the 2nd year if he utilizes another Rs. 2.00 lac, on next year’s renewal will be admitted to the policy with sum insurance of Rs.2.00 lac (Rs. 3.00 lac will be available from Corporate Buffer).
 The member will continue to be entitled for a policy in the successive years with basic sum insurance and Corporate Buffer equivalent to the remaining balance in REMBS till such time the REMBS Medical Benefit limit is fully exhausted.
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 The member will have an option to join the separate Group Mediclaim Policy for retirees of SBI by paying the annual insurance premium from his own sources. But first the claim should be lodged in the policy ‘A’.
7. Payment of premium after exhaustion of limit
Members who have exhausted their entitled limit as prescribed in the Plan will have option to join the separate Group Medical Policy for retirees of SBI by paying the annual premium from his / her own sources.
8. Refund of premium on deletion of member
The Trust will pay the annual insurance premium to the concerned Insurance Company for all the eligible members in advance. However, after such payment, if it is found that some members have already expired or they have already exhausted their REMBS limit, names of such members will be deleted and full premium amount will be refunded by the Insurance Company in such cases.
9. Maximum ceiling of Room Rent & ICU Rent:
Basic Sum Insured (Rs. in lacs)
Corporate Buffer*
(Rs. in lacs)
Total Annual Entitlement subject to cap of life time REMBS Plan limit
(Rs. in lacs)
Room Rent
(Max. ceiling)
(Rs.)
I.C.U Rent
(Max. ceiling)
(Rs.)
1.00 lac
1.00 lac
2.00 lac
5,000/-
7500/-
1.00 lac
2.00 lac
3.00 lac
2.00 lac
2.00 lac
4.00 lac
2.00 lac
3.00 lac
5.00 lac
3.00 lac
4.00 lac
7.00 lac
6,000/-
9,000/-
3.00 lac
7.00 lac
10.00 lac
7,000/-
10,000/-
4.00 lac
11.00 lac
15.00 lac
9,000/-
12,000/-
5.00 lac
15.00 lac
20.00 lac
12,000/-
15,000/-
10. Ambulance Charges:
i. Ambulance charges are payable up to Rs 2500/- per trip to hospital and / or transfer to another hospital or transfer from hospital to home if medically advised. Taxi and Auto expenses in actual maximum up to Rs. 750/- per trip. Ambulance charges actually incurred on transfer from one center to another center due to non availability of medical services/ medical complication shall be payable in full.
ii. Air Ambulance Charges are covered for a limit of Rs. 5,00,000/- (Plan ‘H’ of SBIREMBS).
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DETAILS OF POLICY-‘B’
1. Coverage:
The Scheme shall cover Non members of SBIREMBS and future retirees of State Bank of India, their spouses and disabled child / children (if any). There is no age limit for joining the scheme.
2. Eligibility:
i. SBI retirees on completion of pensionable service in the Bank.
ii. Members of National Pension System on completion of 20 years of confirmed service in the Bank.
iii. Spouse of SBI employee who died whilst in service or after retirement.
iv. Pre-merger retirees of e-SBS, e-SBIN & e-SBICI on completion of pensionable service in the concerned Bank.
v. Surviving spouses of pre-merger retirees /deceased employees of e-SBS, e-SBIN and e-SBICI.
vi. Existing member of SBIREMBS, e-SBSREMBS and e-SBINREMBS.
3. Exclusions:
i. Employees who are / were discharged / dismissed / removed / compulsorily retired / terminated from service.
ii. Officers in whose case Rule 19(3) are / were invoked on attaining the age of retirement and they are / were subsequently discharged / dismissed / removed / compulsorily retired from the service.
4. Duration of cover : One year.
5. Sum Insured / Room rent / ICU rent:
Hospitalization and Domiciliary Treatment coverage as defined in the scheme and maximum ceiling of Room Rent / ICU Rent under the policy will be as under:
Scheme
Sum Insured
(Rs. in lac)
Room Rent
(Max. ceiling in Rs.)
ICU Rent
(Max. ceiling in Rs.)
‘A’
‘B’
‘C’
A
3.00 lac
5,000/-
7,500/-
B
4.00 lac
5,000/-
7,500/-
C
5.00 lac
7,500/-
9,000/-
D
7.50 lac
15,000/-
18,000/-
E
10.00 lac
15,000/-
18,000/-
F
15.00 lac
15,000/-
18,000/-
G
20.00 lac
15,000/-
18,000/-
H
25.00 lac
15,000/-
18,000/-
6. Sum Insurance at next year’s renewal:
i. Sum Insurance will NOT be reduced by amount utilized during the current cover period.
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ii. On the next year’s renewal the member may continue with the same scheme or change the scheme by paying the annual insurance premium from his own sources.
7. Payment of Premium:
Eligible retirees / family pensioners can opt for any one of the Plans by paying the premium from their own sources.
8. Fresh Additions / Deletions:
i. Eligible new retirees / spouses of deceased employees will join the Policy ‘B’ within three months from the date retirement / death.
ii. All additions of employees and family members would be on payment of premium on pro-rata basis, In case, some members join the scheme sometime after the main master policy has been incepted, they would join by paying the pro-rata premium.
iii. In case of addition of new member during the policy period, pro-rata premium will be charged by the Insurance Co. and full Sum Insured will be available to the member and his / family till the expiry of the policy.
iv. Insurance cover for members who pay the premium during 1st day of the month to 14th day of the month will commence from 16th day of the month. Similarly, insurance cover for members who pay the premium during 16th day of the month to the second last day of the month, will commence from 1st day of the next month.
iv. In case of death of a member, coverage will cease automatically from that date. There will be no refund of premium if claim is made under the policy. But the cover will be extended to the dependents of the deceased member till the end of the policy period, if the sum insured is not exhausted.
10. Ambulance Charges
i. Ambulance charges are payable up to Rs 2500/- per trip to hospital and / or transfer to another hospital or transfer from hospital to home if medically advised. Taxi and Auto expenses in actual maximum up to Rs. 750/- per trip. Ambulance charges actually incurred on transfer from one center to another center due to non availability of medical services/ medical complication shall be payable in full.
ii. Air Ambulance Charges are covered for a limit of Rs. 5,00,000/- (applicable to all the plans).
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Discount / Loading Charges for both the policies :
Selected Insurance Company has agreed for continuity cover for three years based on the following matrix:
Claims Ratio
Discount / Loading charges to be applied on the premium
Not exceeding 25%
40% discount
Not exceeding 30%
35% discount
Not exceeding 40%
25% discount
Not exceeding 50%
15% discount
Not exceeding 60%
5% discount
101-110%
No discount / No loading
110-115%
5% loading
116-120%
7% loading
121-125%
10% loading
126-130%
13% loading
131-135%
15% loading
136-140%
18% loading
Beyond 140%
Loading to be negotiated by the Bank & Insurance Company
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DEFINITIONS:
2.1 ACCIDENT: An accident is a sudden, unforeseen and involuntary event caused resulting in injury –
2.2 (A) "ACUTE CONDITION" - Acute condition is a disease, illness or injury that is likely to respond quickly to treatment which aims to return the person to his or her state of health immediately before suffering the disease/illness/injury which leads to full recovery.
(B) "CHRONIC CONDITION" - A chronic condition is defined as a disease, illness, or injury that has one or more of the following characteristics -
i. It needs ongoing or long-term monitoring through consultations, examinations, checkups and/or tests -
ii. It needs ongoing or long-term control or relief of symptoms
iii. It requires rehabilitation or to be specially trained to cope with it.
iv. It continues indefinitely.
v. It comes back or is likely to come back.
2.3 ALTERNATIVE TREATMENTS:
Alternative Treatments are forms of treatment other than treatment "AIIopathy" or "modern medicine” and includes Ayurveda, Unani, siddha homeopathy and Naturopathy in the Indian Context for Hospitalization only and Domiciliary for treatment only under ailments mentioned under clause number 3.18.
(Ref: 3.21 Alternative Therapy)
2.4 ANY ONE ILLNESS:
Any one illness will be deemed to mean continuous period of illness and it includes relapse within 45 days from the date of last consultation with the Hospital / Nursing Home where treatment has been taken. Occurrence of the same illness after a lapse of 45 days as stated above will be considered as fresh illness for the purpose of this policy.
2.5 CASHLESS FACILITY:
Cashless facility means a facility extended by the insurer to the insured where the payments, of the cost of treatment undergone by the employee and the dependent family members of the insured in accordance with the policy terms and conditions, or directly made to
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the network provider by the insurer to the extent pre-authorization approved.
2.6 CONGENITAL ANOMALY:
Congenital Anomaly refers to a condition(s) which is present since birth, and which is abnormal with reference to form, structure or position.
a. Internal Congenital Anomaly which is not in the visible and accessible parts of the body
b. External Congenital Anomaly which is in the visible and accessible parts of the body.
2.7 DAYCARE CENTRE:
A day care centre means any institution established for day care treatment of illness and/ or injuries or a medical setup within a hospital and which has been registered with the local authorities, wherever applicable, and is under the supervision of a registered and qualified medical practitioner AND must comply with all minimum criteria as under;-
- has qualified nursing staff under its employment
- has all qualified medical practitioner(s) in charge
- has a fully equipped operation theatre of its own where surgical procedures are carried out.
- maintains daily records of patients and will make these accessible to the insurance companies authorized personnel.
2.8 DAY CARE TREATMENT:
Day care Treatment refers to medical treatment and or surgical procedure which is:
i. Undertaken under general or local anesthesia in a hospital/day care Centre in less than a day because of technological advancement, and
ii. Which would have otherwise required a hospitalization of more than a day. Treatment normally taken on an out patient basis is not included in the scope of this definition.
2.9 DOMICILIARY HOSPITALIZATION:
Domiciliary Hospitalization means medical treatment for an illness/disease/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:
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c) The condition of the patient is such that he/she is not in a condition to be removed to a hospital or
d) The patient takes treatment at home on account of non-availability of room in a hospital.
2.10 DOMICILIARY TREATMENT
Treatment taken for specified diseases which may or may not require hospitalization as mentioned in the scheme under clause Number 3.18.
2.11 HOSPITAL / NURSING HOME:
A Hospital means any institution established for in-patient care and day care treatment of illness and/or injuries and which has been registered as a Hospital with the local authorities under the Clinical establishments (Registration and Regulation) Act, 2010 or under the enactments specified under the Schedule of Section 56(1) of the said Act OR complies with all minimum criteria as under:
