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RAJASTHAN HOUSING BOARD, JATPURPOLICY 19:20Pano8of18

COVERAGE [ILLUSTRATIVE]1.

2,

The policy holder Rajasthan Housing Board, Jaipur Employees shall be entitled to indoor treatment in all Government hospitals, GovernmentApproved private Hospitals outside the State of Rajasthan, Government approved private hospitals within the State of RajasthanThe policy holder Rajasthan Housing Board, Jaipur Employees and his family members shall be entitled to reimbursementofcost of medicines,tests/investigations (carried out in Government hospital and/or in a private institution on the recommendationofthe treating doctor), cost of implantsimplanted into the body of the patient and any payment made to the Government hospital/concerned Medicare Relief Society for all types ofdiscases/treatments taken as indoor patient in a Government hospital.For the indoor treatment taken in approved private hospital within the State and approved hospitals outside the State Rajasthan: the policy holderRajasthan Housing Board, Jaipur Employees and his family members shall be entitled for reimbursement of following expenses:-A) Room, Boarding, Expenses charged by the Hospital/nursing homeB) Nursing Expenses.C) Surgeon, Anaesthetist, Medical Practitioners, Consultants and Specialists feesD) Anaesthesia, Blood, Oxygen, Operation Theatre charges, surgical appliances, Medicines & Drugs, Diagnostic Materials and X-ray, Dialysis,Chemotherapy, Radiotherapy, cost of Pacemaker, Artificial Limbs and cost of organs and similar expenses.In caseof deathofinsured during policy period the names of family members to be continued till expiryof the policy.

Entitlement category for boarding/accommodation in the Hospital :-Category Pay Scale* Entitlement in Govt, | Entitlement in Approved | Maximum ceiling of

Hospital Private Hospital Boarding/Accommodation Charges as

per CGHS Package RatesA Rs. 64000/- & above Deluxe Private Ward Rs. 3000/- per dayB Rs. 36000/- and above but | Cottage Semi Private Ward Rs. 2000/- per day

less than Rs. 64000/-Cc Below Rs. 36000/- General Ward General Ward Rs, 1000/- per day * Pay scale means basic pay (including grade pay) /fixed remuneration

Note: Actual boarding / accommodation charges of hospital rate shall be applicable but these charges can not be more than CGHS packages rates,indicated as above!Ifinsured takes treatment in higher cate;: gory other than his entitlement, the reimbursementof costof treatment will be limited to his category as prevalentin the hospital.

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The GIF shall not be liable to make any paywith or in respect of:Injury/disease directlydeclared or not),Circumcision unless necessaor change of life or cosmetiany illness.Cost of Spectacles and contact lenses, hearing aidsDental treatment or surgeryofany kind unless requiring hospitalization due to an incident. . .Convalescence, veneral debility, run-down condition or rest cure, congenital extemal disease or defects or anomalies, intentionalself injury and use ofintoxication druys/alcohol/poisonous substances/addicitions.All expenses arising out of any condition directly or indirectly cased to or associated with Human T-Cell Lymph tropic Virus Type II (HTLB-III) orLymphadinopathy Associated Virus (LAV) or the Munts Derivative or Variation Deficiency Syndrome or any syndrome or condition ofa similar kindcommonly referred toas AIDS. |Charges incurred at Hospital or Nursing Homeincidental to the diagnosis and treatment ofHospital/Nursing Home.Expenses on vitamins and tonics unless forming partoftreatment for injury or diseases as certified by the attending physician,Injury or Disease directly or indirectly caused by or contributed to by nuclear weapon / materials.Pre existing disease of Employees and his/her dependents (as per section 3.10) shall be covered under this scheme.In such situations in which there are no urgencyof hospitalization and treatment can be given at home.

ment under this policy in respect of any expenses whatsoever incurred by any Insured person in connection

or indirectly caused by or arising from or attributable to invasion, Act of Foreign enemy, War like operations (whether war be

ry for treatment ofa disease not excluded hereunder or as may be necessitated due to an accident, vaccinationor inoculation:¢ or aesthetic treatment of any description, plastic surgery other than as may be necessitated due to an accident or as a part of

primarily for diagnosis X- ray or Laboratory examinations or other diagnostic studies not consistent with orPositive existence of presence of any ailment, sickness or injury, for which confinement is required at a

ONS:

