Domiciliary Treatment Covered Under Medical Insurance

CLRIFICATIONS FROM UIIC TO ONE OF THE BANKS ON RETIREES MEDICAL INSURANCE

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C H VENKATACHALAM				11:44 PM (12 hours ago)

CLARIFICATION SENT BY UIIC TO ONE OF THE BANKS

FOR YOUR INFORMATION

Issue	Our query	UIIC clarification
Modalities of domiciliary expenses .	What will be the modalities of reimbursing the claim under domiciliary expenses to retirees ?	It can be send to TPA directly or to the nearest Bank office from where it has to be forwarded to zonal office enabling the TPA officer to collect it.
Format for claiming domiciliary  expenses.	Whether you have introduced any prescribed format for claiming domiciliary expenses for retirees ? If yes, please provide us a copy of the same.	Same claim form as being  used for hospitalization. Please advise the retiree to write on the top "For domiciliary treatment".
Nature of expenses admissible.	Please clarify what type/nature of expenses are covered for the treatment of identified 59 ailments.	Same as applicable to employee policy.
Extension of domiciliary treatment to such retirees, who are not the member at present.	Since the  UIICL has introduced option for domiciliary expenses  now, whether such retirees who have not become member of the Scheme so far,  can join the Medical Insurance Scheme now ?	Only present retirees who are covered in the current policy are allowed to join the renewal policy.
Switching over from domiciliary expenses benefit to normal renewal (without domiciliary cover) or vice versa.	Please clarify whether a retiree who opts for domiciliary expenses benefit (Option II) now, be allowed  to  switch over to normal renewal next  year or Vice-versa	The final decision would be taken at the time of r

C H VENKATACHALAM

GENERAL SECRETARY AIBEA

98400 89920
Subject: Clarifications - Reply received from TPA of UIIC
 

Dear members,

We attach the document incorporating the replies of the Paramount Health Services P Ltd., on rules and procedure for reimbursement of domiciliary treatment/expenses and other issues of our concern for information of members.

Regards,

R.K. Powar, GS, AIUBRF,
Asst. General Manager(Retired)
Union Bank Of India
Tel: (M) 7710030963
email: rkpowar@gmail.com

ALL INDIA UNION BANK RETIREES’ FEDERATION (Affiliated to All India Bank Retirees’ Federation) A/12, Girdhar Apt., Kastur Park, Shimpoli Road, Borivali (W), Mumbai 400 092       Chairman                                       President                           General Secretary    D. A. Masdekar                              B. G. Raithatha                             R. K. Powar     9970899393                                   9427207021                               7710030963 damasdekar@gmail.com             ubiretirees@gmail.com               rkpowar@gmail.com

No.106/2016-17                                                                 19th September 2016

Dear Members,

Group Insurance Medical Policy: Reply of T.P.A.

DOMICILIARY TREATMENT – CLARIFICATIONS

We have in our earlier communication informed the members that the Federation has requested The Paramount Health Services Pvt. Ltd, the Third Party Administrator (TPA) of UIIC to clarify the rules and procedure for reimbursement of domiciliary treatment expenses to remove uncertainty.

We have received the reply from TPA which is appended here below for the information.

