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AGREEMENT FOR GROUP HEALTH INSURANCE POLICY
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FOR EMPLOYEES OF STATE PUBLIC SECTOR UND ERTAKIN GS OF ODISHA STATE

Tlis Agreement is made and executed at BHUBANESWAR on this 19tn. day of April, 2016.

By and Between
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LU\ITED INDIA INSUBANCE COMPANY LIMITED, a Company incorporated under Companies Act,
1956 hereinafter referred as the " The lnsurance Company'', which expression shall unless
rlpugnant to the context, mean and include its successors, assigns etc., represented by
Shri Pradipta Kumar Patnaik, Chief Regional Manager, Regional office at OCHC Building, Block-A,
(fth. Floor) lanpath, Unit-3, Bhubaneswar 751001 (one Part)

And

Cliisha State PSU (BBSR) Employees Welfare Society, a society registered under Odisha Society
Att 1s60, herein after called the "Welfare Society" which expression shall unless repugnant to
tEe context, mean and include its successors, assigns etc., represented by Shri Gopal Prasad
i6na President, Head office at Paribahan Bhavan, OSRTC Building, Ashok Nagar, Near AG office
Sachivalaya Marg, Bhubaneswar 751009 (Other Part)
Tuare,

Whereas the Government of Odisha decided to

introduce a group health insurance scheme to
ptovide all employees of State Public Sector.Undertakings in Odisha State and have selected
"[he lnsurance Company" for the said purpose and have finalized the Group Health lnsurance
Stheme for implementation through "Welfare Society".

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And Whereas the parties to the agreement i.e the lnsurance Company on the First Part and the
Welfare Society the Other part have decided to introduce the said health insurance scheme to
provide health insurance coverage to the employees of public sector undertakings of Odisha
State and who are the members of the Welfare Society through lnsurance Company's Group
.Health lnsurance Policy.

NOW THEREFORE IT IS HEREBY AGREED BY AND BETWEEN PARTIES HERETO AS FOLLOWS:

1. SCOPE, DURATION & COMMENCEMENT OF THE AGREEMENT

This Agreement shall cover all serving / retired employees of the State Public Sector
Undertakings and who are members of the Welfare Society and who voluntary opted to be the
insured persons under Group Health lnsurance Policy being operated by the lnsurance Company
as more fully described in the Annexure-l & ll which forms part of the agreement.

2. ELIGIBILTY:
(l) All serving/ retired employees of State Public Sector Undertakings of Odisha, who are
members of the Welfare Society, shall be eligible for coverage.
Dependent legal spouse, dependent first two children and dependent parents up to 80
years of age shall be eligible for coverage under Group Health lnsurance Policy.
(ll) This Agreement shall be in-force for a period of four years commencing from date of
execution unless terminated by notice by either party to the Agreement in accordance
with the provisions contained in Clause No.L4 below.
(lll) The Agreement may be renewed on its expiry for such further period not exceeding four
years at a time as per the terms and conditions as the parties may decide at the time of
renewaland however subject to Clause No.12 below.

3. CATEGORY OF EMPLOYEES COVERED:

(l) The serving /retired employees of State Public Sector Undertakings of Odlsha State and
who are members of the Welfare Society and their dependent family members are
covered under the Group Health lnsurance Scheme. Here the family member is defined
as legally dependent spouse, dependent first two children and dependent parents up to
80 years. The insured employee may opt to cover either of his/her own dependent
parents or dependent Parents-in-law subject to maximum of two in numbers and no
inter/intra changing between parents and parent-in-law shall be allowed.
(ll) However it is optional for an employee of the State Public Sector Undertakings of Odisha
State and who are members of the Welfare Society to participate in the insurance
coverage as described herein at his/ her absolute discretion and payment of premium as
stipulated premium by the employee.
(lll) Participation of the employee and member of the Welfare society in the insurance
scheme is purely on a voluntary basis.
(lV) For all purpose, the contract of insurance is between the lnsurance Company and the
insured person and not between the Welfare Society, Public Sector undertaking and the
lnsured. The Welfare society may act as the facilitator for the scheme.

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4. MODE OF PAYMENT OF PREMIUM :

(i) The payment of premium collected in respect of Group Health lnsurance Policy shall be
paid by the respective Public Sector Undertaking/ Welfare Society by way of NEFT/
Bankers Cheque/ Demand draft to the designated office(s) of the lnsurance Company
along with insured person details in the required format of the lnsurance Company. The
risk coverage shall commence from the date of receipt of premium and the insured
details.
(ii) The lnsurance risk coverage of the insured persons shall be for a period of one year
from the date of receipt of premium and the lnsured person details by the designated
office of the lnsurance Company.
(iii) The Sum lnsured of Rupees five lac per family unit is final till expiry of the policy period.
The sum insured will float amongst all insured family members under the policy. Either
one family member or all family members put together can avail the cover up to sum
insured of Rupees five lac and paid the requlred premium subject to policy terms and
condition of Group Health lnsurance Policy.

5. RISK COVERED:

(i) The Policy, terms, conditions & exclusions read as per ANNEXURE I & llwhich forms part
of the agreement.

(ii) Corporate buffer:

a) Aggregate corporate buffer amount of Rs.1,00,00,000/-( Rupees one crore) shall float
over all Group Health lnsurance Policies issued to PSUs in Odisha State in a year under
the agreement.
b) The above .corporate buffer amount is the final and shall be available under the
agreement to cover admissible expenses in respect of following critical illnesses in
excess of sum insured of insured employee's family unit under the policy up to rupees
five lac per family unit.

