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Medical Insurance Scheme

March 11, 2016
TO ALL OFFICES
HRMD CIRCULAR NO. 300
Medical Insurance Scheme for Retired Officers/Retired employees –
Operational Guidelines
Details of the Medical Insurance Scheme were circulated vide Annexure/ Schedule-IV to PAD Circular No.271 dated 9.6.2015 and HRDD Circular No.694 dated 20.6.2015. However, details of operational guidelines containing instructions for seeking reimbursement / availing benefits under the scheme for retired Officers/retired employees are being circulated herewith as Annexure.
All concerned are advised to go through the provisions of the joint note dated 25.05.2015 for complete details and bring this circular to the notice of retirees drawing pension from their branches and place a copy of this circular on the notice board.
(DINESH SAXSENA)
DY. GENERAL MANAGER
Human Resources Management Division
(Hospitalisation Cell), Head Office: New Delhi
Phone No. – 011‐26174730
Email – hrdhospitalisation@pnb.co.in
FAX – 011‐26196491
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ANNEXURE
BRIEF DETAILS OF MEDICAL INSURANCE SCHEME FOR RETIRED EMPLOYEES
Policy Period 07.11.2015 to 31.10.2016
Plan Type Group Health Policy
Beneficiary Retired employee + Spouse
Sum insured (Annual cover
amount)
Cadre at the time of
retirement
Sum insured (Rs.)
Officers 4,00,000/-
Clerical & Sub Staff 3,00,000/-
Critical illness All diseases are covered from day one.
Coverages 1(i) Inpatient Hospitalisation expenses (all diseases are
covered which require hospitalization)
(ii) Pre/Post hospitalization expenses covered
• Pre-hospitalization for 30 days
• Post Hospitalization for 90 days:
2. Listed Day Care Procedures
3. Domiciliary Hospitalization is covered- It means
medical treatment for an illness/injury which in the
normal course would require care and treatment at a
hospital but is actually taken while confined at home
under any of the following circumstances:-
o The condition of the patient is such that he/she
is not in a condition to be removed to a hospital.
o The patient takes treatment at home on account
of non availability of room in a hospital.
Room Rent – Room Rent upto to Rs.5,000/- per day.
- ICU charges upto Rs.7,500/- per day.
Ambulance Charges – Ambulance charges upto Rs.2500/- per trip.
- Taxi and Auto in actual maximum up to Rs. 750/- per trip
Congenital internal / external diseases / defects/ anomalies
Covered in the policy.
Pre-existing diseases coverage Covered in the policy.
Alternative therapy Reimbursement of expenses due to hospitalization under the recognized system of medicine, viz Unani,
Sidha, Homeopathy, Naturopathy, if such treatment is
2 | P a g e taken in a clinic/hospital registered by the
central/state government. Ayurvedic Treatment Hospitalization expenses are admissible only when the treatment has been undergone in a Government Hospital or in any institute recognized by the Government and/or accredited by Quality Council of
India/National Accreditation Board on Health. Nursing Charges The following charges in the scheme are payable:-
Nursing Charges , Service Charges, IV Administration
Charges, Nebulization Charges, RMO charges
,Anesthetic, Blood, Oxygen, Operation Theatre
Charges, surgical appliances, OT consumables,
Medicines & Drugs, Dialysis, Chemotherapy,
Radiotherapy, Cost of Artificial Limbs, cost of
prosthetic devices implanted during surgical procedure
like pacemaker, Defibrillator Ventilator, orthopedic
implants, Cochlear Implant, any other implant, Intra-
Ocular Lenses, , infra cardiac valve replacements,
vascular stents, any other valve replacement,
laboratory/diagnostic tests, X-ray CT Scan, MRI, any
other scan, scopies and such similar expenses that are
medically necessary, or incurred during hospitalization
as per the advice of the attending doctor.