- Has qualified nursing staff under its employment round the clock.
- Has at least 10 in-patient beds in towns having a population of less than 10 lacs and at least 15 in-patient beds in all other places;
- Has qualified medical practitioner(s) in charge round the clock;
- Has a fully equipped Operation Theatre of its own where surgical procedures are carried out;
- Maintains daily records of patients and makes these accessible to the insurance company’s authorized personnel.
The term ' Hospital / Nursing Home ' shall not include an establishment which is a place of rest, a place for the aged, a place for drug-addicts or place for alcoholics, a hotel or a similar place. This clause will however be relaxed in areas where it is difficult to find such hospitals.
2.12 HOSPITALIZATION:
Hospitalization means admission in a Hospital/Nursing Home for a minimum period of 24 consecutive hours of inpatient care except for specified procedures/treatments, where such admission could be for a period of less than a day, as mentioned in clauses 2.9 and 2.10.
2.13 ID CARD:
ID Card means the identity card issued to the insured person by the THIRD PARTY ADMINISTRATOR to avail cashless facility in network hospitals.
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2.14 ILLNESS:
Illness means a sickness or a disease or pathological condition leading to the impairment of normal physiological function which manifests itself during the policy period and requires medical treatment.
2.15 INJURY:
Injury means accidental physical bodily harm excluding illness or disease which is verified and certified by a medical practitioner.
However all types of Hospitalization is covered under the Scheme.
2.16 IN PATIENT CARE:
In Patient Care means treatment for which the insured person has to stay in a hospital for more than a day for a covered event.
2.17 INTENSIVE CARE UNIT:
Intensive Care Unit means an identified section, ward or wing of a Hospital which is under the constant supervision of a dedicated medical practitioner(s) and which is specially equipped for the continuous monitoring and treatment of patients who are in a critical condition, or require life support facilities and where the level of care and supervision is considerably more sophisticated and intensive than in the ordinary and other wards.
2.18 MEDICAL ADVICE:
Any consultation or advice from a medical practitioner/doctor including the issue of any prescription or repeat prescription.
2.19 MEDICAL EXPENSES:
Medical Expenses means those expenses that an insured person has necessarily and actually incurred for medical treatment on account of illness or accident on the advice of a medical practitioner, as long as these are no more than would have been payable if the insured person had not been insured.
2.20 MEDICALLY NECESSARY:
Medically necessary treatment is defined as any treatment, test, medication or stay in hospital or part of a stay in a hospital which
- is required for the medical management of the illness or injury suffered by the insured;
- must not exceed the level of care necessary to provide safe, adequate and appropriate medical care in scope, duration or intensity;
13
- must have been prescribed by a medical practitioner;
- must confirm to the professional standards widely accepted in international medical practice or by the medical community in India.
2.21 MEDICAL PRACTITIONER:
Medical Practitioner is a person who holds a valid registration from the Medical Council of any State or Medical Council of lndia or Council for Indian Medicine or the homeopathy set up by the Government of lndia or a State Government and is thereby entitled to practice medicine within its jurisdiction; and is acting within the scope and jurisdiction of his license. The term medical practitioner would include physician, specialist and surgeon.
(The Registered practitioner should not be the insured or close family members such as parents, parents-in-law, spouse and children.)
2.22 NETWORK PROVIDER:
Network Provider means hospitals or health care providers enlisted by an insurer or by a Third Party Administrator and insurer together to provide medical services to an insured on payment by a cashless facility. The list of network hospitals is maintained by and available with the THIRD PARTY ADMINISTRATOR and the same is subject to amendment from time to time.
2.23 NON NETWORK :
Any hospital, day care Centre or other provider that is not part of the network.
2.24 NOTIFICATION OF CLAIM
Notification of claim is the process of notifying a claim to the Bank / insurer / Third Party Administrator / ARIBL the address / telephone number of which will be notified.
2.25 OPD TREATMENT:
OPD Treatment is one in which the insured visits a clinic / hospital or associated facility like a consultation room for diagnosis and treatment based on the advice of medical a practitioner. The insured is not admitted as a day care or in-patient.
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2.26 PRE-EXISTING DISEASE:
Pre Existing Disease is any condition, ailment or injury or related condition (s) for which you had signs or symptoms, and / or were diagnosed, and/or received medical advice/ treatment, prior to the first policy issued by the insurer.
2.27 PRE - HOSPITALIZATION MEDICAL EXPENSES:
Medical expenses incurred immediately 30 days before the insured person is hospitalized will be considered as part of a claim as mentioned under Item 1.2 above provided that;
i. such medical expenses are incurred for. the same condition for which the insured person's hospitalization was required and
ii. the inpatient hospitalization claim for such hospitalization is admissible by the insurance company.
2.28 POST HOSPITALISATION MEDICAL EXPENSES:
Relevant medical expenses Incurred immediately 90 days after the Insured person is discharged from the hospital provided that;
a. Such Medical expenses are incurred for the same condition for which the Insured Person's Hospitalization was required; and
b. The In-patient Hospitalization claim for such Hospitalization is admissible by the Insurance Company.
2.29 QUALIFIED NURSE:
Qualified Nurse is a person who holds a valid registration from the Nursing Council of India or the Nursing Council of any state in India and / or who is employed on recommendation of the attending medical practitioner.
2.30 REASONABLE AND CUSTOMARY CHARGES:
Reasonable Charges means the charges for services or supplies, which are the standard charges for the specific provider and consistent with the prevailing charges in the geographical area for identical or similar services, taking into account the nature of the illness/injury involved.
2.31 ROOM RENT:
Room Rent shall mean the amount charged by the hospital for the occupancy of a bed on per day basis.
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2.32 SUBROGATION:
Subrogation shall mean the right of the insurer to assume the rights of the insured person to recover expenses paid out under the policy that may be recovered from any other source. It shall exclude the medical / accident policies obtained by the insured person separately.
2.33 SURGERY:
Surgery or surgical procedure means manual and / or operative procedure(s) required for treatment of an illness or injury, correction of deformities and defects, diagnosis and cure of diseases, relief of suffering or prolongation of life, performed in a hospital or day care Centre by a medical practitioner.
2.34 THIRD PARTY ADMINISTRATOR:
Third Party Administrator means a Third Party Administrator who holds a valid License from Insurance Regulatory and Development Authority to act as a THIRD PARTY ADMINISTRATOR and is engaged by the Insurance Company for the provision of health services as specified in the agreement between the Insurance Company and Third Party Administrator.
2.35 Unproven / Experimental treatment is treatment, including drug Experimental therapy, which is not based on established medical practice in India.
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3. COVERAGES:
3.1 Hospital Charges : The Policy will cover Hospital charges for:
i. Operation Theatre, OT Consumables and Recovery Room.
iii. Prescribed medicines, drugs and dressing for in-patient.
iv. Expenses incurred during the Pre-hospitalization and Post Hospitalization period for 30 days prior to hospitalization and 90 days after discharge respectively.
v. Visiting and treating doctor’s fees are covered provided hospital / nursing home has charged for the same.
3.2 Pre- Existing Diseases / Ailments: Pre-existing diseases are covered under the scheme. In addition, the policy will cover the following:
i. Waiver of 30 days exclusion.
ii. Waiver of first and second years exclusion.
iii. All diseases and ailments without any waiting period.
3.3 Congenital Anomalies: Expenses for Treatment of Congenital Internal / External diseases, defects anomalies are covered under the policy.
3.4 Nursing & Attendant : The policy will cover charges for Nursing / Attendant :
i. During Hospitalization will be payable only in case of recommendation from the treating Doctor.
ii. In cases of ICU /CCU or any other case where the patient is critical and requiring Special Care.
iii. This benefit pays for the services of a qualified and registered nurse benefit for the medically necessary provision of continuing care, at the member’s home, immediately following eligible Domiciliary Treatment.
3.5 Surgical & Anesthetists’ Fees:
The policy will cover Surgeon / Team of Surgeons / Assistant Surgeon and Anesthetists’ fees in case of Hospitalization.
3.6 Specialist Physician’s fees : This benefit will be paid in full for regular visits by a specialist physician during stays in the hospital including intensive care by a specialist physician for as long as is required by medical necessity provided the hospital / nursing home has endorsed the same.
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3.7 Surgical Procedures: Surgical procedures in care of Hospitalization are covered.
3.8 The Policy will cover Medical Practitioner & Consultants in case of Hospitalization in the hospital.
3.9 Laboratory / Diagnostic Tests, X-Ray, CT Scan, MRI, any other scan in case of Hospitalization are covered.
3.10 Nebulization, RMO charges, Blood, Oxygen, Dialysis in case of Hospitalization are covered.
3.11 Psychiatric diseases: Expenses for treatment of psychiatric and psychosomatic diseases be payable with or without hospitalization.
3.12 Advanced Medical Treatment: All new kinds of approved advanced medical procedures for e-g. laser surgery, stem cell therapy for treatment of a disease is payable on hospitalization /day care surgery.
3.13 Treatment for Genetic Disorder and stem cell therapy is covered under the scheme.
3.14 Treatment for Age related Macular Degeneration (ARMD), treatment such as Rotational Field Quantum Magnetic Resonance (RFQMR), Enhanced External Counter pulsation (EECP), etc, are covered under the scheme. Treatment for all neurological/ macular degenerative disorders shall be covered under the scheme.
3.15 Enhanced External Counter Pulsation (EECP) : It will be covered for specific indications viz.:
i. Angina or Angina equivalents with poor response to medical treatment and when patient is unwilling to undergo invasive revascularization procedures.
ii. Ejection fraction is less than 35%.