No.	AIUBRF’s  query	Reply of T.P.A.
1	Why is the procedure for reimbursement of domiciliary treatment not clearly outlined? It is being confused with the domiciliary conditional clause of individuals unable to be hospitalized or lack of space in hospitals?	It is a Domiciliary Treatment and not a Domiciliary Hospitalization.
2	Whether the rules and procedure followed/adopted in respect of in-service employees for sanction of reimbursement of domiciliary treatment is the same for retirees?	YES
3	How frequently can the retired employee be permitted to claim the reimbursement for domiciliary treatment i.e. weekly, monthly, or quarterly?	Monthly
4	Whether the retired employees would be sanctioned reimbursement for domiciliary treatment as per the list of 59 diseases circulated by the Bank, such as Diabetes, hypertension etc., on self certification or based on prescription of the general / family doctor or is it compulsory to obtain prescription from the hospital?	To Claim Domiciliary will need Doctor Consultation, prescription, Medicine bills/Investigation reports all in original.
5	How often must the retiree get fresh certification from the doctor/hospital?	Valid upto 90 days i.e. 3 months and if the prescription says LIFE LONG TREATMENT the same will be valid for 180 days.
6	Are those who retired from the Bank in the last year, entitled to Opt under this new Scheme?	Only who were covered in last year policy.
7	An important advantage of the Scheme is the Cashless facility available for treatment in hospitals. But many hospitals are not covered by tie-up and hence employees are asked to pay for the treatment and then seek reimbursement. How can retires avoid such difficulties to avail cashless treatment facility?	We would request those retirees to check on the portal www.paramounttpa.com/iba the Network list before getting hospitalized.
8	The Settlement and the Scheme clearly provide that retirees would submit the Bills to the Banks and in turn the Banks to submit the Bills to the TPA to get the reimbursement. But in many some of the managements are asking the employees to submit the Bills directly to the TPA.	Should be submitted at your branch office from where you collect your pension.
9	There are instances of death occurring during treatment in hospital and if it happens to be Sunday or holiday, the hospital/TPA does not come to the rescue and the family is facing problems in getting the body of the patient in time.	We are processing the Cashless on week days and on national holidays also so there is no question that TPA doesn’t help during crisis; only issue is there when the Sum Insured is exhausted.
10	Treatments like Dialysis, etc. are disallowed by the TPA though covered by the Scheme and the employees are forced to pay the cost to the hospital. How can the scheme be implemented by the TPAs so that employees are not put into such hardship.	Day care list is already shared to all by Union Bank of India - Day Care List, and we have settled lot of Dialysis cases so where is the question of disallowing the same.
11	In the case of Bills submitted to the Banks for domiciliary treatment, there are many complaints of undue delay by the TPAs and managements are not taking steps to liaise with them to expedite the claims. Special attention is required in this regard.	Last year there was no Domiciliary treatment so where the question of delay and delay is only happens when the documents are not proper or there is a deficiency. So we would request all to submit proper documents and in the given time frame.

We have also requested the Department of Personnel, Central Office and UIIC to clarify on other issues of our concern.  No sooner we receive the same; we will inform all the members.

With warm regards,

      Yours truly,

    (R. K. Powar)

  General Secretary

UNION BANK RETIRED EMPLOYEES' ASSOCIATION

(Registered under Trade Union Act, 1926 : Registration No.G-6201)
(Affiliated to All India Bank Retirees' Federation
through All India Union Bank Retirees' Federation)
403, Sadhana Down Town, Near Punjab National Bank,
Jubilee Chowk, Rajkot - 360 001 (Gujarat).  Phone: 0-94272-07021

  E-mail < ubiretirees@gmail.com > < rajkot@ubiretirees.in >  

======================================================

Date: 10th October,'16

To

All the regular recipients of our Association's e-mails,

Friends,

59 diseases for which bank retirees will be covered in Group

II for reimbursement of domiciliary treatment expenses

   Please see another e-mail and its attachment forwarded herewith (received from Shri R.K.Powar, General Secretary, All India Union Bank Retirees' Federation). 

Yours sincerely,

B.G.Raithatha,

General Secretary

From: "Powar R K" <rkpowar@gmail.com>
To: 
Sent: Monday, 10 October, 2016 16:22:06
Subject: Renewal of Insurance Premium - clarification

Dear all,

We have informed you that the insurance company has sent the communication for the renewal premium for 2016-2017 with two options. (1) Normal Renewal on as is basis (Without Domiciliary cover) and (2) with Domiciliary Expenses Benefits Option (59 diseases as per Employee Policy).

We attach the list of 59 diseases as per Employee Policy for the information of the members which will be covered under Option No. 2.

