Disciplinary & Industrial Relations Department PD(DIR)’s Sl No: 1 O&M No. 2/15-16

Circular No. PD(DIR)/MEDICLAIM/1/OM-2/15-16 02-04- 2015

ALL BRANCHES/OFFICES

Subject : Group Mediclaim Insurance Scheme for Retired Employees for the period of 1st April,2015

to 31st March, 2016

In consideration of the aspects of social security of retired employees as also the need for quality health care at an affordable cost, the Group Mediclaim Insurance Scheme for the Retired Employees of the Bank is being continued for the year 2015-16, i.e. from 01.04.2015 to 31.03.2016, as a welfare measure. In this connection the Bank has engaged National Insurance Company Ltd. who will provide mediclaim insurance benefits to the retired employees and their spouse and also to the spouse of an employee who has deceased while in service or after retirement, by way of reimbursement of hospitalization expenses as per the Scheme elaborated in the enclosed Annexure-I. The Scheme will be in force with retrospective effect from 1st April, 2015. The retired employees willing to be member of the ‘Scheme’ may send their applications in the prescribed format (as per Annexure-II ) in triplicate through the Manager of Branch where the employee is maintaining accounts and/or drawing pension. The prescribed yearly premium (Annexure-I, Para-17) is to be deposited in cash or through cheque to the credit of A/c. No: 0098050000189 in the name of “ Coll. Of Mediclaim Insurance ” through menu option “PAYFEE” only with module “GMC” wherein apart from the premium amount, Name of the Retired Employee and his/her SPF No. will be mandatory fields. The premium can be deposited though any Branch of the Bank. The premium to be borne by the retired employees who have retired prior to 01.04.2015 will be as noted under April’2015 in the table below. Proportionate premium from May 2015 onwards as noted below is applicable only for the employees retiring from April 2015 onwards (who can join the scheme by depositing proportionate premium within TWO months from their date of retire ment). Coverage ** April’15 May’15 June’15 July’15 Aug’15 Sep’15 Oct’15 Nov’15 Dec’15 Jan’16 Feb’16 Mar’16

Rs.1.50 lac 1957 1794 1631 1468 1305 1142 979 815 652 489 326 163

Rs.2.00 lac 3562 3265 2968 2672 2375 2078 1781 1484 1187 891 594 297

Rs.2.50 lac 5702 5227 4752 4277 3801 3326 2851 2376 1901 1426 950 475

Rs.3.00 lac 7841 7188 6534 5881 5227 4574 3921 3267 2614 1960 1307 653

Rs.4.00 lac 8912 8169 7427 6684 5941 5199 4456 3713 2971 2228 1485 743

Rs.5.00 lac 9982 9150 8318 7487 6655 5823 4991 4159 3327 2496 1664 832

**The Retired employees can opt for any one of the above mentioned Insurance coverage options. A member needs to deposit the prescribed amount of premium for his selected coverage limit.

The Heads of the Branches upon verification of the credentials of the retired employees viz. their dates of retirement, SPF/PPO Nos, residential addresses, Transaction No (AA………..) etc. in the appropriate column of the forms, will retain the 3rd copy and forward the applications in duplicate under their signatures so as to reach the Chief Manager, D&IR Division, 13th Floor, Head Office, 11, Hemanta Basu Sarani, Kolkata – 700001 on or before 30.04.2015. Incomplete applications and/or applications received without requisite Transaction No, confirming the deposit towards premium, will be rejected. The APPLICATION FORMS (Annexure-II) for membership should be provided to the retired employees by all Branches/Offices of the Bank. This apart, the instant scheme/application forms can also be downloaded from e-Circular. Photo-copy of the proforma may also be used.

1. All the branches are advised to accept the deposit of annual premium of the intending retired employees of the

Bank using the Challan/Deposit Slip (Annexure-III), through the menu option “PAYFEE” only with module “GMC” wherein apart from the premium amount, Name of the Retired Employee and his/her SPF No. will be mandatory fields. Premium can be received either in cash or through cheque.

2. Payment of premium in the form of Cheque / Draft / Pay Order directly favouring the Insurance Company will not be accepted.

3. Premium received after 30.04.2015 from an applicant who has retired prior to 01.04.2015 will not be accepted by the insurer for enrolment as member.

4. Retired employees intending to join the scheme are required to exercise their options in the Application form as detailed below :-

(a) Choice of coverage amount (Rs. 1.50/2.00/2.50/3.00/4.00/5.00 lac). (b) Choice of branch of the Bank/Pension paying Branchof the employee where mediclaim card is

to be delivered by the Insurance Co.

Due to numerous complaints received from the members regarding non-receipt of mediclaim cards during the last few years, it has been decided to send the individual mediclaim cards to the branches chosen by the members. Branches are instructed to handover the mediclaim cards received by them from the insurance company to the individual members after proper identification and should maintain proper record of delivery of the cards to the retired employees. Mediclaim cards may also be delivered to persons other than the retired employees themselves, on the basis of written authorization from the retired employees and after obtaining a photocopy of photo-identity proof of the person taking delivery of the cards and retaining the same in the branch record. Strict compliance of the aforesaid directions is essential for preventing wrong delivery to any unauthorized person.

5. All heads of the branches/offices are advised to bring the contents of the Circular to the knowledge of all retired employees having accounts/transactions and/or drawing pension from their branches. This apart, a copy of this circular will be displayed at a prominent place in the branches/offices of the bank.

