भ रत य ररज र व ब क RESERVE BANK OF INDIA. CO.HRMD.No. G.47/3622/ / August 14, 2018

Transcription

1 भ रत य ररज र व ब क RESERVE BANK OF INDIA CO.HRMD.No. G.47/3622/ / August 14, 2018 Principal Chief General Manager/ Regional Director, Chief General Manager-in-Charge Chief General Manager/ General Manager (O-in-C) Principal, Training Colleges Reserve Bank of India Dear Sir, Medical Assistance Fund (MAF) Scheme - Group Mediclaim Policy for Retired members of MAFS - Renewal for the period August 15, August 14, Please refer to circular CO.HRMD.No.G.46/3838/ / dated August 11, 2017 on the above subject. 2. As you are aware, the Group Mediclaim Policy (GMP) taken from United India Insurance Company Ltd. expires on August 14, The Policy has since been renewed with effect from August 15, 2018 for a period of one year with Bajaj Allianz General Insurance Co. Ltd. on mutually agreed terms and conditions. 3. There is, however, no change in the Third Party Administrators (TPAs). The allocation of centers among the Third Party Administrators (TPAs) which is the same as during the last GMP is listed in Annex I. All claims pertaining to the MAF members attached to your office will be settled by the designated TPA, irrespective of the place where the treatment is taken. The centers allocated to the TPAs and the new policy will be effective for all hospitalizations commencing on or after August 15, The names, contact numbers and ids of the designated TPAs and representatives of the Insurance Broker are listed in Annex II. 4. As there is a change of insurance company for the Group Mediclaim Policy , new TPA cards will be issued to members for the year. 5. There is change in the grade-wise limit for ICU, room/bed charges which is shown in Table I. There is no change in per hospitalisation limit. Other terms and conditions of the new GMP are the same as that of the previous year day care surgeries are covered under the policy. Any further new advancement in treatment modalities to be covered if it is part of Day Care. The following enhancements/additions are made in current day care list: a) Injections for Autoimmune disorders/arthritis and ankylosing spondylosis. Limit will read as Rs. 25,000/- per case with maximum cap of 3-cases per year per family. म नर स स धन प रब ध वर भ ग, क द र य क य वलय भर न (20 र म ज ल), शह द भगत सस ह म गव, म बई , भ रत फ न : (91-22) फ क स : (91-22) ई-म ल : cgminchrmd@rbi.org.in Human Resources Management Department, Central Office Building (20th Floor), Shahid Bhagat Singh Road, Mumbai , INDIA Tel : (91-22) Fax : (91-22) cgminchrmd@rbi.org.in हहन द आस न ह इसक प रय ग बढ़ इए

2 b) Facility of Chemotherapy at home. 6. The salient features of the GMP are given in Annex III. 7. The list of Indicative Day-Care Procedures which do not require 24 hours hospitalization for the admissibility are furnished in Annex IV. 8. Intimation of hospitalisation should be done within 30 days from the date of admission. In reimbursement cases, claims along with all relevant documents must be submitted to the respective TPAs within 30 days from the date of discharge. TPAs would settle the claims within 15 days provided all the documents are submitted and are in order. 9. It may be noted that service tax, if any, charged by the hospitals will be paid/reimbursed by the TPA, provided it is within the overall monetary ceiling. 10. The members may be advised to contact the respective TPA representative as mentioned in Annex II for any guidance/clarification/ feedback etc., relating to the GMP. In all cases, the members may invariably provide their mobile telephone number for receiving SMS for preauthorization sanction and carry their MAF (photo) Card along with the TPA Identity Card for verification at the time of hospitalization, which may be required for identification. 11. In case of prolonged hospitalization where the claim is on reimbursement basis, the member should inform the designated TPA during the period of hospitalization. 12. There is no change in other instructions issued in this regard from time to time. The contents of this circular may be brought to the notice of / forwarded to all concerned. Yours faithfully, (Chetan Balwir) Deputy General Manager Encl:- As above 2