Regards,

R.K. Powar, GS, UBRA

Asst. General Manager(Retired)
Union Bank Of India
Tel: (M) 7710030963
email: rkpowar@gmail.com

Click Here To Know Nams of Diceases Covered Under Domiciliary Treatment Scheme

Sr. No. Treatments 1 Cancer 2 Leukemia 3 Thalassemia 4 Tuberculosis 5 Paralysis 6 Cardiac Ailments 7 Pleurisy 8 Leprosy 9 Kidney Ailment 10 All Seizure disorders 11 Parkinson’s diseases 12 Psychiatric disorder including schizophrenia and psychotherapy 13 Diabetes and its complications 14 Hypertension 15 Hepatitis –B 16 Hepatitis - C 17 Hemophilia 18 Myasthenia gravis 19 Wilson’s disease 20 Ulcerative Colitis 21 Epidermolysis bullosa 22 Venous Thrombosis(not caused by smoking) Aplastic Anaemia 23 Psoriasis 24 Third Degree burns 25 Arthritis 26 Hypothyroidism 27 Hyperthyroidism expenses incurred on radiotherapy and chemotherapy in the treatment of cancer and leukemia 28 Glaucoma 29 Tumor 30 Diptheria 31 Malaria 32 Non-Alcoholic Cirrhosis of Liver 33 Purpura 34 Typhoid 35 Accidents of Serious Nature 36 Cerebral Palsy 37 Polio 38 All Strokes Leading to Paralysis 39 Haemorrhages caused by accidents 40 All animal/reptile/insect bite or sting 41 Chronic pancreatitis 42 Immuno suppressants Domiciliary Hospitalization / Domiciliary Treatment Sr. No. Treatments Domiciliary Hospitalization / Domiciliary Treatment 43 Multiple sclerosis / motorneuron disease 44 Status asthamaticus 45 Sequalea of meningitis 46 Osteoporosis 47 Muscular dystrophies 48 Sleep apnea syndrome(not related to obesity) 49 Any organ related (chronic) condition 50 Sickle cell disease 51 Systemic lupus erythematous (SLE) 52 Any connective tissue disorder 53 Varicose veins 54 Thrombo embolism venous thrombosis/venous thrombo embolism (VTE)] 55 Growth disorders 56 Graves’ disease 57 Chronic Pulmonary Disease 58 Chronic Bronchitis 59 Physiotherapy and swine flu shall be considered for reimbursement under domiciliary treatment.


Clarification on whether reimbursement is possible for Dental treatment
dkj

UNION BANK RETIRED EMPLOYEES’ ASSOCIATION

(Registered under Trade Union Act,, 1926 : Registration No.G-6201)

(Affiliated to All India Union Bank Retirees’ Federation)

-: Office :-

403(A), Sadhna Down Town, Near Punjab National Bank,

Opp. Alfred High School, Jubilee Chowk, RAJKOT – 360 001 (Gujarat).

‘E’ mail : < ubiretirees@gmail.com  > Cell : 0-94272-07021

Ref:Insurance:2016:129 Date : 15th October,’16

To                                                                                          Only by e-mail

All the members of our Association,

Friends,

Group Medical Insurance scheme

(A) Domiciliary treatment expenses

1. From several messages being received through WhatsApp and other media, it is understood that  there is some confusion among the retirees as to whether by paying higher premium the retirees will really get reimbursement of medical expenses incurred for domiciliary treatments (without hospitalization). Hence our Association thinks it proper to express its views as under.

2. If we refer Schedule IV of the 10th Bipartite Settlement, it contains following particulars for reimbursement of medical expenses.

1. Day Care Treatment undertaken in a hospital for less than a day

2. Domiciliary Hospitalization means medical treatment taken at home when condition of the patient is such that he / she is not in a position to be moved to a hospital or the patient takes treatment at home because of non-availability of room in a hospital

3. Domiciliary Treatment: treatment taken for specified diseases which may or may not require hospitalization. (59 diseases are identified for this purpose)

Though apparently all the three i.e. (a), (b) & (c) mentioned above look identical, in reality terms those are different. For (c) i.e. domiciliary treatment hospitalization is not essential.

