Section A: About the scheme:
Q.A1: What is the name of the scheme?
Ans: Medical Insurance Scheme for the Officers/Employees of IBA Member Banks parties to the Bipartite Settlement / Joint Note dated 25th May 2015 in lieu of existing Hospitalization Scheme.
Q.A2: What is period of the Policy?
Ans: 1st October, 2015 to 30th September, 2016 to be renewed on annual basis.
Q.A3: For whom this scheme applies to?
Ans: This scheme applies to:
- All existing Officers , Employees and their dependent Family members (Spouse + Dependent Children + any two of the Dependent parents / Parent-in-law)
- All new Officers /employees from the date of joining as per their appointment letter
- Continuity benefits coverage to Officers / employees on retirement and also
- The Retired Officers / Employees who may be inducted in the scheme.
Q.A4: What is Sum Insured?
Ans: The Sum Insured for Hospitalization and Domiciliary Treatment Coverage as defined in the scheme per annum
Officers : Rs. 4, 00,000/-
Clerical Staff : Rs.3, 00,000/-
Sub Staff : Rs.3, 00,000/-
Q.A5: Does this scheme apply to the dependents with any age and other restrictions?
Ans: On receipt of list from the member Bank mentioning the data of the employees bifurcated into
Q.A6: How and when the coverage under the scheme would commence?
Ans: On receipt of list from the member Bank mentioning the data of the employees bifurcated into
- Officers with the data of their dependent family members
- Clerical Staff with the data of their dependent family members
- Sub staff with the data of their dependent family members
Q.A7: What would happen in case of hospitalization of any dependent family members whose data yet to be provided to TPA?
Ans: Claim of such member would be settled on certification and recommendation of the appropriate authority of the respective Bank by the authorized TPA
Q.A8: Who is the authorized TPA and by whom the TPA is appointed?
Ans: The Heritage Health TPA Pvt. Ltd. has been appointed by the United India Insurance Co.Ltd., the lead Insurer.
Q.A9: In case of Hospitalization whether all treatment charges are payable under this scheme?
Ans: Reimbursement of following treatment charges are available under the scheme in case of hospitalization for more than 24 hours:-
- Room, Boarding expenses not exceeding Rs.5000/- per day or actual whichever is less
- ICU (Intensive Care Unit) not exceeding 7500/- per day or actual whichever is less
- Doctor, Nursing and all other treatment related expenses for which hospitalization has been advised by the treating doctor and appear customary and reasonable will be reimbursed under the scheme.
- Hospitalization expenses incurred for Donor (excluding cost of organ) in case of organ transplant of the insured member.
Q.A10: In case of hospitalization for less than 24 hours, whether any reimbursement scope available in the scheme?
Ans: Yes, in case of Day Care treatment for specified diseases (mentioned in the Policy) in the following situations:
Any surgery under GA/LA in a hospital/day care centre where patient stays for less than 24 hours because of technological advancement.
Such procedure would have required hospitalization for more than a day
Q.A11: Is there any scope for reimbursement in case patient is treated at Home?
Ans: Yes, this is called Domiciliary Hospitalization benefit and this scheme has been extended to cover 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:
- The condition of the patient is such that he/she is not in a condition to be removed to a hospital or
- The patient takes treatment at home on account of non availability of room in a hospital.
- Domiciliary Treatment shall also be covered under this scheme i.e. treatment taken for Specified Diseases which may or may not require hospitalization as mentioned in the scheme and such Domiciliary Hospitalization /Domiciliary treatment has to be certified by the recognized Hospital authorities and Bank’s Medical Officer when reimbursement would be considered 100% or actual basis subject to limit of sum insured. The cost of Medicines Investigations, consultations etc. In respect of Domiciliary treatment shall be reimbursed for the period stated by 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
Q.A12: Apart from Hospitalization expenses any other incidental expenses incurred by the member whether payable under the scheme?
Ans: Yes, following additional benefits are available under the scheme:
- Pre Hospitalization treatment expenses related to the disease up to 30 days maximum incurred prior to 30 days of hospitalization
- Post hospitalization treatment expenses as per follow up treatment advice on discharge up to a period of 90 days maximum from the date of discharge.
- Additional Ex-Gratia for Critical Illness:
In addition to reimbursement covered under this scheme, Officers / Employees ( Only officers / employees and not their dependents or Retired Officers / Employees) shall be provided additional ex gratia of Rs.1,00,000/- in case an employee contracts a Critical Illness as listed in the Scheme. The benefit shall be provided on first detection/diagnosis of the Critical Illness Hospitalization is not required to claim this benefit.
Q.A13: Whether Maternity benefit can be availed under the scheme? If yes, what are the limits?
Ans: Hospitalization expenses in respect of the new born child can be covered within the Mother’s Maternity Expenses. The maximum benefit allowable under this section will be up to Rs.50000/- for normal delivery and 75000/- for Caesarean Section.
