afta, worery gepyuta wi fet, TAR - SIPF - Government of ...

, WGAGLH

prataa aftesafthtadPresawor starvdsauna fate for(erereetarrFret)

Q- aie Rata ca, Pet qos, oTE, fae H Te, GTAGX-302005

Smail: add.medi.si [email protected]

GRaTe — 2740282, 2740219, 2740292 DRAEmail: add.medi.sip!@

|Website: www.sipf.rajasthan.gov

.In

Afeaerr svat aiferelt(fers Pafic difer)

afta, worerygepyuta wi fet, TARGift =. hangup. /81 /AP.ae

°

orafey - 91.99.2018 B 31.08.2019 (AeA

ae : aeoe a patRETA TES AT A MT.fF, 12 HIF GS

oy anfsrat ROT|ant Ht are : 11.10.2018

jet Sar eae waa2 aa

ae moat ca Sa PRaATgAR MPT RTa

*MfaA :5000/- +30 Category A/B/C HVaeINI

aa weet (radferyfarset): 12

Je waa AT fafeer aa &. 60,360/-

awa.: Nil/-

TATA &. __60,360/-;

Por Ga U. 24942361 feath 31.08.2018 ZIRT. 60,360 /— (AleTt 40 7859393 GATS feat 31.08.18)

team ear gat faor, & aris aaRoTaT Bg Te Afeaers, FRITS

a fa

otfereti—srar aT - 2 ara oft ofa oRaK.

Gitaqatar BseatseorerrggorUTATT. fa ad afte &oRar 4

fara enftet &:

) zrarreg gapt ufera urfer. arte (42),

) seal/SAG fe /Te

) >attra wedfratarg 21 at Bafte seleT

(d) aupramat_frerwrongseraftaonfe. &artisoeonaaMot

oath 3 qa waar gelusa oF. fe. oaie Sae, sas

sarél wr UR vedBt WE SAATAft ora ew Tara Bwaa 2000/-4

afte Feler|

aN 2019-19 HHGAR & area &fewderneve deer wet wegaleachy wr. fe. ga |

arataaaftesafektatfreer, arerer starfrfer

frigSeu, terravedee afstarwes gutecityo.fer.

O-204 | fed aa, S-aite, faet aaH, orto, fee | INT,

TAGX — 302005 (RoRU) WI 18233456656g—Act: [email protected]

anoraanreit URRefaAwera ae: +91 9116742466

(aft orgiesater, trorrot Fore, chy)

su Ufa & dafia areal/ cereal oT ara ahrAR/ iy@ wratera 4oa Heed |(ania A af agoRada dor @ a weetwet yaw Va a orf, fosferrite asec(www.sipf.rajasthan.gov.in) GI Gl Wha z |]

arearer drat A BH AsadaTRA BH BARwat dsealsworprgsaaule ow.fa. afta otsarAR Gerdfatwar F|

ABEaf. freer (Afso)

_—

wee at ve wi. fear seen “a(era)

GLa, GAGE LALA. TORA, AGN

‘ DINED SERVICES Pali

Page 7 of 17 RAJCOMP INFO SERVICES Policy 18-19

COVERAGE [TEEUN TIATIVE ;wvloe Lat Banptiyees shinll be entitted to tidaur teatient od) Gayerient asp, Gaveninent £pyre

WACEUSION|

Ky10

i

IP

The pratiey Tetiler Minfemipe fat te

Prvite Hepittily outst the tite ob Gait, Cavernmient appneyed padvaty fieepiitidy aitlidnn phe State of {ajoAt medicines

Hho patiey table Majer tite neevteea Bid Bangla ane Foleo Cimedty anennbiegs oll be ented ter pe tnditnnss wen 7 oon ——

Hokepation Cenc one Te Chee fempitat iid ii pevate dietitian: on He econnidubiat at hn i" ae a a be

Hinapalirit Vinptiondend Hite tlie: Deady: (ihe paudlenit sively: pnyaead paid po thie Gaivertiinent fnpital/crneemed Avda nny

! mn / Cavenmient hoopla ,[ypite ot fiacanen/ieaitiients Hahei rie iidoe pute HE over int Iiiny pln ona he iat Mabon, the peAioy

TY / ! smd sgypreryed benPave Ue Anvedvvnve tratanoerat than Gob cypparenvaed parvatter Poevsyaltind wHtadin tle fiat sn My 7

Hivaleley Hnjecnnp Dato Aer vdome Reed Hiplayeun andl filo Tnlly pentietn alll be ented far rebarienient of bolle vig een

A) ttvam, Haardin, Eypeimen ebinged by the Heepital oli Sree

Wy Nui Pypenien -

Super, Anieatlietiat, Medioal Primi ionera, ¢ smnuiliinita mid Aypeebillaty teen

arty’ s

Medion & Drugs, Piayaiastie Mutenils mid Atay,Cywile ' Hines

) venthende, Woe Oxygen, Opuration heatre chinyetn, otnyeleut yh a

” ha un Jivani apy. Hinlthrapy, contol Hicaumiker, AtHetad Linibs sid cent ot i Bios ”

Tr cine ob eende a ined dieing patiey period the nines at family members tbe combined WE eoginy ob the panes

Sooncanemutyfoeponersecone ladon. seJLorvtit). ree 5-1 Klantniain ee =

Cilepory Hay Senet peter In Gove, Anonived rivute | Asennling/Accemmentation (Sane

“ Huspitil gyper CONS Minckayy Weiter

A Hn O1Q00/ 8 ubave Deluie Vvivate Wan ‘i Mh me bi

" Hn NOOO, amid onhave |Cotte Head Melvate Yin i ye

Fut tena Hin Ha, (ele:Arey

C Helow fy Wann Coneal Wind Gener Wand Hy PU0U/. yur day

j vale nie vale! ‘ i emmmenation ily « packuues (oles

ee ee rnc! acuattndah Hee ny ee EEeval fy aapprlicuitales ft theo charged eon nol fie mene Wan COWS prsckayes rater

Note. Actual bonrding Ciecommodition ching af tanpitil nt

Inelienterd naibave aa ; eating he fimiled to bis vateyery a

Honan tiker entnt in higher entevory other (in tile eatittenment, the relibusenient of cost of treatment will

prevalvnt tthe hospital

myer Incuned by any Insied pera in' yee eae Whose

CP hall not be Table to make any payment iinder this policy In reapeet of way expenseswhIhe

jan, Act af Porlyn enemy, War fhe aperstons (vAvhen war becommeTON WHT OE TE reapeet alInjury Adio dieetly on indireety eitaed hy or aehhy fone or atilbatible to hives

deeliredan nat) an , to an qecidem, vaceination ar

Cireimebton unlen aeeerniry for Hentmient of a disci tot exclided: herenndyr oF i my i: mm " lied Diei vsoititud due to wn sucidentHnocutatiog on china oF Teor conmene or veatiedie tentnent al any description, pliatie oir eery obbier Hi Ws HY ld ©

Or IE PATE MAY henContal Speetnelen nme contiel fermen, hear iiy abda , tne

Denti ientment or aaenycob ny hited inten requir bespliilization die tain ineldent | a; sfae " ‘i cHescal Moar,

Convirloaeones, peaenil debility, cimdown condi on or reat ere, conpeniinl extent dinense or defects or smomalivs, Sterility, Yenercal ds

Titer tana eelie ii ie ot nitonteation drigaZaleatal/pabienioua nubatineee/nedelle iene a, arp

ATLeyperoen nei outat any condition divertor tndieety enned fe or rysoeled With Ham ECell Lymph tropic Virus hype eT ata

