New Revised Scheme on Reimbursement of hospitalisation and medical expenses in 10th BPS

Here is the details of Newly introduced Medical Insurance Policy in 10th B.P.S.

AIBEA cir.st.08.06.2015

New Revised Scheme on Reimbursement of hospitalisation/medical expenses

Our units and members are aware that while formulating the Charter of Demands for the 10th BP Settlement, our Wages Sub-Committee had recommended certain priorities and one amongst them was the need to substantially improve the health care scheme to provide for full reimbursement of the medical/hospitalisation expenses.  Our Sub-Committee also recommended that we should achieve extension of the scheme to the retired employees also and further that the cost of such health care scheme should be over and above the wage cost agreed in the settlement. 

We are happy that when the 10^th Bipartite Settlement has been signed now, we could achieve all these priority demands as part of the Settlement. 

The new scheme that has been agreed to be introduced provides for full reimbursement of hospitalisation / medical expenses incurred by the employee / dependent family members including domiciliary treatment.  The Scheme would be available to the employees even after their retirement.  In addition, all the existing retired employees would also be covered by the Scheme.  And further, the entire cost of the Scheme would be exclusive of the wage revision cost agreed to by the IBA. 

Hence, at a time, when due to the opening up of the health sector and commercialisation of the health services, medical treatment has become extremely costly and unaffordable to ordinary people, this Scheme is a significant achievement.

We give hereunder the salient feature of the Scheme :

(i)        All existing employees are covered by the Scheme

(ii)        New recruits will be covered from date of joining

(iii)        The Scheme covers Employee + Spouse + Dependents + any two of the dependent Parents /Parents-in-law.

(iv)        Hospitalization / domiciliary hospitalization and domiciliary treatment expenses will be reimbursed.

(v)        No age limit for dependent children (including step children and legally adopted children).

(vi)        A child/parents/parents in law  would be considered dependent if monthly income does not exceed Rs.10,000/- per month

(vii)        Widowed Daughter and divorced / separated daughters, sisters including unmarried / divorced / abandoned or separated from husband/ widowed sisters

(viii)        Physically/mentally challenged Brother / Sister with 40% or more disability shall also be covered as Dependent.

(ix)        Till the new scheme is made effective and gets implemented, the existing provisions as per Bipartite Settlement dated 27.4.2010 will continue to operate.

(x)        The new Scheme as applicable to the employees in service would be continuedbeyond their retirement/ superannuation/ resignation, etc. subject to payment of stipulated premium by them.

(xi)        The new Scheme would also cover the existing retired employees of the Banks and dependent spouse subject to payment of stipulated premium by them.

(xii)        Reimbursement shall cover Room and Boarding expenses as provided by the Hospital/Nursing Home not exceeding Rs. 5000 per day or the actual amount whichever is less.

(xiii)        Reimbursement shall cover Intensive Care Unit (ICU) expenses not exceeding Rs. 7500/- per day or actual amount whichever is less.

(xiv)        Reimbursement shall cover Surgeon, team of surgeons, Assistant surgeon, Anaesthetist, Medical Practitioner, Consultants, Specialists Fees,  Nursing Charges, Service Charges, 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.

(xv)        Hospitalization expenses (excluding cost of organ) incurred on donor in respect of organ transplant to officers/ employee/dependent would also be covered for reimbursement.

(xvi)        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.

(xvii)        Alternative systems of treatments other than treatment under Allopathy or modern medicine shall include Ayurveda, Unani, Siddha, Homeopathy and Naturopathy for Hospitalization and Domiciliary treatment.

(xviii)        CASHLESS FACILITY: The scheme also includes the benefit of cashless treatment facility in hospitals  covered by the scheme.

(xix)        CONTRIBUTION:  The officers / employees shall not be required to share the cost of such benefits under the new scheme.

(xx)        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.

(xxi)        Day care Treatments shall be covered under the scheme

(xxii)        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 :

(xxiii)        The condition of the patient is such that he/she is not in a condition to be removed to a hospital or

(xxiv)        the patient takes treatment at home on account of non-availability of room in a hospital.

(xxv)        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,   

·                  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,

·                  Hemorrhages 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

      

(xxvi)        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.