3. In the 10th BP Settlement, the Indian Banks’ Association had agreed with the United Forum of Bank Unions to take insurance cover for serving and retired employees for hospitalization and also for the treatments specified in 2(a) (b) & (c) above. But the Insurance Company had not agreed to grant reimbursement to the retired employees for the domiciliary treatment (i.e. mentioned in Para 2 (c) with an apprehension that the claims of the elderly people would be much more. The Insurance Company had offered refund of the premium to those who were not willing to continue in the Insurance Scheme because of exclusion of the domiciliary treatment. The stand taken by the Insurance Company was consistent with the law, as any proposal can be accepted partially also and in that case the other party has right to cancel the deal.  

4. Now, when our Insurance Policy is due for renewal, the Insurance Company is agreeing to grant reimbursement of domiciliary treatment expenses even to the retirees provided they pay more premiums.

5. The reimbursement of domiciliary treatment expenses is already being granted to –

1. Employees in service of all the Banks (including their spouses, dependent children and parents or parents in law)
2. Pensioners of State Bank of India

6. On our casual inquires with the (i) Leaders of the serving employees’ / officers’ organizations as well Office Bearers of State Bank of India Pensioners’ Association, it is understood that the system of granting reimbursement of domiciliary expenses is working well. Their claims are being settled. Therefore, there is no reason of any apprehension in our mimfd that our claims would not be settled.

(B) Reimbursement of expenses incurred for dental treatment

8. A similar confusion is persisting for reimbursement of expenses incurred for dental treatment.

9. Please refer the Master Insurance Policy No. 500100 /48 /15/41 /00000522 dated 6th November,’15 issued by the United India Insurance Company for retired employees of our Bank. In Clause No.3.3 thereof certain diseases are specified for which day care treatment is reimbursable provided the treatment is undertaken under General or Local Anesthesia in a hospital / day care centre. Certain diseases include Dental Surgery also.

10. However, in terms of Clause No.4.4 of the same Insurance Policy, expenses incurred for dental treatment / surgery is not reimbursable in the following circumstances.

1. Treatment is taken in a Dental Clinic or
2. The treatment is cosmetic in nature

11. In view of these, the expense incurred merely for clearing the teeth is nor reimbursable, because it is cosmetic in nature. However, if we undergo root canal or tooth implant treatment / surgery, it is reimbursable.

12. To cite specific examples –

1. When I had given an intimation to TPA for my own root canal treatment in a dental clinic, the permission was denied to me.

2. Shri J.P.Shah, a member of our Association – now settled at Baroda had sought permission of TPA for root canal treatment of his two / three teeth in a Multi Specialty Hospital (which had more than 15 beds). The permission was accorded and expenses of around Rs.30,000/- was reimbursed.

13. Therefore, if you want reimbursement of dental surgery from the Insurance Company, please choose any Multi Specialty ora  Corporate Hospital, wherein there are minimum 15 beds; though in fact actual hospitalization is not required for dental treatment.

14. If we go for purchasing any direct Insurance Policy or if we join any other Group Medical Insurance Scheme, dental surgery even in a Hospital having more than 15 beds is not reimbursable. But the IBA’s group medical insurance policy applicable to us is granting this benefit.

15. It is a subjective matter of an individual whether to continue in the renewed insurance policy and that too with or without domiciliary treatment. But the basic idea for issuing this e-circular is to remove misconception, if any, as regards (i) domiciliary treatments and (ii) dental surgeries.

16. This circular is being sent by e-mail to those members whose e-mail IDs. are available with our Association with a request to pass on this message to the members who have no e-mail facility.

 Yours sincerely,

(B.G.Raithatha),

General Secretary