3 RBI- Medical Assistance Fund Scheme (MAFS)-Group Mediclaim Policy ( ) for Retired Members of MAFS Names of designated TPAs and Offices/Departments allotted to each TPA Sr. Name of the TPA Offices/Departments allotted No. 1 Raksha TPA Pvt. Ltd. Agartala Aizawl Bhubaneswar Central Office Departments Gangtok Guwahati Kolkata Shillong 2 Vidal Health TPA Pvt. Ltd. Ahmedabad Bangalore Belapur Bhopal CAB-Pune MRO Panaji Raipur 3 MD-India Healthcare Services (TPA) Pvt. Ltd. Chennai Hyderabad Kochi Nagpur Thiruvananthapuram 4 Medi Assist India TPA Pvt. Ltd. Chandigarh Dehradun Jaipur Jammu Kanpur Lucknow New Delhi Patna Ranchi Shimla Annex I 3

4 Annex II TPA-CONTACT DETAILS OF RELATIONSHIP MANAGERS- LOCATION WISE Raksha TPA Escalations: 1. Ms. Richi Doshi- ( ) 2. Mr. Manoj Mamtani- ( ) Sr. Centre Name E- mail id Contact No. No. 1 MUMBAI(CODs) Ms. Harshada Madge harshada@rakshatpa.com , Mr. Vinayak Pangat vinayak.pangat@rakshatpa.com , KOLKATA Mr. Anoop Kumar Das anup@rakshatpa.com GUWAHATI Mr. Raktim Phukan raktim.phukan@rakshatpa.com BHUBANESWAR Mr. Pradumn Pradhan pradumn@rakshatpa.com AGARTALA Mr. Raktim Phukan raktim.phukan@rakshatpa.com AIZAWL Mr. Raktim Phukan raktim.phukan@rakshatpa.com GANGTOK Mr. Raktim Phukan raktim.phukan@rakshatpa.com SHILLONG Mr. Raktim Phukan raktim.phukan@rakshatpa.com MD- India TPA Escalations: 1. Mr. Manish Pandey - mpandey@mdindia.com ( ) 2. Mr.Sachin Singh Rawat- srawat@mdindia.com ( ) Sr. Centre Name E- mail id Contact No. No. 9 CHENNAI Ms. Naga Jayanthi chennaicorp@mdindia.com HYDERABAD Mr. Nitin Bedarkar hyderabad@mdindia.com NAGPUR Mr. Prashant Sonule nagpurcorp@mdindia.com THIRUVANANTHAPURAM Mr. Praveen V trivandrum@mdindia.com KOCHI Dr. Pinchu Paulson ppaulson@mdindia.com

5 Vidal Health TPA Pvt. Ltd. Escalation: Mr Sudesh Patankar- ( ) Sr. Centre Name E- mail id Contact No. No. 14 AHMEDABAD Mr. Chandrakant Chauhan 15 BANGALORE Mr. Praveenkumar Mr. Avadhut Narkar Mr. Avadhut H.Narkar BHOPAL Mr. Avadhut H. Narkar MRO, Mr. Avadhut H. Narkar BELAPUR 18 PUNE Mr. Sachin PANAJI Mr. Avadhut H. Narkar RAIPUR Mr. Avadhut H. Narkar Medi Assist TPA Escalations: 1. Mr. Prem Singh- ( ) 2. Mr. Nitin Arora- ( ) 3. Dr. Ashwini Mulik- ( ) Sr. Centre Name E- mail id Contact No. No. 21 CHANDIGARH Mr. Amit Sharma JAIPUR Mr. Pankaj Saini JAMMU Mr. Amit Sharma KANPUR Mr. Deepak Shukla LUCKNOW Mr. Sameer Nigam NEW DELHI Mr. Manjeet Singh PATNA Mr. Rajesh Deepak RANCHI Mr. Rajesh Deepak DEHRADUN Mr. Amit Sharma SHIMLA Mr. Amit Sharma

