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PNB Medi Claim – 2015

PERSONNEL ADMN. DIVISION
HOSPITALISATION CELL
HEAD OFFICE: NEW DELHI
Date: 02.12.2014
TO ALL OFFICES
PERSONNEL ADMN. DIVISION CIRCULAR NO. 243/2014
REG: RENEWAL OF ‘PNB MEDI-CLAIM INSURANCE SCHEME FOR RETIRED
EMPLOYEES’ OF THE BANK FOR THE CALENDAR YEAR- 2015 ON
CASHLESS BASIS.
Bank had introduced a medi-claim insurance scheme for retired employees through “The New India Assurance Co. Ltd” as circulated vide HRDD Circular No.220 dated 14.09.2004. Further, the scheme was last renewed with “National Insurance Co. Ltd” for the year 2014 and circulated vide PAD Circular No. 186 dated 16.11.2013.
2. On persistent demands of various Retirees’ Association/Unions and members themselves, further improvements/changes have been made in the existing scheme and accordingly, matter for renewal of the scheme was taken up with Insurance Cell, GSAD, HO for finalization of the rates of premium & Insurance company which shall
manage the scheme for the calendar year 2015. M/S.Marsh & Mclennan Insurance Broking co, the insurance broker, was approved by Insurance Cell, GSAD, HO for this job. After tendering process got done by Insurance Cell, GSAD, HO & M/s. Marsh & Meclennan, the Broker, the premium rates of National Insurance Company
ltd, Jacubpura, Gurgaon, Haryana emerged as L-1 for renewal of the policy on the basis of lowest rates quoted by them. Further, this year also the bank proposes to subsidize a part of the premium @ Rs.2500/- to each member of the scheme, out of the ‘Staff Welfare Fund’ as a benefit to the retired employees. Details of subsidized
premium to be paid by the members is available at Annexure-1.
3. Following improvements have been made in the existing scheme:
- Introduction of one more category of Sum Assured of Four lacs.
- Increase in Room Rent from Rs.1000/2000/3000 to ‘twin sharing basis’ for Sum assured of Rs.One/Two/Three lacs & 1% of sum assured of Rs.4 lacs;
- Increase in ICU rates from 1.5% to 2.00% of Sum Assured (from
Rs.1500/3000/4500 to Rs.2000/4000/6000 & 8000 respectively for Sum Assured of Rs.One /Two/Three lacs & Four lacs;
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- Increase in Sub Limits of Cataract Operation from Rs.7500/10000/12500 to 15000/20000/25000/40000 respectively for Sum Assured of Rs.One/Two/ Three/Four lacs.
- Scheme made open for change (increase or decrease) in sum assured as required by the members.
- Ayurvedic, Homeopathic, Naturopathy, Unani and any other line of treatment covered only at Govt. recognized hospitals or Govt Medical colleges.
- Coverage to be extended only in case of hospitalisation.
- Premium rates reduced which are lower than the existing rates of 2014 calendar year.
- Pre & Post Hospitalisation expenses shall be covered for 30 days & 60 days respectively (earlier 7 days Pre & Post hospitalisation).
- Ambulance charges @ 1% of Sum Assured or minimum of Rs.1500.
- Oral Chemotherapy on OPD basis.
- Orthopaedic OPD treatment in recognized hospitals.
- Health check up expenses to a maximum of Rs.1500 once in block of 2 years, in an event of claim free years.
4 All existing members of the above scheme are requested to send their revised subsidized premium as per Annexure-1 for renewal of their membership to “Chief Manager, Personnel Admn. Division, Punjab National Bank, Head Office, 7-Bhikaiji Cama Place, New Delhi-110066” on or before 26th December, 2014 by way of PNB
CBS Cheque/DD payable at Delhi drawn in favour of “PNB Medi-claim Insurance Scheme for Retired Employees” and mentioning their name and enrolment number on the back of the instrument.
5 Retired employees who are currently not members of the scheme but wish to opt for the same, may send their cases on the Performa available at Annexure-II, along with the commensurate premium amount as per the details available in Annexure 1 by way of PNB CBS Cheque/DD payable at Delhi drawn in favour of “PNB Medi-claim Insurance Scheme for Retired Employees” to Chief Manager, Personnel Admn. Division, Punjab National Bank, 7-Bhikaiji Cama Place, New Delhi-110066 on or before 26th December,
2014. In no case, the cheques/Drafts of other banks shall be accepted.
6 Employees retiring in the calendar year 2015 who wish to become
member of the scheme after the closure of the scheme for the remaining period up to 31.12.2015 shall also be given the benefit of subsidy @ Rs.2500/- per member.
