Indian Banks

1
Indian Banks Association Policy
ISO 90012008 Certified Company
Medical Scheme for the Employees and their Family
members
Raksha TPA
2
SALIENT FEATURES OF THE POLICY

• GMC Policy is through United India Insurance
  Company
• Policy Effective Date Proposed 1st October 2015
  to 30th September 2016
• Policy is issued in the name of Indian Banks
  Association (IBA) Member Banks - giving 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.

Raksha TPA
3
SALIENT FEATURES OF THE POLICY

• Covers Employee Spouse Dependent Children 2
  dependent Parents /in laws.
• No Age Limit for dependent Children (including
  Step and Legally adopted children ).
• Widowed and dependent divorced/separated
  Daughters, sisters including unmarried/
  divorced/abandoned or separated from Husband
  /widowed sisters and Crippled Child shall be
  considered as dependent.

Raksha TPA
4
SALIENT FEATURES OF THE POLICY

• Physically challenged Sister/Brother with 40
  or more disability.
• Child is considered dependent if his/her monthly
  income does not exceed Rs. 10,000/- per month
• No Age Limit for dependent Parents/In laws
• Parents would be considered dependent if there
  monthly income does not exceed Rs. 10,000/-per
  month or as revised by IBA (Indian Bank
  Association)

Raksha TPA
5
SALIENT FEATURES OF THE POLICY

• All the existing permanent officers/employees of
  the Bank are covered in this scheme.
• All New Employees covered from the date of
  joining as per their appointment letter.
• Continuity benefits coverage to
  Officers/employees on retirement subject to
  payment of premium.
• Also cover the existing retired
  officers/employees of the Bank and dependent
  spouse subject to payment of premium.

Raksha TPA
6
SALIENT FEATURES OF THE POLICY

• Sum Insured Hospitalization Domiciliary
  Treatment coverage
• Officers 400000
• Clerical Staff 300000
• Sub Staff 300000
• (Change in sum insured after commencement of
  policy to be considered in case of promotion of
  employee or vice versa)

Raksha TPA
7
CASHLESS AND CLAIMS

• All the employees and their family members would
  be issued ID Cards / E-cards. Which can be
  downloaded from Raksha Mobile App (to download
  from Play Store on your smart Phone) or Register
  your mail Id for downloading the card and all
  future correspondence and update alert from
  Raksha.
• This would enable them to claim from anywhere in
  India and also admit themselves in any Hospital
  by just calling the Call center.
• Most of the claims would be cashless.
• INTIMATION
• Claim Intimation within 7 days for emergency
  Hospitalization from the time of
  Hospitalization/Domiciliary Hospitalization.
  

Raksha TPA
8
CASHLESS AND CLAIMS

• SUBMISSION
• All Claim documents to be submitted within 30
  days from the date of discharge from the
  Hospital.
• Post hospitalization claim documents (limited to
  90 days) to be submitted within 30 days after
  completion of such treatment.
• The Officers/employees would submit the claims to
  the same regional / nodal offices where they have
  been submitting in the past and TPA
  representative will be the backup support and
  supporting the bank in clearing all the claims on
  real time basis.
• Treatment taken in India Only.

Raksha TPA
9
CLAIMS

• CLAIM REJECTION No claim to be rejected by the
  insurance company/ Third Party Administrator
  unless same is rejected by the committee
  comprising of the
• Bank management,
• Insurance Company,
• Third Party Administrator
• Reimbursement claims of pre and post
  hospitalisation or in a few cases of actual
  hospitalisation would be paid to the employees
  through the banks regional/ nodal offices or
  directly credited to the employees account.