Every notice or communication to be given or made under this Pol icy shall be delivered in writing at the address of the TPA/GIF office.Upon the happenit:g of any event which may give rise to a claim under this Policy notice with full particulars shall be sent to the TPAcase of emergency Hospitalization within a period of 24 hours from the timeof Hospitalization.All supporting documents relating to the claim must be filed with TPA/GIFwithin a period of 90 days from the dateof discharge from the hospital. In caseof post-hospitalization, treatment (limited to 45 days), all claim documents should be submitted within 90 days after completionof such treatment.Note : Waiverofthis conditions may considered in extreme cases of hardship where it is proved to the satisfaction of the GIF that under thecircumstance in which the insured was placed it was not Possible for him or any other person to give such notice or file claim with the prescribedtime limit. In such cases Assistant/Deputy/Joint Director can waive up to 6 month delay and Additional Director can waive 6 to 12 month delay,while the delay of 12 to 24 month can be waived by Sr. Additional Director. In any condition no such claim shall be entertained after 2 years.The Insured Person shall obtain and fumish the TPA/GIFwith all original bills, receipts and other documents upon which a claim is based and shall alsogive such additional information and assistance as the TPA/GIF/TPA/GIFmay require in dealing with the claim.Any medical practitioner authorized by the TPA/GIF shall be allowed to examine the Insured Person in case of any alleged injury or diseaserequiringHospitalization when and so often as the same may reasonably be required on behalfofthe TPA/GIFThe GIF shall not be liable to make any payment(s) under this policy in respectof any claim(s) if such claim be in any manner fraudulent or supported byany fraudulent means or device whether by the Insured Person or by any other person acting on his behalf.Ifat the time when any claim arises under this Policy, there is in existence any other insuranceIndia Cancer Society), whether it be effected by or on behalfofany Insured Person in Tespect 0liability, compensation , costs or expenses, the GIF shall not be liable to pay or contribute more than its ratable proportion of any loss, liability,compensation costs or expenses. The benefits under this Policy shall be in excess of the benefits available under Cancer Insurance PolicyThe Policy may be renewed annually by mutual consent. The GIF shall not however be bound to give notice that it is due for renewal and the GIF mayat 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 shallrefund to the insured a pro-rata premium for unexpired Period of Insurance. The GIF shall however, remain liable for any claim, which arose prior to thedate 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 rateonly provided no claim has occurred up to the dateofcancellation.If the TPA, as per terms and conditionsofthe policy or the GIF shall disclaim liabiliwithin 12 calendar months from the date or receiptof the notice of such disclaimer nand intends to recover his claim form the TPA/GIF then the claim shall for allrecoverable hereunder.Cash less facility would be extended to the insured as per terms & conditionsofthe policy.Insured(s) Person shall show their identity to the empanelled hospitals and fill up a prescribed form at the time of admission to take treatment at CGHSrates/packages. Forms are available at the reception counter of all empanelled hospitals, (Appendix-5). If an insured does not show identity and takestreatment without filling prescribed form then it is possible that hospital may charge their actual rates. In such cases GIF shall reimburse only on CGHSrates/ packages, difference amount shall be borne by the insured.

immediately and in

(other than Cancer Insurance Policy in collaboration withf whom the claim may have arisen covering the same loss.

ty to the Insured for any claim hereunder andifthe Insured shall nototify the TPA/GIF in writing that he does not accept such disclaimer

purposes be deemed to have been abandoned and shall not thereafter be

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RAJASTHAN HOUSING BOARD, JAIPURPOLICY 19-20

ASo,

GOVERNMENTOF RAJASTHANSTATE INSURANCE AND PROVIDENT FUND DEPARTMENT. (GENERAL INSURANCE FUND)

‘D’ BLOCK, VITTA BHAWAN, JANPATH, JAIPURemail: add.medi.sipt@rajasthan.gov.in Phone : 014 1-2740252, 2740219, Pax: O141-2740292www,siphrajasthan.pov.in

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GROUP MEDICLAIM INSURANCE POLICY(Rajasthan Housing Board, Jaipur)

(16.04-2019 -15.04.2020)WHEREAS the insured designed in the Schedule hereto has by a proposal and declaration dated asstated in the Schedule which shall be the basis of this Contract and is deemed to be incorporated hasapplied to GENERAL INSURANCE FUND (herein-afler called the GIF) for the insurance hereinafterset forth in respect ofEmployees/Members (including their eligible family members) named in theSchedule hereto (hereinafter called the INSURED PERSON ) and has paid premium as considerationfor such insurance.