Fviiphintinapathy Agootited Virtua (LAY) ofthe Mints Derivative or Virlition Deficleney Syndromeor any syndrome or condition of a similar kine

vommionty catered (oi ATS a

Chime iiemed ab ospitil or Nuring Home primarily tor dliynionls Xe ry on babonitory examinations or other diaviostic studies not consistent

Will-or meldentil tathediqgooil wid beatmient af posiiive exhtence af prencnee of any wilinent, sickness or injury, Jor which contingent ts required

AE Hoxplai/Naming Hone

Dypenes on viii iid tonien dilen forming parbal treatment for injury or dinenoes as cert iied by the attending physician

Injury ar Diseine diteetly of Indirectly caused by or contributed to by nuclear weapon /inateriids,

Natiwopathy Preatnent

Pro exiting diene of Fimployees ind hi/her dependents Ge per sectlon 3,10) ill be covered tinder this scheme,

Tocelaitimtiony in whieh there are neurpeney ofhospitalization and ieatiment enn be piven at home,CONDITIONS;

’

i)

NI

Every notice or communication to be piven or gmde under th Polley shall be delivered i writing at the address of the TPA/GIP office,Upon the happening of any event whieh may give rie toch inden this Polley notice with fall particulars shall he sent to the TVA immediatelyUnd cine of emerpeney Hoapitali zation within perod of 24 hati ton the thie of Hospitalization,Al aipporting doenmentereliting tothe clin mit he led will PPA/GHEWithin period of 90 days tron the diate of discharge fron the hospital, bnving af ponthospititization, treatment (inited to AS diya) wl clin daciments should he submitted within 90 days after completion of suchHrontimnentNote Wolver of thhy conditions may considered ineatreme cies of hivdsbip where itl proved tothe anthetection of the GU tht ander theclremmatince Howhleh the bared wie placed [wie not pomibte for hin ory other person to give sach notes or fie ehstin with the preseribed thie

Hinit fr auch coven Amini /DepatyAlolot Director qiiwilve ap to 6 month deliy ond Adio Director can walve 6 to 12 month delay, while thedelny of 12 to 2 month canbe walved by Se, Additonal Director, Tiny condition ioe sich chil ahiall he entertained after2 years,

The tivied Penion shall obit ind firnbh the PPAZG HAST Longin billy, receipe ind other documents upon which a clalin is based and shallHho vive nicl nddiflonal iiforition md ivedvtince ithe TY A/GIE-APPA/GTEniny require indenting with the olinAny medicnt prietitianer mitharized by the PPA/CII ali] be ntlowed to exile the dase Peron iene of any eved injury or discus sequiring

Hospital ton when ined na often dy tie nie my fenmonibly be required an behallat the PPAZGIE,The (1h shall nor be tinble tome aby payment(n) ander this potiey ta Heopechatainy clingy) Wesueh elaine he in iny nummer taudulent orsupported by any Hiden menin or device whether by the tiated Peron or by iiy other person meting on bls belaltWat the dime when my clini anda inde thls Polley, there bi extstence any offer inoue (other than Cancer lsunince Policy in collaborationWith India Chneer Soviety). whether tebe eteeted by oran belall of any faured Hersen tn hespeetob whom the chim may dive arisen covering thesine Town, Tibility, competion, vontoorexpenign, the CHP ahall not be table to pay or contribute more die is ratte PHoporton ob any hiv,Hbility, COMpUHATTOnCosteorespemen. "The benef under tiiy Policy slat bein exgess of the benetits availible ander Cancer Jinuanes PolicyThe Polley my be renewed anally by aarti coment The GH atid] not however be bound to give notice (iat ils duc lor renewal and the GUmy ob any tine Caneel hh Polley by sending the dammed (0 diye nothee hy registered letter at the inured's fist hnown wddiess aod in ouch event theCD shal refind to thy fosied a promutin premio for iexpiied Period of famine The GU shall however, semuin fable for wy claim, whichWoe poor tothe dite of cancelation, The tied may at iny dine cancel this Policy and dn eueh event the GHP efiall allow refund of premium alC1 short perlod Hite only provided no elaine han aeened upto the dite of camecthitionHithe (PA. i per termi ind condition af the patloy ar tie GI afall dlvctaiin Mability: to the (sured for any lain hereunder and (the lsured shallHOM WHT EZ calendar ont ton the date or recelphot the native of suey dictate HOY the TPAC ie writting that he does not accept suchUhclilier ind titers to ecover file ela forme the PPACCTE then the Gloiny stall forall purposes be deemed to have been abandoned and shall notHhereafer he rewovenble hereunder,Chl [yn fhcllity Would De extyided fo the inated av per terme ae conditions of the pulleyCOTA procera sh Whe mH uo the unjuarntlvd hoapltils ind Ap preached fore atthe Unie of adniisaton to take tremtiment atnd taka nso yeh Porn ie avail nly AE Te reeepHon conten OL aL enpanelled hospi, (Appendiaes), Han inmied doen not show Identity

UH Uihes Hentent Without Any prescribed forme then Ue de pwede tha Hospital may charge thei ngtual rites, In auch cases CA ohall reimbutseonly on COS riley piehipes diterenee mmouit shall be borne hy the Inwared,

WAICOMP INDO SHUVICTS Polley Helo

2.

GOVERNMENT OF RAJASTHAN

STATE INSURANCE AND PROVIDENT FUND DEPARTMENT

(GENERAL INSURANCE FUND)‘1D’ BLOCK, VITTA BHAWAN, JANPATH, JAIPUR

Phone : 0141-2740252, 2740219, Fax: 0141-2740292email: [email protected]

www.sipfrajasthan.gov.in

GROUP MEDICLAIM INSURANCE POLICY

(RAJCOMP INFO SERVICES LTD., JAIPUR)

(01.09-2018 -31.08.2019)_ 4

WHEREAS the insured designed in the Schedule hereto has by a proposal anddeclaration dated as aoe in

the Schedule which shall be the basis of this Contract and is deemed to be incorporated has app reeto

GENERAL INSURANCE FUND (herein-after called the GIF) for the insurance hereinafter ” fort in

respect of Employees/Members (including their eligible family members) named in the mene ule hereto

(hereinafter called the INSURED PERSON)and haspaid premium as consideration for such insurance.

NOW THIS POLICY WITNESSES that subject to the terms, conditions, exclusions and definitions

1 i i i eriod

contained herein or endorsed, or otherwise expressed herein the GIF undertakes that if during thep ri

policy by renewal any insured

stated in the Schedule or during the continuance of this N

person shall contract any disease or suffer from any illness (herein after called DISEASE)or sustain any

disease(s) or injury/injuries shall be

bodily injury through accident(hereinaftercalledINJURY) andif such aniMedical

required. Any such insured person, upon the advice of a duly qualified Physician/Medica

Specialist/Medical Practitioner (hereinafter called MEDICAL PRACTITIONER) or of a duly qualified

Surgeon(hereinafter called SURGEON) to incur hospitalization expenses for medical/surgical treatmentat

any Nursing Home/Hospital in Rajasthan as herein defined (hereinafter called HOSPITAL) as an inpatient,

the GIF will pay through TPA/GIF to the Hospital/Nursing Home or the Insured Person the amount of such

expenses as are reasonably and necessarily incurred in respect thereof by or on behalf of such Insured

Person but not exceeding the Sum Insured in aggregate in any one period of insurance stated in the

schedule hereto.

In the event of any claim/s becoming admissible under this scheme, the GIF shall make payment(s)

through TPA to the Hospital/Nursing Home or the 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 Insured in aggregate

1.

mentioned in the schedule hereto.