General Manager (HRM, IT & ADC)

Annexure-I

1. T i t l e The Scheme shall be called “U.B.I. Group Mediclaim Insurance Scheme for Retired Employees”. 2. Company to extend the Mediclaim facility National Insurance Co. Ltd. (herein after referred as Insurance Company) will extend the instant Mediclaim Insurance Benefit to the Retired Employees. 3. Objective To provide mediclaim insurance benefits up to a maximum limit of Rs.1.50/2.0/2.50/3.0/4.0/5.0 lacs on floater basis as opted by the retired employees of the Bank who would become the member of the scheme and their spouse for treatment in India during the currency of the instant mediclaim policy. 4. E l i g i b i l i t y a) Officers and employees retired from the Bank’s service. (i) On attaining the age of superannuation (ii) As per bank’s voluntary retirement scheme (VRS) (iii) Under Voluntary Retirement (VR) as per Service/Pension Regulations. b) The scheme shall also be open for membership to the spouse of the officer and Award Staff who died whilst in service or after retirement. c) An Officer/Award Staff who has been discharged/dismissed/removed from service/compulsorily retired or terminated as per measure of disciplinary action WILL NOT BE ELIGIBLE.

d) Any employee who retired prior to 01.04.2015 cannot become member of the Scheme after 30.04.2015. Midterm inclusion will be permitted to the employees who will retire from service after 01.04.2015 only, on payment of pro-rata premium. Any employee who has retired prior to 01.04.2015 cannot become member of the Scheme by paying pro-rata premium during the year.

5. Family The coverage under the scheme would be applicable for the family of the retired employee which covers employee himself/herself and his/her spouse (1+1). 6. Age Limit Maximum entry age limit to become the member of the scheme is 80 years. 7. Duration: For One year. 8. Policy Administration The Policy will be serviced through Third Party Administrator (TPA). The region wise contact details of the TPA are given in Annexure A.

Group Mediclaim Insurance Scheme for Retired Employees 2015-16

9. Important Policy Features The policy covers the Hospitalisation Expenses as per the indemnity Limit, i.e. sum insured of Rs.1.50/2.0/2.5/3.0/4.0/5.0 lac (As per the option chosen by the retired employees).

If the insured person is diagnosed with an illness or suffers Accidental Body Injury, which necessitates Hospitalisation, the Insurer will reimburse the Insured Person’s consequent Hospitalisation Expenses. Disease shall mean any illness, ailment, disease or injury warranting hospitalization. 10. Pre-existing Diseases All pre-existing diseases will remain covered under this scheme. However, maternity cases will not be covered under the scheme. 11. Hospitalisation Expenses on hospitalisation for minimum period of 24 hours are admissible. However, cases where the patient is admitted as an out patient and discharged on the same day after undergoing “Day Care Procedures” as per the list of procedures laid down below, 24-hours hospitalisation will not be mandatory. 12. Pre & Post Hospitalisation period Period of hospitalisation shall include the maximum period of 30 days prior to date of admission as pre-hospitalisation and a maximum period of 60 days after the date of discharge as post-hospitalization period 13. Other customized Features � Individual Health ID Cards for each group member which will be sent to the Branches of the Bank as per option exercised by the members, for onward delivery to them.

� E-Card will be provided to the mail id of the Branch from where the card was originally delivered, in case of loss of card after delivery.

Expenses of Hospitalisation for minimum period of 24 hours are admissible. However this time limit is not applied to specific treatments i.e. Dialysis, Parentral Chemotherapy, Radiotherapy, Eye Surgery, Lithotripsy (Kidney Stone removal), Tonsillectomy,

Dental Surgery due to accident, Hysterectomy, Coronary Angioplasty, Coronary Angiography, Surgery of Gall Bladder, Pancreas & Bile duct, surgery of Hernia, Surgery of Hydrocele, Surgery of Prostate, Gastrointestinal surgery, Genital Surgery, Surgery of Nose,

Surgery of Throat, Surgery of Appendix, Surgery of Urinay System, Arthroscopic Knee Surgery, Laparoscopic Therapeutic Surgeries, Any surgery under Anaesthesia, Treatment of Fractures/Dislocation excluding hairline fracture, Contracture releases & minor reconstructive procedures of limbs which otherwise require hospitalization taken in the Hospital/Nursing Home under the network of TPA and the Insured is discharged on the same day. The treatment will be considered under Hospitalisation Benefit).

Relaxation to 24 hours minimum duration for hospitalization is also applicable: A) If they are carried out in day care center networked by TPAs where requirement of minimum number of beds

areoverlooked but it must have (a) Fully equipped Operation Theatre (b) Fully qualified Day care staff (c) Fully qualified Surgeons/Post Operative attending Doctors.

B) If it necessitates hospitalization & involves specialized infrastructural facilities available only in hospital but due to technological advancement hospitalization is required for less than 24 hours and/or the surgical procedure involved has to be done under General anesthesia.

Note: Procedures/treatments usually done in Out Patient Department (OPD) are not payable under the policy.

� Access to a 24 hour Health Help Line for emergency hospitalization. (Preferably Special Help

Lines).

Arunima Paul 9830237200 arunimapaul@rathi.com Saswati Mitra 9830400667 saswatimitra@rathi.com Help Desk no. 033-40020000 ext-251, 254, 256 FHPL(TPA) Toll Free no. 1800-425-4033

� Access to a hospital network (managed by a professional third party medical administrator) across

the country. 14. Settlement of Claims: Cashless: Immediate approval of cashless facility within 2 hours upon prior intimation. The member has to pay the cost of the inadmissible items and get discharged. Reimbursement: � Reimbursement of claim within 15 days after submission of all relevant documents if the claim is

complete in nature. ( in case the group members are not availing cashless facility). � If the documents are insufficient for processing of the claim, query will be raised mentioning the

relevant documents required. The query will be intimated to the member with the help of an SMS to the registered mobile number of the member and a query letter sent to the member’s registered residential address. On non-receipt of the documents within 15 days of the query, three reminder letters will be sent to the member. � If the documents are not received even after the 3rd reminder, the claim will be closed with a final 4th

reminder letter to the member. � If a query is raised due insufficient documents, the claims will be settled within 15 working days

after receipt of the accurate query reply. � In case of a closed claim, the claim will be referred to the Insurance Co. for reopening and will be

settled within 30-45 days after receipt of the accurate query reply. 15. Monitoring

The monitoring will be done by Anand Rathi Insurance Broker’s Ltd. from their Offices at Kolkata, Mumbai & Hyderabad.