Raksha TPA
10
POLICY TERMS AND CONDITIONS

• CORPORATE BUFFER
• Rs. 100,00,00,000/- to be used for Major Ailments
  on a case to case basis at the discretion of the
  Management.
• The Corporate buffer may be appropriated as per
  the premium contribution of the bank. If the
  Corporate buffer of one bank is exhausted , at
  the discretion of the Centralized Committee, the
  same may be augmented from the Corporate Buffer
  of another Bank. This may be done during the
  year, Or at the end of the year, from the
  unutilized amount of a buffer of another Bank.
• Corporate Buffer can be authorized, through an
  Authorized person / Committee as decided by IBA /
  Bank, and informed by the Management directly to
  the THIRD PARTY ADMINISTRATOR by keeping the
  insurance company in the loop.

Raksha TPA
11
POLICY TERMS AND CONDITIONS

• Room Rent including Nursing expenses
• Not exceeding Rs. 5000 per day or the actual
  amount whichever is less.
• Intensive Care Unit (ICU) expenses
• Not exceeding Rs. 7500 per day or actual amount
  whichever is less.
• Surgeon, team of surgeons, Assistant surgeon,
  Anesthetist, Medical Practitioner, Consultants,
  Specialists Fees.

Raksha TPA
12
POLICY TERMS AND CONDITIONS

• Nursing Charges , Service Charges, IV
  Administration Charges, Nebulization Charges, RMO
  charges ,Anaesthetic, 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, orthopaedic implants,
  Cochlear Implant, any other implant,
  Intra-Occular Lenses, , infra cardiac valve
  replacements, vascular stents, any other valve
  replacement, laboratory/diagnostic tests, X-ray
  CT Scan, MRI, any other scan, scopes' and such
  similar expenses that are medically necessary, or
  incurred during hospitalization as per the
  advice of the attending doctor,
• Hospitalization expenses (excluding cost of
  organ) incurred on donor in respect of organ
  transplant to the insured.

Raksha TPA
13
POLICY TERMS AND CONDITIONS

• Pre and Post Hospitalization Expenses
• Actual expenses incurred subject to 30 days
  prior to hospitalization and 90 days after
  discharge.
• PPN (Preferred Provider Network)
• Reimbursement of expenses incurred in Preferred
  Provider Network for the procedures (as listed
  under PPN package) shall be subject to the rates
  applicable to PPN package pricing.

Raksha TPA
14
Domiciliary Treatment

• Medical Expenses in case of the following
  diseases which need Domiciliary treatment needs
  to be certified by the recognized hospital
  authorities and bank's medical officer only then
  shall it be deemed as hospitalization expenses
  and reimbursed to the extent of 100.
• The cost of Medicines, Investigations and
  consultations, etc. in respect of domiciliary
  treatment shall be reimbursed for the period
  stated by the specialist in Prescription. If no
  period stated, the prescription for the purpose
  of reimbursement shall be valid for a period not
  exceeding 90 days.

Raksha TPA
15
Domiciliary Treatment
Raksha TPA
16
Domiciliary Treatment

• Accidents of Serious Nature , Cerebral Palsy, ,
  Polio, All Strokes Leading to Paralysis,
  Haemorrhages caused by accidents, All
  animal/reptile/insect bite or sting , chronic
  pancreatitis, Immuno suppressants, multiple
  sclerosis / motorneuron disease, status
  asthamaticus, sequalea of meningitis,
  osteoporosis, muscular dystrophies, sleep apnea
  syndrome(not related to obesity), any organ
  related (chronic) condition, sickle cell disease,
  systemic lupus erythematous (SLE), any
  connective tissue disorder, varicose veins,
  thrombo embolism venous thrombosis/venous
  thrombo embolism (VTE), growth disorders,
  Graves disease, Chronic obstructive Pulmonary
  Disease, Chronic Bronchitis, Asthma,
  Physiotherapy and swine flu shall be considered
  for reimbursement under domiciliary treatment.

Raksha TPA
17
Domiciliary Hospitalization

• Domiciliary Hospitalization means medical
  treatment for a period exceeding three days for
  such 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
  
• a.    The condition of the patient is such that
  he/she is not in a condition to be removed to a
  hospital or
• b.    The patient takes treatment at home on
  account of non-availability of room in a
  hospital. 