1. Cancer of Specified severity

2. First heart attack of specified severity
3. Coronary Artery Surgery( CABG) Open Chest CABG
4. Heart Valve Replacement
5. Coma of Specified Severity
6. Kidney Failure
7. Stroke Resulting in Permanent Symptoms
8. Major Organ / Bone Marrow Transplant
9. Multiple Sclerosis
10. Major Neurone Disease with Permanent Symptoms
1.1. Permanent Paralysis of Limbs

c) Corporate buffer can be authorized by the management of Welfare Society, on a first-

cum-first serve basis, through an Authorized person / Committee as decided by Welfare
Society, and informed directly to the THIRD PARry ADMINISTRATOR by keeping the
insurance company in the loop.

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 d) ln the event of any claim in respect of critical illness mentioned above becoming
admissible under this policy, the insurance company will pay through Third party
Administrator to the Hospital / Nursing Home or insured the amount of such expenses
as would fall under different heads of policy and as are reasonably and medically
necessary incurred thereof by or on behalf of such insured up to the amount of Rupees
five lac but not exceeding the amount in aggregate under Corporate Buffer provision
mentioned above.

6. INSURANCE PREMIUM RATES:

i. lt is agreed that the State Public Sector Undertakings of Odisha State/ Welfare society
will pay to the designated office of the insurance company premium for all it's
employees opted to be the insured persons under the group health insurance policy at
inception.
ii. lt is agreed that insurance company will charge annual premium @ Rs.6000.00 plus
service tax at the appropriate rate applicable at the date of making the payment, per
employee family unit towards the annual premium.
iii. The cover will cease on expiry of 12 months from the date of receipt of premium by the
lnsurance Company. ln order to ensure continuity of the policy, the State Public Sector
Undertaking of Odisha State/ Welfare Society should arrange to pay the premium for the
next year in advance, to keep the policy continuously in force. Premium is subject to
review on as per condition No. 5.13 & 5.14 of the Group Health lnsurance policy after
expiry of the Policy Period.
iv. The premium payable under the Policy shall be paid in advance. No receipt for Premium
shall be valid except on the official form of the company signed by a duly authorized
official of the company.

7. DEFINITION OF FAMILY:

The following family members of the employee shall be covered under the Group Health
lnsurance Scheme,:
(i) Legal Spouse of the employee and dependent on employee;
(ii) Dependent children of the employee above 3 months of age till they get employed or
married whichever is earlier;
(iii) Parents / Parents-in-law of the employee up the age of 80 years and are dependent on
employee.
A Spouse/child/parent would be considered dependent if their monthly income does not
exceed Rs. 5,000/- per month which is at present and shall be revised as per State Govt.
guidelines to be issued in future.

8. TPA SERVICES:

(i) Third Party Administrators from the panel of the lnsurance Company shall be
-(TPA)
identified by the lnsurance Company, whose services shall be utilized by the insured
persons under the policy.
(ii) The TPA will issue photo identity cards to the insured persons as soon as the policy is
issued by the insurance company.

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(iii) lnsured persons under the policy shall avail cash less facility for hospitalization claims by
producing lD cards issued in network hospitals of TpA subject to terms. conditions of the
group health insurance policy.
(iv) ln case of hospitalization in non- network hospitals, the insured persons shall be
intimate to the servicing TPA in advance in which case the TpA shall guide the insured
employee. Hospitalization claims in non-network hospitals of TPA and claims in respect
of Pre and post hospitalization claims of the insured person will have to first to honour
the bills and submit all treatment related documents, discharge summary, bills, cash
memos etc. in respect of the claim for reimbursement from the servicing TPA subject to
terms conditions of the policy.

9. CLAIM PROCEDURE:

(r) ln case of hospitalization in a network hospital, intimation shall be made to the Third
Party Administrator and shall produce lD card of the insured person issued by TPA at the
network hospital at the time of hospitalization for availing cash less treatment facility.
(ll) ln case of hospitalization in non-network hospital or insured seeking reimbursement of
admitted expenses for hospitalization under the Group Health lnsurance policy, the
insured person shall intimate to the Third Party Administrator within 24 hours of
hospitalization and which would be acknowledged by TPA through mobile application.
The claim documents along with bank details shall be submitted by the claimants to TPA
within 30 days from the date of discharge from the hospital. The lnsured Person shall
obtain and furnish to the Third Party Administrator with all original bills, receipts and
other documents upon which a claim is based and shall also give such additional
information and assistance as the Third Party Administrator/Com pa ny may require in
dealing with the claim.
(r) ln case of hospitalization claims of the insured person in non-network hospitals, the TPA
shall settle the claim within one month from the date of submission of all documents. ln
the unlikely event of delay beyond one month no penalty can be charged. ln any case if
all the relevant documents are not submitted within one year of the hospitalization the
claim will be closed as No Claim. The policy condition under Notice of claim is relaxed in
view of this agreement.

10. NOMINATION FACILITY:

(r) The employee can nominate a person for the benefits available under: the group health
insurance policy in respect of treatment in non-network hospitals as per prescribed
format. Such benefits accruing to the nominee only in the event of death of the insured
person covered under the policy.
(il) Under the policy, if the insured person has not appointed a nominee for the policy
benefit, the insurance company shall settle the claim independently as per the claim
procedure followed by them and such settlement of claims shall be entirely as per their
rules.

11. VALID DISCHARGE AGAINST CLAIM:

(r) The insurance company shall discharge of their liability when payment of the sum
insured is ma-de to the insured person or to the nominee of the insured person at the

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 time of cover as per nomination form of the insurance company or legal heirs as the
case may be.
(ll) All correspondence, including those related to submission and settlement of claims are
to be made between the insured person and the insurance company.
(lll) The State Public Sector Undertaking/Welfa re society shall not have any role in
submission of claim papers or its settlement.
(lV) No liability should devolve on the State Public Sector Undertaking/Welfare Society on
account of non- settlement or delayed settlement of claims by the lnsurance Company.