NOW THIS POLICY WITNESSES that subject to the terms, conditions, exclusions and definitionscontained herein or endorsed, or otherwise expressed herein’ the GIF undertakes that if during theperiod stated in the Schedule or during the continuance of this policy by renewal any insuredperson shall contract any disease or suffer from any illness (herein afler called DISEASE) or sustain anybodily injury through accident(hereinafier called INJURY) andif such disease(s) or injury/injuries shallbe required. Any such insured person, upon the advice of a duly qualified Physician/MedicalSpecialist/Medical Practitioner (hereinafter called MEDICAL PRACTITIONER) or ofa duly qualifiedSurgeon(hereinafter called SURGEON) to incur hospitalization expenses for medical/surgical treatmentat any Nursing Home/Hospital in Rajasthan as herein defined (hereinafter called HOSPITAL) as aninpatient, the GIF will pay through TPA/GIF to the Hospital/Nursing Home or the Insured Person theamount of such expenses as are reasonably and necessarily incurred in respect thereof by or on behalf ofsuch Insured Person but not exceeding the Sum Insured in aggregate in any one period of insurancestated in the schedule hereto,

l. In the event of any claim/s becoming admissible under this scheme, the GIF shall makepayment(s) through TPA to the Hospital/Nursing Home or the insured person the amount ofsuch expenses as would fall under different heads mentioned below and as are reasonably andnecessarily incurred thereof by or on behalf of such Insured Person, but not exceeding the SumInsured in aggregate mentioned in the schedule hereto.(A) — Rooin, Boarding and Nursing Expenses as provided by the Hospital/Nursing Home as

per entitlementoftheemployee 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 oforgans and similar expenses. (N.B.: GIF’s Liability in respect of all claims admittedduring the periodof insurance shall not exceed the Sum Insured per family as mentionedin the schedule)

2. DEFINITIONS:

2.1 HOSPITAL means any registered institution in or outside the state Rajasthanestablished for indoor care and treatment ofdiseases and injuries and which are :-(a) All the Government hospitals in the State of Rajasthan "Including Ayush

Treatment".(b) The Hospitals outside the state of Rajasthan which have been approved by the

Govt. of Rajasthan (Appendix -1)

BAT RAJASTHAN HOUSING BOARD, JAIPUR POLICY 19.20

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212

divatn sayityle oyithy fay Uadpegt hikes sameons ol tfe) rivals Singtel, with in Vaesban J Wy aurovdl‘Vajathian CIV Seren ec Ktendoree : :

mene ti wink with SNS on COONS Pukage Yates ( Appendix-2 ) Thesejnivate Sungitals Which are added in approved Nist from time to time by thCree ON Vajanhan and yive aceptance to work with GIF on CGHachage Mates, obvall ali be automatically anpanelled under the scheme.

(N) Wa private Senpital, which %% approved for treatment of State Govermentumnplayees under Rajasthan Civil Services Medical Attendance Rules 2013. hesNON LIVEN accepnaticg to GISOffice to provide it’s services on CGHS packages/rates and an insured has takenHeatnicnt in such henpital, then he/she shall be paid on CGHS package .difference amount shall be borne by him/herself(Le. insured). ;

‘Surgleal Operation’ means manual and/or operative procedures for correction ofdeformities and defects, repair of injuries, diagnosis and cure of diseases, relief ofsuffering and prolongation oflife,

--Mxpenses on hospitalisation for minimum period of 24 hours are onlyadmissible.However, this time limit is not applied to specific treatments. ie. Dialysis.Chemotherapy, Radiotherapy, Vye Surgery, Dental Surgery in case of accidents.Lihitripsy (Kidney Stone removal), D&C, Tonsillectomy, Hysterectomy, CoronaryAngloplasty, Coronary Angiography, Surgery of Gall Bladder, Pancreas & Bileduct, Genital Surgery, Surgery of Nose, Surgery of Throat, Surgery of Appendics,Surgery of Urinary System, Arthroscopic Knee Surgery, Laparoscopic, TherapeuticSurgeries, Any surgery under Anesthesia, Treatment of Fractures/ Dislocationexcluding hairline fracture, Contracture releases and minor reconstructiveProcedures of limbs which otherwise require hospitalization taken in the approvedHospital/Nursing Home and the Insured is discharged on the same day, the treatment willhe considered to be taken under hospitalisation Benefit. This condition will also notapply in case ofstay in hospital of less than 24 hours provided Explanation the treatmentis such that it, necessitates hospitalisation and the procedure involves specialisedinfrastructural facilities available in hospitals and due to technological advancementhospitalisation is required for Jess than 24 hours only. It would be certified by concerningDoctor under whom treatment is given and weighted by TPA.CGS packages shall be applicable in Rajasthan, as laid down by CGHS for Jaipur Cityand it shall be applicable (exclusive of policy clause 6.3, 9.1 and 9.2) as laid down byCGUS for various places in India. The bed charges shall be paid according to thecategory Of employee. the diseases/ Investigation for which no Packages rate ismentioned in CGHS packages rate then it will be paid according to The "Civil Servicesmedical attendance rules 2013" of Governmentof Rajasthan..

