10th Bipartite Settlement – Medical Insurance Scheme
SCHEDULE FOR REIMBURSEMENT OF HOSPITALISATION EXPENSES
MEDICAL INSURANCE SCHEME
Having regard to the need to extend better coverage and reimbursement of hospitalization and medical expenses incurred by the officers / employees/dependent family members, the demand for full reimbursement of expenses connected with hospitalisation and medical treatment including domiciliary hospitalization and domiciliary treatment was discussed by and between the parties and a new scheme for reimbursement of medical expenses has been formulated.
The salient feature of the Scheme is as under: The scheme shall cover expenses of the officers / employees and dependent family members in cases he/she shall contract any disease or suffer from any illness (hereinafter called DISEASE) or sustain any bodily injury through accident (hereinafter called INJURY) and if such disease or injury shall require any employee/ dependent family member, upon the advice of a duly qualified Physician/Medical Specialist/Medical practitioner (hereinafter called MEDICAL PRACTITIONER) or of a duly qualified Surgeon (hereinafter called SURGEON) to incur hospitalization/ domiciliary hospitalization and domiciliary treatment expenses as defined in the Scheme, for medical/surgical treatment at any Nursing Home/ Hospital / Clinic (for domiciliary treatment)/ Day care Centre which are registered with the local bodies in India as herein defined (hereinafter called HOSPITAL) as an inpatient or otherwise as specified as per the scheme.
The Scheme covers Employee + Spouse + Dependent Children + any two of the dependent Parents /Parents-in-law.
No age limit for dependent children (including step children and legally adopted children).
A child would be considered dependent if his/her monthly income does not exceed ₹10,000/- per month;
Widowed Daughter and dependent divorced / separated daughters, sisters including unmarried / divorced / abandoned or separated from husband/ widowed sisters and Crippled Child shall be considered shall be considered as dependent for the purpose of this policy.
Physically challenged Brother / Sister with 40% or more disability shall also be covered as Dependent.
No Age Limits for Dependent Parents. Any two, i.e. either dependent parents or parents-in-law will be covered as dependent.
Parents would be considered dependent if their monthly income does not exceed ₹10,000/- per month or as revised by Indian Banks’ Association in due course, and wholly dependent on the employee as defined in this scheme.
All the existing permanent officers / employees of the Banks which are parties to this Settlement shall be covered by this Scheme from the date of introduction/implementation of this Scheme. All New Officers / employees shall be covered from the date of joining as per their appointment in the bank.
Till the new scheme is made effective and gets implemented, the existing provisions as per Bipartite Settlement/ Joint Note dated 27.4.2010 will continue to operate.
The new Scheme as applicable to the officers/ employees in service would be continued beyond their retirement/superannuation/resignation, etc. subject to payment of stipulated premium by them.
The new Scheme would also cover the existing retired officers/ employees of the Banks and dependent spouse subject to payment of stipulated premium by them. In the event of any claim becoming admissible under this scheme, the Bank will reimburse the amount of such expenses as would fall under different heads mentioned below and as are reasonably and medically necessary incurred thereof by or on behalf of such employee.
Reimbursement shall cover Room and Boarding expenses as provided by the Hospital/Nursing Home not exceeding ₹5000 per day or the actual amount whichever is less. Intensive Care Unit (ICU) expenses not exceeding ₹7500/- per day or actual amount whichever is less. Surgeon, team of surgeons, Assistant surgeon, Anaesthetist, Medical Practitioner, Consultants, Specialists Fees, 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, scopies 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 officers/ employee/dependent would also be covered for reimbursement. Pre and Post Hospitalization expenses payable in respect of each hospitalization shall be the actual expenses incurred subject to 30 days prior to hospitalization and 90 days after discharge.
Alternative systems of treatments other than treatment under Allopathy or modern medicine shall include Ayurveda, Unani, Siddha, Homeopathy and Naturopathy in the Indian context, for Hospitalization and Domiciliary treatment.
CASHLESS FACILITY: The scheme also includes the benefit of cashless treatment facility in hospitals under a scheme worked by the Banks and the hospitals under a common insurance scheme.
CONTRIBUTION: The officers / employees shall not be required to share the cost of such benefits under the new scheme. However, in the case of officers / employees retiring from the Banks after the scheme is introduced and those who are already retired from the services of the banks and who opt to avail the benefits of the scheme, the amount of contribution by such persons shall be decided at the respective Bank level. Day care Treatments shall be covered under the scheme and would refer to medical treatment and or surgical procedure which is
i. undertaken under general or local anaesthesia in a hospital/day care centre in less than a day because of technological advancement, and
ii. which would have otherwise required hospitalisation of more than a day. Treatment normally taken on an out patient basis is not included in the scope of this definition.
DOMICILIARY HOSPITALIZATION: Domiciliary Hospitalization shall be covered under this scheme and would mean medical treatment for an illness/disease/injury which in the normal course would require care and treatment at a hospital but is actually taken while confined at home under any of the following circumstances :
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.
DOMICILIARY TREATMENT shall also be covered under this scheme i.e. treatment taken for specified diseases which may or may not require hospitalization as mentioned herein below.