Miscellaneous o Expenses for treatment of Congenital
internal/external diseases,defects anomalities
are covered.
o Expenses for treatment of psychiatric and
psychosomatic diseases be payable with or
without hospitalization.
o Treatment taken for Accidents can be payable
even on OPD basis in hospital upto sum insured.
o Treatment for Genetic Disorder and stem cell
therapy is covered under the scheme.
o Treatment for Age Related Macular Degeneration
treatment such as Roptational Field Quantum
magnetic Resonance, enchanced external
Counter Pulsation etc are covered under the
scheme, Treatment for all neurological/macular
degeneration disorder shall be covered under the
scheme.
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OPERATIONAL GUIDELINES
TPA CARD i. The scheme is being operationalised by United India
Insurance Company through Raksha TPA and all the
claims under the scheme are to be processed by the TPA.
ii. Each retiree and their spouses are to be issued separate
TPA ID card containing the photo of the insured.
iii. Circle Offices obtained photographs on the format
prescribed for the purpose of issuing TPA ID cards. In
the meantime the TPA ID card without photograph can
be downloaded through website (rakshatpa.com) and /
or through mobile app as below
iv. For downloading TPA ID Card through website, the
retirees are advised to follow the path >> visit Raksha
TPA web site www.rakshatpa.com >> click on IBA >> click
PNB. System will ask you to fill the ID card No. where
the following is to be filled:-
“UIC545(Employee PF Number) PNBR” eg. If PF number
is 12345, the text to be filled shall be
“UIC54512345PNBR” >> click on search button. New
screen will appear with all details. If details are correct,
click PRINT E-CARD and save the same for records and
future reference.
For downloading TPA ID card through mobile app, use
smart mobile phone for the facility. Download the Mobile
App. ‘Raksha TPA’, on the application. System will show
many options, click on ‘Request E-card’ and enter the
particulars as advised above, then click on search
button. New screen will appear with all details. If details
are correct, click PRINT E-CARD and save the same for
record and future reference.
INTIMATION OF CLAIM
IN CASE OF ALL
HOSPITALISATION
(CASHLESS OR
OTHERWISE)
i. The reimbursement claims are required to be intimated
to Raksha TPA within 24 hours of hospitalization and
original documents are to be submitted within 30 days
of discharge from the hospital.
ii. In case of planned hospitalization, the TPA is to be
informed at least two days before hospitalization, but in
any case within 24 hours of hospitalization.
iii. Intimation has to be sent along with the following
particulars:-
a. Member ID
b. Patient’s Name
c. Name and address of the Hospital
d. Disease / ailment and Treatment given
e. Date of admission
f. Requested amount
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iv. Intimation can be sent by the insured / relatives /
through any of the following methods:-
a. Through e-mail to Raksha TPA at email id
“helpIBA@rakshatpa.com”,
“claimintimation@rakshatpa.com”
b. Through phone by calling any of the following 24
hours toll free No./Call Center and providing above
information
a) 0129 4289999 – Delhi
b) 1800 180 1444 – Delhi
c) 1800 220 456 – Mumbai
d) 1800 425 8910 – Bangalore
c. On line Registration by following the undernoted
procedure:
1. login to www.rakshatpa.com
2. click on claim intimation link
3. Punch in desired details like Member id, date of
admission, name of hospital etc.
4. Acknowledgement No. (i.e. your claim no.) shall be
reflected, a copy of which may be retained
SUBMISSION &
PAYMENT OF MEDICAL
BILLS
(OTHER THAN ON
CASHLESS BASIS)
i. All claims are to be submitted on the prescribed format
of the insurance company. Proforma of the claim form is
enclosed.
ii. Retirees may also lodge claim direct to Raksha TPA or
any Circle Offices or Head Office-Hospitalisation cell.
iii. Circle Offices and HRD Division HO (Hospitalisation Cell)
will submit these bills to TPA on daily basis, after
keeping proper record.
iv. All reimbursements shall be credited in Retirees’ Bank
account directly.