(A) Room, Boarding and Nursing Expenses as provided by the Hospital/Nursing Home as per

entitlement of the employee mentioned in the Schedule.

(B) Surgeon, Anaesthetist. Medical Practitioner, Consultants and Specialists Fees.

(C) Anaesthesia, Blood, Oxygen, Operation Theatre Charges, Surgical Appliances, Medicines &

Drugs, Diagnostic Materials and X-ray, Dialysis, Chemotherapy, Radiotherapy, Cost of

Pacemaker, Artificial Limbs implanted in the body & Cost of organs and similar expenses.

(N.B.: GIF’s Liability in respectofall claims admitted during the periodofinsurance shallnot exceed the Sum Insured per family as mentioned in the schedule)

WwW DEFINITIONS:

| HOSPITAL means any registered institution in or outside the state Rajasthan established for indoor

care and treatmentofdiseases and injuries and which are :-(a) All the Government hospitals in the State of Rajasthan(b) The Hospitals outside the state of Rajasthan which have been approved by the Govt. of

Rajasthan (Appendix —1)

(c) Private Hospitals with in Rajasthan duly approved by Govt. of Rajasthan under the RajasthanCivil Services Medical Attendance Rules 2013 and also given the acceptance to work with

GIF on CGHS Package Rates ( Appendix-2 ). Those private hospitals which are added in

approved list from time to time by the Government of Rajasthan and give acceptance towork with GIF on CGHS Package Rates, shall also be automatically empanelled under the

scheme.(d) If a private hospital, which is approved for treatment of State Government employees under

Rajasthan Civil Services Medical Attendance Rules 2013, has not given acceptance to GIS

RAJCOMP INFO SERVICES Policy 18-19

3.3

3.4

3.5

3.6

3.7

3.8

3.9.1

Office to provide it’s services on CGHS packages/rates and an insured has taken treatment

in such hospital, then he/she shall be paid on CGHS package, difference amount shall be

borne by him/herself (i.e. insured). .

2.2 ‘Surgical Operation’ means manual and/or operative procedures for correctionofdeformities

and defects. repair of injuries. diagnosis and cure of diseases, relief of suffering and

prolongationof life.

Expenses on Hospitalisation

this time limit is not applied to specific treatments,

Radiotherapy. Eye Surgery, Dental Surgery in case of accidents =k

removal), D&C, Tonsillectomy taken in the approved Hospital/Nursing Home and the

Insured is discharged on the same day.in such cases the treatment will be considered to be

taken under hospitalisation benefit. This condition will also not apply in case of stay in

hospital of less than 24 hours provided Explanation to the treatment Is such that it

necessitates hospitalisation and the procedure involves specialised infrastructural pees

available in hospitals and due to technological advancement hospitalisation 1s required for

less than 24 hours only. It would be certified by concerning Doctor under whom treatment Is

given and vetted by TPA. ;

2.4. CGHS packages shall be applicable in Rajasthan, as laid 5 eta

and in other States it shall be applicable(exclusive of policy clause 9.1 and 9.2) as laid down

by CGHS for various places in India. The bed charges shall be paid according to the

category of the employee. The diseases for which no package rate 1smentioned in CGHS

package rate then it will be paid according to AIIMS package rates. If there is no CGHS and

AIIMS package rate then actual payment shall be paid.

ANYONE ILLNESS :-Any one illness will be deemed to mean contin

45 days from the date of discharge from the Hospital/Nursing

taken. Occurrenceofthe same illness after a lapse of 45 days as state

fresh illness for the purposeofthis policy.

PRE-HOSPITALISATION :-

Relevant medical expenses incurred during period up to 30 days prior to hospitalisation on

disease/illness/injury sustained will be considered as part of claim.

POST HOSPITALISATION :-

Relevant medical expenses incurred during period up to 45 days after hospitalisation on

disease/illness/injury sustained will be considered as part of claims.

MEDICAL PRACTITIONER means a person who holds a degree/diploma of a recognized

institution and is registered by Medical Council of respective State . The term Medical Practitioner

would include Physician, Specialist and Surgeon.

QUALIFIED NURSE means a person who holdsacertificate of a recognized Nursing Council and

who is employed on recommendationofthe attending Medical Practitioner.

MATERNITY EXPENSES BENEFIT means treatment taken in Hospital/Nursing Home arising from or

traceable to pregnancy. Childbirth including normal Caesarean Section. -

TPA means a Third Party Administrator who, for the time being, is licensed by the Insurance

Regulatory and Development Authority, and is engaged, for a fee or remuneration, by whatever

name called as may be specified in the agreement with the GIF, for the provision of health services.

CASHLESS FACILITY -Cashless facility would be extended to the Insured in the private networkingHospitals for the critical ailments (Means:- i. Coronary Artery Surgery ii.Cancer iii.RenalFailure1.e. failure of both the kidneys iv. Stroke v. Multiple Sclerosis vi. Meningitis vii. Major Organtransplants like Heart, Kidney, Liver, Lung, Pancreas or Bone marrow Transplantation) .

However, The TPA would decide the merit of the case and it will not be claimed as a matter of right

by the insured. The denialof cashless facility does not mean the denialof treatment from concerned

hospital & reimbursement thereof.CLAIM INTIMATION TO TPA - It is required by the employees that the claims arising in private

hospitals should be intimated’by cashless request form/ claim intimation form, available in thehospital, to the TPA positively. If the claim intimation does not reach the TPA the same day when

thepatient is admitted to the hospital, then the employee shall not be entitled for re-imbursement.

Claim Intimation to TPA in case of Government Hospitals — It is not required by the employees

that the claim(s) arising in Govt. Hospitals should be intimated in writing to the concerned

TPA/GIF, on the same day patient is admitted in the hospi

for minimum period of 24 hours are only admissible. However.

i.e. Dialysis. Chemotherapy,

s. Lithotripsy (Kidney Stone

w wo

down by CGHS for Jaipur City

uous periodofillness and it includes relapse within

Home where treatment has been

d above will be considered as

B54 RAJCOMP INFO SERVICES Policy 18-19 Page2of17

3.10

mnstan

wo—

an os

ar

tn

Dn

nm ~s

6.3

6.4

DEPENDENT FAMILY - The ‘family’ of the employee shall include the employee, his/her spouse, not

more than two dependent children upto 21 years of age and dependent parents. The parents shall be

regarded as wholly dependent upon the RAICOMP INFO SERVICES LTD Employee, if-

(a) they normally reside with the Rajeomp Info Services Ltd Employee at the place

(b) their total monthly income from all sources does not exceed Rs.2000/- per month. ; —

FAMILY DETAIL — Every newly recruited employee shall have to providedetails of the family &

photographs for preparing the database & for issuing identity cards in the preveniee

form(Appendix 3) immediately after joining the service otherwise his salary bill of the designate

month will not be passed by the Treasury Officer. — canae eet

Explanation — Details ofthe family means : Name, Designation, DDO, Date of joining Govern

Service, Names of Family members, Age. Pay/ Pay Scale/Stipend.

SCHEDULE:The Schedule enclosed will be deemed to be a part ofthe policy.