Service Providers

Anand Rathi Insurance Brokers Ltd.

Centralized Monitoring is done from:- Central Plaza, Room No : 501 & 502, 5th floor,

2/6, Sarat Bose Road, Kolkata – 700 020 Telephone No : 033 4002 0000

Fax No : 033 24544679

Contact Persons:

Sl. No. Name Phone Email

1 Arunima Paul 9830237200 arunimapaul@rathi.com

2 Saswati Mitra 9830400667 saswatimitra@rathi.com

3 Ravi Balmiki 9051975023 ravibalmiki@rathi.com

4 Tuhin Nag 9007801093 tuhinnag@rathi.com

5 Arnab Mukherjee 9830249135 arnabmukherjee@rathi.com

16. Limits on Specific categories

� Room Tariff In case of hospitalisation, following room tariff will be applicable:

Coverage limit Upto Rs.3 lac Rs.4 lac Rs.5 lac Maximum Tariff for Normal room per day Rs.2000 Rs.3500 Rs.4500 Maximum Tarif for HDU/CCU per day Rs.5000 Rs.5000 Rs.5000 Maximum Tariff for ICU/ICCU/ITU per day No Limit No Limit No Limit

� Cataract Operation

Maximum permissible reimbursable limit for cataract operation (including IOL) will be Rs.25,000/- per eye on admission under Day Care Procedure.

17. Premium

• The premium to be borne by the retired employees who have retired prior to 01.04.2015 will be as noted for April 2015 in the table below. Proportionate premium from May 2015 onwards as noted below is applicable only for the employees retiring from April 2015 onwards (who can join the scheme by depositing proportionate premium within TWO months from the date of their retirement).

Coverage ** April’15 May’15 June’15 July’15 Aug’15 Sep’15 Oct’15 Nov’15 Dec’15 Jan’16 Feb’16 Mar’16 Rs.1.50 lac 1957 1794 1631 1468 1305 1142 979 815 652 489 326 163 Rs.2.00 lac 3562 3265 2968 2672 2375 2078 1781 1484 1187 891 594 297 Rs.2.50 lac 5702 5227 4752 4277 3801 3326 2851 2376 1901 1426 950 475 Rs.3.00 lac 7841 7188 6534 5881 5227 4574 3921 3267 2614 1960 1307 653 Rs.4.00 lac 8912 8169 7427 6684 5941 5199 4456 3713 2971 2228 1485 743 Rs.5.00 lac 9982 9150 8318 7487 6655 5823 4991 4159 3327 2496 1664 832

**The Retired employees can opt for any one of the above mentioned Insurance coverage options. A member needs to deposit the prescribed amount of premium for his selected coverage limit.

• The above premium amount will be borne by the retired employees themselves.

• The above premium will be valid for a period of one year during the operation of the scheme from

01.04.2015 to 31.03.2016.

• The prescribed yearly premium as per the above mentioned chart is to be deposited to the credit of A/c. No. 0098050000189 in the name of “ Coll. Of Mediclaim Insurance” using the Challan/Deposit Slip (Annexure-III), through the Branches of the Bank where members have been maintaining accounts and/or drawing pension.

• Branches are to accept the deposit of annual premium of the intending retired employees of the Bank using the Challan/Deposit Slip (Annexure-III), through the menu option “PAYFEE” only, under module “GMC” wherein apart from the premium amount, Name of the Retired Employee and his/her SPF No. will be mandatory fields. Premium can be received either in cash or through cheque.

• Payment of premium in the form of Cheque / Draft / Pay Order directly favouring the Insurance Company will not be accepted.

• The Heads of the Branches will certify upon verification of the credentials of the retired employees

viz. their dates of retirement, SPF/PPO Nos., residential addresses, the Transaction No (AA……….. ) in the appropriate column of the forms.

• Premium received after 30.04.2015 from an applicant who has retired prior to 01.04.2015 will not be accepted by the insurer for enrolment as member.

• Ex-employees who have retired prior to 01.04.2015 and have not become member of the scheme may

join the scheme for the period 2015-16 against payment of premium as per above mentioned premium chart within the stipulated time limit of 30.04.2015.

• Retired employees intending to join the scheme are required to exercise their options in the Application form as detailed below :- (a) Choice of coverage amount (Rs. 1.50/2.00/2.50/3.00/4.00/5.00 lac). (b) Choice of branch of the Bank where mediclaim card is to be delivered by the Insurance Co.

Due to numerous complaints received from the members regarding non-receipt of mediclaim cards during the last few years, it has been decided to send the individual mediclaim cards to the branches chosen by the members. Branches are instructed to handover the mediclaim cards received by them from the insurance company to the individual members after proper identification and after maintaining proper record of delivery of the cards to the retired employees. Mediclaim cards may also be delivered to persons other than the retired employees themselves, on the basis of written authorization from the retired employees and after obtaining a photocopy of photo-identity proof of the person taking delivery of the cards and retaining the same in the branch record. Strict compliance of the aforesaid directions is essential for preventing wrong delivery to any unauthorized person. 18. Cash-less Facility/Claim for Reimbursement under the Scheme The Insurance Company will provide Cash-less facility for hospitalisation through their network Hospitals as per the list of Hospitals (to be sent to the individual members directly by the Family Health Plan TPA Limited along with the Health Card). All members who have been advised for hospitalisation by the attending doctor may avail the above cash-less facility by getting themselves admitted in any of the network hospitals of the Family Health Plan TPA Limited. Admission to such hospitals under the facility will be allowed on production of the Health Card to be issued by the Family Health Plan TPA Limited to each member. Reimbursement Claim operating Protocol (Annexure-B) and Cashless operating Protocol (Annexure-C) under GMC Policy of Retired Employees are attached herewith. In case of pre-planned hospitalisation at a Network Hospital a member will be required to Approach the TPA/Insurance Desk of the Network Hospital 4-5 DAYS PRIOR TO ADMISSION IF PRE-PLANNED / WITHI N 48 HOURS IN CASE OF EMERGENCY. However, in case a member of the scheme does not receive the Health Card from the Family Health Plan TPA Limited within a maximum period of 15 days from date of collection of Forms from D & IR Division, Head Office by Insurance Broker and during the said period he/she is required to be admitted in a hospital for treatment, he would be required to take up the matter with any of the representatives of the Family Health Plan TPA Limited/Anand Rathi Insurance Brokers Ltd. over