iii. Co-morbid conditions co-exist which increase the risk of surgery e.g. DM, Congestive Cardiac Failure, Cor. Pulmonale, Renal dysfunction, Ischemic or Idiopathic Cardio Myopathy.
3.16 Rental Charges for External and or durable Medical equipment of any kind used for diagnosis and or treatment including CPAP, CAPD, Bi-PAP,
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Infusion pump etc. will be covered under the scheme. However purchase of the above equipment to be subsequently used at home in exceptional cases on medical advice shall be covered.
3.17 Physiotherapy Charges: Physiotherapy charges shall be covered for the period specified by the Medical Practitioner even if taken at home. All claims admitted in respect of any / all insured person/s during the period of insurance shall not exceed the Sum insured stated in the schedule and Corporate Buffer if allocated.
3.18 Domiciliary Hospitalization / Domiciliary Treatment on outpatient basis : Medical expenses incurred in case of the following diseases 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% shall be considered for reimbursement under domiciliary treatment :
Sl
Name of Disease
Sl
Name of Disease
1
Cancer
33
Diphtheria
2
Leukemia
34
Malaria
3
Thalassemia
35
Non-Alcoholic Cirrhosis of Liver
4
Tuberculosis
36
Purpura
5
Paralysis
37
Typhoid,
6
Cardiac Ailments
38
Accidents of Serious Nature
7
Pleurisy
39
Cerebral Palsy
8
Leprosy
40
Polio
9
Kidney Ailment
41
All Strokes Leading to Paralysis
10
All Seizure disorders
42
Hemorrhages caused by accidents
11
Parkinson's diseases
43
All animal/reptile/insect bite or sting
12
Psychiatric disorder including Schizophrenia and Psychotherapy
44
Chronic pancreatitis
13
Diabetes and its complications
45
Immuno Suppressants
14
Hypertension
46
Multiple sclerosis / motor neuron disease
15
Asthma
47
Status Asthmatics
16
Hepatitis – B
48
Sequalea of Meningitis
17
Hepatitis – C
49
Osteoporosis
18
Hemophilia
50
Muscular Dystrophies
19
Myasthenia gravis
51
Sleep apnea syndrome(not related to obesity)
19
20
Wilson's disease
52
Any organ related (chronic) condition
21
Ulcerative Colitis
53
Sickle cell disease
22
Epidermolysis bullosa
54
Systemic lupus Erythematous (SLE)
23
Venous Thrombosis(not caused by smoking)
55
Any connective tissue disorder
24
Aplastic Anaemia
56
Varicose veins
25
Psoriasis
57
Thrombo Embolism Venous Thrombosis / Venous Thrombo embolism (VTE)
26
Third Degree burns
58
Growth disorders
27
Arthritis
59
Graves' disease
28
Hypothyroidism
60
Chronic Pulmonary Disease
29
Hyperthyroidism
61
Chronic Bronchitis
30
Expenses incurred on Radiotherapy and Chemotherapy in the treatment of Cancer and Leukemia
62
Physiotherapy
31
Glaucoma
63
Swine flu
32
Tumor
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.
3.19 Day Care Benefits : Expenses on Hospitalization for minimum period of a day are admissible. However, this time limit is not applied to specific treatments, such as:
DAY CARE PROCEDURES AS PER IBA SCHEME
Sl
Name of Disease
Sl
Name of Disease
1
Adenoidectomy
20
Haemo dialysis
2
Appendectomy
21
Fissurectomy / Fistulectomy
3
Ascetic / Plueral tapping
22
Mastoidectomy
4
Auroplasty not Cosmetic in nature
23
Hydrocele
5
Coronary angiography /Renal
24
Hysterectomy
6
Coronary angioplasty
25
Inguinal/Ventral/Umbilica /Femoral Hernia
7
Dental Surgery
26
Parenteral chemotherapy
8
D&C (Dilation & Curettage)
27
Polypectomy
20
9
Excision of cyst / granuloma / lump / tumor
28
Septoplasty
10
Eye surgery
29
Piles / fistula
11
Fracture including hairline fracture /dislocation
30
Prostrate surgeries
12
Radiotherapy
31
Sinusitis surgeries
13
Chemotherapy including parental chemotherapy
32
tonsillectomy
14
Lithotripsy
33
Liver aspiration
15
Incision and drainage of abscess
34
Sclerotherapy
16
Varicocelectomy
35
Varicose Vein Ligation
17
Wound suturing
36
All scopies along with biopsies
18
FESS
37
Lumbar puncture
19
Operations/Micro surgical operations on the nose, middle ear / internal ear, tongue, mouth, face, tonsils & adenoids, salivary glands and salivary ducts, breast, skin & subcutaneous tissues, digestive tract, female / male sexual organs
In addition to the above list , this policy will cover the following Day Care procedures:
ENT: Operation of the ear
1
Stapedotomy or Stapedectomy
2
Myringoplasty (Type -I Tympanoplasty)
3
Tympanoplasty (closure of an eardrum perforation)
4
Reconstruction and other Procedures of the auditory ossicles
5
Myringotomy
6
Removal of a tympanic drain
7
Mastoidectomy
8
Reconstruction of the middle ear
9
Fenestration of the inner ear
10
Incision (opening) and destruction (elimination) of the inner ear
ENT: Procedures on the nose & the nasal sinuses
1
Excision and destruction of diseased tissue of the nose
2
Procedures on the turbinates (nasal concha)
3
Nasal sinus aspiration
ENT: Procedures on the tonsils & adenoids
1
Transoral incision and drainage of a pharyngeal abscess
2
Tonsillectomy and / or adenoidectomy
21
3
Excision and destruction of a lingual tonsil
4
Quinsy drainage
OPTHALMOLOGY: Procedures on the eyes
1
Incision of tear glands
2
Excision and destruction of diseased tissue of the eyelid
3
Procedures on the canthus and epicanthus
4
Corrective surgery for entropion and ectropion
5
Corrective surgery for blepharoptosis
6
Removal of a foreign body from the conjunctiva
7
Removal of a foreign body from the cornea
8
Incision of the cornea
9
Procedures for pterygium
10
Removal of a foreign body from the lens of the eye
11
Removal of a foreign body from the posterior chamber of the eye
12
Removal of a foreign body from the orbit and eyeball
13
Operation of cataract
14
Chalazion removal
15
Glaucoma Surgery
16
Surgery of Retinal Detachment
Procedures on the skin & subcutaneous tissues
1
Incision of a pilonidal sinus
2
Other incisions of the skin and subcutaneous tissues
3
Surgical wound toilet (wound debridement)
4
Local excision or destruction of diseased tissue of the skin and subcutanous tissues
5
Simple restoration of surface continuity of the skin and subcutanous tissues
6
Free skin transplantation, donor site
7
Free skin transplantation, recipient site
8
Revision of skin plasty
9
Restoration and reconstruction of the skin and subcutaneous tissues
10
Chemosurgery to the skin
11
Excision of Granuloma
12
Incision and drainage of abscess
Procedures on the tongue
1
Incision, excision and destruction of diseased tissue of the tongue
2
Partial glossectomy
3
Glossectomy
4
Reconstruction of the tongue
Procedures on the salivary glands & salivary ducts
1
Incision and lancing of a salivary gland and a salivary duct
22
2
Excision of diseased tissue of a salivary gland and a salivary duct
3
Resection of a salivary gland
4
Reconstruction of a salivary gland and a salivary duct
Procedures on the mouth & face
1
External incision and drainage in the region of the mouth, jaw and face
2
Incision of the hard and soft palate
3
Excision and destruction of diseased hard and soft palate
4
Incision, excision and destruction in the mouth
5
Plastic surgery to the floor of the mouth
6
Palatoplasty
Trauma surgery and orthopaedics
1
Incision on bone, septic and aseptic
2
Closed reduction on fracture, luxation or epiphyseolysis with osteosynthesis
3
Suture and other Procedures on tendons and tendon sheath
4
Reduction of dislocation under GA
5
Arthroscopic knee aspiration
6
Aspiration of hematoma
7
Excision of dupuytren's contracture
8
Carpal tunnel decompression
9
Surgery for ligament tear
10
Surgery for meniscus tear
11
Surgery for hemoarthrosis /pyoarthrosis
12
Removal of fracture pins/nails
13
Removal of metal wire
14
Joint Aspiration - Daignostic / therapeutic
Procedures on the breast
1
Incision of the breast
2
Procedures on the nipple
3
Excision of breast lump /Fibro adenoma
Procedures on the digestive tract
1
Incision and excision of tissue in the perianal region
2
Surgical treatment of anal fistulas
3
Surgical treatment of haemorrhoids
4
Division of the anal sphincter (sphincterotomy)
5
Ultrasound guided aspirations
6
Sclerotherapy
7
Therapeutic Ascitic Tapping
8
Endoscopic ligation /banding
9
Dilatation of digestive tract strictures
10
Endoscopic ultrasonography and biopsy
23
11
Replacement of Gastrostomy tube
12
Endoscopic decompression of colon
13
Therapeutic ERCP
14
Nissen fundoplication for Hiatus Hernia /Gastro esophageal reflux Disease
15
Endoscopic Gastrostomy
16
Laparoscopic procedures e.g. colecystectomy, appendicectomy etc.
17
Endoscopic Drainage of Pseudopancreatic cyst
18
Hernia Repair (Herniotomy / herniography / hernioplasty)
Procedures on the female sexual organs
1
Incision of the ovary
2
Insufflation of the Fallopian tubes
3
Dilatation of the cervical canal
4
Conisation of the uterine cervix
5
Incision of the uterus (hysterotomy)
6
Therapeutic curettage
7
Culdotomy
8
Local excision and destruction of diseased tissue of vagina and Pouch of Douglas
9
Procedures on Bartholin’s glands (cyst)
10
Endoscopic polypectomy
11
Myomectomy , hysterscopic or laparascopic biopsy or removal
Procedures on the prostate & seminal vesicles
1
Incision of the prostate
2
Transurethral excision and destruction of prostate tissue
3
Open surgical excision and destruction of prostate tissue
4
Radical prostatovesiculectomy
5
Incision and excision of periprostatic tissue
Procedures on the scrotum & tunica vaginalis testis
1
Incision of the scrotum and tunica vaginalis testis
2
Operation on a testicular hydrocele
3
Excision and destruction of diseased scrotal tissue
4
Plastic reconstruction of the scrotum and tunica vaginalis testis
Procedures on the testes
1
Incision of the testes
2
Excision and destruction of diseased tissue of the testes
3
Orchidectomy- Unilateral / Bilateral
4
Orchidopexy
5
Abdominal exploration in cryptorchidism
6
Surgical repositioning of an abdominal testis
7
Reconstruction of the testis
24
8
Implantation, exchange and removal of a testicular prosthesis
Procedures on the spermatic cord, epididymis and Ductus Deferans
1
Surgical treatment of a varicocele and hydrocele of spermatic cord
2
Excision in the area of the epididymis
3
Epididymectomy
4
Reconstruction of the spermatic cord
5
Reconstruction of the ductus deferens and epididymis
Procedures on the penis
1
Procedures on the foreskin
2
Local excision and destruction of diseased tissue of the penis
3
Amputation of the penis
4
Plastic reconstruction of the penis
Procedures on the urinary system
1
Cystoscopical removal of stones
2
Lithotripsy
3
Haemodialysis
4
PCNS (Percutaneous nephrostomy)
5
PCNL (Percutanous Nephro-Lithotomy)
6
Tran urethral resection of bladder tumor
7
Suprapubic cytostomy
Procedures of Respiratory System
1
Brochoscopic treatment of bleeding lesion
2
Brochoscopic treatment of fistula /stenting
3
Bronchoalveolar lavage & biopsy
4
Direct Laryngoscopy with biopsy
5
Therapeutic Pleural Tapping
Procedures of Heart and Blood vessels
1
Coronary angiography (CAG)
2
Coronary Angioplasty (PTCA)
3
Insertion of filter in inferior vena cava
4
TIPS procedure for portal hypertension
5
Blood transfusion for recipient
6
Therapeutic Phlebotomy
7
Pericardiocentesis
8
Insertion of gel foam in artery or vein
9
Carotid angioplasty
10
Renal angioplasty
11
Varicose vein stripping or ligation
OTHER Procedures
1
Radiotherapy for Cancer
25
2
Cancer Chemotherapy
3
True cut Biopsy
4
Endoscopic Foreign Body Removal
5
Vaccination / Inoculation - Post Dog bite or Snake bite
6
Endoscopic placement/removal of stents
7
Tumor embolisation
8
Aspiration of an internal abscess under ultrasound guidance
This condition will also not apply in case of stay in hospital of less than a day provided -