7 In case the minimum group size remains less than the required numbers, as envisaged by the Insurance Company, the scheme may be withdrawn and in that eventuality, the premium received shall be refunded/ returned without interest.
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8 All claims under the above scheme are to be submitted directly to M/s. Park Medi claim TPA Ltd, 702, Vikrant Tower, Rajindra Place, New Delhi-110008, designated by the Insurance Company and under no circumstances, the same shall be routed through the bank.
9 Advance intimation of hospitalisation is to be given invariably to the concerned Insurance Company & its TPA on the address given above to avoid rejection of their claims.
10 Copy of this circular is available on bank’s website “pnbnet.net.in”
11 As the bank is functioning as a facilitator only & hence, will not be responsible for any deficiency in services, whatsoever, by the concerned Insurance Company or its TPA.
12 Members are advised to go through the guidelines contained in the related circular to avoid queries/rejections of their claims.
13 All the offices/branches are advised to get this circular noted from the retired member employees who have retired or are drawing pension from their branches. A copy of this circular be also displayed on the Notice Board.
(K.L. BAREJA)
DEPUTY GENERAL MANAGER
ANNEXURE-I
1 .TITLE:
The Scheme shall be called ‘PNB Medi-claim Insurance Scheme for Retired Employees’.
2. ELIGIBILITY :
i) Employees retired from the Bank’s service
‐ On attaining the age of superannuation.
- Under the bank’s voluntary retirement scheme.
ii) Employees retired on medical ground.
iii) Retiring employees can opt for the scheme immediately at the time of their retirement.
iv) In case of the death of an employee during his/her service period or after his/her retirement, the option to join the membership of the ‘PNB Medi-claim Insurance Scheme for Retired Employees’ shall remain open for the spouse of the said employee.
v) Employees who have been discharged/ dismissed/ removed from service/ compulsorily retired or terminated on grounds of misconduct will not be eligible.
3. WHEN TO OPT FOR THE SCHEME:
‐ Membership to the scheme is optional subject to the fulfillment of the eligibility criteria stated under point no. 2 above.
- Membership is permitted only at the time of renewal of the scheme each year which is valid separately for each calendar year.
- Mid- term Membership under the scheme is not permitted by the Insurance Company during the currency of the policy, except for those employees who retire during the relevant calendar year and opt for membership of the scheme immediately after their retirement from the bank service for the remaining part of the year.
4. PERSONS COVERED UNDER THE SCHEME:
The benefits of the scheme is allowed only to the ex-employees and their spouses.
5. AGE LIMIT:
There is no lower/ upper age limit for joining the scheme. However, the premium required to be paid for membership to the scheme is related to the age of the beneficiary member.
6. OBJECTIVE:
The scheme has been floated with an object to provide assistance to the retired employees of the Bank and their spouses, which makes them eligible to seek reimbursement of hospitalization expenses incurred anywhere in India at any time during the currency of the
scheme. Beneficiaries under the scheme are covered for incidents/ eventualities that may result in injury or disease/ illness leading to :hospitalization including admission to a nursing home. Expenses with respect to pre- hospitalization and post-hospitalization are also covered under the scheme as per details below.
7. OPERATION OF THE SCHEME:
The medical insurance cover under the scheme shall commence from 1st January 2015 and would be valid upto 31st December 2015. Details of the premium to be paid is available at point no. 13.
8. DEFINITIONS:
The following words, terms or expressions wherever they may appear in this scheme or even otherwise, shall be deemed to have meaning expressed hereunder:-
a) Member: shall mean a member of ‘PNB Mediclaim Insurance Scheme for Retired Employees’.
b) Hospital/ Nursing Home: would mean any institution in India established for indoor care and treatment of sickness and injuries and which has been registered as a Hospital or Nursing Home with the local authorities and is under supervision of a Registered and qualified Medical Practitioner. The Hospital or 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 of alcoholics, a hotel or a similar place.
c) Surgical Operation : would mean manual and / or operative procedures for correction of deformities and defects, repair of injuries, diagnosis and cure of disease, relief of suffering and prolongation of life.
9. Minimum Period: shall mean expenses on hospitalization for minimum period of 24 hours are admissible. However, this time limit is not applied to specific treatments i.e. Dialysis, Chemotherapy, Radiotherapy, Eye Surgery, Lithotripsy (Kidney stone removal), D & C,
Tonsillectomy if taken in the Hospital/ Nursing Home as ‘Day Care’ and the Insured is discharged on the same day; the treatment will be considered to be taken under hospitalization benefit.
10. Period of Hospitalisation: shall include a maximum period of 30 days as prehospitalisation and maximum period of 60 days as post- hospitalisation period.