12. RENEWAL OF AGREEMENT:

The Agreement may be renewed for a further period of four years by mutual agreement on
the said terms and condition as may be mutually agreed upon and between both parties
and however it is subject to condition no. 5.13 & 5.14 of the Group Health Insurance policy.

13. Except otherwise provided for in this agreement, if the State Public Sector Undertakings/
Welfare Society submit the details of the insured persons in the format supplied by the
insurance company and makes the payment of premium as stated in clause no. 6, the State
Public Sector Undertaking/ Welfare society is absolved from the liability as regards claims of
the insured persons under this agreement or policy.

14. MODIFICATION / ALTERNATION/ TERMINATION OF AGREEMENT:

(i) Either parties to the agreement by giving advance notice of atleast three months before
expiry of the insurance policy period may propose notification/ alternation of any or all
the persons of this agreement. The modalities of determination of the agreement in
respect of closing of accounts, settling claims, notification to all concerns regarding
ceassion of 'the risk coverage etc.,shall be worked out by both parties by mutual
agreement without any way adversely affecting the interest of the insured persons
existing at the time of determination of the agreement.
(ii) At the option of either of the parties to this agreement, this agreement can be
cancelled/ terminated sub.iect to an advance notice of at least three months by the party
intending to terminate the agreement. The agreement shall be automatically cancelled/
terminated on expiry of three months from the date of receipt of notice by the other
party, unless the notice is revoked before expiry. lf and when the agreement is
terminated invoking clause no 14. Of this agreement, it will ipso-facto be applicable to
all insured person under the policy. The modalities after termination of the agreement in
respect of closing the accounts, settling claims, notification to all concerned regarding
cessation of risk coverage etc. shall be worked out by both parties by mutual agreement
without any way adversely affecting the interest of the insured person exiting at the
time of determination of the agreement.

15. ARBITRATION:

Any question, dispute, claim or difference arising out of, relating to, concerning this
agreement shall be first endeavoured to be settled by mutual understanding failing which
such question, dispute, claim or differences shall be governed and regulated by the
Arbitrator and Conciliation Act 1996. The venue of the arbitration proceeding shall be

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 Bhubaneswar. Any other matter not specifically included herein will be mutually settled
through negotiations between both the parties to this agreement.

lN WITNESS WHEREOF the lnsurance Company represented by its Chief Regional Manager,
United lndia lnsurance Company Limited, Regional Office, Bhubaneswar of the first part and
the said Welfare Society represented by its President, odisha State PsU (BBSR) Employees
Welfare Society, Head Office, Bhubaneswar of the second part have hereto, respectively
signed and affixed their signatures on this day and month and year at the place first herein
above mentioned.

For UNITED INDIA INSURANCE COMPANY For ODISHA STATE PSU (BBSR)
LIM ITED EMPLOYEES WELFARE SOCIETY

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IPRADIPTAIKUMAR PATNAIK] lGo ALP D JENA]
CHIEF REGIONAL MANAGER PRESIDENT

Witness:

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 ANNEXURE-I

UNITED INDIA INSURANCE COMPANY LIMITED

REGISTERED & HEAD OFFIGE: 24, WHITES ROAD, CHENNAI-600014

HEALTH INSURANCE POLICY - GROUP

1 WHEREAS the insured designated in the Schedule hereto has by a proposal and declaration dated as
stated in the Schedule which shall be the basis of this Contract and is deemed lo be incorporated herein
has applied to UNITED INDIA INSURANCE COMPANY LTD. (hereinafter called the COMPANY) for the
insurance hereinafter set forth in respect of Employees/Members (including their eligible family members)
named in the Schedule hereto (hereinafter called the INSURED PERSON) and has paid premium as
consideration for such insurance.

1.'l NOW THIS POLICY WITNESSES that subject to the terms, conditions, exclusions and definitions
contained herein or endorsed, or otherwise expressed hereon the Company undertakes that if during the
period stated in the Schedule or during the continuance of this policy by renewal any insured person shall
contract any disease or suffer from any illness (hereinafler called DISEASE) or sustain any bodily injury
through accident (hereinafter called INJURY) and if such disease or injury shall require any such insured
Person, upon the advice of a duly qualified Physician/Medical Specialisvlvledical practitioner (hereinafter
called MEDICAL PRACTITIONER) or of a duly qualified Surgeon (hereinafter called SURGEON) to incur
hospitalisation/domiciliary hospitalisation expenses for medical/surgical treatment at any Nursing
Home/Hospital in lndia as herein defined (hereinafter called HOSPITAL) as an inpatient, the Company
will pay through TPA to the Hospital / Nursing Home or lnsured the amount of such expenses as are
reasonably and necessarily incurred in respect thereof by or on behalf of such lnsured Person but not
exceeding the Sum lnsured in aggregate in any one period of insurance stated in the schedule hereto.

1.2 ln the event of any claim becoming admissible under this scheme, the company will pay through TPA
to the Hospital / Nursing Home or insured person the amount of such expenses as would fall under
different heads mentioned below and as are reasonably and necessarily incurred thereof by or on behalf
of such insured person but not exceeding the Sum lnsured in aggregate mentioned in the schedule
hereto.

A. Room, Boarding and Nursing expenses as provided by the Hospital/Nursing Home not exceeding 1%
of the sum insured per day or the actual amount whichever is less. This also includes nursing care, RMO
charges, lV Fluids/Blood transfusjon/injection administration charges and similar expenses.