6 Offices/ Departments allocated Agartala Aizawl Bhubaneswar CODs Gangtok Guwahati Kolkata Shillong Ahmedabad Bangalore Belapur Bhopal CAB-Pune MRO Panaji Raipur Chennai Hyderabad Kochi Nagpur Thiruvananthapuram Chandigarh Dehradun Jaipur Jammu Kanpur Lucknow New Delhi Patna Ranchi Shimla Aditya Birla Insurance Brokers Limited Communication Matrix as per the Zones and TPA allocation. Name Raksha TPA Pvt. Ltd. ID Moumita Mukherjee SPOC ( ) Parvati Gurung Escalation 1 ( ) Siddhi M Warang siddhi.warang@adityabirlacapital.com Escalation 2 ( ) Vidal Health TPA Pvt. Ltd. Parvati Gurung parvati.gurung@adityabirlacapital.com SPOC ( ) Bharat Hirway bharat.hirway@adityabirlacapital.com Escalation 1 ( ) Siddhi M Warang siddhi.warang@adityabirlacapital.com Escalation 2 ( ) MD-India Healthcare Services (TPA) Pvt. Ltd. Sandhya V sandhya.v@adityabirlacapital.com SPOC ( ) Jayanthi M jayanthi.m@adityabirlacapital.com Escalation 1 ( ) Siddhi M Warang siddhi.warang@adityabirlacapital.com Escalation 2 ( ) Medi Assist India TPA Pvt. Ltd. Karishma V SPOC ( ) Parvati Gurung Escalation 1 ( ) Siddhi M Warang Escalation 2 ( ) karishma.vasudev@adityabirlacapital.com parvati.gurung@adityabirlacapital.com siddhi.warang@adityabirlacapital.com 6

7 Annex III The Policy covers expenses of Group Mediclaim Policy Salient Features Hospitalization (room charges, Doctors/surgeons fees, ICU/ICCU, medicines, pathology reports, etc.) on a reimbursement/cashless basis, incurred as a result of illness and/or accidents as an inpatient in a recognised hospital. Dental treatment following an injury/accident. Hospitalization expenses incurred in connection with accidents caused due to terrorism. Pre/Post Hospitalization expenses are covered for 30 & 60 days respectively. Standard day care procedures (140+) indicative list of procedures as mentioned in Annex IV. Additional features:- 1. Cashless facility (Minimum 24 hour hospitalization or irrespective of day care surgeries) for hospitalization procedures arising out of sickness or accident. Claims can be made on cashless/reimbursement basis. 2. For repeated hospitalization of the same ailments within 45 days of hospitalization, reimbursement facility will be available, except in the case of serious ailments viz. cancer, CRF & heart ailments, etc., where cashless facility would continue. 3. Chemotherapy, Dialysis, Radiotherapy, Chronic Renal failure including medicines, AIDS & HIV, Indoor Ayurvedic Treatment taken in Government run/government approved hospital and at CGHS empanelled Ayurveda hospitals. 4. Supply and fitting of external prosthetic devices, artificial aids including eye glasses, hearing aids, artificial limbs, etc. if the same is necessitated following an accident. 5. Local Ambulance charges for admission, transfer to another hospital and /or discharge under critical condition as advised by the doctor. 6. Surcharges levied by hospital or any other charges similar in nature would be payable under the policy. 7. Registration charges levied by hospital or any other charges similar in nature would be payable under the policy. 8. Charges for special nurse for persons irrespective of age during the hospitalization. 9. Special nursing charges for persons above 75 years of age for a maximum period of 60 days after hospitalization, if recommended by attending doctor or hospital. 10. In case of bilateral knee or hip replacement surgery done during the same hospitalization, reimbursement to be made up to twice the ceiling applicable and Cashless Extended in empanelled hospitals to be made twice the ceiling applicable as per Table Cataract operation with a cap of Rs.40,000/- per eye uniform for all. 12. Cost of intra vitreous injection Avastin/Lucentis/Macugen/Ozurdex etc. upto a ceiling of Rs.25,000/- which includes full hospitalization cost, per dose/per eye with a maximum of three dosages per eye during the policy period. 13. The expenses for Oral Chemotherapy will be covered in day care facilities subject to sum insured on cumulative basis upto one grade-wise monetary ceiling applicable to the retired MAF member. 14. Expenses incurred towards endoscopy/colonoscopy are included in the day care procedure. 15. Investigation charges and medicines charges levied during hospitalization will be reimbursed in full irrespective of room occupied. Pro-rata deduction will not be applicable on investigation charges and medicines. 16. In case of physiotherapy, post- hospitalization will be reimbursed up to 180 days, subject to the 7