PROCEDURE & TIME
SCHEDULE FOR
SUBMISSION OF
MEDICAL CLAIMS
All supporting documents in original, i.e Discharge Card,
Medical Prescription, Medicine Bills, related Reports, X-rays,
ECG strips, CT scan pictures and other documents relating to
the claim must be submitted with the claim form within 30
days from the date of discharge from the hospital. In case of
post-hospitalization treatment (limited to 90 days), all claim
documents should be submitted within 30 days after
completion of such treatment.
HOSPITALISATION
CLAIMS -
(CASHLESS BASIS)
i. The benefit of cashless hospitalisation facility is available
in many hospitals on provider’s network. The list of such
hospitals can be accessed on Raksha TPA’s website.
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ii. Retirees are advised to contact TPA counter of the
hospital along with TPA ID Card and a Govt. Photo ID
proof of the patient for seeking cashless hospitalization
claim.
iii. On production of ID card, the TPA desk of the hospital
shall inform the TPA, the requisite particulars of
employee, the patient admitted, reason for
hospitalization etc. and seek initial approval of the
estimated hospitalization expenses.
iv. Some hospitals have a policy of seeking an advance for
treatment to start. The same is refundable once the
cashless approval is received.
v. After treatment, the hospital’s TPA desk will submit the
bills to the TPA and on receipt of sanction, the patient
shall be discharged. Claim amount shall be paid by
Insurance Company through TPA directly to the hospital
concerned.
vi. Any amount not admissible under the scheme and not
sanctioned by the TPA shall have to be paid by the
retiree to the hospital at the time of discharge of patient.
vii. In case of post-hospitalisation treatment, all claim
documents should be submitted within 30 days after
completion of such treatment.
EMERGENCY
HOSPITALISATION
In case of an emergency admission to a hospital which is not
in PP Network, the officers / employees can approach the TPA
for cashless treatment by intimating the Third Party
Administrator, call centre number (0129-4289999,
1800-180-1444(Delhi), 1800-220-456(Mumbai),
1800-425-8910(Bangalore), mentioning his ID card No. and
name. The hospital authorities would fax / mail the details of
hospitalisation to the Third Party Administrator, who would
again revert by fax / mail a confirmation to the hospital to
proceed with the claim.
IF HOSPITAL IS NOT IN
THE APPROVED LIST
OF TPA
Wherever the hospital is not in the approved list of Third Party
Administrator, the Third Party Administrator will take
necessary action for considering addition of such hospital on
their network hospital list in consultation with bank. In an
emergency the claim payment would be made to the hospital
and empanelment of the hospital would be considered.
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Advisory Efforts have been made for issuance of TPA photo ID cards
to all the retirees alongwith their spouses. It is understood
that some of the application forms are still lying in the
branches, where these have submitted. These should be
sent to nearby Circle Offices so that these are forwarded to
TPA.
In the meantime ID cards without photo shall be honoured
by TPA.
EX-staff to ensure providing of photos of self and spouse to
concerned Circle Offices so that next time i.e. Policy period
01.11.2016 to 31.10.2017, Photo ID Cards are issued by
TPA.
GRIEVANCE REDRESSAL In the event of any grievance relating to the insurance, the
insured Person may raise query and grievance in writing to
the TPA, through its website www.rakshatpa.com link
online grievance.
The insured person may also submit in writing to the
Policy Issuing Office or Grievance Cells at the Regional
Office of the United India Insurance on https://uiic.co.in
link online complaint
CLAIM FORM – PART A’ to ‘CLAIM FORM FOR HEALTH INSURANCE POLICIES OTHER THAN TRAVEL AND PERSONAL ACCIDENT – PART A
TO BE FILLED BY THE INSURED
The issue of this Form is not to be taken as an admission of liablity
DETAILS OF PRIMARY INSURED:
a) Policy No.:
(To be Filled in block letters)
SECTION A SECTION B
b) Sl. No/ Certificate no.
c) Company/ TPA ID No:
e) Address:
DETAILS OF INSURANCE HISTORY:
a) Currently covered by any other Mediclaim / Health Insurance: b) Date of commencement of first Insurance without break:
c) If yes, company name: Policy No.