B. lntensive Care Unit (lCU) expenses not exceeding 2Yo of lhe sum insured per day or actual amount
whichever is less.

C. Surgeon, Anaesthetist, Medical Practitioner, Consultants, Specialists Fees.

D. Anaesthetic, Blood, Orygen, Operation Theatre Charges, surgical appliances, Medicines & Orugs,
Dialysis, Chemotherapy, Radiotherapy, Cost of Artificial Limbs, cost of prosthetic devices implanted
during surgical procedure like pacemaker, orthopaedic implants, lnfra cardiac valve replacements,
vascular stents, relevant laboratory/diagnostio tests, X-ray and other medical expenses related to the
treatment.

E. Hospitalisation expenses (excluding cost of organ) incurred on donor in respect of organ transplant to
the insured.

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Note : 1. The amount payable unde|1.2 C & D above shall be at the rate applicable to the entitled room
category. ln case the lnsured person opts for a room with rent higher than the entitled category as in 1.2
A above, the charges payable under 1.2 C & D shall be limited to the charges applicable to the entitled
category. This will not be applicable in respect of medicines & drugs and implants.

2. No payment shall be made under 1.2 C other than as part of the hospitalisation bill

1 .2.1 Expenses in respect of the following specified illnesses will be restricted as detailed below:

Hosp ital i sation Be nef its LllvllTS per surgery RESTRICTED TO

a. Cataract, Hernia, Hysterectomy a. Actual expenses incurred or 25% of the sum

insured whichever is less
b. Major surgeries'
b. Actual expenses incurred or 70% of the Sum
lnsured whichever is less.

* Major surgeries include Cardiac surgeries, Brain Tumor surgeries, Pacemaker implantation for sick
sinus syndrome, Cancer surgeries, Hip, Knee, joint replacement surgery, Organ Transplant.
* The above limits speciried are applicable per hospitalization/surgery.

1.3 Pre and Post Hospitalisation expenses payable in respect of each hospitalisation shall be the actual
expenses incurred subject to a maximum of 10olo of the Sum lnsured.

1.4 ln addition to the above, the following would apply to claims arising out of persons aged more than 60
years

EXPENSES ON MAJOR ILLNESSES TO BE SETTLED WITH A CO-PAY ON 80:20 BASIS.

CHARGED AS A TOTAL PACKAGE The co-pay ol 20o/o will be applicable on the admissible
claim amount-

(N.B: Company's Liability in respect of all claims admitted during the period of insurance shall not exceed
the Sum lnsured per person as mentioned in the schedule)

2. DEFINITIONS:

2.1 HOSPITAL / NURSING HOME means any institution in lndia established for indoor care and
treatment of sickness and injudes and which

Either
(a) has been registered as a Hospital or Nursing Home with the local authorities and is under the
supervision of a registered and qualified Medical Practitioner.
Or
(b) Should comply with minimum criteria as under:-
i) lt should have at least '15 inpatient beds.
ii) Fully equipped operation theatre of lts own wherever surgical operations are caried out.
iii) Fully qualified Nursing Staff under its employment round the clock.
iv) Fully qualified Doctor (s) should be in-charge round the clock.
v) Maintains a daily record for each of its patients.
N.B: 1 . ln class 'C' towns condition 2.1 b(i) in respect of number of beds be reduced to 10.

2. For Ayurvedic/Homeopathic/Unani Treatment. Hospitalization expenses are admissible only when the
treatment is taken as in patient in a Government Hospital/Medical College
Hospital.

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2i I fhe 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.

2.2 'Surgical Operation'means manual and / or operative procedures for correction of deformities and
defects, repair of injuries, diagnosis and cure of diseases, relief of suffering and prolongation of life.

2.3 Hospitalisation means admission in a Hospital/Nursing Home in lndia upon the written advice of a
Medical Practitioner for a minimum period of 24 consecutive hours. However, this time limit is not applied
to specific treatments, such as:

1. Adenoidectomy 19, FESS

2. Appendectomy 20. Haemo dialysis
3. Ascitic./Pleural tapping 2'1. Fissurectomy/Fistulectomy
4. Auroplasty 22. lvlastoidectomy
5. Coronary angiography 23. Hydrocele
6. Coronary anqioplasty 24. Hysterectomy
7. Dental surgery 25. lnguinal/ventraUumbilicay Femoral hernia
8. D&C 26. Parenteral chemotherapy
9. Endoscopies 27. Polvpectomv
10. Excision of CysUGranuloma/lump 28. Septoplasty
1 1. Eye surgery 29. Piles/fistula
'12. Fracture/dislocation excluding hairline fracture 30. Prostate
'13. Radiotherapy 31. Sinusitis
14. Lithotripsy 32. Tonsilectomy
15. lncision and drainage of abcess 33. Liver aspiration
16. Colonoscopy 34. Sclerotherapy
17. Varicocelectomy 35. Varicose Vein Ligation
18. Wound suturinq

Or any other surgeries / procedures agreed by the TPAJ Company which require less than 24 hours
hospitalisation and for which prior approvalfrom TPA is mandatory.

2.3.1 Further if the treatmenvprocedure/surgeries of above diseases are canied out, in Oay care centres
which is fully equipped with advanced technology and specialized infrastruclure where the insured is
discharged on the same day, the requirement of minimum beds will be overlooked provided following
conditions are met.

i.The operation theatre is fully equipped for the surgical operation required in respect of sickness/ ailment
/ injured covered under the policy.

ii. Day Care nursing staff is fully qualified

iii. The doctor performing the surgery or procedure as well as post operative attending doctors are also
fully qualifled for the speclfic surgery/procedure.

Note: Procedures/treatments usually done in out patient department are not payable under the policy
even if converted as an in-patient in the hospital for more than 24 hours

2.4 DOMICILIARY HOSPITALISATION BENEFIT: means lvledical treatment for a period exceeding three
days for such illness / disease / injury which in the normal course would require care and treatment at a
hospital / nursing home but actually taken whilst conflned at home in India under any of the following
circumstances namely:-
i) The condition of the patient is such that he / she cannot be removed to the hospital / nursing home or
ii) The patient cannot be removed to Hospital / Nursing home for lack of accommodation therein Subject
however that domiciliary hospitalisation beneflts shall not cover:

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l) Expenses incurred for pre and post hospital treatment and
ll) Expenses incurred for treatment for any of the following diseases:-
1) Asthma
2) Bronchitis
3) Chronic Nephritis and Nephritic Syndrome
4) Diarrhoea and all type of Dysenteries including Gastroenteritis
5) Diabetes Mellitus and lnsipidus
6) Epilepsy
7) Hypertension
8) lnfluenza, Cough and Cold
9) All Psychiatric or Psychosomatic Disorders
10) Pyrexia of unknown Origin for less than 10 days
11) Tonsillitis and Upper Respiratory Tract infection including Laryngitis and pharangitis
12) Arthritis, Gout and Rheumatism

Note: When treatment such as dialysis, Chemotherapy, Radiotherapy., etc is taken in the hospjtal /
nursing home and the insured is discharged on lhe same day the treatment will be considered to be t3ken
under hospitalisation benefit section. Liability of the company under this clause is restricted as stated in
the Schedule attached hereto.

3.0 ANY ONE ILLNESS:

Any one illness means continuous period of illness and it includes relapse within 45 days from the date of
discharge from the Hospital / Nursing Home from where treatment has been taken. Occurrence of same
illness after a lapse of 45 days as stated above will be considered as fresh illness for the purpose of this
policy.

3.1 PRE - HOSPITALISATION:

Relevant medical expenses incuned during period up to 30 days prior to Hospitalisation on disease /
illness / injury sustained will be considered as part of claim as menlioned under item 1.2 above.

3.2PoST HoSPITALISATIoN:
Relevant medical expenses incurred during period up to 60 days after Hospitalisation on disease i illness
/ injury sustained will be considered as part of claim mentioned under item 1.2 above.

3.3 IVIEDICAL PRACTIONER means a person who holds a degree / diploma of a recognised institution
and is registered by Medical Council of respective State of lndia. The term Medical Practitioner would
include Physician, Specialist and Surgeon.

3.4 QUALIFIED NURSE means a person who holds a certificate of recognised Nursing Council and who
is employed on recommendation of the attending iiledical Practitioner.

3.5 MATERNITY EXPENSES BENEFIT means treatment taken in Hospital/Nursing Home arising from or
traceable to pregnancy, childbirth including normal Caesarean Section. This is an optional benefit
available on payment of additional premium. When lvlaternity Expenses Beneflt is opted for in the policy,
Exclusion 4.12 of the policy stands deleted. The hospitalization expenses in respect of the new born child
can be covered within the Mother's Maternity expenses subject to an overall limit of Rs.50,0001.

3.6 TPA means a Third Party Administrator who holds a valid License from lnsurance Regulatory and
Development Authority to act as a THIRD PARTY ADMINISTRATOR and is engaged by the Company for
the provision of health services as specifled in the agreement between the Company and TPA .

3.7 Network Hospital means the Hospital/Nursing Home or such other medical aid provider that has
agreed with the TPA to provide cashless access seryices to Policy holders. The list of network hospitals is
maintained by and available with the TPA and the same is subject to amendment from time to time.

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3.8 Cashless facility ; means facility whereby the TPA agrees on the insured's request to settle the
admissible claim directly to the network hospital.

3.9 lD card : means the identify card issued to the insured person by the TPA to avail cashless facility in
network hospitals.

3.10 Day-care procedure means the course of medical treatmenusurgical procedure in specialized day
care centres which enables the insured to be discharged on the same day.

3.11 Pre-Existing condition/Disease - Any condition, ailment or injury or related condition(s) for which
insured person had signs or symptoms, and/or were diagnosed, and/or received medical advice/
treatment, within 48 months prior to his/her llrst policy with the company.

3-12 REASONABLE AND NECESSARY EXPENSES

For a networked hospital, it shall mean the rate agreed between Networked Hospital and the TPA for
surgical/medical treatment.
For any other hospital, it shall mean the cost of surgical/medical treatment that is necessary, customary
and reasonable for treating the condition for which insured person was hospitalized to the extent relatable
to such condition.

4. EXCLUSTONS:

The company shall not be liable to make any payment under this policy in respect of any expenses
whatsoever incurred by any lnsured Person in connection with or in respect of:

The company shall not be liable to make any payment under this policy in respect of any expenses
whatsoever incurred by any lnsured Person in connection with or in respect of:

4.1 Any Pre-existing condition(s) as defined in the policy, until 48 months of continuous coverage of such
insured person have elapsed since inception of hisiher Iirst policy with the Company.

4.2 Any disease other than those stated in clause 4.3 below, contracted by the lnsured person during the
Iirst 30 days from the commencement date of the policy. This exclusion shall not however, apply in case
of the lnsured person having been covered under an lnsurance scheme with our Company for a
continuous period of preceding 12 months without any break.

4.3 During the first two years of the operation of the policy, the expenses on treatment of diseases such
as Cataract, Benign Prostatic Hyperthrophy, Hysterectomy for Menorrhagia, or Fibromyoma, Hernia,
Hydrocele, Congenital internal disease, Fistula in anus, piles, Sinusitis and related disorders, Gall Bladder
Stone removal, Gout & Rheumatism, Calculus Diseases are not payable.

4.4 During the ,lrst four years of the operation of the policy, the expenses related to treatment of Joint
Replacement due to Degenerative Condition and age-related Osteoarthritis & Osleoporosis are not
Payable.
lf these diseases mentioned in Exclusion no.4.3 and 4.4 (other than congenital lnternal Diseases) are
pre-existing at the time of proposal they will not be covered even during subsequent period of renewal
subject to the pre-existing disease exclusion clause. lf the lnsured is aware of the existence of congenital
internal disease be{ore inception of the policy, the same will be treated as pre-existing.

4.5 lnjury / disease directly or indirectly caused by or arising from or attributable to War, invasion, Act of
Foreign enemy, War like operations (whether war be declared or not).

4.6 a. Circumcision unless necessary for treatment of a djsease not excluded hereunder or as may be
necessitated due to an accident.
b. Vaccination or inoculation.

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c. Change of life or cosmetic or aesthetic treatment of any description such as correction of eyesight., etc,
d. Plastic surgery other than as may be necessitated due to an accident or as part of any.illness.

4.7 Cost of spectacles and contact lenses, hearing aids.

4.8 Dental treatment or surgery of any kind unless necessitated by accident and requiring hospitalisation.

4.9 Convalescence, general debility; run-down condition or rest cure, Obesity treatment and its
complications including morbid obesity, Congenital external disease/defects or anomalies, treatment
relating to all psychiatric and psychosomatic disorders, infertility, Sterility, Venereal disease, intentional
self injury and use of intoxication drugs / alcohol.

4,10 All expenses arising out of any condition directly or indirectly caused to or associated with
Human T-Cell Lymphotropic Virus Type lll (HTLB - lll) or lymphadinopathy Associated Virus (LAV) or the
Mutants Derivative or Variation Deficiency Syndrome or any syndrome or condition of a similar kind
commonly referred to as AIDS.

4.11 Charges incurred at Hospital or Nursing Home primarily for diagnosis x-ray or Laboratory
examinations or other diagnostic studies not consistent with or incidental to the diagnosis and treatment
of positive existence of presence of any ailment, sickness or injury, for which confinement is required at a
Hospital / Nursing Home.

4.12 Expenses on vitamins and tonics unless forming part of treatment for injury or diseases as certified
by the attending physician

4.13 lnjury or Disease directly or indirectly caused by or contributed to by nuclear weapon / materials

4.14 Treatment arising from or traceable to pregnancy, childbirth, miscarriage, abortion or complications
of any of these including caesarean section, except abdominal operation for extra uterine pregnancy
(Ectopic pregnancy), which is proved by submission of Ultra Sonographic report and Certillcation by
Gynaecologist that it is life threatening one if left untreated.

4.'15. Naturopathy Treatment, acupressure, acupuncture, magnetic therapies, experimental and unproven
treatments/ therapies.

4.'16 External and or durable lvledical / Non-medical equipment of any kind used for diagnosis and or
lreatment including CPAP, CAPD, lnfusion pump etc. Ambulatory devices i.e., walker, crutches, Belts,
Collars, Caps, Splints, Slings, Braces, Stockings, elastocrepe bandages, external orthopaedic pads, sub
cutaneous insulin pump, Oiabetic foot wear, Glucometer / Thermometer, alpha / water bed and similar
related items etc., and also any medical equipment, which is subsequently used at home etc.

4.17. Genetic disorders and Stem Cell implantation/surgery.

4.'18. Change of treatment from one system of medicine to another unless recommended by the
Consultant / hospital under whom the treatment is taken.

4.19. Treatment for Age related Macular Degeneration (ARMD), treatment such as Rotational Field
Quantum magnetic Resonance (RFOMR), Enhanced External Counter Pulsation (EECP), etc.

4.20. All non-medical expenses including convenience items for personal comfort such as charges for
telephone, television, ayah, private nursing/barber or beauty services, died charges, baby food,
cosmetics, tissue paper, diapers, sanitary pads, toiletry items and similar incidental expenses.

4.21 Any kind of Service charges, Surcharges, Admission Fees/Registration Charges, Luxury Tax and
similar charges levied by the hospital

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, 5. CONDTTIONS

5.'1 Contract :the proposal form, declaration pre-acceptance health check-up and the policy issued shall
constitute the complete contract of insurance.

5.2 Every notice or communication regarding hospitalization or claim to be given or made under this
Policy shall be delivered in wfltrng at the address of the TPA office as shown in the Schedule. Other
matters relating to the policy may be communicated to the policy issuing office.

5.3 The premium payable under this Policy shall be paid in advance. No receipt for Premium shall be
valid except on the official form of the company signed by a duly authorised official of the company. The
due payment of premium and the observance and fulfilment of the terms, provisions, conditions and
endorsements of this Policy by the lnsured Person in so far as they relate to anything to be done or
complied with by the lnsured Person shall be a condition precedent to any liability of the Company to
make any payment under this Policy. No waiver of any terms, provisions, conditions and endorsements of
this policy shall be valid unless made in writing and signed by an authorised official of the Company.

5.4 Notice of Communication : Upon the happening of any event which may give rise to a claim under this
Policy notice with full particulars shall be sent to the TPA named in the schedule immediately and in case
of emergency hospitalization within 24 hours from the time of Hospitalisation/Domiciliary Hospitalisation

5.5 All supporting documents relating to the claim must be filed with TPA within 15 days from the date of
discharge from the hospital. ln case of post-hospitalisation, treatment (limited to 60 days), all claim
documents should be submitted within 7 days after completion of such treatment.

Note: Waiver of this Condltion may be considered in extreme cases of hardship where it is proved to the
satisfaction of the Company that under the circumstances in which the insured was placed it was not
possible for him or any other person to give such notice or file claim within the prescribed time-limit.

5.5 The lnsured Person shall obtain and furnish the TPA with all original bills, receipts and other
documents upon which a claim is based and shall also give the TPA,/ Company such additional
information and assistance as the TPAJCompany may require in dealing with the claim.

5.6 Any medical practitioner authorised by the TPA / Company shall be allowed to examine the lnsured
Person in case of any alleged injury or disease leading to Hospitalisation if so required.

5.7 The Company shall not be liable to make any payment under this policy in respect of any claim if such
claim be in any manner fraudulent or supported by any fraudulent means or device whether by the
lnsured Person or by any other person acting on his behalf.

5.8 lf at the time when any claim arises under this Policy, there is in existence any other insurance (other
than Cancer lnsurance Policy in collaboration with lndian Cancer Society), whether it be effected by or on
behalf of any lnsured Person in respect of whom the claim may have arisen covering the same loss,
liability, compensation,costs or expenses, the Company shall not be liable to pay or contribute more than
its rateable proportion of any loss, liability, compensation costs or expenses. The benefits under this
Policy shall be in excess of the benefits available under Cancer lnsurance Policy.

5.9 The Policy may be renewed by mutual consent and jn such event the renewal premium shall be paid
to the Company on or before the date of expiry of the Policy or of the subsequent renewal thereof. The
Company shall not be bound to give notice that such renewal premium is due, provided however that if
the insured shall apply for renewal and remit the requisite premium before the expiry of this policy,
renewal shall not normally be refused, unless the Company has reasonable justification to do so.

Cancellation CIause ;

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The Company may at any time cancel this Policy by sending the lnsured 15 days notice by registered
letter at the insured's last known address and in such event the Company shall refund to the lnsured a
pro-rata premium for unexpired Period of lnsurance. The Company shall, however, remain liable for any
claim, which arose prior to the date of cancellation.

The lnsured may at any time cancel this Policy and in such event the Company shall allow relund of
premium at Company's short period rate only (Table given here below) provided no claim has occurred up
to the date of cancellation.

PERIOD ON RISK RATE OF PREMIUM TO BE CHARGED

Upto one month /4 th of the annual rate

'I

Upto three months /2 of the annual rate

'l

Upto six months 3/4rh of the annual rate

Exceeding six months Full annual rate.

5.10 lf any dispute or difference shall arise as to the quantum to be paid under the policy (liability being
otheMise admitted) such difference shall independently of all other questions be referred to the decision
of a sole arbitrator to be appointed in writing by the parties or if they cannot agree upon a single arbitrator
within 30 days of any party invoking arbitration, the same shall be referred to a panel of three arbitrators,
comprising of two arbitrators, one to be appointed by each of the parties to lhe dispute/difference and the
third arbitrator to be appointed by such two arbitrators and arbitration shall be conducted under and in
accordance with the provisions of the Arbitration and Conciliation Act, 1996.

It is clearly agreed and understood that no difference or dispute shall be referable to arbitration as herein
before provided, if the Company has disputed or not accepted liability under or in respect of this Policy.
It is hereby expressly stipulated and declared that it shall be a condition precedent to any right of action or
suit upon this policy that award by such arbitrator/arbitrators of the amount of the loss or damage shall be
first obtained.

5.11 lf the TPA, as per terms and conditions of the policy or the Company shall disclaim liability to the
lnsured for any claim hereunder and if the lnsured shall not within 12 calendar months from the date or
receapt of the notice of such disclaimer notify the TPtu Company in writing that he does not accept such
disclaimer and intends to recover his claim from the TPAJCompany then the claim shall for all purposes
be deemed to have been abandoned and shall not thereafter be recoverable hereunder.

5.12 All medical/surgical treatments under this policy shall have to be taken in lndia and admissible
claims thereof shall be payable in lndian currency. Payment of claim shall be made through TPA to the
Hospital/Nursing Home or the lnsured Person as the case may be.

5.'13 Low Claim Ratio Discount (Bonus):

Low Claim Ratio Discount at the following scale will be allowed on the total premium at renewal only
depending upon the incurred claim ratio for the entire group insured under the Group lvlediclaim
lnsurance Policy for the preceding 3 completed years excluding the year immediately preceding the date
of renewal where the Group Mediclaim lnsurance Policy has not been in force for 3 completed years,
such shorter period of completed years excluding the year immediately preceding the date of renewal will
be taken in to account

lncurred Claim ratio under the group policy Discount 70

Not exceeding 600/o 5
Not exceeding 50% 15
Not exceedinq 40% 25
Not exceeding 30% 35
Not exceedinq 25% 40

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5.14 High Claims Ratio Loading (MALUS)

The total premium payable at renewal of the Group Policy will be loaded at the following scale
depending upon the incurred claims ratio for the entire group insured under the Group Mediclaim
lnsurance Policy for the preceding year (immediately preceding the date of renewal).

lncurred claims ratio under this group policy Loading

Between 70% and 100%

Between 'l 0 1 % arld '125 o/o 55%
Between 126 o/o and 150 % 90%
Between 151 o/o and 175 o/o 12O o/o

Between 'l 76 and 200 150o/o

Over 200 % Cover to be reviewed

Note:
1. Low Claim Ratio Discount (Bonus) or High Claim Ratio loading (Malus) will be applicable to the
Premium at renewal of the Policy depending on the incurred claims Ratio for the entire Group Insured.
2. lncurred claim would mean claims paid plus claims outstanding in respect of the entire group insured
under the policy during the relevant period.

The insured shall throughout the period of insurance keep and maintain a proper record of register
containing the names of all the insured persons and other relevant details as are normally kept in any
institution/ Organisation. The insured shall declare to the company any additions in the number of insured
persons as and when arising during the period of insurance and shall pay the additional premium as
agreed.