Maternity expenses/treatment shall include:
- Medical treatment expenses traceable to childbirth(including complicated deliveries and Caesarean sections incurred during hospitalization)
- Expenses towards medical termination of pregnancy during the policy period
- Pre-natal & post natal charges in respect of maternity benefit are covered under the policy up to 30 days and 60 days only, unless the same requires hospitalization.
- Complications on maternity would be covered up to the Sum Insured plus the Corporate Buffer
Q.A14: Whether any expenses related to complications of new born baby after birth is recoverable under this scheme?
Ans: All expenses incurred on the on the new born baby during maternity will be covered in addition to maternity limit and up to Rs.20,000/-
Q.A15: Whether transportation Charge for shifting of patient to hospital and home is reimbursable?
Ans: Ambulance charges are payable up to Rs.2500/-
per trip maximum for carrying patient 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) may also be considered based on valid proof of such incurred expenses.
Q.A16: Whether any treatment in OPD set up is reimbursable?
Ans: Only treatment taken for Accidents can be considered even on OPD basis in Hospital.
Q.A17: Whether charges incurred for Nurse / Attendant during hospitalization period is reimbursable?
Ans: Such charges during hospitalization will be payable only in case of recommendation from the treating doctor in case of stay in ICU/CCU, Neo Natal nursing care or any other case where the patients critical and requiring special care.
Q.A18: Whether alternative treatments apart from “Allopathy” are covered under this scheme?
Ans: Yes, Alternative Treatments are forms of treatment other than treatment of “Allopathy” or “modern medicine” and includes Ayurveda, Unani, Siddha, Homeopathy and Naturopathy in the Indian Context, for hospitalization only and Domiciliary hospitalization treatment only as specified in the scheme.
Q.A19: For Ayurvedic treatment is there any specific guideline in the scheme?
Ans: For Ayurvedic Treatment, hospitalisation expenses are admissible only when the treatment has been undergone in a Government Hospital or in any Institute recognised by the Government and/or accredited by Quality Council of India/National Accreditation Board on Health.
Section B: For Enrolment & Issue of ID cards:
Q.B1: How enrolment of membership in the scheme would be done?
Ans: The member Bank will submit their employee data along with photographs and pay the premium to Lead Insurance Company i.e. United India Insurance Co.Ltd.
Q.B2: What is ID card and for what purpose the same will be used?
Ans: The TPA will issue an Identification (Physical/E Card)
card to each insured for identification purpose
. The ID card has a unique number which will be helpful in communication with the TPA and this number should be quoted in all communications with the TPA.
Q.B3: Is photo ID card necessary?
Ans: The ID cards will be mainly useful in availing cashless. Hence, photo ID card is necessary for availing cashless facility. Till the time, employee data & photographs are provided to the TPA, cashless facility will be provided after due confirmation from the authorised personnel of the bank.
Q.B4: How will I get my ID card?
will be generated shortly on receipt of the employee/dependent data and made available on our Website which can be accessed and downloaded.
Physical ID Cards
will be issued after receipt of insured data & photographs. The ID card kit will be sent to the respective zonal offices.
Q.B5: What documents do I get along with Physical ID cards?
Ans: A Guide Book for the insured containing general information and important tips related to claim procedures, List of Network Hospitals/Nursing Homes throughout India; specimen of Pre-authorization Request Form for cashless hospitalisation purpose.
Section C: Claims:
Q.C1: What is Cashless claims?
Ans: Cashless Claim service is the service where patient need not to pay any amount either as a deposit
at the time of admission or for the admissible treatment cost
as per hospital bills subject to policy terms & condition. This facility is available only at network providers
. To avail the “Cashless Service” patient need to get an authorization from Heritage for hospitalization in the network.
Q.C2: Is there any time limit for cashless?
Ans: TPA would ensure prompt cashless authorization on receipt of such request, through completed pre-authorization request as per format annexed in Guide Book.
In case of Emergency hospitalisation insured may submit the copy of ID within 24 hours of admission to the TPA Desk of the hospital.
Q.C3: What is a Reimbursement claim?
Ans: Claim for which cashless benefit not extended/availed, such claim is referred as “Reimbursement” claim. In other words, expenses incurred by insured for hospitalisation treatment upfront and subsequently request placed for reimbursement.
Q.C4: What is intimation?
Ans: Intimation is preliminary notice of claim with particulars relating to policy number, name of insured person in respect of whom claim is to be made, his / her ID Card Number &/or Employee S.r. Number; nature of illness/injury and name and address of attending medical practitioner/Hospital/Nursing Home to the TPA. It is required to record claim on reimbursement basis.
Q.C5: Is there any time limit for intimation?
Ans: Intimation of claims should be made at the earliest within 7 days from time of admission or before time of discharge whichever is earlier.