ANYONE ILLNESS 3-Any one illness will be deemed to mean continuous period of illness and it includes relapsewithin 45 days from the date ofdischarge from the Hospital/Nursing Home where treatment hasbeen taken,, Occurrence of the same illness after a lapse of 45 days as stated above will beconsidered as fresh illness for the purposeof this policy.3

3.2

33

PRE-HOSPITALISATION :-Relevant medical expenses incurred during period up to 30 days prior tohospitalisationon discase/ilIness/injury sustained will be considered as partof claim.POST HOSPITALISATION :-Relevant medical expenses incurred during period up to 45 days after hospitalisation ondiscase/illness/injury sustained will be considered as part of claims.MEDICAL PRACTITIONER means a person who holds a degree/diploma of arecognized institution and is registered Medical Council of respective State and stream.The Medical Practitioner would include physician, specialist and surgeon.

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3.10

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(b)3.11

QUALIFIED NURSE means a person who holds a certificate of a recognized NursingCouncil and who is employed on recommendationofthe attending Medical Practitioner,MATERNITY EXPENSES BENEFIT means treatment taken in Hospital/Nursing Homearising 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 InsuranceRegulatory and Development Authority, and is engaged, for a fee or remuneration, by whatevername called as may be specified in the agreement with the GIF, for the provision of healthservices.CASHLESS FACILITY-Cashless facility would be extended to the Insured in the privatenetworking Hospitals for the critical ailments (Means:- i. Coronary Artery Surgeryii.Cancer iii.Renal Failure i.e. failure of both the kidneys iv. Stroke v. MultipleSclerosis vi. Meningitis vii. Major Organ transplants like Heart, Kidney, Liver, Lung,Pancreas or Bone marrow Transplantation) . However, The TPA would decide themerit 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 denial of treatment from concerned hospital &reimbursement thereof.CLAIM INTIMATION TO TPA - It is required by the employees that the claims arising inprivate hospitals should be intimated by cashless request form/ claim intimation form,available in the hospital, to the TPA positively. If the claim intimation does not reach theTPA the same day when the patient is admitted to the hospital, then the employee shallnot be entitled for re-imbursement.Claim Intimation to TPA in case of Government Hospitals — It is not required by theemployees that the claim(s) arising in Govt. Hospitals should be intimated in writing tothe concerned TPA/GIF, on the same day patient is admitted in the hospital.DEPENDENT FAMILY — The ‘family’ of the employee shall include the employee, his/herSpou-e, not more than two dependent children upto 21 years of age and dependent parents. 'Theparents shall be:regarded as wholly dependent upon the Rajasthan Housing Board, JaipurEmployee, if-

they normally reside with the Rajasthan Housing Board, Jaipur Employee at the place ofhis/her duty, andtheir total monthly income from all sources does not exceed Rs.2000/- per month,FAMILY DETAIL — Every newly recruited employee shall have to provide details of thefamily & photographs for preparing the database & for issuing identity cards in theprescribed form(Appendix 3) immediately after joining the service otherwisebill of the designated month will not be passed by the Treasury Officer,Explanation — Details of the family means : Name, Designation, DDO, DateGovernment Service, Names of Family members, Age, Pay/ Pay Scale/Stipend.

his salary

ofjoining

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

EXCLUSIONS: —:The GIF shall not be liable to make any payment under thiswhatsoever incurred by any Insured person in connection with or in respect of:5.15.2

3.3

5.45.5

policy in respect ofany expenses

Diagnostics/ Investigations unless followed by indoor treatment of 24 Hours,Injury/disease directly or indirectly caused by or arising from or attributable to invasion,Act of Foreign enemy, War like operations (whether war be declared or not).Circumcision unless necessary for treatment of a disease not excluded hereunder or asmay be necessitated due to an accident, vaccination or inoculation or change of life orcosmetic or aesthetic treatment of any description, plastic surgery other than as may benecessitated due to an accident or asa partofany illness.Cost of Spectacles and contact lenses, hearing aidsDental treatment or surgery of any kind unless requiring hospitalisation due to anincident.

RAJASTHAN HOUSING BOARD, JAIPURPOLICY 19-20Pave 3of 18

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\ A expanses aabsigy OWE END CEUTATMA HOEY ve HAE CANAAAEE HY AE adaenettinadWLAN Traian POSTE Exar tage Vir Type THE QHEPE TEED) ae Vvavyyatnanet liveay nantlyASSos hE VSCE AV 8 the MAES DRE ative at Vaiedaatlany Daath tanto SON WMATA ANAS (ayAY NVTRT IIE OP CTEIOU OE STATUE Mintel earnly peter fabs VIDS,

SS Charges Tour at Clogpitial oe Nueatig Towne peinaedly Rae tlagtmoda, N WYLaboratory eraariinations ob atten dliagnoastle station mat contort AV TN ae UOTE AyWe dhaanersiy and Crtntent ofpositive orivtemoe at paewenee OC iY aL, MWKMOOL OPWEY, Re VERT OUT OMOHE fs pada aE ay Elagpiial Niet Hane,