Domiciliary Hospitalization / Domiciliary Treatment : Medical expenses incurred in case of the following diseases which need Domiciliary Hospitalization /domiciliary treatment as may be certified by the recognized hospital authorities and bank’s ’medical officer shall be deemed as hospitalization expenses and reimbursed to the extent of 100%. Cancer, Leukemia, Thalassemia, Tuberculosis, Paralysis, Cardiac Ailments , Pleurisy , Leprosy, Kidney Ailment, All Seizure disorders, Parkinson’s diseases, Psychiatric disorder including schizophrenia and psychotherapy, Diabetes and its complications, hypertension, Asthma, Hepatitis –B, Hepatitis – C, Hemophilia, Myasthenia gravis, Wilson’s disease, Ulcerative Colitis, Epidermolysis bullosa, Venous Thrombosis (not caused by smoking) Aplastic Anaemia, Psoriasis, Third Degree burns, Arthritis, Hypothyroidism, Hyperthyroidism, expenses incurred on radiotherapy and chemotherapy in the treatment of cancer and leukemia, Glaucoma, Tumor, Diphtheria, Malaria, Non-Alcoholic Cirrhosis of Liver, Purpura, Typhoid, 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 / motor neuron 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 Pulmonary Disease, Chronic Bronchitis, Physiotherapy and swine flu shall be considered for reimbursement under domiciliary treatment.
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.
HOSPITAL / NURSING HOME: A Hospital under this scheme would mean any institution established for in-patient care and day care treatment of illness and/or injuries and which has been registered as a Hospital with the local authorities under the Clinical establishments (Registration and Regulation) Act, 2010 or under the enactments specified under the Schedule of Section 56(1) of the said Act OR complies with all minimum criteria as under:
Has qualified nursing staff under its employment round the clock.
Has at least 10 in-patient beds in towns having a population of less than 10 lacs and at least 15 in-patient beds in all other places;
Has qualified medical practitioner(s) in charge, round the clock;
Has a fully equipped Operation Theatre of its own where surgical procedures are carried out;
Maintains daily records of patients and makes these accessible to the insurance company’s authorized personnel.
This clause will however be relaxed in areas where it is difficult to find such hospitals. The term ‘ Hospital / Nursing Home ‘ shall not include an establishment which is a place of rest, a place for the aged, a place for drug-addicts or place for alcoholics, a hotel or a similar place.
HOSPITALIZATION: Hospitalization would mean admission in a Hospital/ Nursing
Home for a minimum period of 24 consecutive hours of inpatient care except for specified procedures/treatments, where such admission could be for a period of less than a day, ID CARD: In terms of the scheme arrived at between the Banks and insurance companies, ID Cards would be issued to all the officers / employees/ dependent family members/retired officers / employees/their dependents for the purpose of availing cashless facility in network hospitals.
PRE-EXISTING DISEASE: Pre Existing Diseases would be covered for reimbursement under this scheme.
PRE–HOSPITALISATION MEDICAL EXPENSES: Medical expenses incurred immediately 30 days before the insured person is hospitalized will be considered as part of a claim provided that such medical expenses are incurred for the same condition for which the insured person’s hospitalization was required.
POST HOSPITALISATION MEDICAL EXPENSES: Relevant medical expenses incurred immediately 90 days after the employee/ dependent/ retirement employee is discharged from the hospital provided that such medical expenses are incurred for the same condition for which the Insured Person’s Hospitalization was required. Additional Ex-Gratia for Critical Illness : In addition to the reimbursement covered under this scheme, officers / employees (only officers / employees and not their dependents or retired officers / employees) shall be provided additional ex gratia of ₹ 1,00,000/- . In case an employee contracts a Critical Illness as listed below, the sum of ₹1,00,000/- shall be paid. This benefit shall be provided on first detection/diagnosis of the Critical Illness.
Cancer including Leukemia
By Pass Surgery
Major Organ Transplant/Bone marrow transplantation
End Stage Liver Disease
Heart Valve Replacement Surgery
Hospitalization is not required to claim this benefit.
3.3 Expenses on Hospitalization for minimum period of a day are admissible. However, this time limit shall not be applied to specific treatments, such as:
This condition will also not apply in case of stay in hospital of less than a day provided 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 which would have otherwise required hospitalization of more than a day.
MATERNITY EXPENSES BENEFIT EXTENSION : Hospitalization expenses in respect of the new born child can be covered within the Mother’s Maternity expenses. The maximum benefit allowable under this clause will be up to ₹ 50000/- for normal delivery and ₹ 75,000/- for Caesarean Section.
Baby Day one Cover: 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 and
up to Rs, 20,000/-.
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. Taxi and Auto expenses in actual maximum up to Rs750/- per trip will also be reimbursable. 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.
Congenital Anomalies: Expenses for Treatment of Congenital Internal / External diseases, defects anomalies are covered under the scheme.
Psychiatric diseases: Expenses for treatment of psychiatric and psychosomatic diseases shall be payable with or without hospitalization.
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 /day care surgery. Treatment taken for Accidents can be payable even on OPD basis in Hospital.
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.
Treatment for Genetic Disorder and stem cell therapy shall be covered under the scheme. Treatment for Age related Macular Degeneration (ARMD), treatment such as Rotational Field Quantum magnetic Resonance (RFQMR), Enhanced External Counter Pulsation (EECP), etc. are covered under the scheme. Treatment for all neurological/ macular degenerative disorders shall be covered under the scheme.
Rental Charges for External and or durable Medical equipment of any kind used for diagnosis and or treatment including CPAP, CAPD, Bi-PAP, 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. 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 shall be covered for the period specified by the Medical Practitioner even if taken at home.
While reimbursement to the officers / employees shall be made by the Banks as hitherto, the Scheme shall be administered by the Banks through a scheme worked out between IBA/Banks and Insurance companies and officers / employees would in no way be directly bound by the terms and conditions of such scheme or arrangements.
However, for the purpose of clarity and information, the details of the Scheme worked out between IBA/Banks and insurance companies is appended herein as Appendix I & II.
The above stated scheme would not supersede the continuation of any bank-level arrangement or scheme providing for reimbursement of medical expenses, which is not covered herein, that may be in operation in any Bank.