EXCLUSIONS : oe

The GIF shall not be liable to make any payment under this policy in respect of any expenses

whatsoever incurred by any Insured person in connection with or in respect of:

Diagnostics/ Investigations unless followed by indoor treatment 0

Injury/disease directly or indirectly caused by orarising from or attr

Foreign enemy, War like operations (whether war be dec

Circumcision unless necessary for treatment of a disease not excluded hereunder or as er be

necessitated due to an accident, vaccination or inoculation or change oflife or cosmetic or aest eu

treatment of any description, plastic surgery other than as may be necessitated due to an accident o1

as a part ofany illness.Cost of Spectacles and contact lenses, hearingaids —_ a

Dental treatment or surgeryofany kind unless requiring hospitalisation due to an incident.

Convalescence. general debility; run-down condition or rest cure. congenital external diseaseor

defects or anomalies. Sterility, Vencreal disease, intentional self injury and use of intoxication

drugs/alcohol/poisonous substances/Addictions.

All expenses arising out of any condition directly

T-Cell Lymph tropic Virus Type III (HTLB-III) or L

the Mutants Derivative or Variation Deficiency Syndrome or

similar kind commonly referred to as AIDS.

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.

Expenses on vitamins, proteins and tonics unless forming part oftreatment for injury or diseases as

certified by the attending physician.

Injury or Disease directly or indirectly caused by or contributed to by nuclear weapons / materials.

Naturopathy Treatment.

Pre existing disease of employee and his/her dependents will be covered under this scheme.In such situations in which there are no urgency of hospitilisation and treatment can be given at home and

ofhis/her duty, and

f 24 Hours.

butable to invasion, Act of

ared or not).

or indirectly caused to or associated with Human

ymphadinopathy Associated Virus (LAV) or

any syndrome or condition of a

which is not pertain to section 2.3.

CONDITIONS:Every notice or communication to be given or made under this Policy shall be delivered in writing at theaddress of the TPA/GIF office.The premium payable under this Policy shall be paid in advance. No receipt for Premium shall be validexcept on the official form of the GIF signed by a duly authorized official of the GIF. The due payment ofpremium and the observance and fulfillment of the terms, provisions, conditions and endorsementsofthispolicy by the Insured Person in so far as they relate to anything to be done or complied with by the InsuredPerson shall be a condition precedent to any liability of the GIF to make any payment under this Policy. Nowaiver of any terms, provisions, conditions and endorsements of this policy shall be valid unless made inwriting and signed by an authorized official of the GIF.In case of grave emergency viz. life threatening (Means:- Coronary, Artery Surgery, Cancer, Renal Failure

i.e, failure of both the Kidneys, Stroke, Multiple Sclerosis, Meningitis, Major Organ Transplants like

Kidney, Lung, Pancreas or Bone Marrow, Accidents, Delivery, Tubal Pregnancy & Related Complication,

Swine Flu, Dengue Fever, Burst Appendicitis, Pancreatitis) in which Employee has taken treatment asindoor patient in a non empanelled private hospital, at the time of claim submission the emergent nature of

hospitalization has to be established by an affidavit (Appendix-6) of the employee supported by a certificateofthe treating doctor. Claim shall be paid as per CGHS Package Rates upto the limit of sum assured.

Insured shall show their identity to the empanelled hospitals and fill up a prescribed form at the time ofadmission to take treatment at CGHS rates/packages. Forms

Vaye Sof l7

6.6

6.7

6.8

6.9

6.10

6.11

6.14

empanelled hospitals (Appendix-5). If an insured person(s) do/does not show his/her identity and takes

treatment without filling prescribed form then it is possible that hospital may charge their actual rates. Insuch cases, GIP shall reimburse only on CGHS rates/ packages, difference amount shall be borne by theinsured.

All supporting documents relating to the claim must be filed with FPA/GIE within 90 days from the date of

discharge from the hospital. In case of post-hospitalisation, treatment (limited to 45 days), all claim

documents should be submitted within 90 days afier completion of such treatment.

The Insured Person shall obtain and furnish the TPA/GIF with all original bills, receipts verifications and other

documents upon which a claim is based and shall also give such additional information and assistance as the

IPAGIE may require in dealing with the claim.Any medical practitioner or an officer authorised by the TPA/GIF shall be allowed to examine the Insured

Person in case of any alleged injury or disease requiring Hospitalisation when and so often as the same may

reasonably be required on behalfofthe TPA/VGIF, . .

The Gir shall not be liable to make any payment(s) under this policy in respect of any claim(s) if such claim

be found in any manner fraudulent or supported by any fraudulent means or device whether by the Insured

Person or by any other person acting on his behalf. .

If at the time when any claim arises under this Policy, there is in existence any other insurance (other than

Cancer Insurance Policy in collaboration with Indian Cancer Society), whether it be effected by or onbehalf

of any Insured Person in respect of whom the claim may have arisen covering the same loss, liability,

compensation, costs or expenses, the GIF 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 ofthe benefits available under Cancer Insurance Policy. . .

If and when the Employee has submitted his/her family details to the concerned TPA/GIF and identity cards

have been issued to the insurer, then only he/she shall be entitled for cashless facility. .

The Policy may be renewed by mutual consent. The GIF shall not however be bound to give notice that it is

due for renewal and the GIF may at any time cancel this Policy by sending the Insured 30 days notice by

registered letter at the insured’s last known address and in such event the GIF shall refund to the insured a

in liable for any claim,pro-rate premium for unexpired Period of Insurance. The GIF shall however, remai

which arose prior to the date of cancellation. The Insured may at any time cancel this Policy and in such

event the GIF shall allow refund of premium at GIF’s short period rate only (Table given here below)

provided no claim has occurred up to the dateof cancellation.

PERIOD ON RISK RATE OF PREMIUM TO BE CHARGED

Upto one month 1/4"ofthe annual rateUpto three months Y% ofthe annual rate

Upto six months ¥ath of the annual rate

Exceeding six months Full annual rate

in case if any dispute or difference arises as to the quantum to be paid under the policy (liability

being otherwise 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 the dispute/difference and the third arbitrator to be appointed by such two arbitrators andarbitration 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 GIF has disputed or not accepted liability under or in

respectof 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 amountof the loss or damage shall be first obtained.If the TPA, as per terms and conditions of the policy or the GIF shall disclaim liability to the

Insured for any claim hereunder and if the Insured shall not within 12 calendar months from the

date or receipt of ‘the notice of such disclaimer notify the TPA/GIF in writing that he does not

accept such disclaimer and intends to recover his claim form the TPA/GIF then the claim shall for

all purposes be deemed to have been abandoned and shall not thereafter be recoverable hereunder.

All medical/surgical treatments under this policy shall have to be taken in approved hospitals in and

outside the state of Rajasthan and admissible claims thereof shall be payable in Indian currency.

Payment of claim shall be made through TPA/GIF to the Hospital/Nursing Home or the Insured

Person as the case may be. The list of approved hospitals is available at (Appendix 2).


Pave $of 17

-owm

“AN

6.15

6.16

6.17

6.18

6.19

Note:

In case of death of insured during policy period then the names of family members to be continued

till expiry ofthe policy.

Entitlement category for boarding/accommodation in the Hospital :-

Category Pay Scale* Entitlement in

Govt. Hospital

Entitlement — in

ApprovedPrivate Hospital

Maximum ceiling of

Boarding/Accommodation

Charges as per CGHS

Package Rates

Private Ward Rs. 3000/- per day

and above but

less than Rs.

64000/-

Ward

A Rs. 64000/- &| Deluxe

above

B Rs. — 36000/-| Cottage Semi Private| Rs. 2000/- per day

Rs. 1000/- per daypo

General Ward General Ward

—Below. Rs.

36000/-

* Pay scale means basic pay /fixed remuneration

Note: Actual boarding / accommodation charges ©

charges can not be more than CGHS packages rates, indicated as above.

