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Mapping the under writing, process, servicing and claims for the Medical Scheme of the Employees and their family members of Member Banks of Indian Banks' Association


Appendix II


Mapping the under writing, process, servicing and claims for the Medical Scheme of the Employees and their family members of Member Banks of Indian Banks' Association

1. The policy will be issued in the name of Indian Banks' Association Member Banks and the list of the member banks would be mentioned giving the data of the employees bifurcated into:-

a) Officers with the data of their dependent family members. Clerical staff with the data of their dependent family members.

c) Sub staff with the data of their dependent family members.

The premium is decided by the number of employees uniformly but not based on the number of dependent family memberes. The collection of data of dependent family members at the initial stage may take long time. In such cases claims pertaining to dependent family members of employees pending collection of data may be settled on certification and recommendation of the appropriate authority of the respective bank.

2. The policy will commence on a uniform date for all the member banks to ensure they get the benefit of the large number of employees which has been instrumental in the procurement of the most competitive premium quote and would eventually also reflect in a positive claim ratio.

3. The member banks will submit their data and pay the premium to the lead Insurance company viz. United India Insurance Co. Ltd. , in proportion to their employee strength.

4. The insured name of Indian Banks' Association is used for getting the benefit of mass scale under writing and a positive claim ratio that would benefit all the member Banks. All under writing, process and claim servicing will be done by the member Banks' directly with United India Insurance Co. Ltd. and K. M. Dastur Reinsurance Brokers Pvt. Ltd.

5. The Corporate Buffer of all the member banks will be in proportion to the percentage of their premium contribution.

6. The allocation and use of this Corporate Buffer would rest with the individual management of the member bank. At the end of the year we would have a joint review on how many banks have totally utilized their Corporate Buffer and how many other member banks have not utilized their Corporate Buffer totally. The unutilized Corporate Buffer of the member banks would now be proportionately available to the member banks whose Corporate Buffer has been totally utilized. this would be one of the major benefits of the Group under writing of all the member banks under one policy and at the same time individual under writing of each member banks for data processing, servicing and claims.

7. The claim settlement of the member banks would be done in the same process as followed in the past, by each individual member banks.

8. The Third Party Administrator, appointed by the lead insure viz United India Insurance Co. Ltd. will station their representative at the banks regional/ nodal offices from where these banks have been settling medical claims of their employees.

9. The Third Party Administrator, would have a Dedicated Office, Server and a 24 X 7Call Centre for the Member Banks of the Indian Banks' Association.

10. The employees would submit the claims to the same regional / nodal offices where they have been submitting in the past and the Third Party Administrator representative will be the backup support and ensure claim settlement is completed in thirty minutes.

11. (The Third Party Administrator should ensure placement of representative in all the regional/nodal offices of the member banks where the employees have been submitting their claims in the past)

12. No claims would be rejected by the insurance company/ Third Party Administrator unless the same is rejected by the committee comprising of the Bank management,Insurance company, Third Party Administrator and K. M. Dastur Reinsurance Brokers Pvt Ltd.

13. All the employees and their family members would be issued ID cards by the Third Party Administrator, of the Insurance company ie. United India Insurance Co. Ltd. Incase the employee or his family member gets admitted in any of the preferred Provider Network of Hospitals on production of ID card, the Hospital authority in turn shall notify by fax / mail the details of Hospitalisation along with ID card number and Name of the employee to the Third Party Administrator, who would again revert by fax / mail a confirmation to the Hospital to proceed with the claim. this would even enable them to claim from anywhere in India and they would be able to admit themselves in Hospitals anywhere in India by merely calling the dedicated call centres of the Third Party Administrator, which would be working on a 24x7 basis. The Third Party Administrator, would even be able to advise the employees on the nearest Hospital available in their area. In case of an emergency admission to a Hospital which is not in PP Network, the employees also have a benefit to get himself admitted on a cashless basis by intimating the Third Party Administrator, call centre number,mentioning his ID card No and name. The Hospital authority 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.

14. Most of the claims would be cashless; which would be paid directly to the Hospital concerned.

15. The 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.

16. In case of reimbursement claim where the employee has not informed the banks Regional / Nodal offices; they may phone the 24 X 7 call centre of the Third Party Administrator giving the details of their card ID number and name. In such cases the reimbursement claim should be submitted on completion of Hospitalisation and not later than 30 days of discharge from the Hospital. In case of post- Hospitalisation treatment, all claim documents should be submitted within 30 days after completion of such treatment. Wherever the Hospitals are not in the approved list of Third Party Administrator, the Third Party Administrator should take necessary action for addition of those Hospitals on their network Hospital list in consultation with bank. In an emergency the claim payment would be paid to the Hospital account and empanelment of the Hospital would be considered.

17. All the addition and deletion of the employees and dependents of the various member banks would be done on a monthly basis. A newly recruited employee would automatically be admitted in the medical scheme from the date of his appointment letter. this has to be reflected in the addition / deletion statement to be sent to the Third Party Administrator/ K. M. Dastur Reinsurance Broker Pvt. Ltd. , before the 10thof the beginning of every month.

18. ID cards will be prepared within 10 working days from the date of receipt of data. These cards can be couriered to the respective branch office in which the employee is located. The cards can be distributed by at the branch office by the bank's branch manager / any other person who is made responsible for the same. Corrections in cards, if any can be e-mailed to an exclusive id which will be exclusive for cards correction erro Rs. this cards will be corrected and resent within 2 working days from the receipt of correction mail.

19. An adequate deposit premium have to be placed by the member banks for this addition, as this is a regulatory compliance under section 64 V B of the Insurance Act; wherein no insurance can be initiated without the payment of the premium.

20. At the same time refund premium of all deletions would be credited in the deposit account of the member banks.

21. All additions / deletions of employees and family members would be on prorata basis. In case, some member banks joined the scheme sometime after the main master policy has been incepted, they would also be joining on a prorate premium.