Sum insured (Rs.) d) Have you been hospitalized in the last four years since inception of the contract?
Diagnosis: e) Previously covered by any other Mediclaim /Health insurance : :
Date: M M
Y
Y
Y
Y
f) If yes, company name:
DETAILS OF INSURED PERSON HOSPITALIZED: :
DETAILS OF HOSPITALIZATION: :
DETAILS OF CLAIM:
DETAILS OF BILLS ENCLOSED:
Sl. No. Bill No. Date Issued by Towards Amount (Rs)
DETAILS OF PRIMARY INSURED’S BANK ACCOUNT::
SECTION C SECTION D SECTION E SECTION F SECTION G
1. D D M M Y Y
2.
3.
4.
5.
6.
7.
8.
9.
10.
D D M M Y Y
D D M M Y Y
D D M M Y Y
D D M M Y Y
D D M M Y Y
D D M M Y Y
D D M M Y Y
D D M M Y Y
D D M M Y Y
City: State:
Pin Code Phone No: Email ID:
City: State:
Pin Code Phone No: Email ID:
D D
D D
M M
M M
Y Y
Y Y
Yes No
Yes No
Yes No
d) Name: S U R N A M E F I R S T N A M E M I D D L E N A M E
a) Name: S U R N A M E F I R S T N A M E M I D D L E N A M E
b) Gender Male Female c) Age years Months d) Date of Birth M M Y Y Y Y
e) Relationship to Primary insured: Self Spouse Child Father Mother Other (Please Specify)
f) Occupation Service Self Employed Home Maker Student Retired Other (Please Specify)
g) Address (if diffrent from above) :
a) Name of Hospital where Admited:
b) Room Category occupied: Day care
D D M M Y Y H H M H H H M H
D D M M Y Y Y Y
D D M M Y Y
Single occupancy Twin sharing 3 or more beds per room
c) Hospitalization due to: Injury Illness Maternity d) Date of injury / Date Disease first detected /Date of Delivery:
e) Date of Admission: f) Time g) Date of Discharge: h) Time: :
I) If Medico legal Yes No
j) System of Medicine:
I) If injury give cause: Self inflicted Road Traffic Accident Substance Abuse / Alcohol Consumption
ii) Reported to Police iii. MLC Report & Police FIR attached Yes No
a) Details of the Treatment expenses claimed
I. Pre -hospitalization expenses
iii. Post-hospitalization expenses
v. Ambulance Charges:
Rs.
Rs.
Rs.
ii. Hospitalization expenses Rs.
iv. Health-Check up cost:
vi. Others (code):
Rs.
Rs.
Total Rs.
vii. Pre -hospitalization period: days viii. Post -hospitalization period: days
b) Claim for Domiciliary Hospitalization: Yes No (If yes, provide details in annexure)
c) Details of Lump sum / cash benefit claimed:
i. Hospital Daily cash: Rs.
Rs.
Rs.
iii. Critical Illness benefit:
v. Pre/Post hospitalization Lump sum benefit:
ii. Surgical Cash:
iv. Convalescence:
vi. Others:
Rs.
Rs.
Rs.
Total Rs.
Claim Documents Submitted – Check List:
Claim form duly signed
Copy of the claim intimation, if any
Hospital Main Bill
Hospital Break-up Bill
Hospital Bill Payment Receipt
Hospital Discharge Summary
Pharmacy Bill
Operation Theater Notes
ECG
Doctor’s request for investigation
Investigation Reports (Including CT
/ MRI / USG / HPE)
Doctor’s Prescriptions
Others
Hospital main Bill
Pharmacy Bills
Post-hospitalization Bills: Nos
Pre-hospitalization Bills: Nos
a) PAN:
c) Bank Name and Branch:
d) Cheque / DD Payable details:
b) Account Number:
e) IFSC Code:
(IMPORTANT: PLEASE TURN OVER)
DECLARATION BY THE INSURED:
I hereby declare that the information furnished in the claim form is true & correct to the best of my knowledge and belief. If I have made any false or untrue statement, suppression
or concealent of any material fact with respect to questions asked in relation to this claim, my right to claim reimbrusement shall be forfeited, I also consent & authorize TPA /
Insurance Company, to seek necessary medical information / documents from any hospital / Medical Practitioner who has attended on the person against whom this claim is made.