• Phone No.09230101116 (contact person – Mr. Ayan Gupta), • Phone No.09231001008 (contact person – Arnab Roy), • Phone No.09830237200 (contact person – Mr. Arunima Paul), • Phone No.09830400667 (contact person – Mr. Saswati Mitra ),

who would pass on necessary instructions to the concerned hospital where the member concerned desires to be admitted authorizing the admission of the member for treatment.

However, if the hospitalisation is warranted due to emergency, then intimation is to be sent to the Family

Health Plan TPA Limited/Anand Rathi Insurance Broker Ltd. within 7 days of admission and at-least 24 hours prior to discharge from the hospital. Expenses made by a member towards his/her hospitalisation in a network hospital will be borne by the Family Health Plan TPA Limited under the cash-less facility (subject to maximum amount of Rs.1.50/2.0/2.5/3.0/4.0/5.0 lacs per annum as per the option chosen by the member) excluding the expenses which are not incidental to the treatment like Food for Attendants, Telephone Bills, Laundry Expenses, any treatment made otherwise than advised by the attending physician. Such in-eligible expenses and/or expenses beyond the insured limit of Rs.1.50/2.0/2.5/3.0/4.0/5.0 lac will be borne by the members themselves and to be settled with the hospital authority at the time of discharge from the hospital. In case of admission in a Network Hospital, the member shall claim the expenses for pre-hospitalisation for 30 days and post-hospitalisation for 60 days from the Insurance Company within 15 days from the date of expiry of post-hospitalisation of 60 days. Once a claim for pre and post-hospitalisation period is submitted, no further claim for any part of such period for reasons whatsoever will be entertained.

A member of the scheme will not be eligible to avail the cash-less facility on his own option by getting him/her admitted in a non-network hospital. In such cases, concerned member or his/her dependant will be required to send intimation to the toll free number - 18004254033 of the Family Health Plan TPA Limited within a period of 07 (seven) days from the date of admission in the hospital. In such cases of admission in a non-network hospital, a member will have to make full payment of the hospitalisation bill and submit his claim to the Insurance Company within 15 days of his/her discharge from the hospital including the expenses incurred during pre-hospitalisation period or 30 days prior to the date of hospitalisation. However, for post-hospitalisation expenses, a member will submit a separate claim with the Insurance Company within 15 days from the date of expiry of post-hospitalisation period of 60 days. If a part of post-hospitalisation period of expenses is already included by the member in his/her initial claim for hospitalisation expenses, he/she can claim for residual post-hospital expenses separately within a period stipulated above.

All such claims (Claim Submission Form along with Bank A/c Details:- Annexure-D & E are to be sent

directly to � FAMILY HEALTH PLAN TPA LTD . to their address located at 16/2 Lakeview Road, Kolkata-

700 029, Phone-033- 65503901/02/03, Fax-033-24659377, Toll Free-18004254033, For Intimation : intimation@fhpl.net , Website : www.fhpl.net along with his/her membership details and bill relating to hospitalisation should accompany the documents as described in Annexure – F. OR

� ANAND RATHI INSURANCE BROKERS LTD . To their address located at 501 & 502, Central Plaza, 2/6, Sarat Bose Road, Kolkata-700020 along with his/her membership details and bill relating to hospitalisation should accompany the documents as described in Annexure – F.

19.Continuance of the Policy The Insurance Company shall not discontinue the instant scheme in the middle of the period of operation of the scheme.

20. Exclusions National Insurance Co. Ltd. shall not be liable to make any payment under this policy in respect of any expenses whatsoever incurred by any Insured Persons in connection with or in respect of :

1. Injury or disease directly or indirectly caused by or arising from or attributable to War Invasion Act of

Foreign Enemy Warlike operations (whether war be declared or not) and Injury or disease directly or indirectly caused by or contributed to by nuclear weapons/materials.

2. Circumcision unless necessary for treatment or 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 as accident or as part of any illness.

3. Surgery for correction of eye sight, cost of spectacles, contact lenses, hearing aids etc.

4. Dental treatment or surgery-corrective, cosmetic or aesthetic procedure, filling of cavity, root canal, wear &

tear unless arising due to an accident and requiring hospitalisation.

5. Convalescence general debility `Run Down’ condition or rest cure, congenital external disease or defects or anomalies, sterility, infertility/sub fertility or assisted conception procedures, venereal disease, intentional self-injury, suicide, all psychiatric & psychosomatic disorders/diseases, accidents due to misuse or abuse of drugs/alcohol or use of intoxicating substances.

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 or a similar kind commonly referred to as AIDS, complications of AIDs and other sexually transmitted diseases (STD).

7. Expenses incurred primarily for evaluation/diagnostic purposes not followed by active treatment during

hospitalization.

8. Expenses on vitamins and tonics unless forming part of treatment for injury or disease as certified by the attending physician.

9. Naturopathy, unproven procedure/treatment, experimental or alternative medicine/treatment including

acupuncture, acupressure, magneto-therapy etc.