a. The treatment is undertaken under General or Local Anesthesia in a hospital /day care Centre in less than a day because of technological advancement; and
b. Which would have otherwise required hospitalization of more than a day.
3.20 OPD Treatment : Treatment taken for Accidents can be payable even on out-patient basis in Hospital up to Sum Insured.
3.21 Alternative Therapy : Reimbursement of Expenses for Hospitalization or Domiciliary treatment (under clause 3.18) under the recognized system of medicines , viz. Ayurvedic ,Unani, Sidha, Homeopathy,Naturopathy , if such treatment is taken in a clinic / hospital registered, by the central and state government.
3.22 Change of Treatment : Change of treatment from one system of medicine to another is covered in the policy if recommended by treating doctor.
3.23 Ambulatory Devices : Ambulatory devices i.e., walker, crutches, Belts, Collars, Caps, Splints, Slings, Braces, Stockings, Elastocrepe bandages, external orthopedic pads, Subcutaneous insulin pump, Diabetic foot wear, Glucometer (including Glucose Test Strips) / Nebulizer/ prosthetic devise/ Thermometer, alpha I water bed and similar related items etc., will be covered under the scheme.
3.24 Mortal Remains : This benefit provides for reimbursement of Rs. 10,000/- as expenses incurred for transportation of the mortal remains of the Insured / Insured Person from Hospital to his / her place of residence in the event of death of the Insured / Insured Person at the Hospital while under treatment for disease / illness / injury etc.
26
3.25 Dental Root Canal Surgery : The policy will cover Dental Root Canal Surgery for a limit of Rs. 7,500/-.
3.26 Taxes and other Charges : All Taxes, Surcharges, Service Charges, Registration charges, Admission Charges, Nursing, and Administration charges to be payable. Charges for diapers and sanitary pads are payable if necessary as part of the treatment. Charges for Hiring a nurse / attendant during hospitalization will be payable only in case of recommendation from the treating doctor in case ICU / CCU or any other case where the patient is critical and requiring special care.
27
4. EXCLUSIONS:
The Insurance Company shall not be liable to make any payment under this policy in respect of any expenses whatsoever incurred by any Insured Person in connection with or in respect of:
4.1 Injury / disease directly or indirectly caused by or arising from or attributable to War, Invasion, Act of Foreign enemy, War like operations (whether war be declared or not).
4.2 a) Circumcision unless necessary for treatment of a disease not excluded hereunder or as may be necessitated due to an accident.
b) Vaccination or inoculation.
c) Change of life or cosmetic or aesthetic treatment of any description is not covered.
d) Plastic surgery other than as may be necessitated due to an accident or as part of any illness.
4.3 Cost of spectacles and contact lenses, hearing aids other than Intra-Ocular Lenses and Cochlear Implant.
4.4 Dental treatment or surgery of any kind which are done in a dental clinic and those that are cosmetic in nature.
4.5 Convalescence, rest cure, Obesity treatment and its complications including morbid obesity, treatment relating disorders, Venereal disease, intentional self-injury and use of intoxication drugs / alcohol.
4.6 All expenses arising out of any condition directly or indirectly caused to or associated with Human T-Cell Lymphotropic Virus Type III (HTLB-Ill) or Lymphadinopathy Associated Virus (LAV) or the Mutants Derivative or Variation Deficiency Syndrome or any syndrome or condition of a similar kind commonly referred to as AIDS (Acquired Immuno Deficiency Syndrome).
4.7 Hospitalization for Investigations only: Charges incurred at Hospital or Nursing Home primarily for diagnosis X-ray or Laboratory examinations or other diagnostic studies not consistent with or incidental to the diagnosis and treatment of positive existence of presence of any ailment, sickness or injury, for which confinement is required at a Hospital / Nursing Home, unless recommended by the attending doctor.
28
4.8 Expenses on vitamins and tonics unless forming part of treatment for injury or diseases as certified by the attending physician
4.9 Injury or Disease directly or indirectly caused by or contributed to by nuclear weapon / materials.
4.10 All non-medical expenses including convenience items for personal comfort such as charges for telephone, television, /barber or beauty services, diet charges, baby food, cosmetics, tissue paper, diapers, sanitary pads, toiletry items and similar incidental expenses, unless and otherwise they are necessitated during the course of treatment.
29
5. MANAGEMENT OF CLAIMS:
5.1 Claims will be managed through the same Office of the Bank from where claims under existing SBIREMBS are managed at present. The Insurance Companies / TPA / ARIBL will set up a help desk at that office and will be supporting the bank in clearing all the claims on real time basis.
5.2 The Third Party Administrator (TPA), appointed by the selected Insurance Company will station their representative at the Bank’s Zonal Offices from where claims under SBIREMBS are being settled.
5.3 The TPA would have a Dedicated Office, Server and a 24 x 7 Call Centre for the existing and Future retirees of SBI. Anand Rathi Insurance Broker will also have 24 Hrs call center and dedicated server.
5.4 The members would submit the claims to the same Zonal Offices through their pension paying branch and the TPA representative will be the backup support and ensure claim settlement is completed within shortest possible time.
5.5 All the Cashless Claims would be paid directly to the hospital concerned by the TPA.
5.6 The reimbursement claims of pre and post hospitalization or in a few cases of actual hospitalization would be paid to the members through the Bank’s Zonal Offices or directly credited to the members account.
5.7 No claims would be rejected by the insurance company / TPA unless the same is rejected by the committee comprising of the Bank management, Insurance Company, TPA and M/s Anand Rathi Insurance Broker Pvt. Ltd.
5.8 The claim shall be rejected in the event of misrepresentation, mis-description or non-disclosure of any material fact. In case of rejection of claims it would go through a Committee set up of the Bank, TPA and the concerned Insurance Company unless rejected by the committee in real time the claim should not be rejected.
5.9 Every notice or communication regarding hospitalization or claim to be given or made under this Policy shall be communicated (Telephonically /e-mail / fax / online) to the office of the Bank dealing with Medical Claims, and / or the TPA’s office at the earliest in case of emergency hospitalization within 7 days from the time of Hospitalization / Domiciliary Hospitalization..
30
5.10 If the hospital opted is not on the panel of TPA, the member may take admission to the hospital and submit the claim for reimbursement. In such a case, the hospital should satisfy the criteria of hospital as defined in the policy.
5.11 All supporting documents relating to the claim must be filed with the office of the Bank dealing with the claims or THIRD PARTY ADMINISTRATOR within 30 days from the date of discharge from the hospital. In case of post-hospitalization, treatment (limited to 90 days), (as mentioned in para 2.30) all claim documents should be submitted within 30 days after completion of such treatment.
Note: Waiver of these Conditions 5.9 and 5.10 may be considered in extreme cases of hardship where it is proved to the satisfaction of the Bank that under the circumstances in which the insured was placed it was not possible for him or any other person to give such notice or deliberate or file claim within the prescribed time-limit. The same would be waived by the TPA without reference to the Insurance Company.
5.12 The Insured Person shall obtain and furnish to the office of the Bank dealing with the claims / THIRD PARTY ADMINISTRATOR with all original bills, receipts and other documents upon which a claim is based and shall also give such additional information and assistance as the Bank through the THIRD PARTY ADMINISTRATOR / Company may require in dealing with the claim.
5.13 Any medical practitioner authorized by the Bank /Third Party Administrator / shall be allowed to examine the Insured Person in case of any alleged injury or disease leading to Hospitalization, if so required.
5.14 The Insurance Company shall not be liable to make any payment under this policy in respect of any claim if such claim be in any manner fraudulent or supported by any fraudulent means or device whether by the Insured Person or by any other person acting on his behalf.
5.15 All the members and their family members would be issued ID cards by the Third Party Administrator, of the Insurance Company. In case the member or his family member gets admitted in any of the preferred Provider Network of hospitals on production of ID card, the hospital authority in turn shall notify by fax / mail the details of hospitalization along with ID card number and Name of the member to the Third Party Administrator, who would again revert by fax / mail a confirmation to
31
the hospital to proceed with the claim. This would even enable them to claim from anywhere in India and they would be able to admit themselves in hospitals anywhere in India by merely calling the dedicated call centres of the Third Party Administrator, which would be working on a 24 x 7 basis. The Third Party Administrator, would even be able to advise the members on the nearest hospital available in their area. In case of an emergency admission to a hospital which is not in TPA Network, the members also have a benefit to get himself admitted on a cashless basis by intimating the Third Party Administrator, call centre number, mentioning his ID card No and name. The Hospital authority would fax / mail the details of hospitalization to the Third Party Administrator, who would again revert by fax I mail a confirmation to the hospital to proceed with the claim.
5.16 In case of reimbursement claim where the member has not informed the Bank’s Zonal Office; they may phone the 24 x 7 call centre of the TPA giving the details of their card ID number and name. In such cases the reimbursement claim should be submitted on completion of hospitalization and not later than 30 days of discharge from the hospital. In case of post-hospitalization treatment, all claim documents should be submitted within 30 days after completion of such treatment. Wherever the hospitals are not in the approved list of TPA, the TPA should take necessary action for addition of those hospitals on their network hospital list in consultation with bank. In an emergency the claim payment would be paid to the hospital account and empanelment of the hospital would be considered.
5.17 ID cards will be prepared within 10 working days from the date of receipt of data. These cards can be couriered to the respective branch office in which the employee is getting pension. The cards can be distributed by at the branch office by the Branch Manager / any other person who is made responsible for the same. Corrections in cards, if any, can be e-mailed to an exclusive ID which will be exclusive for cards correction errors. This cards will be corrected and resent within 2 working days from the receipt of correction mail.
5.18 All the reimbursement claims will be settled once in a month.