SO Bypousos on vitaunndanss rteties aint tavern aneatons Can eindinar patel a ANAANNIONE HOE TUTE attiscrnsos as COUTHERAT DY tho attending ply ariel,

SAU Tayfuey or Dihsoade tirortly ae Tttineetly aammisedd OY oe CAMNTET MEER FEY HOTA WeNPUEWartenlals,

SUL We existlog disoase ot employes andl bis hoe dependents WiLL Be eawened under ibyshane

SAS UW surely Situations He vvtiet thon wee no ugeHey Of HaxplHisatlon aid Hettaent oan beSAVER Aho aval whieh is not portal to seotlan Id

CONDULIONS :at Bveny notion or commotion fy De alver ae anaes vider dbs Patlow atall be cetivened ti

AUTH AL Tho adtdoss AP ENE PRA GIE athlona2 Wire prea poavadtyte tnddoe this Baton shall be pall (i addyattees Nov needy) ie Peerndiny AhatE he

Valid oxeopt on the ottlodal Ruri at the GUE signet Oy a lity authiorlaed attiokal at de Gleb theMae porraren tot peoUndHHTe at he obhseey ane ancl CYL TONE AE ENE GREENS, pean delat, CeMnnedLnaE Crdtorsemtents of this pation Oy the Tastinad Penson Tse Rie ae they betate fa any thing fa beatone ot comption WHEN by The Tasted Dorset shall be a condition precedtoat ta any HAbiliy at iheQTE to take any payment andlor (iis Botley, No Wabver at any Ferny, poarbalatia, Candi lane aedetorrements OF TNS potloy stall bo vali annatoos enact Ue averted ane slamat Ay aie aunetiael naloticlal ot the GUE,

Os We eaise Of grave crereney Ute TH thnttontng hase Coronary Arter y Supaety, VaseuharSunxery, Hodihins Disease Acute Recension of artre more (hin ts Aeute My aeurtttiatInrerton Aeute Phenuamuitis,AcuteRespiratory Divtressay Canon, Borat Badline boy dainoP bate the Kidneys, Starkey Multiple Selonasis, Mentigttis Malo Onan Vivi tinie UkeKidneys Lungs Panonas, Heart Ehvenor Hone Marna, Abeltentss Dotlvery, Publ Moanaand Related Complication, Swine Bhi Dente Bover Test Appondlodiox, Damenaititha inatedEnyplayee fas baker treatiienl als titooe pallor it a non ernpamo tort pedvate hoprdtal at te lineOF chai submission the erenere Matin at hospital vation hae to be oxtabtatoat Wy ay verityttCAppendineo) of the employee supported by ae cortithoate at the Vsti lawton Chal stat bepaid as por CGUIS prckage Rates of yoneedh wait apte the Tato ann eno,

Ou Tasted shall show thete tdontlty: to the empamettodt tovyttints anal itt Vy preowned Aven ae theTie of adindsston to take treatert aL COEIS ttos paiokaess Bani ate avatlable at Wooeptlancounters of all empanetlod hoxpthals GAppendlyea dy Tan tisieed PETRY hoe Wet vlanhis her identity wnet ies Hastert a TOU TH proserthodt taeme then Ut bi Pventvto Hat HarpttielMay charge their aerial rites. Te stieh eases, GEE what petarbuene (TY OT CATLIN Fate package,diNerenes aman shall be bacne by the hasan,

0.5 ATL supporting documents roliting (0 the elim must bo (ed wtih beat actin 00 lays thaythe chite af discharge thom the hoxptal tease at Wortehoxpttaliaatlons Cheatinent Ctted ta dsdays all elaine documents shoul be submitted witht OO diya ater wvnptotlaty ot suettreatment,

6.6 Nhe Tasted Person stall obratiy and endsh the Tecate with all orginal bithy WElpoyVerifeations and other documents upon whtel a okie be based amd abatl ato why wichcuctaditicnnrel Tiverton ave osbsteiee ay Ce ERATE nana vegan Uh toatl ttle the etal,

6.7 Any medical practitioner ar an ottiowe authorised by the He vate tall be allowedt ta examine thensuired Person Ti case of any: atlopod tilary ar disease coqulelins Hospliatbavtlan when andl seoften as the same may teasonably be requlbed an bela lot the EPA

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The GIF shall nof be liable to make any payment(s) under this policy in respect of any claim(s) ifsuch claim be found in any manner fraudulent or supported by any fraudulent means or devicewhether 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 beeffected by or on behalf of any Insured Person in respect of whom the claim may have arisencovering the same loss, liability, compensation, costs or expenses, the GIF shall not be liable topay or contribute more than its rateable proportion of any loss, liability, compensation costs orexpenses. The benefits under this Policy shall be in excessof the benefits available under CancerInsurance Policy.If and when the Employee has submitted his/her family details to the concerned TPA/GIF andidentity cards have been issued to the insurer, then only he/she shall be entitled for cashlessfacility.The Policy may be renewed by mutual consent. The GIF shall not however be bound to givenotice that it is due for renewal and the GIF may at any time cancel this Policy by sending theInsured 30 days notice by registered letter at the insured’s last known address and in such eventthe GIF shall refund to the insured a pro-rate premium for unexpired Period of Insurance. TheGIF shall however, remain liable for any claim, which arose prior to the date ofcancellation. TheInsured may at any time cancel this Policy and in such event the GIF shall allow refund ofpremium:at GIF’s short period rate only (Table given here below) provided no claim hasoccurred up to the date of cancellation.