If insured takes treatment in higher category other than entitlement, the reimbursement of cost of

treatment will be made according to category as prevalent in the hospital.

his/her dependents (as per section 3.10) will be covered under

f hospital rate shall be applicable but these

Pre-existing disease of employee and I

this scheme.

Medical examination of the Rajcomp Info Services Ltd Employee or any member of his

not be a condition for issue of Mediclaim Policy.

A fe male employee can get the Mediclaim coverage either for her parents or Parents in law in

case they are dependent on her and their monthly income is less than Rs. 2000/- and they are

residing with her generally.

The policy has been issued to D.D.O. Rajcomp Info Services Ltd, Jaipur. It is required fromD.D.O.

of Rajcomp Info Services Ltd that they would brought into notice of all the newly recruited

employees regarding terms & conditions of the policy. It is also expected that every newly recruited

employee must have gone through the terms & conditions of the policy.

This Policy is available at website : www.sipf.rajasthan.gov.in

HIGH CLAIMS RATIO LOADING (MALUS)

The total premium payable at the time of 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 Insurance Policy for the preceding three completed years excluding the year

immediately preceding the date of renewal, where the Group Mediclaim Policy has not been in

force for the three completed years, such shorter periods of completed years, excluding the year

immediately preceding the date of renewal will be taken in to account.

family shall

Incurred Claim ratio under the group policy Loading

Between 70% and 100% 25%



Between 151% and 175% 120%

150%Between 176 and 200

Over 200% Cover to be reviewed |

High Claim loading (Malus) will be applicable to the Premium at renewal of the Policy depending

on the incurred claims Ratio for the entire Group Insured.

Incurred claimi would mean claims paid plus claims outstan

group insured under the policy during the relevantperiod.

MATERNITY EXPENSES BENEFIT EXTENSION : (Whereverapplicable)

per family per year

3,00,000 per family

ding in respect of the entire

The maximum benefit allowable under this clause will be up to Rs. 50,000/-

restricted to two living children. This amount is including sum-assured of Rs.

per annum.

Page Sof 17 —

9.5

1010.1

10.4

The Maternity benefits under this policy are categorized into three :I Maximum limit under normal delivery : Rs. 10000/-I Maximum limit under caesarean delivery; Rs. 20000/-Ill Maximum limit under delivery related

complications (Including child care) : Rs. 50000/-

Special conditions applicable to Maternity expenses Benefit Extension:

I These Benefits are admissible onlyifthe expenses are incurred in Hospital/Nursing

Home as in-patients in empanelled Hospital.

II A waiting period of9 months is not 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.

Hl Claim in respect of delivery for only first two children and/or operations associated

therewith will be considered in respect of any one Insured Person covered under thepolicy

or any renewal thereof. Those Insured Persons who are already having two or more living

children will not be eligible for this benefit.

IV Expenses incurred in connection with voluntary medical termination of pregnancy during

the first 12 weeks from the date of conception are not covered.

Vv Pre-natal and post-natal expenses are not covered unless admitted in Hospital/Nursing Home

and treatment is taken there.VI New born child’s expenses will also be treated as Maternity Expenses.

PAYMENT OF CLAIM

The insured shall submit the claim form through DDO to the TPA in the prescribed Performa

(Appendix 4).

For Re-imbursement photo will be pasted by the concerned employee (if he doesn’t possess the

identity card) which will be duly verified by the treating doctor/ DDO so as to confirm the identity

of the Patient. °

Cashless facility will not be provided if the identity cards have not been obtained by the policy

holder.

Payment of claim shall be made through TPA/GIF to the Hospital or to the Insured Person asthe

case may be normally within 30 days from the date of receipt of completed claim proposals by the

TPA.


Appendix : |

List of Referral Hospitals approved by the State Government for treatment

outside Rajasthan

I. All India Institute of Medical Sciences, New Delhi.

2. Bombay Hospital. Bombay.

3. Christian Medical College & Hospital, Vellore.

4. Fortis Hospital, New Delhi.

5. Gujarat State Cancer & Research Institute (M.P. Shah Cancer Hospital), Ahmadabad.

6. Post Graduate Institute and Research Centre, Chandigarh.

7. Rajeev Gandhi Cancer Institute and Research Centre, Delhi.

8. Tata Memorial Hospital, Bombay.

9. The Gujarat Research & Medical Institute (Rajasthan Hospital), Ahmadabad.

10. Institute of Liver and Billary Science, New Delhi (For Liver disease only).

Hl. Medanta, the Medicity, Gurgaon (For Cardiology, CT Surgery, Joint Replacements and Liver transplant).

12. Shalby Hospital, Ahmedabad, (For Joint Replacements only).

13. Indraprastha Apollo Hospital, New Delhi (Liver Transplant).

I4. Global Hospital, Chennai (Liver Transplant).

15. Sterling Hostpital, Ahmedabad.

RAJCOMP INFO SERVICES Policy 18-19 of 17

o1.01.2004 g wee aware Praet Prgat wer oftay, fageafta

fare.ay,Aaaaa Forgan Prof oreaerett A A

(Updated on 18-09-2018)

Public Private Partnership Hospital Tota | No. of Approve

Appendix 2

d Hospitals : 99

wdAA Pra/atel &ararai

of 17

ji .

XO SERVICES Policy 18-19

|Order Number Order Date

Name of Hospita3/7/2013

a TT Speciality Hospital, Jaipur [F.6(4)FO/RULES/2003Pt. yt1 |Metro Manas Arogya Sadan Heart Care and Multi - spe :

Multispecialty Hospital Order Number Order Date | Valid UpTo— r

i020

S No. Name of Hospital =Z lp Fb(Rules 2013 Pt-l 2/20/2015 —

1 [Agarwal Hospital, Tonk F6(2)FD(Rules 2013Pt-Il 9/9/2014 Oa

2_[Apex Hospital Put, Ltd, Malviva Nagar, SPU" F.6(2)FbD/Rules/2016 6/13/2016 {6/1

3 |Barala Hosptial and Research Centre, Chomu, Jaipur = -onFD[Rules 5013 Pll 9/9/2014 spree

4 [Bhandari Hospital and Research Centre, SPU F 6(2)FD/RULES/2013 PT-I 2/10/2015 _|2/9/20

5 [Bharat Vikas Parishad Hospital & Research Centre,Kota = FD) FDIRules 5013Pt-l 7/30/2015 7/29/202

6 |Bindal Hospital, Sikar __ Rules/2016Part-lll 1/8/2018 1/7/2023

; h F.6(2)FD. 6/12/2021

7 |CKRD Memorial Hospital & Research Institute, Jhunjhunu = coy /Rules 5016 6/13/2016 /

8 |Dhanvantari Hospital and Research Centre, Jaipur __ = FD [Rules)2013 mull 2/20/2015 2/19/2020

9 |Dhukia Hospital, Jnunjhnu - Fa(7iFb[Rules 7013 Pt 2/20/2015 2/19/2020

10 |Dr. Choudhary Hospital and Medical Research Centre Pvt. Ltd., Udaipur :

, |i [10/5/2021, F.6(2)FD(Rules 2016PT-II

11 |G.P. Shekhwati Hospital and Research Centre, Jaipur ean Tules)/2013Ptll 9/9/2014 9/9/2019

12 |GBH American Hospital, Udaipur =a >) FD Rules)/2013Pt-ll 9/9/2014 9/9/2019

13 |Geetanjali Medical College and Hospital, Udalput FaroiRule 5016 Phill 9/26/2017 9/25/2022