I hereby declare that I have included all the bills / receipts for the purpose of this claim & that I will not be making any supplementary claim except the pre/post-hospitalization
claim, if any.
Date D D M M Y Y Y Y Place: Signature of the Insured
GUIDANCE FOR FILLING CLAIM FORM – PART A (To be filled in by the insured)
DATA ELEMENT DESCRIPTION FORMAT
SECTION A – DETAILS OF PRIMARY INSURED
a) Policy No. Enter the policy number As allotted by the Insurance Company
b) Sl. No/ Certificate No.
Enter the social Insurance number or the certificate number of
As allotted by the oraganization
social health insurance scheme
c) Company TPA ID No. Enter the TPA ID No.
Licence number as allotted by IRDA and printed
in TPA documents.
d) Name Enter the full name of the policyholder Surname, First name, Middle name
e) Address Enter the full postal address Include Street, City and Pin code
SECTION B -DETAILS OF INSURANCE HISTORY
a) Currently covered by any other Mediclaim / Health
Insurance?
Indicate whether currently covered by another Mediclaim /
Health Insurance
Tick Yes or No
b) Date of commencement of first Insurance without break Enter the date of commencement of first Insurance Use dd-mm-yy-forrmat
c) Company Name Enter the full name of the Insurance Company Name of the organization in full
Policy No. Enter the policy number As allotted by the Insurance Company
Sum insured Enter the total sum insured as per the policy In rupees
d) Have you been Hospitalized in the last four years since
Inception of the contract?
Indicate whether hospitalized in the last four years Tick Yes or No
Date Enter the date of Hospitalization Use mm-yy format
Diagnosis Enter the diagnosis details Open Text
e) Previously covered by any other Mediclaim / Health Tick Yes or No
Insurance?
Indicate whether previously covered by another mediclaim /
Health Insurance
f) Company Name Enter the full name of the Insurance Company Name of the organization in full
SECTION C -DETAILS OF INSURED PERSON HOSPITALIZED
a) Name Enter the full name of the patient Surname, First name, Middle name
b) Gender Indicate Gender of the patient Tick Male or Female
c) Age Enter age of the patient Number of years and months
d) Date of Birth Enter Date of Birth of patient Use dd-mm-yy format
e) Relationship to primary Insured Indicate relationship of patient with policyholder Tick the right option, if others, please specify
f) Occupation indicate occupation of patient Tick the right option. If others, please specify.