Raksha TPA
18
Domiciliary Hospitalization

• Domiciliary hospitalization benefits shall not
  cover
• i) Expenses incurred for pre and post hospital
  treatment and
• ii)Expenses incurred for treatment for any of
  the following diseases-
• Chronic Nephritis and Nephritic Syndrome
• Diarrhoea and all type of Dysenteries including
  Gastroenteritis
• Epilepsy
• Influenza, Cough and Cold
• Pyrexia of unknown Origin for less than 10 days
• Tonsillitis and Upper Respiratory Tract infection
  including Laryngitis and pharangitis
• Gout and Rheumatism

Raksha TPA
19
CRITICAL ILLNESS

• Cover starts on inception of the policy. In case
  an employee contracts a Critical Illness as
  listed below, the total sum insured of
  Rs.1,00,000/- is paid, as a benefit (subject to a
  sum insured of Rs. 1,00,000/-).
• Hospitalization is not required to claim this
  benefit. Further the Employee can claim the cost
  of hospitalization on the same from the Group
  Mediclaim Policy as cashless / reimbursement of
  expenses for the treatment taken by him.
• This benefit is provided on first
  detection/diagnosis of the Critical Illness.

Raksha TPA
20
CRITICAL ILLNESS

• Names of Illness
• Cancer Stroke Paralysis By Pass Surgery
  Major Organ Transplant End Stage Liver Disease
  Heart Attack Kidney Failure Heart Valve
  Replacement Surgery.

Raksha TPA
21
MATERNITY EXPENSES BENEFIT

• Maximum Maternity benefit Limit
• Normal Delivery Rs .50,000/-
• Caesarean Section Rs. 75,000/-
• Special Conditions
• 9 months waiting period waived.
• Pre-Post Natal charges in respect to Maternity
  benefit are covered under the policy up to 30
  days and 60 days only, unless same requires
  hospitalization.
• Missed Abortions, Miscarriage or abortions
  induced by accidents are covered under the limit
  of Maternity

Raksha TPA
22
MATERNITY EXPENSES BENEFIT

• Complications in Maternity including operations
  for extra uterine pregnancy / ectopic pregnancy
  would be covered in the up to the Sum Insured
  Corporate Buffer
• Expenses incurred for Medical termination of
  pregnancy
• Claim in respect of delivery to be given
  irrespective of the number of children.

Raksha TPA
23
BABY COVER

•  
• However if the baby contacts any illness the same
  shall be considered in the Sum Insured
  Corporate buffer.
• Baby to be taken as an additional member within
  the normal family floater.
• New born baby is covered from day one. All
  expenses incurred on the new born baby during
  maternity will be covered in addition to the
  maternity limit up to Rs, 20000/-.
•  

Raksha TPA
24
OTHER COVERAGES

• Day Care procedures
• Expenses on Hospitalization for minimum period of
  a day are admissible. However, this time limit is
  not applied to attached specific treatments.
• 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.

Raksha TPA
25
OTHER COVERAGES

• Alternative Therapy/Ayurvedic Treatment
  Reimbursement of Expenses for hospitalization
  under the recognized system of medicines , viz,
  Ayurvedic ,Unani, Sidha, Homeopathy , Naturopathy
  , if such treatment is taken in a clinic
  /hospital recognized by the central and state
  government is covered.
• Ambulance Charges
• 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.
• 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.
• Taxi and Auto expenses in actual maximum up to
  Rs750/- per trip.

Raksha TPA
26
OTHER COVERAGES

• Pre- Existing Diseases / Ailments Pre-existing
  diseases are covered under the scheme.
• Congenital Anomalies Expenses for Treatment of
  Congenital Internal / External diseases, defects
  anomalies are covered under the policy
• Psychiatric diseases Expenses for treatment of
  psychiatric and psychosomatic diseases be payable
  on hospitalization.
•  

Raksha TPA
27
OTHER COVERAGES

• Treatment for Age related Macular Degeneration
  (ARMD), treatment such as Rotational Field
  Quantum magnetic Resonance (RFQMR), Enhanced
  External Counter Pulsation (EECP), etc. to be
  covered under the scheme.
• Treatment for all neurological/ macular
  degenerative disorders shall be covered under the
  scheme.
•  

Raksha TPA
28
OTHER COVERAGES

• 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.
• 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, Neo natal nursing care or any other
  case where the patient is critical and requiring
  special care.

Raksha TPA
29
OTHER COVERAGES

• Rental Charges for External and or durable
  Medical equipment of any kind used for diagnosis
  and or treatment including CPAP, CAPD, 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.
• Treatment taken for Accidents can be payable even
  on OPD basis in Hospital up to Sum Insured.
• Treatment for Genetic Disorder and stem cell
  therapy to be covered under the scheme.

Raksha TPA
30
OTHER COVERAGES

• Ambulatory devices i.e., walker, crutches, Belts,
  Collars, Caps, Splints, Slings, Braces,
  Stockings, elastocrepe bandages, external
  orthopaedic pads, sub cutaneous insulin pump,
  Diabetic foot wear, Glucometer (including Glucose
  Test Strips)/Nebulizer/ prosthetic devise/
  Thermometer, alpha / water bed and similar
  related items etc., will be covered under the
  scheme.
• Physiotherapy charges Physiotherapy charges to
  be covered, if recommended even if taken at home.
•  

Raksha TPA
31
EXCLUSIONS

• 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)
• 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 such as correction
  of
• eyesight., etc,
•   d. Plastic surgery other than as may be
  necessitated due to an accident or as part of any
  illness.

Raksha TPA
32
EXCLUSIONS

• Cost of spectacles and contact lenses, hearing
  aids. Other than Intra-Ocular Lenses and Cochlear
  Implant.
• Dental treatment or surgery of any kind which are
  done in a dental clinic and those that are
  cosmetic in nature.
• Convalescence, rest cure, Obesity treatment and
  its complications including morbid obesity, ,
  treatment relating disorders, infertility,
  Sterility, Venereal disease, intentional self
  injury and use of intoxication drugs / alcohol.

Raksha TPA
33
EXCLUSIONS

• 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 Variation
  Deficiency Syndrome or any syndrome or condition
  of a similar kind commonly referred to as AIDS.
• 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.

Raksha TPA
34
EXCLUSIONS What is not covered?

• Expenses on vitamins and tonics unless forming
  part of treatment for injury or diseases as
  certified by the attending physician
• Injury or Disease directly or indirectly
  caused by or contributed to by nuclear weapon /
  materials.
• Change of treatment from one system of
  medicine to another unless recommended by the
  consultant/hospital under whom the treatment is
  taken.
• All non-medical expenses including convenience
  items for personal comfort such as charges for
  telephone, television, ayah, private
  nursing/barber or beauty services, died charges,
  baby food, cosmetics, tissue paper, diapers,
  sanitary pads, toiletry items and similar
  incidental expenses.

Raksha TPA
35
For Assistance

• Log on to our portal www.rakshatpa.com
• or mail us at helpIBA_at_rakshatpa.com
• Call Us at
• 0129 4289999 - Delhi
• 1800 180 1444 - Delhi
• 1800 220 456 - Mumbai
• 1800 425 8910 - Bangalore

Raksha TPA
36
Important Points for availing the Benefit

• Claim Intimation Submission
• As per the process the reimbursement claims are
  required to be intimated to Raksha TPA with in 24
  hour of hospitalization and compulsory have to be
  submitted original documents within 30 days of
  discharge from the hospital. This will ensure
  claims pay ability else the claims wouldn't be
  payable under intimation/submission clause.

Raksha TPA
37
How to intimate?

• Via writing mail by insured/relative/HR to Raksha
  (claimintimation_at_rakshatpa.comneeraj_at_rakshatpa.co
  m) with information
• Member ID
• Patient Name
• Hospital Name and Address
• Treatment
• Date of Admission
• Requested Amount

Raksha TPA
38
How to intimate?