14 |Getwell Hospital and Research Centre, Sikar =a) PDIRoles)/2016PT-ll 10/6/2016 10/5/2021

15 |Gheesibai Memorial Mittal Hospital and Reasearch Centre, Ajmer F.6(2) *

na Jodhpur F.6(2)FD/Rules/2013 Pt Il 3/11/2015 —_|3/10/2020i ntre, Jo u16 |Goyal Hospital & Research Cen p =eiairbiRules 501 PE 2/20/2015 2/19/2020

17. [Harish Hospital Pvt. Ltd., Alwar aor oRules)2013PEN 9/9/2014 9/9/2019

18 |Jaipur Hospital, Jaipur one 9/25/2022

- Pt-lll 9/26/2017

19 |Jaipur National University Institute of Medical Sciences and research Centre, F.6(2)FD/Rules 2016

Jaipur (2)FD(Rules)/2013Pt-ll 9/9/2014 (9/9/201920 |Jaiswal Hospital & Neuro Institute, Kota

F.6(2)FD(Rules4

F.6(2)FD(Rules)/2016PT-II! 12/2/2016 12/1/20

21. |Kailash Hospital, Behror (Alwar) . Sra sjaj0id 3/9/2019

22 |Kalpana Nursing Home Pvt. ttd., Udaipur F.6(2)FD(Rules)/20 t-

iF.6(2)FD(Rules)/2013Pt-Il 9/9/2014 9/9/2019

23 |Kota Heart Institute, Kota F014) rani Srafo2l

24 |Krishana Hospital, Bhilwara F.6(2)FD/Rules/2016 6/ aa

25 |Kshetrapal Hospital multispecialty &Research Centre, Ajmer F.G(2)FD/Rules/2016 Part-Ill 5/21/2018 /

26 {Madhur Hospital, Dausa F.6(2)FD(Rules)2013 Pt-ll 2/20/2015 2/19/2020

27. [Mahatma Gandhi Medical College & Hospital, Jaipur F.6(2)FD(Rules)/2013Pt-Il 9/9/2014 9/9/2019

28 |Marudhar Hospital Jaipur F.6(2)FD/Rules/2016 6/13/2016 6/12/2021

29 |Medipulse Hospital, Jodhpur F.c(2}FD/Rules/2016 6/13/2016 6/12/2021

30 |Mittal Hospital, Alwar F.6/2)FD(Rules)/2016PT-II 10/6/2016 10/5/2021

31 |Narayana Multispecialty Hospital, Jaipur F.G(2)FD(RULES)2013 PT-II 1/27/2016 1/26/2021

32. [Pacific Medical College and Hospital, Udaipur F.6(2\FD/Rules/2016 5/26/2017 5/25/2022

33 |Porwal Hospital, Bhilwara F.6(2)FD(Rules)/2013Pt-I 7/30/2015 7/29/2020

34 |Ramsnehi Hospital and Research Centre, Bhilwara F.6/2)FD/RULES/2013 PT-II 2/10/2015 2/9/2020

35 |Ranthambore Sevika Hospital, Sawai Madhopur F.6(2)FD(Rules)2013 Pt-ll 2/20/2015 2/19/2020

36 |RavindraHospital, Jnunjhunu F.6,2)FO/Rules/2016 Part III 10/6/2017 10/5/2022

37 |S.B. Mittal Memorial Heart and Critical Care Hospital, Sikar F.6(2°FD(Rules)2013 Pt-Il 2/20/2015 2/19/2020

38 |S.R. Kalla Memorial Gastro & General Hospital, Jaipur F.6(2'FD(Rules)2013 Pt-Il - 2/20/2015 2/19/2020

39 |Sania Hospital, Alwar F.6(2)FD(Rules)2013 Pt-Il 2/20/2015 2/19/2020

40 |Sh. K.M. Memorial Jain Heart and General Hospital, Sikar F.6(2)FD(RULES)2013 PT-II 1/27/2016 1/26/2021

41 |Shree Siddhi Vinayak Hospital, Bhilwara F.6(2)FD(RULES)2013 PT-II 1/27/2016 1/26/2021

42 |Shri Krishan Hospital, Lalsot Road, Dausa F.6(2)FD(Rules)/2016 2/27/2017 2/26/2022

43 _[Solank! Hospital, Alwar F.(2;FO(Rules)/2016PT-I 9/21/2016 [9/20/2021

44 {Soni Hospital, Jaipur F.6,2:FD(Rules)/2013-Pt-ll 8/7/2014 18/6/20194S {Soni Manipal Hospital, Jaipur eaepoRules)/2016PT-I 10/6/2016 10/5/2021

46 |Sudha Hospital & Medical Research Centre, Kota Soe bec tbtantes)/2013Pt-I1 9/9/2014 [9/9/201947 Tagore Hospital & Research Institute, Jaipur is aaAD Nules2013Pt-ll 9/9/2014 9/9/2019

be aia PRY fo,

Mk

NELoo

penny

ne

Cardiology and CT Surgery Specialty Hospital

K No. Name of Hospltal Order Nurnber Order Date | Valid Upto

Heart & General Hospital, Jalpur F.6(2)FD/RULES/2013PT-} A/23/2015= 14/22/2020

2 WJaipur Heart Institute, Jaipur f.G(2)D/RULES/2013 PEM 2/10/2015 2/9/2020

3 |Krishna Heart and General Hospital, Jalpur F.0(2)F O(Rules)/2016 2/27/2017 = |2/26/2022

ENT Specialty Hospital

S No. Name of Hospital Order Number Order Date | Valid UpTo

1 [Jain ENT Hospital, Jaipur F,6(2)f D(Kules)/2016PTl 9/21/2016 |9/20/2021

ospital

SNo. Name of ——__Neureswna Specialty Hosp Order Number Order Date valid ore

1 |Indowestern Brain & Spine Hospital, Jaipur F.0(2)FD/MULES/2013 PTH 2/10/2015 2/9/2020

spital

S No. Name of Hospital Oncology Specialty Hose Order Number Order Date | Valid UpTo

1 |Bhagwan Mahaveer Cancer Hospital and Research Centre, Jalpur ,6(2)ED(Rules)/2013Pt-I 9/9/2014 9/9/2019

y Hospital

5 No. Name ofa pnthalmeloeySpecial nese Order Number Order Date Valid UpTo

1 |Alakh Nayan Mandir Eye Hospital, Udaipur F,6(2)FD/Rules/2016Part-Il 10/13/2017 |10/12/2022

2 {Anand Hospital and Eye Centre, Jaipur F.6(2)FD(Rules)/2016PT-M 9/21/2016 {9/20/2021

3 {Anita Eye Hospital and Retinal Centre, Kota £.6(2)D/Rules/2016 6/13/2016 6/12/2021

4 {Anupam Eye Hospital & Research Centre Pvt. Ltd., Lalkothl, Jaipur F.0(2)FD/Rules/2016Pt-lll 9/26/2017 _ {9/25/2022

5 _|ASG Hospital Pvt. Ltd. Banipark, Jaipur F.6(2)FD(Rules)/2013Pt-ll 8/25/2015 2/24/2020

6 {ASG Hosaital Pvt. Ltd., Udaipur F.C(2jFD/Rules/2016PartIl! 10/6/2017 10/5/2022

7 |D.D. Eye Institute, Dada Bari, Kota F.6(2)FD/fules/2016 Pt-lll 6/5/2018 6/4/2023

8 |Dr. Kotharis Eye Hospital, Udaipur F.6Q)FD/Kules/2016 6/13/2016 _|6/12/2021

9 |Dr. Virendra Laser & Phaco Surgery Centre, Jaipur F.b(2)FO(RULES)2013PT-Il 1/27/2016 {1/26/2021