10. Expenses on irrelevant investigations/treatment; private nursing charges, referral fee to family physician, outstation Doctor/Surgeon/ consultants’ fees etc.

11. Genetic disorders/stem cell implantation/surgery

12. External/ durable medical/Non-medical equipments of any kind used for diagnosis/treatment including

CPAP, CAPD, infusion Pump etc., ambulatory devices like walker/ crutches/ belts/ collars/caps/ splints/ slings/ braces/ stockings/ diabetic foot-wear/ glucometer/ thermometer & similar related items & any medical equipment which could be used at home subsequently.

13. Non-medical expenses including personal comfort/ convenience items/ services such as telephone/

television/ aya/ barber/ beauty services/ diet charges/ baby food/ cosmetics/napkins/ toiletries/ guest services etc.

14. Change of treatment from one pathy to another unless being agreed/allowed & recommended by the

consultant under whom treatment is taken.

15. Treatment for obesity or condition arising there from (including morbid obesity) and any other weight control program/services/supplies.

16. Arising from any hazardous activity including scuba diving, motor racing, parachuting, hand gliding, rock

or mountain climbing etc. unless agreed by insurer.

17. Treatment received in convalescent home/hospital, health hydro/nature care clinic & similar establishments.

18. Stay in hospital for domestic reason where no active regular treatment is given by specialist.

19. Out-patient diagnostic/medical/surgical procedures/treatments, non-prescribed drugs/medical

supplies/hormone replacement therapy, sex change or any treatment related to this.

20. Any kind of service charges/surcharges, admission fees/registration charges etc. levied by the hospital.

21. Doctor’s home visit charges/attendant, nursing charges during pre & post hospitalization period.

22. Treatment which the insured was on before hospitalization and required to be on after discharge for the ailment/disease/injury different from the one for which hospitalization was necessary.

23. Treatment arising voluntary medical termination of pregnancy.

21. False Claim/Information In case any false claim/information/document is found to have been submitted by any member at any stage, his/her membership will be cancelled forthwith and his/her premium amount along with the claim due from the Insurance Company, if any, will automatically be forfeited. Besides, if any amount has already been reimbursed to him/her based on such false claim/information/document the said amount will be refunded by him to the Insurance Company. 22. Redressal of Grievances Grievances arose from delay in receiving Health Card and in settlement of claims; members may lodge complaints (Annexure-G) with .

_________________

Address of Head Office:- National Insurance co. Ltd. 3, Middleton Row, Kolkata-700 071

For any grievance or complaint, please write to – Grievance Cell National Insurance Co. Ltd. 3, Middleton Row, Kolkata-700 071

Concerned Office: National Insurance Co. Ltd.

8, India Exchange Place, 1st Floor, Kolkata-700001 Tel:033-22319294/95/96

Annexure II

Fill up the form in “BLOCK LETTERS” N.B. : Proportionate premium from May 2015 onwards as

noted in table below is applicable only for the employees

retiring from April 2015 onwards

*Sum Insured opting for _________ Lacs (1.5/2.0/2.5/3.0/4.0/5.0

Lacs)

Name of Retired Employee*:

Date of

Retirement*: Pension Drawing From*(Branch Name):

Branch from which delivery of Mediclaim Card is to be made :

Is this the 1st time you are taking this policy or it is a continuation?* (‘ Tick ’ the correct option) 1st Time/Continuation

S.P.F. No.*: P.P.O. No.: (If Any)

Address* (For Correspondence) - Kindly fill up the address properly to help us contact you if required.

Is the mentioned address same as last year? Yes / No (Tick the correct option)

House No. & Street Name*:

Landmark*:

Post Office*: Police Station*: City*: Pin Code*:

Any additional information regarding the address:

Tel. No. (with STD Code): Mobile No.*:

Email ID (To help us reach you better)*:

Pension A/c No.(13 digit No.)*: IFSC Code* (Mandatory):

Mode of Retirement*: Superannuation/Voluntary Retirement under Service/Pension Regulations/Under VRS

Details of Members Covered* (Retired Employee + Spouse) / (Spouse of deceased employee)

Name on Members* Date of Birth* Age Sex (M/F) Sum Insured

Retd. Emp. (Tick)

1.5/2.0/2.5/3.0/

4.0/5.0Lac Wife/Husband

Nomination : I, Mr./Mrs./Ms.________________________________________, a retired employee/spouse of the deceased employee

of the Bank do hereby assign the money payable by "National Insurance Co. Ltd." in case of my death to Mr./Mrs./Ms.

______________________ Relation____________ and further declare that his/her receipt shall be sufficient discharge of the company.

Place:

Signature of Retired Employee / Spouse of Deceased Employee Date:

For U.B.I. Branch Use Only (Kindly follow the premium chart for the correct amount of premium)

Coverage April’15 May’15 June’15 July’15 Aug’15 Sep’15 Oct’15 Nov’15 Dec’15 Jan’16 Feb’16 Mar’16 Rs.1.50 lac 1957 1794 1631 1468 1305 1142 979 815 652 489 326 163

Rs.2.00 lac 3562 3265 2968 2672 2375 2078 1781 1484 1187 891 594 297

Rs.2.50 lac 5702 5227 4752 4277 3801 3326 2851 2376 1901 1426 950 475

Rs.3.00 lac 7841 7188 6534 5881 5227 4574 3921 3267 2614 1960 1307 653

Rs.4.00 lac 8912 8169 7427 6684 5941 5199 4456 3713 2971 2228 1485 743

Rs.5.00 lac 9982 9150 8318 7487 6655 5823 4991 4159 3327 2496 1664 832

Certified that Shri./Smt.___________________________________, (SPF No. ___________) is a retired employee/spouse of the

deceased employee of the Bank and he/she remitted the premium as per the following details:

Transaction No. Date: Amount:

United Bank of India

Name of Forwarding Branch:

Place:

_________________________________________Signature of UBI Branch Manager with Seal Date:

**This form duly complete in all respects may be sent by the Branch in duplicate to: The Chief Manager, Disciplinary & Industrial Relati on Division, United Bank of India, Head Office, 13th Floor, 11, Hemanta Basu Sarani, Kolkata-700001 (Tel. No. 033-2248-2935)

Medical Insurance Proposal Form For the use of Retired Employees only.