1
ANNEXURE-II
PROCESS OF MIGRATION OF EXISTING MEMBERS OF SBIREMBS TO GROUP MEDICLAIM POLICY-‘A’
i. Employees who retire on or after 1st January, 2016 will not be admitted to SBI Retired Employees’ Medical Benefit Scheme (SBIREMBS). They will have the option to join Family Floater Group Health Insurance Policy ‘B’ of United India Insurance Co. Ltd.. However, the employees who retire on or before 31.12.2015 may be allowed to join SBIREMBS within the stipulated time schedule as prescribed in SBI Retired Employees Medical Benefit (SBIREMBT) Rules and they will be subsequently covered by Policy ‘A”.
ii. Detailed particulars of all the existing members of SBIREMBS, their spouses and disabled children (if any), plan amount and residual amount in the REMBS accounts of the individual members as on 31st March 2016 will be made available to the selected Insurance Company, United India Insurance Co. Ltd.. All the members of SBIREMBS as on 31.03.2016 will be migrated to Policy ‘A’.
iii. First year’s Annual Premium for all the existing members (as on the date of adoption) will require to be paid in advance by SBIREMB Trust to United India Insurance Co. Ltd. by debit to SBIREMB Trust Fund Operational account maintained at Madam Cama Road Branch at the following rate:
Sl
Category
Basic Sum Insured (Rs.)
Premium rate*
(Rs.)
1
REMBS-I / PLAN-A / PLAN A-1
1.00 lac
3,472/- + Ser Tax
2
PLAN B / B1
1.00 lac
4,975/- + Ser Tax
3
PLAN C / C1
2.00 lac
6,370/- + Ser Tax
4
PLAN D / D1
2.00 lac
7,764/- + Ser Tax
5
PLAN - E
3.00 lac
9,926/- + Ser Tax
6
PLAN - F
3.00 lac
12,423/- + Ser Tax
7
PLAN - G
4.00 lac
15,529/- + Ser Tax
8
PLAN - H
5.00 lac
18,634/- + Ser Tax
* inclusive of premium on Corporate Buffer of Rs. 10.00 cr.
However, after such payment, if it is found that some members have already expired or they have already exhausted their REMBS limit, names of such members will be deleted and full premium amount will be refunded by the Insurance Company in such cases.
2
iv. On receipt of the First year’s Advance Premium, United India Insurance Co. Ltd. will allot the existing members of SBIREMBS to at least 3 to 4 select Third Party Administrators (TPAs) having adequate presence in various zones.
v. As soon as the data relating to existing members SBIREMBS are provided to TPAs, e-Medical cum ID cards will be made available within 48 hours, which can be downloaded and used by the members to avail Cashless / Wellness facilities of TPAs.
vi. In addition, the concerned TPAs will arrange to prepare Physical Medical cum ID (Med-ID) cards within 15 working days from the date of receipt of data by them.
vii. Med-ID cards will be couriered to the respective branch office from where the employee is getting pension. The cards may be distributed at the branch office by the Branch Manager / any other person who is made responsible for the same. Corrections in cards, if any, can be e-mailed to an ID which will be exclusive for correction of card errors. The cards will be corrected and resent within 2 working days from the receipt of correction mail.
viii. The TPA appointed by the selected Insurance Company will station their representative at the Bank’s Zonal Office centres from where claims under SBIREMBS are being settled.
ix. The TPA would have a Dedicated Office, Server and a 24 x 7 Call Centre for the existing and future retirees of SBI. The engaged insurance broker, M/s Anand Rathi Insurance Broker will also have 24 x 7 call center and dedicated server.
x. On receipt of the Med-ID Cards, members will start getting Cashless Medical treatment at any network hospital throughout the country or can submit the claims to the same Zonal Offices through their pension paying branch and the TPA representative will be the backup support and ensure claim settlement within shortest possible time. The representative of United India Insurance Co. Ltd. has assured that claims will be entertained on the basis of data in the absence of Med-ID Cards.
3
CLAIM SETTLEMENT PROCESS UNDER POLICY ‘A’
& ROLE OF THIRD PARTY ADMINISTRATOR
i. Claims will be managed through the same office (Zonal Office of the pension paying branch) of the Bank from where claims under existing SBIREMBS are managed at present. The Insurance Companies / Third Party Administrator (TPA) / Anand Rathi Insurance Broker Ltd. (engaged Insurance Broker) will set up a help desk at Zonal Office centres and will be supporting the bank in clearing all the claims on real time basis.
ii. The TPA appointed by the selected Insurance Company will station their representative at the Bank’s Zonal Office centres from where claims under SBIREMBS are being settled.
iii. The TPA would have a Dedicated Office, Server and a 24 x 7 Call Centre for the existing and future retirees of SBI. Anand Rathi Insurance Broker will also have 24 x 7 call center and dedicated server.
iv. The members would submit the claims to the same Zonal Offices through their pension paying branch and the TPA representative will be the backup support and ensure that claim settlement is completed within shortest possible time. Turn Around Time (TAT) for settlement of claims will be as under:
Turn around Time
For Cashless Treatment : Maximum 2 to 4 hours for approval
by TPA
For reimbursement / OPD : Maximum 1 week from the date of
submission of complete documents
v. TPA engaged by the Insurance Company will ensure completion of minimal formalities so that hassle free cashless medical treatment can be obtained in quick time at any network hospital.
vi. Process of getting Cashless Treatment :
(a) To call the Relationship Manager of the TPA and place the request for admission to preferred Network Hospital.
4
(b) To approach nearest Network Hospital with the medical cum ID card already given.
(c) In case the member or his family member gets admitted in any of the preferred Provider Network of hospitals on production of ID card, the hospital authority in turn shall notify by fax / mail the details of hospitalization along with ID card number and name of the member to the TPA, who would again revert by fax / mail a confirmation to the hospital to proceed with the claim. This would even enable them to claim from anywhere in India and they would be able to admit themselves in hospitals anywhere in India by merely calling the dedicated call centres of the TPA which would be working on a 24 x 7 basis.
(d) The TPA would even be able to advise the members on the nearest hospital available in their area. In case of an emergency admission to a hospital which is not in TPA’s Network, the members also have a benefit to get himself admitted on a cashless basis by intimating the TPA, call centre number, mentioning his ID card No and name.
(e) Network hospital will give treatment without asking for deposit / payment of hospital bills upto the authorized amount.
(f) All the Cashless Claims would be paid directly to the hospital concerned by the TPA.
vii. Every notice or communication regarding hospitalization or claim to be given or made under the policy shall be communicated (Telephonically /e-mail / fax / online) to the office of the Bank dealing with Medical Claims and / or the TPA’s office at the earliest in case of emergency hospitalization within 7 days from the time of Hospitalization / Domiciliary Hospitalization.
viii. If the hospital opted is not on the panel of TPA, the member may take admission to the hospital and submit the claim for reimbursement. In such a case, the hospital should satisfy the criteria of hospital as defined in the policy.
Note: Waiver of these Conditions (vii) and (viii) may be considered in extreme cases of hardship where it is proved to the satisfaction of
5
the Bank that under the circumstances in which the insured was placed it was not possible for him or any other person to give such notice or deliberate or file claim within the prescribed time-limit. The same would be waived by the TPA without reference to the Insurance Company.
ix. The reimbursement claims of pre and post hospitalization or in a few cases of actual hospitalization would be paid to the members through the Bank’s Zonal Offices or directly credited to the members account.
x. No claims would be rejected by the insurance company / TPA unless the same is rejected by the committee comprising the Bank management, Insurance Company, TPA and M/s Anand Rathi Insurance Broker Pvt. Ltd.
xi. The claim shall be rejected in the event of misrepresentation, mis-description or non-disclosure of any material fact. In case of rejection of claims it would go through a Committee set up of the Bank, TPA and the concerned Insurance Company unless rejected by the committee in real time the claim should not be rejected.
xii. All supporting documents relating to the claim must be filed with the office of the Bank dealing with the claims or THIRD PARTY ADMINISTRATOR 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.
xiii. The Insured Person shall obtain and furnish to the Zonal office of the Bank dealing with the claims / TPA with all original bills, receipts and other documents upon which a claim is based and shall also give such additional information and assistance as the Bank through the TPA/ Insurance Company may require in dealing with the claim.
xiv. Any medical practitioner authorized by the Bank /Third Party Administrator / shall be allowed to examine the Insured Person in case of any alleged injury or disease leading to Hospitalization, if so required.
6
xv. The Insurance Company shall not be liable to make any payment under this policy in respect of any claim if such claim be in any manner fraudulent or supported by any fraudulent means or device whether by the Insured Person or by any other person acting on his behalf.
xvi. In case of reimbursement claim where the member has not informed the Bank’s Zonal Office, he may call the 24 x 7 call centre of the TPA giving the details of their card ID number and name. In such cases the reimbursement claim should be submitted on completion of hospitalization and not later than 30 days of discharge from the hospital. In case of post-hospitalization treatment, all claim documents should be submitted within 30 days after completion of such treatment. Wherever the hospitals are not in the approved list of TPA, the TPA should take necessary action for addition of those hospitals on their network hospital list in consultation with bank. In an emergency the claim payment would be paid to the hospital account and empanelment of the hospital would be considered.
xvii. All the reimbursement claims will be settled once in a month.
MANAGEMENT OF RECORDS & PREPARATION OF FINAL ACCOUNTS
i. The select TPAs and the engaged Insurance Broker M/s Anand Rathi Insurance Brokers Ltd. (ARIBL) will maintain the member wise record of settlement of claims and provide the data to Bank on exhausted / outstanding limit of the members on monthly basis.
ii. On the basis of monthly data received from TPA / ARIBL, REMBS accounts of individual members will be updated at Zonal Offices which will help in deciding the premium at next year’s renewal.
iii. The Insurance Company / TPA will provide to each member at half yearly intervals, a statement giving details of medical expenses incurred during the cover period and the remaining balance available.
iv. Final Accounts of SBI Retired Employees’ Medical Benefit Trust will be prepared at PPG Department for the financial year ending on 31st March.