10 |i Max Eye Care Hospital, Sikar F.(2)FD/Rules/2016PartIll 10/6/2017 10/5/2022

11 |J P Eye Hospital, Tonk Road, Jaipur F.C(2)FD/Rules/2016 Part-II 10/13/2017 {10/12/2022

12 |K.C. Memorial Eye Hospital, Jaipur F.0(2)FD(RULES)2013PT-II 1/27/2016 1/26/2021

13 |Kabra Eye Hospital, Jaipur FU,2)FD(Rules)/2013 Pt-ll 8/25/2015 8/24/2020

14 |Kapoor Hospital and Eye Centre, Jaipur F.6(2)FD/Rules/2016 Part II 10/6/2017 10/5/2022

15 |Kota Eye Hospital and Research Foundation, Kota F.4(2)FD/Rules/2016 Part-lll 10/13/2017 |10/12/2022

16 |Kshetrapal Eye Hospital and Lasic Laser Center, Ajmer F.6(2)FD(Rules)/2013Pt-I 7/30/2015 7/29/2020

17 |New Delhi Centre for Sight Ltd., Malviya Nagar, Jaipur F.0(2)FD/RKules/2016 6/13/2016 6/12/2021

18 |Sahai Hospital and Research Centre, Jaipur F.u\2)FD(Rules)/2016 2/27/2017 2/26/2022

19 |Tibra Eye Hospital and Retina Centre, Sikar F.0/2)FD/Rules/2016 6/13/2016 6/12/2021

Orthopedics Specialty Hospital

S No. Name of Hospital Order Number Order Date | Valid UpTo1 {Kota Trauma Hospital, Kota F.0(2)FD/Kules/2016 6/13/2016 6/12/2021

2 _|Mewar Hospital Pvt. Ltd., Udaipur F.6(2)FD/RULES/2013PT-I 4/23/2015 — |4/22/20203 |The Royal Orthopaedic Hospital and Sports Injury Centre, Lalkothi Scheme, |F.0(2)FD(Rules)/2016 2/27/2017 2/26/2022

Jaipur

Multispecialty Hospital (Not Empanelec! Now- Non Active)

1 |Anurag Nursing Home, Bundi F(2)ED(RULES)/2013 5/9/2014 {5/8/2017

2 {Goyal Hospital and Emergency Care Centre, Baran F.6(1)FD(rules)/2013 Pt 9/20/2013 |9/19/2016

3. {Kamla Nagar Hospital, Jodhpur F.8(2)FD(Rules)/2016 5/13/2016 |6/12/2016

4 |M.N. Hospital and Research Centre, Bikaner F.€(2)FD(RULES)/2013 5/9/2014 {5/8/2017

5 | National Institute of Medical Sciences & Research Centre (NIMS) Delhi

Highway, Jaipur F.6(2)FD(Rules)/2016 Pt-Ill_ [1/9/2018 |1/8/20186 |Sanjeevani Vyas Hospital Anusandhan Kendra, Jhalawar F.5(2)FD(Rules)/2013Pt [12/17/2013 12/16/2016

Ophthalmology Specialty Hospital (Not Empaneled Now - Non Active)

1_|Royal Eye Care and Research Centre, Adarsh Nagar, Jaipur [F.6(2)FD/Rules/2016 Part-I [10/13/2017[6/30/2018 |

ae: facefounterr arpaifeatProffefarcarcral a wet A waaroefd a are oad faurr arr warferdafseemvifetratoxa)oryett|

Poye tt of ww™

reagfartentwarlordAtsact

§amidaa 81 gaPohPafecareai A doraaa Gis wyeiviigaTy A

& poke Rarare aR eTahaERI waa TetST TTT

UPDATED ON 18.09.2018

Multispecialty Hospital

S No. Name of Hospital Order Number Order Date | Valid UpTo

1 Amar Medical & Research Cetre, Kiran Path, Manserover, Jaipur F.6(2)FD{Rules)/2016Proll! 30/07/2018| 30/09/2018

7 {ananta Institute of Medical Sciences and Research Centre, F.6(2)FD(Aules)/2016 2/27/2017 {2/26/2022

\ si ps

3 aval Hooral ion F.6(2)FD(Rules)/2013 Prt! 10/18/20 10/15/2020

2 |Arihant Hospital and Research Sensthan, Bhilwara F.6(2)FO(RULES)2013PTI! 1/27/2016 |1/26/2021

5 |Eterna! Heart Care Centre and Research Institute Pvt Ltd. Jaipur F.6(2)FD/Ru'2s/2016 6/13/2016 6/12/2921 |

Fortis Escorts Hospital, Jaipur F.6(2)FD{Rules)/2013Pe-il 3/3/2014 3/3/2019 |

7 |Gangauri Hospital, Sawai Madhopur F.6(2)FD/Rules/2016Parl ay 13872023 |

8 |Global Heart and General Hospital, Jaipur F.6(2)FD(Rules)/2016PT-I 12/2/2016 12/1/2021 |

a |Guru Kripa Hospitals, SikarF.6(2)©D/RULES)2013 PT-ll 1/27/2016 1/26/2021

10 |Imperial Hosiptal end Research Centre, Shastri Nager, Jaipur Se 6/5/2018 6/4/2023 |

11. [Jeevan Rekha Critical Care & Trauma Hospitel, Jegetpure, Jaipur F.6{2)FD/R: 12/22/2017 12/21/2022

12 |Kothari Hospital and Research Institute, Bikaner F.6(2)=D/RULES/2013 PT-l }2/20/2015 {2/3/2020

13 |Opere Hospital Medical and Research Centre Pvt. Ltd., Kota FaeDeveso1spenam [2/5027 [20/12/2022

14 [Rungte Hospital, Jaipur F.6(2)£D/RULES)2013PT [1/27/2016 1/25/2021

15 |S.N. Pareex Memorial Hospital and Reasearch Centre, Kota F.6(2)ED/Rv'es/2016 Pearl 30/23/2027 10/12/2022 |

16 |Santokba Durlabji Memorial Hospital cum Research Institute, Jaiour F.6(2)ED/Ru'es/2016 Pll 9/26/2017 —_ [3/25/2022 |

17. ‘Star Hospital, Bhiwari, Alwar F.6(2)FD/Rules/2016 Pil 5/21/2018 5/20/2023

Ophthalmology Specialty Hospital

>No. |Name of Hospital |Order Numder {Order D aie [Valid UpTo

L ASG Hospital Pvt. Ltd. Jodhpur|5/21/2018 5/20/2023 |

, Dr. Khungar Eye Care and Research Centre Pvt. Ltd., Ajmer |4/23/2015 oa

; Royal Eye Care & Reasearch Centre, Adrash Naeger, Jaipur )13/10/2037 30/09/2021

Orthopedics Specialty Hospital

S No. Name of Hospital Order Date Valid UpTo

1 Chandni Hospital, Talwandi, Kota 10/8/2017 10/5/2022

2 ‘|Jyoti Nursing Home Pvt. Ltd., Jaipur |2/27/2017 2/26/2022

Nephrology Specialty Hospital

S No. Name of Hospital Order Number Order Date Jelid UpTo

1 Maxwell Hospital, Jaipur F.6(2)=D(Rules)/2016 |2/27/ 2017 2/26/2022


eal

ati

~\

ah

3

ahAWM

OTR

Appendix : 3

Wald—-4AWORT UHR

wee star vd wraerelt Per fer Career star fafey)

Saito, fact vas, ora, cane Te, STAGE (TGR)

— 2740219, 2740292 (hq)

feats difert &ferySertaeg RawfraFamily Detail for Mediclaim Policy Database

aafans) grr weit ateryBRD a atte FyaMoiftars F1TYoH fordAe er AWT

gaPeedwefearaT!