PERIOD ON RISK RATE OF PREMIUM TO BE CHARGEDUpto one month 1/4"of the annual rateUpto three months ’% of the annual rateUpto six months %th of the annual rateExceeding six months Full annual rateIn 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 otherquestions be referred to the decisionof a sole arbitrator to be appointed in writing by theparties or if they cannot agree upon a single arbitrator within 30 days of any partyinvoking arbitration, the same shall be referred to a panel of three arbitrators, comprisingof two arbitrators, one to be appointed by each of the parties to the dispute/differenceand the third arbitrator to be appointed by such two arbitrators and arbitration shall beconducted under and in accordance with the provisions of the Arbitration andConciliation Act, 1996.

It is clearly agreed and understood that no difference or dispute shall be referableto arbitration as herein before provided, if the GIF has disputed or not accepted liabilityunder or in respectofthis Policy.

It is hereby expressly stipulated and declared that it shall be a condition precedentto any right of action or suit upon this policy that award by such arbitrator/arbitrators ofthe amounofthe loss or damage shall be first obtained.If the TPA, as per terms and conditionsofthe policy or the GIF shall disclaim liability tothe insured for any claim hereunder and if the Insured shall not within 12 calendarmonths from the date or receipt of the notice of such disclaimer notify the TPA/GIF inwriting that he does not accept such disclaimer and intends to recover his claim form theTPA/GIF then the claim shall for all purposes be deemed to have been abandoned andshall not thereafter be recoverable hereunder.All medical/surgical treatments under this policy shall have to be taken in approved hospitalsin and outside the state of Rajasthan and admissible claimsthereofshall be payable in Indiancurrency. Payment ofclaim shall be made through TPA/GIF to the Hospital/Nursing Homeor the Insured Person as the case may be. The list of approved hospitals is available at(Appendix 2).In case of deathof insured during policy period then the names of family members to becontinued till expiryofthe policy.

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Cauyny Vay nade — Saditlement in Entitlement in Maximum ceiling ofCorl Mospital | Approved | Boarding/Accommodation

Private Hospital Charges as per CGHS: } ; _ | Package RatesA ¥s, YIN? & VedAure Vrivae Ward | Rs, 3000/- per day

are ____| |Y 4s, WANN Coptrue Semi Privase | Rs. 2000/- per day

wd dre ba Wardhess then Bs, |de bel !Melon ¥s, Goad Ward General Ward | Ks, 1000/- per dayVIP _ |

O56 Vatthement category Sor brayding/aceommodation in the Hospital --

* Vay scale means basic pay Mixed remuneraionShe: Actucl teasding | axsnnmodaion chases of hospital rate shall be applicable but thesecharges can nn be more then CGMS packages rales, indicated as above.Sf invared takes treztrnent in higher category other than entitlement, the reimbursement of costANteainant wil) be made aconding to category as prevalent in the hospital,ONT Vre-existing divcave of coployce and his/her dependents (as per section 3.10) will be

wwe under this xheme.Medical examination of the Rajasthan Housing Board, Jaipur Employee or any memberOShis family shall not be 2 condition for issue of Mediclaim Policy.

659 A Setmale employee can get the Mediclaim coverage cither for her parents or Parents inlaw in cave they are dependent on her and their monthly income is less than Rs. 2000/-and they are residing with her generally.

6.20 the policy has been issued to D1.0.. Rajasthan Housing Board, Jaipur. It is requiredfrom D.0.0. of Rajanhan Housing Board, Jaipurthat they would brought into notice ofall the newly recruited employees regarding terms & conditions of the policy. It is alsocapected that every newly recruited employee must have gone through the terms &conditions of the policy.