8 applicable per hospitalization ceiling. 17. The day care list will also be inclusive of the following day care Medical Treatment undertaken due to advancement of technology: Injections for Autoimmune disorders/arthritis and ankylosing spondylosis. Limit will read as Rs.25,000/- per case with maximum cap of 3-cases per year per family. Chemotherapy at home is covered. 18. Ayurvedic treatment for cancer patients at Private Ayurvedic Hospitals up to the sum insured. 19. Service Charge levied by the Hospital or any other charges similar in nature would be payable under the policy with in the ceiling. 20. Psychiatric Treatment included on IPD basis up to the Sum Insured. 21. EECP (Enhanced external counter pulsation) included under the policy on OPD basis up to the per hospitalization limit. Settlement of claim to be done on reimbursement basis only after completion of full treatment 22. Donor Medical expenses in case of transplants like kidney, liver etc. covered within the sum insured (Organ cost not covered under policy) 23. All Organ transplants, including stem cell transplants for blood cancer covered. 24. In case of death of the insured during hospitalization or within 48 hours of discharge from the hospital full amount excluding non-medical items of the hospital bills will be paid irrespective of limit specified in Table In case of treatment taken in government/municipal hospital where the cashless facility is not available on account (advance) payment facility, 50% of the estimated cost of treatment within the limit per hospitalization will be paid directly to the hospital from where the estimate is taken 26. Bifurcation need not be given by the hospital if package charges on PTCA, CABG, Renal transplantation, etc. if charged with in the entitled ceiling of the employee & approved by the TPA. Settlement of Claims: In the event of the insured utilizing Room Rent higher than his limits, such claims will be settled on proportionate basis. However, the minimum payment will be made as per PPN tariff irrespective of the higher room rent. (Applicable in death cases also) In case of death of the insured during hospitalisation or within 48 hours of discharge from the hospital full amount excluding non-medical items of the hospital bill will be paid irrespective of limit specified in Table II provided the insured utilizes his eligible room rent. In all cases, the members may be advised to provide their Cell number for receiving SMS for pre-authorisation sanction and carry their MAF (photo) Card along with the TPA Identity Card for verification at the time of hospitalization, which may be required for identification. Room & Board charges are applicable as per Table1. In the event of the insured utilizing room rent higher than his/her limits then following procedure will be followed in settling the claim. (Applicable in death cases also) (a) If such list is not available then the charges will be settled on pro-rata basis. (b) In any case the pro-rata claim cannot be below the procedure charges of such treatment (c) Investigation charges and medicines charges levied by the hospital during hospitalisation related to the ailment will be reimbursed in full irrespective of room occupied subject to per hospitalisation limits. Pro-rata deduction will not be applicable on investigation charges and medicines. 8