Period: From 01/04/2015 To 31/03/2016

All the fields marked with (*) are mandatory. For queries call: Anand Rathi Insurance Brokers Ltd.

(033-40020000 Ext No. 251,256,254)

Annexure III

Cash / Transfer Voucher Cash / Transfer Voucher

BRANCH COPY MEMBER’S COPY

United Bank of India United Bank of India

Challan for Depositing Premium for Enrolment in Medical

Insurance Scheme for Retired Employees

Challan for Depositing Premium for Enrolment in Medical

Insurance Scheme for Retired Employees

(To be filled by the Retired Employee) (To be filled by the Retired Employee)

Name of Retired Employee(In BLOCK LETTERS) Name of Retired Employee(In BLOCK LETTERS)

Shri/Smt : Shri/Smt :

S.P.F. No.: S.P.F. No.:

Bank Name: United Bank of India Bank Name: United Bank of India

Account No. 0098050000189 Account No. 0098050000189

Account Name: Coll. Of Mediclaim Insurance Account Name: Coll. Of Mediclaim Insurance

Premium Amount:___________________ Premium Amount:___________________

(Rupees____________________________________________

_____________________________________________

(Rupees_________________________________________

________________________________________________

Signature of Retired Employee

Signature of Retired Employee

Contact No. of Retired Employee:

Contact No. of Retired Employee:

To be filled by the Branch To be filled by the Branch

Branch Name: Branch Name:

Branch SOL ID: Branch SOL ID:

Transaction No. Transaction No.

Date of Deposit: Date of Deposit:

Signature of Authorized Signatory with Seal

Signature of Authorized Signatory with Seal

To be received through menu option “PAYFEE” only with module “GMC” wherein apart from the premium amount, Name of the Retired Employee and his/her SPF No. will be mandatory fields. Premium can be received either in cash or through cheque.

Annexure A T.P.A.

Family Health Plan(TPA) Ltd.

Centralized Processing is done from:-

16/2,Lake View Road, Kolkata – 700 029

Telephone No : 033-65503901/02/03 Fax-033-24659377

TOLL FREE – 18004254033

FOR INTIMATION : intimation@fhpl.net Website: www.fhpl.net

Contact Persons:

Name Phone Email

Centalized

Processing Branch: Arnab Roy 9231001008 arnabray@fhpl.net

Regional SPOCs:

Head office

Ayan Gupta 9230101116 anindya.mondal@fhpl.net

Kolkata (North)

Kolkata (South)

Nadia

24 Pgs(South)

24 Pgs(North)

Behala

Hooghly

Burdwan

Malda Paschim

Medinipur Purba Medinipur

Murshidabad

North Bengal

Purulia

New Delhi Vikash

Chouhan 9212256978 vikas.chauhan@fhpl.net

Meerut

Western Nisha Poojari 9223329009 nisha.poojari@fhpl.net

Bihar

Binay Kumar 9709894185 BinayKumar@fhpl.net Jharkhand

Katihar

Bhubaneswar Sairam Patro 9238000601 sairam@fhpl.net

Sambalpur

Lucknow Anil Srivastava 9235534001 anilsrivastava@fhpl.net

Southern Mr.BHARANI 9282100890 bharani.r@fhpl.net

Dibrugarh

Biswajit Das 9864108389 biswajit.das@fhpl.net

Guwahati

Cachar

Nagaon

Tripura

Sibsagar

Chandigarh Vikash Singh 9888260305 vikash.singh@fhpl.net

Raipur P. Phani Kumar

Rao 9229171101 phanirao@fhpl.net

Bangalore Chandrashekar

L 9243700389 l.chandrashekar@fhpl.net

Annexure-B

For Circulation to Retired Employees

REIMBURSEMENT CLAIM OPERATING PROTOCOL OF UNITED BA NK OF INDIA RETIRED EMPLOYESS GMP

UBI Retired Employees to Intimate TPA /Anand Rathi Insurance Brokers Ltd. Prior to or within 24 hrs of

hospitalization

MEMBERs TO SEND THE CLAIM TO Anand Rathi Insurance Brokers Ltd. OR FHPL Kolkata Office

CLAIM PROCESSING TAT (5 WORKING DAYS FROM RECEIPT OF THE CLAIM)

IN CASE THE CLAIM IS COMPLETE IN NATURE AND ALL DOCUMENTATIONS ARE COMPLETE, TENABLE SETTLEMENT

WILL BE DONE WITHIN 15-20 WORKING DAYS FROM THE DAT E OF RECEIPT OF THE CLAIM

INCASE OF ANY QUERY; 3 REMINDERS WITH REQUIREMENT D ETAILS WILL BE ISSUED AT AN INTERVAL OF 15 DAYS .ON NON RE CEIPT OF THE REQUIRED DOCUMENTS THE CLAIM IS TO BE CLOSED AFTER GIVING A

FINAL REMINDER AT THE 4 TH INSTANCE. ON RECEIPT OF THE REPLY AFTER THE CLOSURE THE CLAIM WILL BE

REFFERED FOR RE-OPENING AND PROCESSING THEREOF

ON RECEIPT OF THE ACCURATE QUERY REPLY TENABLE SETTLEMENT WILL BE DONE WITHIN 15 WORKING DAYS FROM

THE DATE OF RECEIPT OF THE LAST QUERY REPLY

Annexure-C

For Circulation to Retired Employees

CASHLESS OPERATING PROTOCOL OF UNITED BANK OF INDIA RETIRED EMPLOYESS GMP

UBI Retired Employees to approach the TPA/Insurance Desk of the Network Hospital (4-5