11. Disease : shall mean any illness, disease or injury requiring hospitalization. The following diseases/ surgical measures are to be treated as Special/Critical Operations:
i) Nephritis of any Aetiology plus Bacterial renal failure requiring Kidney Transplantation and/ or Dialysis.
ii) Cerebral or Vascular Strokes.
iii) Open and Close Heart Surgery (inclusive of C.A.B.G. inclusive cost of valves, PTCA. Heart Failure.
iv) Malignancy disease which were confirmed on Histopathological report,Encephalitis (Viral).
v) Neuro Surgery.
vi)
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vii) Total Replacement of joints.
viii) Liver disorder (Hepatitis B & C) associated with complications like Cirrhosis of liver (excluding caused by alcohol ).
ix) Grievous injury including multiple fracture of long bones, head injury leading to unconsciousness, burns of more than 40%, injury requiring artificial ventilator support plus Vertebral Column injury.
12. DOMICILARY AND NON-HOSPITALISATION : -Not covered.
(Except Chemotherapy/ Radiotherapy/ Dialysis if under taken in hospital).
13. PREMIUM: The premium payable after adjustment of subsidy @ 2500/- per member shall be as under:
Sum Assured
Rs. Premium for age upto 70 years Rs. Premium for age Above 70 &  to 80 years Rs. Premium for age Above 80 years.
Rs. 1 Lac 3766 4382 5146
Rs  2 Lacs 9140 10332 12032
Rs  3 Lacs 13637 14392 17409
Rs 4 Lacs 19892 20418 24118
The above premium amounts are inclusive of Service Tax.
14. COVERAGE UNDER THE SCHEME : The scheme which covers the member and his/her spouse provides as under :
14.1 Rs. One Lac on floater cover basis for the member and his/ her spouse subject to a maximum ceiling as under:
- Hospitalisation expenses for treatment of Special/Critical Operations as indoor patient as specified in the scheme on production of original bills/ cash memos etc. – Max. Rs. 70,000/-.
- Non surgical hospitalization expenses as indoor patient on production of original bills/ cash memos etc. — Max. Rs. 30,000/-.
- Hospitalisation expenses for surgical interference as indoor patient on production of original bills/ cash memos etc. – Max. Rs. 30,000/- ( including the cost of any surgical Implant ).
- This sub-limit for non-surgical hospitalization & surgical interference put together, shall not exceed — Max. Rs.30000/-.
- However, this sub limit in case of Cataract operation (including I.O.L.) is Max. Rs.15000/- only per eye. In such cases, sticker of lens used must be accompanied with claims.
- The sub limits enumerated would be applicable directly in proportion to the sum insured, in multiples of Rs.1 lac.
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- 30 days pre-hospitalization and 60 days post-hospitalization expenses are covered.
- Pre existing diseases are covered.
- Hospitalization/Admission on or after the date of commencement of the scheme is covered. However, Persons already admitted at the time of commencement of the scheme/ policy shall not be covered.
14.2 SUB LIMITS :
( Amt. in Rs. )
14.3 Package charges for specialized treatment subject to insurance cover with details as above.
15. EXCLUSIONS :
1. The 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 Injury or 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 ).
2. Circumcision unless necessary for treatment of a disease not excluded hereunder or as may be necessitated due to an accident, vaccination or inoculation or change of life or cosmetic or aesthetic treatment of any description, plastic surgery other than as may be necessitated due to an accident or as a part of any illness.
3. Cost of spectacles and contact lenses, hearing aids.
4. Any dental treatment or surgery which is a corrective cosmetic or aesthetic procedure, including wear and tear, unless arising from disease or injury and which requires hospitalization for treatment.
5. Convalescence, general debility, “Run-down” condition or rest cure, congenital external disease or defects or anomalies, sterility, venereal disease, intentional self-injury and use of intoxicating drugs/alcohol.
Sum Assured Room Rent            ICU                       Cataract
Max. per day    (Max. per day )      Operation
1,00,000        Twin sharing            2000                           15000
2,00,000        Twin sharing            4000                           20000
3,00,000         Twin sharing           6000                           25000
4,00,000        Twin sharing            8000                           40000

                                  4000/-
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6. All expenses arising out of any condition directly or indirectly caused to or associated with Human T-Cell Lymphotropic Virus type III (HTLB-III or Lymphadinopathy associated Virus ( LAV) or the Mutants Derivative or Variations Deficiency Syndrome or any Syndrome or condition of a similar kind commonly
referred to as AIDS.
7. Charges incurred at Hospital or Nursing Home primarily for diagnostic, X-ray or laboratory examinations not consistent with or incidental to the diagnosis and treatment of the positive existence or presence of any ailment, sickness or injury, for which confinement is required at a Hospital/ Nursing Home.
8. Expenses on vitamins and tonics unless forming part of treatment for injury or disease as certified by the attending Physician.
9. Injury or Disease directly or indirectly caused by or contributed to by nuclear weapons/ material.
10.Treatment arising from or traceable to pregnancy, childbirth, miscarriage, abortion or complications of any of this, including caesarian section.
16. PROCEDURE FOR MEMBERSHIP:
The eligible retired employees as well as their spouses desirous to become member of the scheme shall submit their duly filled application in the format (Annexure II ) latest by
26th December 2014 along with a prescribed yearly premium in the form of PNB CBS cheque / DD payable at Delhi favoring ‘PNB Medi-claim Insurance Scheme for Retired Employees’. Applications received without necessary premium and prescribed format duly
filled in and signed will not be entertained. Those who are retiring during the tenure of the policy must send their application along with prescribed yearly premium immediately on their
retirement.
17. MODE OF SETTLEMENT OF CLAIM:
‐ Settlement of claims lodged by the members will be made by the Insurance Company through its TPA- M/s. Park Medi-claim TPA ltd, 702, Vikrant Tower, Rajindra Place, New Delhi-110008, designated by National insurance company ltd, Divisional Office- II, 386-387, Old Railway Road, Jacubpura, Gurgaon, HR. on the basis of claims made by the retired employees / legal heirs as the case may be, whose decision shall be final and binding. In no case, the claims are to be sent to the bank directly.
‐ The application/ enrolment form for membership will be available at Personnel Admn. Division, HO. New Delhi besides being available at all Circle Offices of the Bank.
- All claims must be accompanied by original documents including Discharge Certificate and details/ break up of hospitalization expenses.
18. FALSE CLAIM / INFORMATION:
In case, any false claim /information is found to have been submitted by any member at any stage, his/her membership shall be cancelled for all times and he/she shall not be eligible for re- enrollment. In such cases, subscription paid will automatically be forfeited and claim
preferred if any, will not be reimbursed and any reimbursement
already received by the member under the scheme will have to be refunded to the Insurance Company.
19. GENERAL:
i) The operation of the scheme is subject to availability of minimum required number of retired employees. The Bank has discretion to discontinue the scheme at any point of time.
ii) Mid- term inclusion of the membership in the scheme is permitted in case of retiring employees only any time during the year, on the payment of pro- rata premium on monthly basis. In such cases, insurance coverage would be available up to 31st December during the currency of the scheme.
iii) Modifications/ Amendments to the scheme is the sole discretion of the bank.
iv) Fresh enrolment form need not be submitted for existing members who wish to renew their membership.
v) For renewal of membership, remittance of premium within the stipulated time along with existing enrolment number by way of CBS cheque / DD shall be sufficient.
vi) As the scheme is run on Cashless basis, it is advised to send the correct and complete particulars along with the required premium. For details of the “chain of empanelled hospitals of the TPA” and all other related information, please visit website of the TPA: www.parkmediclaim.co.in
vii) Please do not forget to send mandatory intimation of hospitalization to the TPA/insurance company otherwise the claims may be rejected by them. Tel.No.of National Insurance Co.: 0124-4201100, 4201101 and Park Mediclaim TPA: 011-
43191023, 011-43191000-30.
ANNEXURE II
APPLICATION / ENROLMENT FORM FOR ‘PNB MEDI CLAIM INSURANCE SCHEME
FOR RETIRED EMPLOYEES’.
(To be sent latest by 26.12.2014 in case of retired employees and or immediately at the time of retirement for retiring employees.
Chief Manager
For Office use only
Punjab National Bank,
Personnel Admn. Division
Enrolment No., _____
Head Office, 7 Bhikhaiji Cama Place,
New Delhi-110066.
Dear Sir/Madam,
Please affix joint
photograph of self and
spouse
Please enrol me as Member of the above scheme to which I hereby opt. I have gone through the rules and regulations of the scheme and agree to abide by the rules and regulations of the same as may be modified / amended from time to time. Particulars about myself and
my spouse are given below:
1. Name of Employee ________________________ 2. P.F No.____________
(In Block Letters)
3. Name of Spouse _________________________
4. PPO No. _____________ 5. Name of the Pension Paying Branch _________
5. Father’s/Husband ‘s Name_____________________________________________
(In Block Letters)
6. Date of Birth a) Self ______________ b) Spouse___________
7. Date of retirement ___________________
8. Office from which retired _____________________________
Under CO/RO____________________________
(Write the name) ZO/HO________________________
09. Designation & Scale