(xxvii)        ID CARD: ID Cards would be issued to all the  employees/ dependent family members/retired  employees/their dependents for the purpose of availing cashless facility in network hospitals. 

    

(xxviii)        PRE-EXISTING DISEASE: Pre Existing Diseases would be covered for reimbursement under this scheme.

(xxix)        PRE–HOSPITALISATION MEDICAL EXPENSES: Medical expenses incurred immediately 30 days before the employee is hospitalized will be considered as part of a claim

(xxx)        POST HOSPITALISATION MEDICAL EXPENSES:  Relevant medical expenses incurred immediately 90 days after the employee/ dependent/ retirement employee is discharged from the hospital

(xxxi)        Additional Ex-Gratia for Critical Illness :  In addition to the reimbursement covered under this scheme,  employees (only  employees and not their dependents or retired employees) shall be provided additional ex gratia of  Rs.  1,00,000 in case an employee contracts a Critical Illness as listed below:

·         Cancer  including  Leukemia

·         Stroke 

·         Paralysis

·         By Pass Surgery

·         Major Organ Transplant/Bone marrow transplantation

·         End Stage Liver Disease

·         Heart Attack  

·         Kidney Failure

·         Heart Valve Replacement Surgery

·         Hospitalization is not required to claim this benefit.

(xxxii)        Expenses on Hospitalization for minimum period of a day are admissible.  However, this time limit shall not be applied to specific treatments, such as:

1	Adenoidectomy	19	Haemo dialysis
2	Appendectomy	20	Fissurectomy / Fistulectomy
3	Auroplasty  not Cosmetic in nature	21	Mastoidectomy
4	Coronary angiography /Renal	22	Hydrocele
5	Coronary angioplasty	23	Hysterectomy
6	Dental surgery	24	Inguinal/ventral/umbilical/femoral hernia
7	D&C	25	Parenteral chemotherapy
8	Excision of cyst/granuloma/lump/tumor	26	Polypectomy
9	Eye surgery	27	Septoplasty
10	Fracture including hairline fracture /dislocation	28	Piles/ fistula
11	Radiotherapy	29	Prostate surgeries
12	Chemotherapy including parental chemotherapy	30	Sinusitis surgeries
13	Lithotripsy	31	Tonsillectomy
14	Incision and drainage of abscess	32	Liver aspiration
15	Varicocelectomy	33	Sclerotherapy
16	Wound suturing	34	Varicose Vein Ligation
17	FESS	35	All scopies along with biopsies
18	Operations/Micro surgical operations on the nose, middle ear/internal ear, tongue, mouth, face, tonsils & adenoids, salivary glands & salivary ducts, breast, skin & subcutaneous tissues, digestive tract, female/male sexual organs.	36 37	Lumbar puncture Ascitic Pleural tapping

(xxxiii)        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.

(xxxiv)        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 Rs 50,000/- for normal delivery and Rs. 75,000/-  for Cesarean Section.

(xxxv)        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/-.          

(xxxvi)        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 Rs 750/- per trip will also be reimbursable.

(xxxvii)        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.

(xxxviii)        Congenital Anomalies: Expenses for Treatment of Congenital Internal / External diseases, defects anomalies are covered under the scheme.

(xxxix)        Psychiatric diseases: Expenses for treatment of psychiatric and psychosomatic diseases shall be payable with or without hospitalization.

(xl)        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.

(xli)        Treatment taken for Accidents can be payable even on OPD basis in Hospital.

(xlii)        Taxes and other Charges : All Taxes , Surcharges , Service Charges , Registration charges, Admission Charges , Nursing ,  and Administration charges to be payable.

(xliii)        Charges for diapers and sanitary pads are payable, if necessary, as part of the treatment. 

(xliv)        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.

(xlv)        Treatment for Genetic Disorder and stem cell therapy shall be covered under the scheme.

(xlvi)        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.

(xlvii)        Treatment for all neurological/ macular degenerative disorders shall be covered under the scheme.

(xlviii)        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.

(xlix)        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.

   (l)        Physiotherapy charges: Physiotherapy charges shall be covered for the period specified by the Medical Practitioner even if taken at home.

  (li)        While reimbursement to the 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 employees would in no way be directly bound by the terms and conditions of such scheme or arrangements.

(lii)        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.