DAYS PRIOR TO ADMISSION IF PLANNED/WITHIN 48 HOURS IN CASE OF EMERGENCY) – List of

Hospitals will be available on the website of FHPL (TPA)

AT THE HOSPITAL MEMBER SHOWS THE CASHLESS CARD AND THE PHOTO ID PROOF ALONG WITH MEDICAL DOCUMENTS

(Doctor's advice/Investigation Reports) - Cashless form attached for reference and one set of the form is also

available with the hospitals

HOSPITAL FILLS UP THE CASHLESS REQUEST FORM AND SENDS THE SAME ALONG WITH THE SUPPORTING DOCUMENTS TO

FHPL FOR NECESSARY ACTION

APPROVAL WILL BE PROVIDED IF THE CLAIM IS ADMISSIBLE (Approval will be provided within 2 hrs

on receipt of complete medical information)

MEMBER WILL PAY THE NON-PAYABLE ITEMS AND GET DISCHARGED (List Enclosed)

ON RECEIPT OF THE QUERY REPLY AND THE CLAIM IS TENABLE SETTLEMENT WILL BE DONE WITHIN 15 WORKING

DAYS FROM THE DATE OF RECEIPT OF THE QUERY REPLY

ANNEXURE-D

NATIONAL INSURANCE COMPANY LTD. (Subsidiary of General Insurance Corporation of India)

Regd. Office: 3, MIDDLETON STREET. CALCUTTA – 7000 071

ISSUING OFFICE HOSPITALISATION AND DOMICILIARY HOSPITALISATION BEN EFIT POLICY CLAIM FORM

Claim No. CL

Issuance of this form does not amount to admission of any liability under the claim on the part of the insurers. Please give the following information correctly and completely to enable the Company to process your claim promptly. If the claim is under Personal Accident Insurance, please complete a Personal Accident Claim Form.

1. 2.

Name of the Insured:

(In whose name policy is issued) SUR NAME

Details of the Insured person (In respect of whom claim is made)

INITIALS : …………………………………

For Office use only

(a) Name & relationship to the insured : ……………………………………… (b Present Completed Age

: ………………………………………

(c)

Occupation

: ……………………………………….

(d) Residential Address

: ………………………………………. …………………………………………

3. Policy No. 4.

Details of Previous Mediclaim Polices

: ………………………………………..

i)

Policy No. and Policy Period

: ………………………………………..

ii) Policy No. and Poliyc Period iii) Policy No. and Poliyc Period Note: Essential if Cost of Health Check-up is claimed.)

:………………………………………… :…………………………………………

5.

Nature of Disease/illness contracted or injury suffered

6.

Date of injury sustained or Disease/ Illness first detected.

:

Date Mth Year 7 . (a) Name & Address of the attending Medical Practitioner (b) Qualification & Telephone No (c) Registration No. 8. (a) Name & Address of the Hospital/ Nursing Home/Clinic (b) Date of Admission

: ……………………………………..

: ……………………………………..

Pin Code…………………………….

State/U. Territory……………………

: …………………………………… :

: …………………………………….

Pin Code ……………………………

State/U. Territory …………………… :

9

(c) Date of Discharge

If the claim is for Domiciliary

Hospitalisation, Please indicate (a) Date of Commencement of treatment

(b) Date of Completion of treatment (c) Name & Address of attending Medical Practitioner (d) Telephone (e) Registration No

: ………………………………. : …………………………………….

Pin Code …………………………….

State/U. Territory ……………………

: …………………………………..

:

I have incurred on the treatment of disease/illness accident referred to above, the expenses as per the details given by me in the Schedule of Expenses given overleaf. In Support of the above claim, I enclose the following documents (Please indicate by � ) : –––– 1

. 2

. 3

. 4

. 5

. 6

.

7.

8.

Bill Receipt and discharge Certificate/card from the Hospital.

Cash Memos form the Hospital/Chemist(s), supported by the proper prescription.

Receipt and pathological tests reports from a pathologist supported by the note from the attending Medical Practitioner/Surgeon demanding such Pathological tests.

Surgeon’s certificate Stating nature of operation performed and Surgeon’s bill and receipt. Attending Doctor’s/Consultant’s/Specialist’s Anesthetist’s bill and receipt and certificate regarding diagnosis. In case of domiciliary Hospitalisation, receipt from a qualified nurse who attended the patient at his/her residence duly supported by a certificate from attending Medical Practitioner. Certificate from the attending Medical Practitioner giving reasons for allowing treatment at home. Certificate from the attending Medical Practitioner/Surgeon that the patient is fully cured.

I hereby warrant the truth of the foregoing particulars in every respect and I agree that if have made or shall make any false or untrue statement, suppression or concealments, my right to claim reimbursement of the said expenses shall be absolutely forfeited. I further declare that, in respect of the above treatment, no benefits are admissible under any other Medical Scheme or Insurance. Dated…………………this……………………..day of ………………………….2013.

Signature of the Claimant FOR OFFICE USE: Date of Claim

CATEGORY OF BENEFIT……………………….

Schedule of Expenses incurred by the claimant

To be filled in by the claimant

FOR OFFICE USE ONLY

Details of expenses claimed under Hospitalisation Domiciliary Hospitalisation (To be supported by Bills / Receipts, Cash Memo etc.)

Amount claimed Amount available

Amount payable

Amount not payable

Balance benefit to the credit

I (A) HOSPITALISATION BENEFITS

(a) Room, Board, Nursing Expenses for …….. days …..@...... per day

(b) I C Unit for ……days…….@...... per day

(B) Hospitalisation Benefits other than Room Board & Nursing Expenses & ICCU (including pre & post Hospitalisation) 1. Surgeon, Anaesthetist, Medical Practitioner, Consultant, Specialist fees. 2. Anesthesia, Blood, Oxygen, Operation Theatre Changes, Surgical Appliances, Medicines & Drugs, Diagnostic, Materials & X-Ray, Dialysis, Chemotherapy, Radiotherapy, cost of Pacemaker Artificial limbs & cost of Organs and similar other expenses.