1
ANNEXURE-III
DETAILED PROCESS FOR JOINING GROUP MEDICLAIM POLICY-‘B’
BY NEW RETIREES AND EXISTING MEMBERS / NON-MEMBERS OF SBIREMBS, SURVIVING SPOUSES OF DECEASED EMPLOYEES AND PENSIONERS
 The applicant must possess a valid P.F. Index number (allotted by the Bank) for online application.
 The applicant should maintain sufficient balance in the pension account (other a/c in case of P.F. optees of e-SBS & e-SBIN) for payment of premium + service tax.
i. Visit the Portal for SBI Retired Employees with Web address: https://www.sbi.co.in/sbipension/user.htm and click on ‘Registration for Group Mediclaim Policy-B’ icon, which will be available w.e.f. 01.01.2016. On clicking the link, the system will ask for PF Index No.
ii. On putting the valid PF Index number, full application form will appear on the screen with certain details viz. PF Index No., name, address etc. already filled in. The applicant will fill up remaining particulars and may change the fetched particulars in the editable fields in the application form and upload the same online.
iii. On uploading the application, the applicant will get an onetime password through SMS to his / her mobile. The applicant will be required to put the onetime password to complete the process of submission of application online.
iv. On successful submission of the application, applicable premium amount along with service tax & Swachha Bharat Cess will be debited to the account of the applicant and the same will be credited online to the current account opened at the concerned Zonal Office styled as ‘Mediclaim Policy for SBI Retirees (Policy-‘B’).’
v. After that the applicant will be required to take a print out of the same and submit the duly signed hard copy of the application (Specimen enclosed at Annexure-IV) in duplicate & two latest joint photographs of self and spouse to the pension paying branch.
2
vi. The branch on receiving the hardcopy of the application along with two joint photographs will verify the genuineness of the applicant and forward the same to the concerned Zonal Office. Tear off portion of Application Form will be given to the applicant duly signed by the authorized official of the Branch / Office as an acknowledgement.
vii. Zonal office on receiving the hardcopies of the application form from the branch, will verify the necessary details, eligibility of the applicant and receipt of the premium amount in the account maintained by the Zonal Office styled as ‘Mediclaim Policy for SBI Retirees (Policy-‘B’)’and forward the same to the local branch of United India Insurance Co. with full signature of the authorized official and stamp of the office. A copy of the application form will be retained at Zonal Office for future reference.
viii. Please note that the Insurance cover to members who pay the premium during 1st day of the month to 14th day of the month will commence from 16th day of the month. Similarly, insurance cover to members who pay the premium during 15th day of the month to the second last day of the month, will commence from 1st day of the next month. Therefore, each Zonal office will simultaneously prepare a list (as per Annexure-V) containing the details of the applicants and the collected premium amount and send the soft copy through email and duly signed hardcopy of the list to PPG Department, Corporate Centre and transfer the consolidated amount to the Main Collection Account to be maintained at SBI Madame Cama Road Branch at fortnightly intervals.
Email Address : dgm.pm@sbi.co.in
Current A/c No. 35411898837
Address: The Deputy General Manager
PM & PPG DEPARTMENT,
STATE BANK OF INDIA, CORPORATE CENTRE,
16TH FLOOR, STATE BANK BHAVAN,
MADAME CAMA ROAD, NARIMAN POINT, MUMBAI-400021
ix. PPG Department at Corporate Centre, on receiving the lists from each zonal office, will collate the same and prepare a zonal office wise consolidated list and send the same to the Insurance Company along with collected premium amount (including service
3
tax & Swachha Bharate Cess) by means of a single cheque at fortnightly intervals.
Note : In-house development of the requisite software and its linkage with SBI Pensioners’ Portal will be done by SBI, GITC, Belapur. However, till such time the software is ready, the following process will be adopted:
a) Eligible retirees will fill up the application form manually by downloading the same from ‘Pensioners’ Portal’ or by physical collection from branches and submit to the pension paying branch along with two latest joint photographs of self and spouse.
b) The branch will arrange for debiting the applicant’s account with the amount of applicable insurance premium along with service tax @ + 0.50% Swachha Bharat cess and credit the same to a newly opened current account styled as ‘Mediclaim Policy for SBI Retirees (Policy-‘B’)’ to be maintained by the concerned Zonal Office and forward the completed application forms [mentioning (a) Transaction No. (b) Date of Transaction; and (c) Amount] to concerned Zonal Office for further action.
c) Zonal office on receiving the hardcopy of the application form from the branch, will verify the necessary details and eligibility of the applicant and forward the same to the local branch of United India Insurance Co. with full signature of the authorized official and stamp of the office.
d) Each Zonal office will simultaneously prepare a list (as per Annexure-V) containing the details of the applicants and the collected premium amount and send the soft copy through email and duly signed hardcopy of the list to PPG Department, Corporate Centre and transfer the consolidated amount to the Main Collection Account to be maintained at SBI Madame Cama Road Branch at fortnightly intervals.
Email Address : dgm.pm@sbi.co.in
Current A/c No. 35411898837
Address: The Deputy General Manager
PM & PPG DEPARTMENT,
STATE BANK OF INDIA, CORPORATE CENTRE,
16TH FLOOR, STATE BANK BHAVAN,
MADAME CAMA ROAD, NARIMAN POINT, MUMBAI-400021
4
e) PPG Department at Corporate Centre, on receiving the list and the premium amount from each zonal office, collate the same and prepare a zonal office wise consolidated list and send the same to the Insurance Company along with collected premium amount (including service tax & Swachha Bharate cess) by means of a single cheque drawn on the main collection account at fortnightly intervals.
f) On receipt of the application forms and the advance Premium, United India Insurance Co. Ltd. will arrange for issuance of Medical ID Cards to the applicants through Third Party Administrators (TPAs). E-Medical cum ID cards will be made available to the applicants within 48 hours, which can be used by them to avail Cashless / Wellness facilities of TPAs.
g) In addition, the concerned TPAs will arrange to prepare Physical Medical cum ID (Med-ID) cards within 15 working days from the date of receipt of data by them from the concerned Insurance Company.
h) Med-ID cards will be couriered by the TPA to the respective branch office from where the employee is getting pension. The cards may be distributed at the branch office by the Branch Manager / any other person who is made responsible for the same. Corrections in cards, if any, can be e-mailed to an email ID which will be exclusive for cards correction errors. The cards will be corrected and resent within 2 working days from the receipt of correction mail by the TPA.
i) On receipt of the Med-ID Cards, members will start getting Cashless Medical treatment at any network hospital throughout the country or submit the claims to the same Zonal Offices through their pension paying branch and the TPA representative will be the backup support and ensure claim settlement is completed within shortest possible time. United India Insurance Co. Ltd. has assured that claims will be entertained on the basis of data in the absence of Med-ID Cards.
5
CLAIM SETTLEMENT PROCESS UNDER POLICY ‘B’
& ROLE OF THIRD PARTY ADMINISTRATOR
i. Claims will be managed through the same office (Zonal Office of the pension paying branch) of the Bank from where claims under existing SBIREMBS are managed at present. The Insurance Companies / Third Party Administrator (TPA) / Anand Rathi Insurance Broker Ltd. (engaged Insurance Broker) will set up a help desk at Zonal Office centres and will be supporting the bank in clearing all the claims on real time basis.
ii. The TPA appointed by the selected Insurance Company will station their representative at the Bank’s Zonal Office centres where claims under SBIREMBS are being settled.
iii. The TPA would have a Dedicated Office, Server and a 24 x 7 Call Centre for the existing and future retirees of SBI. Anand Rathi Insurance Broker will also have 24 x 7 call center and dedicated server.
iv. The members would submit the claims to the same Zonal Offices through their pension paying branch and the TPA representative will be the backup support and ensure that claim settlement is completed within shortest possible time. Turn Around Time (TAT) for settlement of claims will be as under:
Turn around Time
For Cashless Treatment : Maximum 2 to 4 hours for approval
by TPA.
For reimbursement / OPD : Maximum 1 week from the date of
submission of complete documents
v. TPA engaged by the Insurance Company will ensure completion of minimal formalities so that hassle free cashless medical treatment can be obtained in quick time at any network hospital.
vi. Process of getting Cashless Treatment :
(a) To call the Relationship Manager of the TPA and place the request for admission to preferred Network Hospital.
6
(b) To approach nearest Network Hospital with the medical cum ID card already given.
(c) In case the member or his family member gets admitted in any of the preferred Provider Network of hospitals on production of ID card, the hospital authority in turn shall notify by fax / mail the details of hospitalization along with ID card number and name of the member to the TPA, who would again revert by fax / mail a confirmation to the hospital to proceed with the claim. This would even enable them to claim from anywhere in India and they would be able to admit themselves in hospitals anywhere in India by merely calling the dedicated call centres of the TPA which would be working on a 24 x 7 basis.