Q.C6: What is Network Hospital?
Ans: Hospital/Nursing Home is having agreement with TPA for providing cashless facility to the insured members of the concerned TPA.
Q.C7: What is non- Network Hospital?
Ans: Any Hospital / Nursing Home not enlisted in the Network of the TPA for providing cashless facility.
Q.C8: Where do I get list of Network Hospital?
Ans: An updated list of Network Hospitals is available on our website i.e. www.heritagehealthservice.com
and/or with our call centre/help line.
The list is also available in the Guidebook issued by us along with ID card which is subject to change.
Q.C9: I want cashless facility for my planned treatment, please, guide me.
Ans: For planned hospitalisation, insured to approach network hospital of his/her choice along with Photo ID card, Doctor’s advice for hospitalization, prescription/consultation, all investigation reports etc.The network hospital would arrange to forward to TPA duly filled in pre-authorization request form seeking cashless authorization of the insured.
Q.C10: What will I need to do in case of an Emergency admission?
Ans: In case of emergency admission to Network hospital, ID card and other treatment details to be made available to the hospital within 24 hours from the time of emergency admission. Hospital will arrange to forward documents along with completed pre-authorization request form to TPA for cashless authorization.
In case of non network hospital, concerned employee must coordinate with the TPA with full details
- At Toll Free No. : 1800 102 4547
- Help Line No. : 033-40334141
Q.C11: What documents are required for availing cashless?
- Photo ID card
- Doctor’s advice for hospitalization
- Prescription/consultation, all investigation reports etc to be submitted to the Cashless Desk of the network hospital who will arrange for completed pre-authorization request form.
Q.C12: I have not yet received ID card, what should I do to avail cashless?
Ans: Cashless facility will not be available in the absence of Photo ID card duly issued by the TPA.
However, during the transition period, the same can be considered on timely receipt of:
- - Copy of employee’s identity card bearing employee ID with photo
- - Email from concerned nodal officer of the concerned Bank, indicating employee ID No., Sum Insured etc.
Q.C13: What documents shall I get on discharge from hospital in cashless case?
Ans: The hospital will submit all original documents directly to TPA for payment in cashless cases. The copy of Discharge Summary with advice of follow up treatment, copy of final bill etc may be collected by the patient party. However, original money receipt against payment by patient party will be made available.
Q.C14: What is the process of bills settlement of the hospital in cashless?
Ans: The patient must sign the final bill before leaving the hospital. Hospital will submit all original documents to TPA seeking payment against authorization. Payment to Hospital would be directly made by TPA after due verification.
Q.C15: Can I claim for the expenses incurred during pre-hospitalisation & post-hospitalisation?
Ans: Yes, as per the policy term and condition, the expenses of 30 days prior to & related to the disease for which insured have been hospitalized and 90 days after date of discharge can be claimed on production of original bills, cash memos, prescription, reports etc.
Q.C16: What is the process of getting reimbursement claim?
Ans: In case of submission of request seeking reimbursement of treatment cost, insured should submit:
- Claim form duly completed showing his/her total monetary claim by enclosing original
- Prescription, bill/receipt and Discharge Certificate /Card from the Hospital
- Cash Memos from Hospitals (s) / Chemists (s), supported by proper Prescriptions
Receipt and Pathological Test reports from Pathologist supported by the note from the
Attending Medical Practitioner/Surgeon recommending such Pathological Test
Related to hospitalization treatment.
- Certificate, if any, from attending Medical Practitioner / Surgeon that the patient is fully cured.
Q.C17: Is there any time limit for submission of claim documents?
Ans: For hospitalisation and pre-hospitalization expenses, claim should be made within 30 days from the date of discharge
from hospital. For Post hospitalization
(available up to a period of 90 days from date of discharge) claims should be submitted to the TPA within 30 days from the date of completion of such treatment.
Q.C18: How payment will be made in reimbursement of my expenses?
Ans: Reimbursement claim settlement would be made by directly transferring the amount of settlement to the bank account of the employee through NEFT/RTGS
Q.C19: Whom do I contact for my queries/question related to claims?
Ans: To the office of TPA in their Dedicated set up -
- Toll Free No. : 1800 102 4547
- Help Line No. : 033-40334141
Q.C20: Is there any Time limits for approval of Cashless Hospitalisation Claims?
- Authorization of Initial Cashless facility - Within 1/2 Hour from receipt of complete Documents
- Authorization of Final approval on
Discharge during Cashless facility - Within 1/2 Hour from receipt of complete Documents
Q.C21: Is there any Grievance Redressal mechanism?
Ans: In case of any grievance insured may contact TPA at
Email ID for grievance and complaint : email@example.com
Finally, disputes arising out of decision TPA, if any, would be resolved by constitution of Regional redressal committee constituted at each R.O. as per administrative guideline issued.