II DOMICILIARY HOSPITALISATION

1. Medical Practitioner, Consultants & Specialists fee for visits etc.

2. Blood, Oxygen, Diagnostic materials, X-ray employement of qualified Nurses, Medicines and Drugs and similar expenses

III COSTING OF HEALTH CHECK UP

TOTAL RS.

Date: Place: Signature of the Claimant

FOR OFFICE USE ONLY Checked by: Total amount payable under the claim Rs……………. Less: Advance on account payble, if any Rs……………. Net amount payable Rs…………… Approved by: In case entire claim is not admissible, reason thereof Passed for payment of Rs …………………..

COMPETENT AUTHORITY Note: Payment of claim will be made through electronic transfer only. Cancelled cheque leaf of the bank account to which the claim amount need to be transferred need to be mandatorily submitted along with documents.

Annexure-E

Bank NEFT Format (FOR RETIRED EMPLOYEES OF UNITED BANK OF INDIA)

Beneficiary's Name : _______________________________________________ Beneficiary's Address : ________________________________________________ ________________________________________________ Beneficiary's Bank Name : ________________________________________________ Beneficiary's Branch Name : ________________________________________________ Beneficiary's Account Type : ________________________________________________ Beneficiary's Account No. : ________________________________________________ Beneficiary's Branch IFSC Code : ________________________________________________ Beneficiary's MICR No. : ________________________________________________ ** “Mandatory Requirement” : Cancelled Cheque_________________________________ Telephone/Mobile No. : ________________________________________________ Retired Employee's Signature : ________________________________________________ Place : __________________________________ Date : __________________________________

Annexure-F

CHECKLIST FOR THE MRC CLAIM

REQUIRED DOCUMENTS

PLEASE TICK

S

L

.

N

O

.

IN CASE OF HOSPITALISATION CLAIM PLEASE TICK

S

L

.

N

O

.

IN CASE OF PRE & POST

HOSPITALISATION CLAIM

1 COMPLETELY FILLED CLAIM FORM 1 COMPLETELY FILLED CLAIM FORM

2 PHOTO COPY OF THE TPA CARD AND PHOTO ID

2 PHOTO COPY OF THE TPA CARD AND PHOTO ID

3 ADVICE FOR ADMISSION (IN CASE OF PLANNED)/EMERGENCY MEDICAL OFFICER'S

NOTE(IN CASE OF EMERGENCY)

3 ATTESTED PHOTO COPY OF THE DISCHARGE SUMMARY

4 ORIGINAL DISCHARGE SUMMARY/ATTESTED COPY OF CASE SUMMARY AND DEATH CERTIFICATE OF

THE HOSPITAL (IN CASE OF DEATH)

4 ALL THE BILLS SHOULD BE SUPPORTED BY THE RELEVANT

ORIGINAL/ ATTESTED PRESCRIPTION & INVESTGATION REPORTS OF

PRE/POST HOSPITALISATION PERIOD.

5 ORIGINAL CONSOLIDATED BILL WITH BILL No.DETAIL BREAKUP BILL OF ALL ITEMS/PACKAGE

5 IF THE MEDICINES ARE NOT PRESCRIBED IN THE DISCHARGE

SUMMARY, PRESCRIPTION IS MUST TO SUBSTANTIATE ANY MEDICINE BILL

6 STICKER AND INVOICES OF IMPLANTS/IOL AND IOL CARD

7 CASH/MONEY RECEIPT for BILLS PAID (Advance and Final) WITH RECEIPT No.

8 If DOCTORS / SURGEONS CHARGE IS NOT INCLUDED IN THE FINAL BILL THEN SEPARATE RECEIPT IN ORIGINAL (mentioning the Regn. No.) FROM THEM IS A MUST.

9 ALL THE BILLS SHOULD BE SUPPORTED BY THE RELEVANT ORIGINAL PRESCRIPTION/INDENTS OF MEDICINES & INVESTGATION REPORTS AT THE TIME OF HOSPITALISATION

10

IN CASE OF ROAD TRAFFIC ACCIDENT/BURNS/POISIONING/OTHER ACCIDENTS-MLC/FIR COPY AND TREATING DOCTORS CERTIFICATE STATING CAUSE OF INJURY

ANNEXURE - G FORMAT FOR LODGING GRIEVANCE / COMPLAINT

Signature: -----------------------------------------------------------------------------------------------------------------------------------------------

For office use only • Date of receipt : • Office of receipt : • Grievance number alloted : • Acknowledgment sent on • Name and designation of grievance officer : • Date of disposal of grievance :

Notes

1. Please fill up all the columns specially item number 1 to 15 2. Grievance format to be addressed to the concerned grievance officer 3. The letter should be addressed to the policy issuing office as mentioned in the policy

1. Name (In Capital)

2. Date of Birth

3. Sex

4. Pan Card No. / Voter ID Card No. / Passport No. / Ration Card No. (Any one)

5. Address for Communication

6. Occupation

7. Designation (if in service)

8. Mobile no. & Landline no. (any one)

9. Email id

10. Nature of Complaint (please tick) Delay in issuing policy

Delay in settlement of claim Repudiation / Rejection of claim

Disputes in quantum

Other if any (Pls specify)

11. Details of complaint

12. Policy No. and Period

13. Claim Number

14. Date of Loss

15. Name and address of policy issuing office

16. Any other references

17. Whether any correspondance / reference made earlier to policy issuing office

18. Whether the grievance department of the concerned RO has been consulted (if not done so far, we suggest for the same for obtaining speedy resolution of the grievance)

Date: Place: