Tenders

The Oriental Insurance Company Ltd. sought following clarifications on paperless processing of claims.

i. Procedure for paperless processing of reimbursement claims

ii. Requirement of physical copies for verification /validation and audit purpose in select claims

iii. What will be the fraud control and documents authentication mechanism will be implemented to ensure genuineness of uploaded records.

The participants were informed that

i. Reimbursement claims shall be processed paperless based on documents uploaded by the retiree through the TPA portal. Physical documents shall not be mandatorily required. Claims shall be settled on actuals and not restricted to network or discounted rates.

ii. The Bank shall work with the selected insurer and the TPAs to evolve an appropriate mechanism to address verification and audit requirements under the paperless claim processing framework. The final decision in this regard shall rest with the Bank.

iii. Appropriate fraud control and document authentication measures shall be put in place under the claim processing framework. Technological tools and audit mechanisms may be deployed by the Insurance Company/TPA for this purpose in consultation with the Bank.

The Oriental Insurance Company Ltd. requested to provide clarification on “Option of both cashless and reimbursement claims through the TPA”.

i. As multiple TPAs are currently servicing the policies, kindly confirm whether all TPAs have arrangements in place to provide cashless facilities at diagnostic center and pharmacies.

ii. We request the detailed network list of empaneled diagnostic center and pharmacies under each TPA for our reference.

The participants were informed by representatives of Marsh that

i. The current TPAs have arrangements in place to provide cashless facilities at diagnostic centres and pharmacies and the selected insurer may also collaborate with the TPAs to expand their network.

ii. The selected insurance company may undertake a pre-policy network building exercise with the TPAs on the basis of the past claim preferences to encourage cashless settlement of claims. 

The Oriental Insurance Company Ltd. requested to provide clarification on the following:

i. Coverage for Over-the-Counter (OTC) Medicines

ii. Since the policy has been active during the current year, please confirm whether the Bank has approved any additional OTC items beyond those listed. If yes, kindly share details of such approved items.

The participants were informed that

i. The policy provides coverage for OTC medicines up to cumulative limit of ₹2,000/- per year which are curative in nature and do not require a doctor's prescription.

ii. An indicative list of OTC medicines is provided in the plan design. Additional curative items may be approved by the Bank, however, the same shall be subject to a cumulative limit of ₹2,000 in a policy year.

The Oriental Insurance Company Ltd. requested to provide clarification on the following

i. Coverage on attaining the of age 60/75 years.

ii. In the unfortunate event of the demise of a pensioner and/or their spouse, will coverage for eligible dependent child(ren) continue under the policy? If coverage continues, whether within the current policy year or in subsequent renewals, please clarify the basis on which their sum insured will be determined.

The participants were informed that

i. Pensioners attaining age 60 shall be added from the first day of the succeeding month. Pensioners attaining age 75 shall have their sum insured enhanced from the first day of the succeeding month.

ii. In the event of the pensioner’s demise, the coverage for the family members, which includes the spouse and eligible disabled dependent children, will continue. 

The Oriental Insurance Company Ltd. requested to provide clarification on the following:

i. Admissions and Exits – Deposit Premium Mechanism

ii. How compliance with Section 64VB of the Insurance Act, 1938 (requirement of receipt of premium prior to assumption of risk) will be ensured, particularly in circumstances where the available deposit premium is insufficient at the time of addition of new members. The mechanism proposed to ensure that adequate premium is available before risk commencement for newly added members.

The participants were informed that

i. Admissions and exits are proposed to be processed on an annual premium (deposit) basis with fortnightly declarations. Further, coverage shall not be denied on the ground of inadequacy of deposit premium for a particular month.

ii. The selected insurer shall monitor utilisation of the deposit premium and raise timely intimation/notes for replenishment of the cash deposit sufficiently in advance to avoid any shortfall. Necessary coordination in this regard shall be undertaken to ensure continuity of coverage in compliance with applicable regulatory requirements.