• Calling to our 24 Hours Toll Free no./Call Center
  and providing above information
• 0129 4289999 - Delhi
• 1800 180 1444- Delhi
• 1800 220 456 - Mumbai
• 1800 425 8910- Bangalore

Raksha TPA
39
How to intimate?

• Online Registration
• Login to www.rakshatpa.com
• Click on Claim Intimation link (on left side of
  website home page)
• Punch in desired details like member id, date of
  admission, hospital name etc.
• Acknowledgement No. (i.e. your claim no.) shall
  reflect, please keep a copy of the same.

Raksha TPA
40
Steps to download ecard

• Step 1 Log in to www.rakshatpa.com 
• Step 2 Click on the link " IBA  .Click on PNB
  icon.
• Step 3 Fill your member id in ID Card number (IN
  CAPS)
• Step 4  Insured and dependant details will be
  reflected on screen, please select whose ecard
  need to be viewed or printed and then click show
  ecard. 
• Step5 Ecards will be reflected, please take
  print of the same as and when required.

Raksha TPA
41
Process Flow

• For availing Cashless Benefit.
• In case of planned hospitalization, please inform
  the TPA at least two days before hospitalization.
• You may visit www.rakshatpa.com and click on
  providers network for updated list of network
  hospital with contact details for availing
  cashless benefit.
• Ensure to keep copy of government photo id proof
  of patient along with BCCL employee id.
• In case of emergency, please ensure the treatment
  starts ASAP. Some hospitals have a policy of
  asking an advance for treatment start. The same
  is refundable once the cashless approval is
  received
• Please intimate the TPA in case of all
  hospitalization, even if you are paying for same
  and claiming later. The reimbursement claims are
  payable only in case the TPA is intimated within
  24 hours of hospitalization and documents in
  original are submitted within 15 days from date
  of discharge.
• Please keep a photo copy of all claim documents
  before taking discharge.
• Please review all bills at time of discharge and
  recheck consultant no. of visits against billed
  visits.
• Initial approval given is not the final approval
  and may vary with estimate cost given by
  hospital, final decision is given post
  adjudication of discharge summary which is issued
  at time of discharge.

Raksha TPA
42
Hospitalization Through Networking Hospital
Employee Approaches Network Hospital with
Raksha TPA ID Card
Hospital Intimates Raksha TPA and sends
Pre-Authorisation Request
Employee Bears Outpocket Expenses if
Hospitalisation Not Covered Under Policy
Conditions

Raksha TPA issues Authorisation Letter As per
Eligibility and Coverage
Advantages -Regulated Payouts in form of medical
expenses -Access to Top Quality Service
Providers( Hospitals) -No Arrangement of Funds
required for hospitalisation
At The Time Of Discharge Employee Leaves Back All
The Documents
- Minimum TAT of 2 Hours and in emergencies 1
Hour. - Incase of planned hospitalisation
intimation at least 2-3 days before admission
and incase of emergency as early as possible
Raksha TPA
43
REIMBURSEMENT HOSPITALISATION SERVICES
Insured Gets Hospitalised In Non-network Hospital
Claim Folder Is Sent To Raksha TPA
If Documents Are Insufficient Immediately
Intimated To Employee
Claim is Processed
Claim Passed / Rejected
Maximum Turn Around Time Subject To
Availability Of All Necessary Documents Will Be
10 working days
Raksha TPA
44
How to submit the documents for Reimbursement?

• Documents need to be submitted within 30 days
  from date of discharge from the hospital to your
  Regional / Nodal Offices where they have been
  submitted in the past and TPA representative
  will be the backup support and supporting the
  bank in clearing all the claims on real time
  basis.
• In case of query is being raised while processing
  the claim, satisfactory query reply need to be
  submitted within 30 days from query raised date
  failing to which file will be closed and insurer
  consent would be required to reopen the claim
  file.
• Pre (30 days from date of admission) Post (90
  days from date of discharge) claim need to be
  submitted within 30 days after completion of such
  treatment.

Raksha TPA
45
THANK YOU
Raksha TPA