9 Annex IV Day Care Facilities 140+ day care surgeries are covered under the policy. Any further new advancement in treatment modalities to be covered if it is a part of Day Care. The list of 140+ day care surgeries but not limited to: Operation on the Ears: Microsurgical Operations on the Middle Ear Stapedotomy Stapedectomy Revision of a Stapedectomy Other operations on the auditory ossicles Myringoplasty(Type 1- tympanoplasty) Tympanoplasty(Closure of an eardrum perforation and reconstruction of the auditory ossicles) Revision of a Tympanoplasty Other Microsurgical operations on the Middle Ear Other Operations on the Middle and Internal Ear Paracentesis(myringotomy) Removal of a tympanic drain Incision of the mastoid process and middle ear Mastoidectomy Reconstruction of the middle ear Other excisions of the middle and inner ear Fenestration of the inner ear Revision of fenestration of the inner ear Incision (opening) and destruction(elimination) of the inner ear Other operations on the middle and inner ear Operation on the nose and the Nasal Sinuses Excision and destruction of disease tissue of the nose Operations on the turbinates (Nasal Concha) Other operations on the nose Nasal Sinus aspiration Operation on the eyes Incision of the tear glands Other operation on the tear ducts Incision of diseased eyelids Excision and destruction of diseased tissue of the eyelid Operations on the canthus and epicanthus Corrective surgery for entropion and ectropion Corrective surgery for blepharoptosis Removal of foreign body from conjunctiva Removal of foreign body from the cornea 9

10 Incision of the cornea Operations for pterygium Other operations on the cornea Removal of foreign body from the lens of the eye Removal of foreign body from the posterior chamber of the eye Removal of a foreign body from the orbit and eyeball Operation of cataract with a cap of Rs.40000/- per eye. Reimbursement of cost of intra vitreous injection Avastin/Lucentis/Macugen/Ozurdex etc. up to ceiling of Rs.25000/- (inclusive of all cost) per dose/ per eye and maximum three dosages per eye during the policy year. Total sub-limit is Rs.75000/- per eye. Operation of the skin and subcutaneous tissue Incision of a pilonidal sinus Other incisions of the skin and subcutaneous tissues Surgical wound toilet(wound debridement) and removal of diseased tissue of the skin and subcutaneous tissue Local excision of the diseased tissue of the skin and subcutaneous tissues Other excisions of the skin and subcutaneous tissues Simple restoration of surface continuity of the skin and subcutaneous tissues Free skin transplantation, donor site Free skin transplantation, recipient site Revision of skin plasty Other restoration and reconstruction of the skin and subcutaneous tissues Chemosurgery of the skin Destruction of diseased tissue in the skin and subcutaneous tissues Operation on mouth and face Operation on the tongue Incision, excision and destruction of diseased tissue of the tongue Partial glossectomy Glossectomy Reconstruction of the tongue Other operation on the tongue Operation on the salivary glands and salivary ducts Incision and lancing of a salivary gland and salivary duct Excision of diseased tissue of a salivary gland and salivary duct Resection of salivary gland Reconstruction of a salivary gland and salivary duct Other operations on the salivary glands and salivary ducts. Other operations on the Mouth and Face External incision and drainage in the region of the mouth, jaw and face Incision of the hard and soft palate Excision and destruction of diseased hard and soft palate Incision, excision and destruction in the mouth Plastic surgery to the floor of the mouth Palatoplasty 10

11 Other operations in the mouth Operations on the Tonsils and adenoids Transoral incision and drainage of a pharyngeal abscess Tonsillectomy without adenoidectomy Tonsillectomy with adenoidectomy Excision and destruction of a lingual tonsil Other operations on the tonsils and adenoids Traumatological surgery and orthopaedics Incision on bone, septic and aseptic Closed reduction on fracture, laxation or epiphyseolysis with osteosynthesis Suture and other operations on tendons and tendon sheath Reduction of dislocation under GA, including K-wire Arthroscopic knee aspiration Operation on the breast Incision of the breast Operation on the nipple. Operation on the digestive tract Incision and excision of tissue in the perianal region Surgical treatment of anal fistula Surgical treatment of haemorrhoids Division of the anal sphincter(sphincterotomy) Other operations on the anus Ultrasound guided aspirations Sclerotherapy Endoscopy /Colonoscopy Operations of female sexual organs Incision of the ovary Insufflation of the fallopian tube Other operation on the fallopian tube Dilation of the cervical canal Conisation of the uterine cervix Other operations on the uterine cervix Incision of the uterus(hysterotomy) Therapeutic curettage Culdotomy Incision of the vagina Local excision and destruction of the diseased tissue of the vagina and the pouch of douglas Operations on bartholin s gland(cysts) Incision of the vulva 11