g) Address Enter the full postal address Include Street, City and Pin code
Include STD code with telephone number
Complete e-mail address
h) Phone No
1) E-mail ID
Enter the phone number of patient
Enter e-mail address of patient
SECTION D – DETAILS OF HOSPITALIZATION
a) Name of Hospital where admited Enter the name of hospital Name of hospital in full
Tick the right option
Tick the right option
Use dd-mm-yy format
Use dd-mm-yy format
Use hh-mm- format
Use dd-mm-yy format
Use hh-mm- format
Tick the right option
Tick Yes or No
Tick Yes or No
Tick Yes or No
Open Text
b) Room category occupied
c) Hospitalization due to
d) Date of injury/Date Disease first detected / Date of
Delivery
e) Date of admission
f) Time
g) Date of discharge
h) Time
I) If injury give cause
If Medico legal
Reported to Police
MLC Report & Police FIR attached
j) System of Medicene
indicate the room category occupied
indicate reason of hospitalization
Enter the relevant date
Enter date of admission
Enter time of admission
Enter date of discharge
Enter time of discharge
indicate cause of injury
indicate whether injury is medico legal
indicate whether police report was filed
indicate whether MLC report and Police FIR attached
Enter the system of medicine followed in treating the patient
SECTION E – DETAILS OF CLAIM
a) Details of Treatment Expences
b) Claim for Domiciliary Hospitalization
c) Details of Lump sum/ Cash benifit claimed
d) Claim documents Submitted-Check List
Enter the amount claimed as treatment expences
indicate whether claim is for domiciliary hospitalization
Enter the amount claimed as lump sum / cash benefit
indicate which supporting documents are submitted
Tick Yes or No
Tick the right option
In rupees (Do not enter paise values)
In rupees (Do not enter paise values)
SECTION F – DETAILS OF BILLS ENCLOSED
Indicate which bills are enclosed with the amount in rupees
SECTION G – DETAILS OF PRIMARY INSURED’s BANK ACCOUNT
a) PAN
b) Account Number
c) Bank Name and Branch
c) Cheque/ DD payable details
c) IFSC Code
Enter the permanent account number
Enter the Bank account number
Enter the Bank name along with the branch
Enter the name of the beneficiary the cheque / DD should be
made out to
Enter the IFSC code of the Bank branch
As allotted by the Income Tax Department
As allotted by the Bank
Name of the Bank in full
Name of the individual / organization in full
IFSC code of the Bank branch in full
SECTION H – DECLARATION BY THE INSURED
Read declaration carefully and mention date (in dd:mm:yy format), place (open text) and sign.
SECTION H

(2)PUNJAB NATIONAL BANK
HUMAN RESOURCES MANAGEMENT DIVISION
H O: 7, Bhikhaiji Cama Place, New Delhi – 110 607
Date: 13-10-2016
HRMD CIRCULAR NO. 333
Reg: Group Medical Insurance Scheme for retired
officers/employees -Renewal of policy from 01.11.2016 to
31.10.2017
In view of the communication received from IBA on behalf of
United India Insurance Company Ltd., the renewal premium of
Group Medical Insurance Scheme for retired officers/employees for
the policy period from 01.11.2016 to 31.10.2017 has been revised.
United India Insurance Company has also given an additional
option to the retirees to renew their policy with a Domiciliary sublimit
of 10% i.e. Rs.40000.00 for Officers and Rs.30000.00 for
Award Staff within Sum Insured (Option 2).
Thus, the revised premium for the policy period from 01.11.2016
to 31.10.2017 will be as under:-
Sum
Insured
Without Domiciliary
coverage-OPTION 1
With domiciliary
coverage of 10% of
sum insured –
OPTION 2
Base
Rate
Including
service tax
@15%
Base
Rate
Including
service
tax @15%
Officers 400000.00 13935.00 16025.00 17400.00 20010.00
Award
Staff
300000.00 10452.00 12020.00 13000.00 14950.00
The retirees are advised to submit their option in writing by
25.10.2016 to any branch of the Bank and the same will be
uploaded in HRMS by that Branch under “Manager selfservice>
MED.INSU.DOMI CONSENT(EX-EMP).
Those retirees who want to opt out of the Group Medical Insurance
Scheme due to increase in premium, he/she is necessarily
required to send an email at hrdhospitalisation@pnb.co.in latest
by 25.10.2016 failing which, it shall be deemed that they wish to
continue under Option-1 and the premium will be deducted
automatically.
Please note that no fresh option for enrolment is available to the
retirees, who are not presently covered under the policy.
Incumbents are advised to bring the content of this circular to the
knowledge of all the retirees drawing pension from branches and
obtain their fresh revised consent, if they are interested for
coverage of domiciliary treatment and advise them to maintain
sufficient balance in their account. A copy of this circular is also
being placed at pnbnet.net.in.
Circles/Zonal Offices/Divisions are also advised to get the exercise
completed within stipulated time without fail.
Please ensure compliance
(Alok Srivastava)
General Manager