(d) The TPA would even be able to advise the members on the nearest hospital available in their area. In case of an emergency admission to a hospital which is not in TPA’s Network, the members also have a benefit to get himself admitted on a cashless basis by intimating the TPA, call centre number, mentioning his ID card No and name.
(e) Network hospital will give treatment without asking for deposit / payment of hospital bills upto the authorized amount.
(f) All the Cashless Claims would be paid directly to the hospital concerned by the TPA.
vii. Every notice or communication regarding hospitalization or claim to be given or made under the policy shall be communicated (Telephonically /e-mail / fax / online) to the office of the Bank dealing with Medical Claims and / or the TPA’s office at the earliest in case of emergency hospitalization within 7 days from the time of Hospitalization / Domiciliary Hospitalization.
viii. If the hospital opted is not on the panel of TPA, the member may take admission to the hospital and submit the claim for reimbursement. In such a case, the hospital should satisfy the criteria of hospital as defined in the policy.
7
Note: Waiver of these Conditions (vii) and (viii) may be considered in extreme cases of hardship where it is proved to the satisfaction of the Bank that under the circumstances in which the insured was placed it was not possible for him or any other person to give such notice or deliberate or file claim within the prescribed time-limit. The same would be waived by the TPA without reference to the Insurance Company.
ix. The reimbursement claims of pre and post hospitalization or in a few cases of actual hospitalization would be paid to the members through the Bank’s Zonal Offices or directly credited to the members account.
x. No claims would be rejected by the insurance company / TPA unless the same is rejected by the committee comprising the Bank management, Insurance Company, TPA and M/s Anand Rathi Insurance Broker Pvt. Ltd.
xi. The claim shall be rejected in the event of misrepresentation, mis-description or non-disclosure of any material fact. In case of rejection of claims it would go through a Committee set up of the Bank, TPA and the concerned Insurance Company unless rejected by the committee in real time the claim should not be rejected.
xii. All supporting documents relating to the claim must be filed with the office of the Bank dealing with the claims or TPA 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.
xiii. The Insured Person shall obtain and furnish to the Zonal office of the Bank dealing with the claims / TPA with all original bills, receipts and other documents upon which a claim is based and shall also give such additional information and assistance as the Bank through the TPA/ Insurance Company may require in dealing with the claim.
xiv. Any medical practitioner authorized by the Bank /Third Party Administrator / shall be allowed to examine the Insured Person in
8
case of any alleged injury or disease leading to Hospitalization, if so required.
xv. The Insurance Company shall not be liable to make any payment under this policy in respect of any claim if such claim be in any manner fraudulent or supported by any fraudulent means or device whether by the Insured Person or by any other person acting on his behalf.
xvi. In case of reimbursement claim where the member has not informed the Bank’s Zonal Office, he may call the 24 x 7 call centre of the TPA giving the details of their card ID number and name. In such cases the reimbursement claim should be submitted on completion of hospitalization and not later than 30 days of discharge from the hospital. In case of post-hospitalization treatment, all claim documents should be submitted within 30 days after completion of such treatment. Wherever the hospitals are not in the approved list of TPA, the TPA should take necessary action for addition of those hospitals on their network hospital list in consultation with bank. In an emergency the claim payment would be paid to the hospital account and empanelment of the hospital would be considered.
xvii. All the reimbursement claims will be settled once in a month.
xviii. The select TPAs and the engaged Insurance Broker M/s Anand Rathi Insurance Brokers Ltd. (ARIBL) will maintain the member wise record of settlement of claims and provide the data to Bank on exhausted / outstanding limit of the members on monthly basis.
xix. On the basis of monthly data received from TPA / ARIBL, REMBS accounts of individual members will be updated at Zonal Offices which will help in deciding the premium at next year’s renewal.
xx. The Insurance Company / TPA will provide to each member at half yearly intervals, a statement giving details of medical expenses incurred during the cover period and the remaining balance available.
9
Chief Manager (HR) ANNEXURE-IV State Bank of India,
Zonal office,
__________________________
Dear Sir,
SUB: Family Floater Group Health Insurance Policy for SBI Retirees
I am interested in joining the Family Floater Group Health Insurance Policy ‘B’ of State Bank of India and furnish the required information as under:
Sl.
Particulars
Remarks
01
P.F Index No.
02
Name
03
Name of the Bank
SBI/e-SBS/e-SBIN
04
Date of joining the Bank
05
Date of confirmation in service
06
Date of Retirement
07
Retired as
Clerical/Sub-staff/JMGS-I/MMGS-II/MMGS-III/SMGS-IV/SMGS-V/TEGS-VI/TEGS-VII/TEGSS-I/TEGSS-II
08
Age (in years) as on the date of retirement
09
Gender
i. Male
ii. Female
10
Type
i. Pensioner
ii. Family Pensioner
11
Category
i. SBI retirees on completion of pensionable service in the Bank.
ii. Members of National Pension System on completion of 20 years of confirmed service in the Bank.
iii. Spouse of SBI employee who died whilst in service or after retirement.
iv. Pre-merger retirees of e-SBS and e-SBIN on completion of pensionable service in the concerned Bank.
v. Surviving spouses of pre-merger retirees /deceased employees of e-SBS and e-SBIN.
vi. Existing member of SBIREMBS, e-SBS REMBS and e-SBINREMBS.
12
Whether discharged / dismissed / removed / compulsorily retired / terminated from service. (Tick)
Yes / No
13
Whether Rule 19(3) was invoked on attaining the age
Yes / No
Affix coloured joint photograph
of the member and spouse
10
of retirement
(If yes, please furnish the details of the disciplinary case, date of its conclusion and penalty, if any imposed )
14
Date of Birth
dd/mm/yy
15
Date of Death (in case of deceased employee / pensioner)
dd/mm/yy
16
Address for communication
House No.
Street No.
Nearest Landmark
Post Office
Police Station
City
State
Pin Code
17
Landline No. (with STD code)
18
Mobile No.
19
Email ID
20
Name of Spouse (if any)
21
Date of Birth of Spouse
dd/mm/yy
22
Name of disabled Child / Children (if any).
(Attach valid disability certificate issued by medical officer not below the rank of Civil Surgeon)
Sl
Name of the disabled child
Date of Birth
dd/mm/yy
dd/mm/yy
dd/mm/yy
23
Name of the pension/family pension paying branch
Name of the Branch
Code No.
24
Pension Account No. (11 digit)
25
IFSC Code
26
Sum Insured opting for
(Please tick the appropriate Scheme)
ST = Service Tax
SBC = Swachh Bharat Cess
Sl
Scheme
Sum Insured
Insurance Premium
1
A
Rs. 3.00 lac
Rs. 5,577/- +ST+SBC
2
B
Rs. 4.00 lac
Rs. 7,282/- +ST+SBC
3
C
Rs. 5.00 lac
Rs. 9,285/- +ST+SBC
4
D
Rs. 7.50 lac
Rs. 12,677/- +ST+SBC
5
E
Rs. 10.00 lac
Rs. 16,902/- +ST+SBC
6
F
Rs. 15.00 lac
Rs. 25,353/- +ST+SBC
7
G
Rs. 20.00 lac
Rs. 33,804/- +ST+SBC
8
H
Rs. 25.00 lac
Rs. 42,255/- +ST+SBC
Declaration of Nominee/s :
I, Mr./Mrs./Ms. _____________________ , a retired employee / spouse of the deceased employee / pensioner of the Bank do hereby assign the money payable by “United India Insurance Co. Ltd.” in case of my death to Mr. / Mrs./ Ms. _________________________ Relation ______________ and further declare that his/her receipt shall be sufficient discharge of the company.
11
Debit Authority :
I am aware that I along with my spouse and disabled child/children will be eligible for a health insurance cover of Rs. ________ lac under the Family Floater Group Health Insurance policy. I hereby authorize the Bank to debit the annual insurance premium amount of Rs. _________ to my pension / family pension account No. _______________ now and to renew the policy every year by debiting the renewal premium as communicated by the insurance company to my above account without further reference to me unless my intension not to renew the policy is informed to at least one month in advance of the renewal date. I undertake to keep sufficient balance in my above account for debiting current insurance / renewal premium failing which the policy may not be issued / renewed.
Place :
Date :
Signature of Retired Employee / Spouse
For office use only
Certified that Shri / Smt. _______________________ is a retired employee / spouse of the retired / deceased employee of the Bank and he / she has remitted the insurance premium as per the following details:
Transaction No. _______________
Date : ______________
Amount : ______________
State Bank of India
Name of the Forwarding Branch (Code No.):
Place :
Date :
_____________________________________
Signature of the Branch Manager with seal
……………………………………………………………………………………………………………
ACKNOWLEDGEMENT
(to be given to the applicant by the branch receiving the Form)
Received from Shri/Smt._________________________________________________
Application for membership of Family Floater Group Mediclaim Policy ‘B’ along with the draft No. _________ dated _____ for Rs._______________ issued by ____________________ and drawn on_______ _______________________for onward submission to Admin Office.
Date _______
Branch ______ Stamp of the Branch Signature of the officer receiving the Form
12
ANNEXURE-V
PREMIUM FORWARDING SHEET A.O. :
Date of transfer of consolidated amount of premium to Current Account at Madame Cama Branch :
Sl. No.
Name of Retiree
PF Index
Name of Bank (SBI / e-SBS / e-SBIN)
Circle
Name & code no. of Pension Paying Branch
Date of application
Plan opted
Premium
Policy Preium
(a)
Service Tax
(b)
Swachh Bharat Cess
(c )
Total
(a+b+c)
1
2
3
4
5
6
7
8
9
10
Grand Total
Seal & Signature
Name :
Designation :
Date :
Mobile No. :






 

Updated:20.12.2015:      The Executive Committee of Central Board of the Bank in its meeting held on 16th December,2015 has approved two tailor-made Family Floater Group Health Insurance Policies ( Policy 'A' and Policy 'B') towards Medical Benefits of Retired Employees.


        The details of the Scheme is up loaded and  available by clicking the relevant item in the list given at the end of this page.







15.12.2015
News Update: Annual Report of the SBI Pensioners' Association, year 2014-2015 is uploaded as ''Add Files''. As the file was too large the report is broken in to three parts-- Cover page, page 1 to 10 and 11 to 20.



: 21;11;2015---- October, 2015 issue of ''Pensioners' Hitchintak" has since been uploaded.

Attention 10th Bipartite Retirees : Provident Fund deducted from the arrears along with bank's share has been refunded on 11-09-2015 to the respective pension accounts (.)

The exercise of calculation of  difference in payment of Gratuity is in process and the same will be paid shortly. 


 
 





ORIGIN OF NARMADA RIVER
               AMARKANTAK


                    Sanchi Stupa                                  Bhedaghat, Jabalpur

      
    
               Rajwada, Indore                                             Fort, Gwalior

          





























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Sbipensionersassociation Indore,
Dec 20, 2015, 12:47 AM
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Sbipensionersassociation Indore,
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Sbipensionersassociation Indore,
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Sbipensionersassociation Indore,
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Sbipensionersassociation Indore,
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Sbipensionersassociation Indore,
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Sbipensionersassociation Indore,
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Sbipensionersassociation Indore,
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