1. @yaN) oT WI AAName of Employee

2. fia /att ot AAName of Father/Husband © sssssssssssssssssssssessssesssseeenceeceerecssnnnnnnnssnssssnners set00000 0001220002 SIT

wantaaretaecrfey

ada AA /VASA(Pay/Remuneration)

FORT SGT FPR oeccseneneeeneeenntnar feet ERT GN Ysie.S1. TAR ....FATA TE cesssssstsesstetntntseeststntsenennmnnnnneneneesPresent Designation csessccssesesscssssssesesssssesscrsnnneceensnnresscnsserecannscensets

8. ada areeerfacrerafter ar ve(fet4)(In English) ..........-

&Noma

Home Address (In Emghish) ........sscsccssssssssssesssssnsssecccersennesseccessnunnaaennnnnnrsscette 220s

10 WHY PIR TTD ac cceceecessesenensenenen PRIA ceccscssssssssesseteneeeseeeee

garweet #21 af Hoeaw & 2 aed or Aveces fo wdafeara_fiar A afaRraona co wre offme A or 8wdShed 3 cee wT WRUTBeved a

alsaatvectrafearord | ;

3 Rayuel@eraasa SGre feroxota Ta Ww RTER BYcen wadweafoRadwlelwaa Wa eg

WITTHUT |

=

featmerRawrwoirarwea &aiearg egfour vet rae | Acient@Maaawelar ona oyfear & oifeferrite

ange (www.sipf.rajasthan.gov.in) 1 2d oa wom ena vert Geer & | eae WY META we |

BE cnmnunnunnnneTA/TA/TA Accscnnaennn TE nn commun US UOT Gat & fh SR

BARR silane/wat

artesRawr orafaaRats @ citsae Peer areneeeAn rerwafer a onanarta oqsnl fear oT eI

arerer wa faraRer arferarefeara:wmUa

afaRad/aga / sa/ wera Pree,wea Hat va wo fo fart

RAICOME INFO SERVICES Policy 18-19

of V7

Appendix 4WRI, UH

wey Aa vd waar) PRY Aa(airemeer Ayr Ff)

“Sete, er cet, Mer ares, Gere, GragE|WHT : 2740219, 2740202

Afsaer Dar uffed wear wes

1. AAMT TT ATT cccccccccccsccccssece sesneusenseseessenusseee dae wrafeay wart wb fewBT yer Any

WTS SUR. Acccccssssssasuesusvansenansanssnanansansenan(Srad ay V diferdy or) at ag 2) STAT Aacccscssesesnseesssssessenee

2. Tiferd wen raft a aa

3. WA aftaarfray&. aa aieseaMer waeya. ada yet airy 07 OR wT aT

YFwy Fo ' -FaTge Ao

4. WPTIT/aA atof ade oryaHR

5. aefestaforafe de om a wader8M 1UeellUR Val eT

Rate ATE a |@omemmre FT) Cl] Co

fetta aTe ag |

8. afearen aftarhsear ail &fay & at Goa aang

®, Boa Bus arfeaia @, UTI Waaeh wT fratH

LE} LE} CE hEfesta Ae ag festa Ae ag

T. STIRHeacl fafeerH wTAAaie et —

9. UP ad orAaa faa :—

(1) wa foeran(akaat, ator anf&oeag):

aa2

10. &a% Greatto (salary a/c number)4% or wonger, ageeetais va da/aia a am,fiat(crataefo ear AGTear &forddae ore gas BH oraaAe edPeerAeoer daw Bt urea ears wy)11 GaryBada

Afsmem ater uRay Ae fafa ater «oma«ey(Raaoaoresal a a Refs A Whar vielferernar |)I, orate &fea, wig sikBISGMoT WAM oa/ are |I, ofedARBort & wer onaarea wd cadet daewattsRays AtIV. wh cor S wt 8 wakaota Rats S eer vd te Bd a ¥ wadsV. aftartona af& dar Aon BouFsaldem ae) ahwaad @ wawieRes weSTARGelarefaferaar waaay |

VI. Soe ae iy Fares 8 area Fore fer sitar oreralat aaiter &oinkGAR aesfryTW ell

VIL. Sra ae are fafoorn / wor 8ae wAT—ayfasma Wea Gan B| (Seams fee)

RAJCOMP INFO SERVICES Policy 18-19 of 17

aNaeTTbe

wae eRe Breer area &feSuef Pere wn rare Awee teat reroe sft araPra

sr & ae yoferar euwesane yA ont toe awe Per gear tar A aNA er re ora PHT

ator a ar & ort yetae fer ara BI

Sarnaa SKTMeR

WgaeaA aOl

feare:—

Bap:—wear

sgenftre ren caren & fos GuRTaRTTGA fay ET EI

cemfra Prar cra BAA BN / SATA /GO / GOneers aada 4 ga orate 4

ROMA SVESAB TATA neces J) HoarPTAA FTHARMGATT


of 17

Appendix 5

(1.1.2004 waGeet owerPyar over gywise or, fer. crage wefan are eT ATA)

roaahrvaoraeredt Pr fart rervenferr Afsaerr ifr wactersereBINTPothwawa, al ue soa fear oat z |)

1. Wf or AA(Name ofPatient)

2. afta afar or am

(Insured Employees)

3. Wh o otal GF wer(Relation of patient with insured)

4. stRuca A acl et or fearn(Date of Admission in Hospital)

5. wanta worera 4fafa fete

(Date of appointment in Rajcomp, Jaipur)

6. atat or fer

(Department of Employees)

7. Heatoaa

(Pay scale of Employees)

38. Healwr Vative Ao

(NPS No. of Employees)

g. Star ATT GIT GT SATE AO aecnnetnttnrcnenrnesnntrnni

(1D No. issued by SI & PF deptt.)

40. aeFaTr aT SC./AVE FO neesceenseennntennnnetsssseennsnennnesnnnts

(Tel. /Mobile No. of Employees)

qq. arta SA TS eesseeenneenneetnsnennnnnnnunnnennnntnnnty

(E-mail address of Employees)

42. AAT HT TA TAT ananssnnnnnnnnnnnsnnnnnnnnnnnnnnnnnnnnnnnnnnnnnssnss

(Permanent address of the Employees) cecsssscuceseneeseeceaesesessseceeeseneegeseenseeeasy


0f17 |) |=

3x-~-9)

=k

4

u\Hi=

Weqete

Vly

ii:F&c:3a

153

ay

y)

}My

G3

ie

U4

rd=

.ee

»iyoh

3G

0|r

Y,

(4

iLi

Iv

bii—

Whte

|[2

vy

ie,

a (

IWitt

i)

qd

fiyry

§

be’m

N\GY

(4

Is,8

\N

I"ops

4)w

ft7

|b

ree

(Uaoa

ml

es

1¥

G

NCp.

vtAw

(ds

Vy

iy

—.

oP

qe

Ie

%me

;a

‘it

4G

:Kee

le2.

ee

ehp

={He

lu>

(Erok

4a

pey¥

uip

7ty

NWpe

Weofe

Yann

Z:

tlafa

xvo

ae

fy

afta, worery gepyuta wi fet, TAR - SIPF - Government of ...

Documents

Transcript of afta, worery gepyuta wi fet, TAR - SIPF - Government of ...