It is hereby agreed and understood that, that this insurance being a Group Policy availed by the lnsured
covering Members, the benefit thereof would not be available to Members who cease to be part of the
group for any reason whatsoever.

Such members may obtain further individual insurance direclly from the Company and any claims shall be
governed by the terms thereof.

5.'15 MATERNITY EXPENSES BENEFIT EXTENSION: (Wherever applicable)

This is an optional cover, which can be obtained on payment of 10o/o ol total basic premium for all the
lnsured Persons under the Policy.

Option for lvlaternity Benefits has to be exercised at the inception of the Policy period and no refund is
allowable in case of lnsured's cancellation of this option during currency of the policy.

5.16 The hospitalisation expenses in respect of the new born child can be covered within the Mother's
Maternity expenses. The maximum beneflt allowable under this clause will be up to Rs. 50,000/- or the
sum insured opted by the group whichever is lower.

Special conditions applicable to Maternity expenses Benefit Extension:

'1. These Benefits are admissible only if the expenses are incurred in Hospital / Nursing Home as
in-patients in lndia

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2. A waiting perlod of I months is applicable for payment of any claim relating to normal delivery or
caesarean section or abdominal operation for extra uterine pregnancy. The waiting period may be relaxed
only in case of delivery, miscarriage or abortion induced by accident or other medical emergency.

3, Claim in respect of delivery for only first two children and / or operations associated therewith will be
considered in respect of any one lnsured Person covered under the policy or any renewal thereof. Those
lnsured Persons who are already having two or more living children will not be eligible for this beneflt.

4. Expenses incurred in connection with voluntary medical termination of pregnancy during the first 12
weeks from the date of conception are not covered.

5. Pre-natal and postnatal expenses are not covered unless admitted in Hospital / Nursing Home and
treatment is taken there.

Note: When group policy is extended to include Maternity Expenses Benefit, the exclusion No.4.14 of the
policy stands deleted.

6 REASONABLE ANO NECESSARY EXPENSES:

1. For a networked hospital, it shall mean the rate pre-agreed between Networked Hospital and the TPA
for surgical / medical treatment that is necessary, customary and reasonable for treating the condition for
which the insured person was hospitalized
2. Fot any other hospital, it shall mean the cost of surgical / medical treatment that is necessary,
customary and reasonable for treating the condition for which insured person was hospitalised to the
extent relatable to such condition.

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 ANNEXURE.II

UNITED INDIA INSURANCE COMPANY LIMITED

REGIONAL OFFICE, BHUBANESWAR

SPECIAL CONDITIONS TO BE ATTACHED TO

P HEATTH INSURANCE POTICY FOR STATE PUBLIC SECTOR UNDERTAKINGS of ODISHA ST E

1. Sum lnsured:
The Sum lnsured of Rupees five lac per family unit is final till expiry of the policy period.
The sum insured will float amongst all insured family members under the policy. Either
one family member or all family members put together can avail the cover up to sum
insured of Rupees five lac subject to policy terms and condition of Group Health
lnsurance Policy.
2. Corporate Buffer:-
a. Aggregate corporate buffer amount of Rs.1,00,00,000/-( Rupees one crore) shall
float over all Group Health lnsurance Policies issued to PSUS in Odisha State in a year
under the agreement.
b. The above corporate buffer amount is the final and shall be available under the
agreement to cover admissible expenses in respect of following critical illnesses in
excess of sum insured of insured employee's family unit under the policy up to a
maximum of Rupees five lac per family unit.

i. Cancer of Specified severity

ii. First heart attack of specified severity
.i.
t. Coronary Artery Surgery( CABG) Open Chest CABG
iv. Heart Valve Replacement
Coma of Specified Severity
vi. Kidney Failure
vii. Stroke Resulting in Permanent Symptoms
viii. Major Organ / Bone Marrow Transplant
ix. Multiple Sclerosis
x. Major Neurone Disease with Permanent Symptoms
xi. Permanent Paralysis of Limbs

c. Corporate buffer can be authorized by the management of Welfare Society, on a

first-cum-first serve basis, through an Authorized person / Committee as decided by
Welfare Society, and informed directly to the THIRD PARTY ADMINISTRATOR by
keeping the insurance company in the loop.
d. ln the event of any claim in respect of critical illness mentioned above becoming
admisslble under this policy, the insurance company will pay through Third Party
Administrator to the Hospiial / Nursing Home or insured the amount of such
expenses as would fall under different heads of policy and as are reasonably and
medically necessary incurred thereof by or on behalf of such insured up to the

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 amount of Rupees five lac per family unit but not exceeding the amount in aggregate
under Corporate Buffer provision mentioned above.

3. Waivers:
a. Pre-existing clause of 4.1 of the standard group health insurance policy stands
waived.
b. 30 days/2 years & 4 years waiting period clauses of 4.2; 4.3; & 4.4 of the
standard group health insurance policy stands deleted.
4. Ambulance charges:
Actual expenses incurred subject to a maximum of Rs.2,500/- in a policy is admissible.

5. Maternity Benefit Extension (Sl.No. 5.15 of the policy) for women employees:-
a. Maximum benefit allowable under this clause will be as under:-
i. in-case of Normal delivery : Rs.30,000/-
ii. ln case ofcaesarean section: Rs.50,000/-
iii. Expenses reasonably and necessarily lncurred in hospital/ nursing home
in connection with complications of pregnancy : Not exceeding lnsured
person's sum insured.
iv. New born baby care: From day one, not exceeding lnsured person's sum
insured under maternity option.
b. Waiting period of 9 months relating to normal delivery or cesarean section or
abdominal operation for extra uterine pregnancy stands waived.
c. Claim in respect of delivery for only two children and /
or operations associated
therewith will be considered in reipect of any one lnsured Person covered under
the policy.

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