6.2) This Policy is available at website: www.sipfrajasthan.gov.in

6NG

HIGH CLAIMS RATIO LOADING (MALUS)She wtal premium payable at the time of renewal of the Group Policy will be loaded at thefNowing xale depending upon the incurred claims ratio for the entire group insured under theGroup Mediclaim Insurance Policy for the preceding three completed years excluding the yearimmediately preceding the date of renewal, where the Group Mediclaim Policy has not been inforce Sor the three completed years, such shorter periods of completed years, excluding the yearimmediately preceding the date ofrenewal will be taken in to account,

Incurred Claim ratio under the group policy LoadingBetween 70% and 100% 25%Between JOI% and 25% 55%Between 126% and 150% 90%Between 151% and 175% 120%Between $76 and 200 150%Over 200% Cover to be reviewed

High Claim loading (Malus) will be applicable to the Premium at renewal of the Policydepending on the incurred claims Ratio for the entire Group Insured.Incurred claim would mean claims paid plus claims outstanding in respect of the entiregroup insured under the policy during the relevant period.

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- : (Wherever applicable)The maximum benefit allowable under this clause will be up to Rs. 50,000/- per familyper year restricted to two living children. This amount is including sum-assured of Rs.3,00,000 per family per annum,The Maternity benefits under this policy are categorized into three :1 Maximum limit under normal delivery : Rs. 10000/-I Maximum limit under caesarean delivery: Rs. 20000/-I Maximum limit under delivery related

complications (Including child care) : Rs. 50000/-Special conditions applicable to Maternity expenses Benefit Extension:I These Benefits are admissible only if the expenses are incurred inHospital/Nursing Home as in-patients in empanelled Hospital.I A waiting period of9months is not applicable for payment of any claim relatingto normal delivery or caesarean section or abdominal operation for extra uterinePregnancy. The waiting period may be relaxed only in case of delivery,miscarriage or abortion induced by accident or other medical emergency.Il Claim im respect of delivery for only first two children and/or operationsassociated therewith will be considered in respect of any one Insured Personcovered under the policy or any renewal thereof. Those Insured Persons who arealready having two or more living children will not be eligible for this benefit.IV Expenses incurred in connection with voluntary medical termination ofpregnancy during the first 12 weeks from the dateof conception are not covered.Vv Pre-natal and post-natal expenses are not covered unless admitted inHospital/Nursing Home and treatment is taken there.

VI Mother and Newly born child would be single unit for 3 days from the dateof delivery.VII Indoor Treatment of Sterility/ Infertility shall be payable up to the limit of 20,000/- in apolicy year.

10 PAYMENT OF CLAIM10.1 The insured shall submit the claim:form through DDO to the TPA in theprescribed

Performa (Appendix 4).For Re-imbursement photo will be pasted by the concerned employee (if he doesn’tpossess the identity card) which will be duly verified by the treating doctor/ DDO so asto confirm the identity of the Patient.Cashless facility will not be provided if the identity cards have not been obtained by thepolicy holder.Payment of claim shall be made through TPA/GIF to the Hospital or to the InsuredPerson as the case may be normally within 30 days from the date of receipt of completedclaim proposals by the TPA.

RAJASTHAN HOUSING BOARD, JAIPURPOLICY 19-20. Pave 7 of 18

Appendix; |

List of Referral Hospitals approved by the State Government fora ' treatment outside Rajasthan

All India Institute of Medical Sciences, New Delhi.

i 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. Rajcev Gandhi Cancer dnstitute and Research Centre, Delhi.

8. Tata Memorial Hospital, Bombay.

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

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

I. 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).

14, Global Hospital, Chennai (Liver Transplant).

15, Sterling Hostpital, Ahmedabad.

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(Updated on 08-05-2019)

Public Private Partnership Haspital

S No. Name of Hospital Order Number Orderpate | ~1 {Metro Manas Arogya Sadan Heart Care and Multi Speciality Hospital, Jalpur L6(4)FD/RULES/2003/1, O/ 04-44

' Multispeclalty Hospital —S.No. Name of Hospital Order Number Order Date Valid Upto

1 |Agarwal Hospital, Tonk E.A(2)FD(Nules)2013 Pull aO2-1A woe2 |Amar Medical & Research Centre, Kiran Path, Mansarovar, Jaipur £.6(2)£D(Nules)2016 Prd 4.07 201K {0h JO3 [Apex Hospital Pvt. Ltd., Malviya Nagar, Jalpur £.6(2)(D(fules)/201PUI 049 04 14 aud ys4 |Barala Hosptial and Research Centre, Chomu, Jaipur £.6(2)FD/Rules/2016 Hy 0h 1b 170hno ”5 |Bhandari Hospital and Research Centre, Jaipur £.0(2)FD(Mules)/2013 Pull ood il Qu04 146 {Bharat Vikas Parishad Hospital & Research Centre, Kota C.6(2)PD/RULES/2013 PT-Il 1 02-1h ayo A7 |Bindal Hospital, Sikar POW Difules\/201401 | 07 Th pin8 |CKRD Memorial Hospital & Research Institute, Jhunjhunu £.6(2)£D/Rules/2016 Part OWOLTH aralay

9 |Dhanvantari Hospital and Rese: rch Centre, Jalpur £.6(2))D/Rules/2016 10616 0b 71 .