12 Operations of the Male Sexual Organs Operations on the Prostate and Seminal Vesicles Incision of the prostate. Transurethral excision and destruction of prostate tissue. Transurethral and percutaneous destruction of prostate tissue. Open surgical excision and destruction of Prostate tissue. Radical Prostatovesiculectomy. Other excision and destruction of prostate tissue. Operations on the seminal vesicles. Incision and excision of peri prostatic tissue. Other Operations on the prostate. Operation on the Scrotum and Tunica Vaginalis Testes Incision of the Scrotum and Tunica Vaginalis testes. Operation on a testicular hydrocele. Excision and destruction of diseased scrotal tissue. Plastic reconstruction of the Scrotum and tunica vaginalis testes. Other operations on the scrotum and tunica vaginalis testes. Operation on the Testes Incision of the Testes Excision and destruction of diseased tissue of the testes. Unilateral orchidectomy. Bilateral orchidectomy. Orchidopexy Abdominal exploration in cryptorchidism Surgical reposition of an abdominal testes Reconstruction of the testis Implantation, exchange and removal of a testicular prosthesis. Other operations on the testis. Operations on the Spermatic Cord, Epididymis and Ductus Deferens Surgical treatment of a varicocele and a hydrocele of the spermatic cord. Excision in the area of the epididymis. Epididymectomy. Reconstruction of the spermatic cord. Reconstruction of the ductus deferens and epididymis. Other operations on the spermatic cord, epididymis and ductus deferens. Operations on the Penis Operations on the foreskin. Local excision and destruction of diseased tissue of the penis. Amputation of the penis. Plastic reconstruction of the penis. Other operations on the penis. 12

13 Operations on the Urinary System Cystoscopical removal of stones. Other Operations / Procedures Lithotripsy. Coronary angiographies. Dialysis Coronary CT angiography Chemotherapy & radiotherapy Chemotherapy at home Oral chemotherapy subject to sum insured on cumulative basis. Age related Macular Degeneration (Laser Treatment) Carotid Artery Angiography Foam sclerotherapy Treatment of pemphigus varigaris by retuximab therapy (injection rituximab) All types of Angiography covered Cystoscopy Photo dynamic laser therapy covered under ARMD treatment Cost of CRF/CKD treatment including the cost of injection Erythropoietin/ Cyclosporine/ Sandimmune up to admissible per hospitalization limit on cumulative basis Zolendronic Injection, Bortezomib Injection & Terifrac Injection administration covered under day care procedures subject to sum insured on cumulative basis. Injections for Autoimmune disorders/arthritis and ankylosing spondylosis. Limit will read as Rs.25, 000/- per case with maximum cap of 3- cases per family per year. 13

14 Table I Category Grade-wise limits-sum insured & limit of Bed charges of Retired Employee & Spouse Sum Insured & Limit per hospitalisation Limit of Bed Charges per day for normal hospitalization Limit of Bed charges per day for ICU (Rs.) (Rs.) (Rs.) 1 Workmen 2,25,000 3,000 3,700 (Class III & IV) 2 Officers 3,00,000 4,000 5,500 (Grade A, B & C ) 3 Officers 3,75,000 6,000 7,500 (Grade D,E & F) 4 EDs 5,00,000 Unlimited Unlimited 5 DG & Governors Unlimited Unlimited Unlimited 14