10 [Dhukia Hospital, Jhunjhnu ’ Loip(hules)2013 Pol 02-14 wow11 |r. Choudhary Hospital and Medical Research Centre Pvt, Ltd., Udaipur L6(2)ED( Rules)2014 PLL 2002-14 woe 012. |G.P. Shekhwati Hospital and ResearchCentre, Jaipur £.6(2)FD(Rules)/2016PTI OO10-16 OHO AL ~

13. [GBH American Hospital, Udaipur L.6(2)(D(Rules)/2013PCH Ov 00-14 onM14 |Geetanjali Medical College and Hospital, Udaipur £.6(2)FD(Rules)/201PLA ov0o 14 quauty

15 |Getwell Hospital and Research Centre, Sikar £.0(2) D/Rules/2016 PL POUT ND)16 |Gheesibai Memorial Mittal Hospital and Reasearch Centre, Ajmer £.6(2)FD(Rules)/201627-1 OO 016 On at -

17 |Goyal Hospital & Research Centre, Jodhpur £.6(2)FD/Rules/2014Ptll WO wb 20-18 |Harish Hospital Pvt. Ltd., Alwar E.6(2)£D(Rules)2013 Prt 2002-14 02 20

19 [Jaipur Hospital, Jaipur £.6(2)FD(Rules)/2013PUI OW OTA ov0od9

20 Jaipur National University Institute of Medical Sciences and research Centre, £.6(2)ED/Nules/2016 PLlll 200017 NOD?

21 = |Jaiswal Hospital & Neuro Institute, Kota £.0(2)FD(Mules)/2019? UL QO00 14 Oo 19

22. |Kailash Hospital, Behror (Alwar) £.6(2)FD(fules)/20162 1-1 O26 Olds At

23 |Kalpana Nursing Home Pvt. Ltd Udaipur L.6(2)FD(Aules)/20132 tI OO 09-14 00-19

24 {Kota Heart Institute, Kota ' EO(2)ED(Nules/201 Pcl 09.0914 a)25 |Krishana Hospital, Bhilwara £.0(2)FD/Rules/2016 10006 1 0001

26 |Madhur Hospital, Dausa £.6(2)FD (ules)2014 Pull 20.0214 19.022027 |Mahatma Gandhi Medical College & Hospital, Jalpur LG(2)/ D(Mules)/201 30H On 1A Oo 00 18

28 |MarudharHospital Jaipur L.0(2)1 D/Nules/2016 106-16 120021

29 |Medipulse Hospital, Jodhpur L.O(2)0D/Nules/2016 WV O616 1200-7130 |Mittal Hospital, Alwar E.(2) D(Mules)/20100 Ell Ob VO 1O OW OAL31 |Narayana Multispecialty Hospital, Jalpur E.G(2)ED(RULES)2013 PTI 27 01-16 20019)

32 |Pacific Medical College and Hospital, Udaipur LO(2)ED/Rules/2016 200% 17 Oh 22

33 |Porwal Hospital, Bhilwara LiO(2)/ D( Rules)/2013PUI sOOF14 2907-20 \34 |Ramsnehi Hospital and Research Centre, Bhilwara LO(2)ED/NULLS/2013 PEL 10-0214 09.0220

35 |Ranthambore Sevika Hospital, Sawai Madhopur LOl2}ED(Rulos)2013 Pelt 200214 IOP 2036 [Ravindra Hospital, Jnunjhunu LO(2)ED/Nules/2016 Cactll OOO 1022 / /37 |S.B. Mittal Memorial Heart and Critical Care Hospital, Sikar LO(2)FD(Mules)2019 PLA 20 0214 19.02 wy ' r

38 |S.N. Super Speciality Hospital Pvt, Ltd., Sri Ganganagar £.6(2)f D/Mules/2018 aoLd9 ALOLR \

39 |S.R. Kalla Memorial Gastro & General Hospital, Jalpur CG(2)FD(Rules)2013 [tell 20.0214 1900-20 Oe40 [Sania Hospital, Alwar LO(2)CD(Kules)2013Pull 200214 WOW41 |Sh. K.M. Memorial Jain Heart and General Hospital, Sikar (C.0(2)CD(WULES)2013 PLL 270116 ON42 |Shree Siddhi Vinayak Hospital, Bhilwara LO(2EB(WULES}2013 ELI A701 OL at43 |Shri Krishan Hospital, Lalsot Road, Dausa LOl(2}FD(Nuten)/2016 270217 20222

page 11 0f 18

WAFANTITAN HOUSING HOATDTATPUR POLICY 1920

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(AM, GeFa Vite) (4M, Fe Aa Vier)

RAJASTHAN HOUSING BOARD, JAIPURPOLICY 19-20