Sbi New Health InsurSBI NEW HEALTH INSURANCE SCHEMEance Scheme

7/23/2019 Sbi New Health InsurSBI NEW HEALTH INSURANCE SCHEMEance Scheme

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NEW HEALTH INSURANCE SCHEME

The Executive Committee of Central Board of the Ban in it! meetin"held on #$th %ecem&er' ()#* ha! a++roved t,o tailor-made .amil/

.loater 0rou+ Health In!urance 1olicie! 21olic/ 3A4 5 1olic/ 3B46to,ard! medical &enefit! of retired em+lo/ee!7 We furni!h &elo,'

an extract of the !cheme7 We have hi"hli"hted the im+ortant

+rovi!ion! in red7

Scheme details for the rst year will be as under:

0rou+ Mediclaim 1olic/ 8A8

2R!7 in lac!6

REMBS

1lan!

A 5

A#

B 5

B#

C 5

C#

% 5

%#

E . 0 H

REMBS

Limit!

2R!76

(7)) 97)) :7)) *7)) ;7)) #)7)) #*7)) ()7))

No7 of

exi!tin"

Mem&er

!

(:':)

)

<9= $99 9'<$9 9(':<

9

$*; #9< ;<

Ba!ic

Sum

In!ured

#7)) #7)) (7)) (7)) 97)) 97)) :7)) *7))

Cor+ora

te

Buffer

#7)) (7)) (7)) 97)) :7)) ;7)) ##7)) #*7))



Room

Rent>

2R!76

*')))

?-

*')))

?-

*')))

?-

*')))

?-

$')))

?-

;')))?

-

<')))?

-

#(')))

?-

ICU

Rent>

2R!76

;'*))

?-

;'*))

?-

;'*))

?-

;'*))

?-

<')))

?-

#)')))

?-

#(')))

?-

#*')))

?-

Annual

In!uran

ce

+remiu

m +er

famil/

2excludi

n"

Service

Tax 5

S,achh

Bharat

Ce!!6

2in R!76

9':;(

?-

:'<;*

?-

$'9;)

?-

;';$:

?-

<'<($

?-

#(':(9

?-

#*'*(<

?-

#='$9:

?-

> Maximum Ceilin"

Under Policy ‘A’ Total Annual limit (Basic Sum Insured

!or"orate Bu#er$ of a member will not e%ceed the

residual medical Benet limit under e%istin& SBI')BS*

All the e%istin& members of SBI')BS as on +,*-+*.-,/ will be

shifted to the Policy ‘A’ and the "remium will be "aid

annually by the SBI')B Trust to the



Insurance !om"any by debit to ‘SBI')BT 0"eration Account’

maintained at )adame !ama 'oad Branch* The "olicy will

be renewed annually and will continue

till the medical benets to members under the scheme are

fully e%hausted sub1ect to su2ciency of ')BT cor"us*

No em+lo/ee ,ho retire after 9#7#(7()#* ,ill &e admitted to

SBI Retired Em+lo/ee!4 Medical Benefit Scheme7 The/ ,ill have theo+tion to @oin .amil/ .loater 0rou+ Health In!urance 1olic/ 3B4

of United India In!urance Co7 Ltd7 Ho,ever' the em+lo/ee! ,horetire on or &efore 9#7#(7()#* ma/ &e allo,ed to @oin SBIREMBS

,ithin the !ti+ulated time !chedule a! +re!cri&ed in SBI

Retired Em+lo/ee!4 Medical Tru!t 2SBIREMBT6 Rule! and the/ ,ill &e!u&!euentl/ covered &/ 1olic/ 3A47

0rou+ Mediclaim 1olic/ 3B4

It ,ill &e availa&le to future retiree! of the Ban and exi!tin" non

mem&er! of SBIREMBS includin" !+ou!e! of em+lo/ee! ,ho die?died,hile in !ervice7 Thi! +olic/ ,ill cover +ermanent em+lo/ee! of the

Ban' ,ho retire on or after #!t

anuar/' ()#$ ? S+ou!e! ofem+lo/ee! ,ho die ,hile in !ervice on or after #!t anuar/' ()#$ andexi!tin" Non mem&er! of SBIREMBS' their !+ou!e! and di!a&led

child ? children if an/7 There ,ill &e no a"e limit for @oinin" the+olic/7

Survivin" !+ou!e! of decea!ed +ermanent em+lo/ee! ? +en!ioner!

,ill &e allo,ed to @oin the +olic/7

The +olic/ ,ill al!o cover the +re-mer"er retiree! ? !urvivin"

!+ou!e! of +re-mer"er retiree!? decea!ed em+lo/ee! of er!t,hile

State Ban of Saura!htra 2e-SBS6' er!t,hile State Ban of Indore 2e-SBIN6 and e-SBICI

Ho,ever' em+lo/ee! ,ho are ? ,ere di!char"ed ? di!mi!!ed ?

removed ? com+ul!oril/ retired ? terminated from !ervice ,ill not &e

eli"i&le to @oin the +olic/7



The +olic/ ,ill +rovide Sum In!ured' Room rent and ICU rent a!

under for the #!t /ear

Scheme

Sum

In!ured

2R!7 in

lac6

Room

Rent

2Max7

ceilin"6

2R!76

ICU Rent

2Max7

ceilin"6

2R!76

Annual 1remium

+er famil/

2excludin"

Service Tax 5

S,achh Bharat

Ce!!6

2R!76

3A4

3B4

3C4

3%4

A

97)) lac

*')))?-

;'*))?-

*'*;;?-



B

:7)) lac

*')))?-

;'*))?-

;'(=(?-

C

*7)) lac

;'*))?-

<')))?-

<'(=*?-

%

;7*) lac

#*')))?-

#=')))?-

#('$;;?-

E

#)7))

lac

#*')))?-

#=')))?-

#$'<)(?-

.

#*7))

lac

#*')))?-

#=')))?-

(*'9*9?-

0

()7))

#*')))?-

#=')))?-

99'=):?-



lac

H

(*7))

lac

#*')))?-

#=')))?-

:('(**?-

Ne, retiree! ? !+ou!e! of decea!ed em+lo/ee! ,ill &e allo,edto @oin the 1olic/ 3B4 ,ithin three month! from the date

retirement ? death7

1ro!+ective mem&er! can o+t for an/ one of the !cheme! &/

+a/in" the +remium from their o,n !ource!7

Sum In!ured ,ill NDT &e reduced &/ the amount utilied durin"

the current cover +eriod7

Dn next /ear4! rene,al the/ ma/ continue ,ith the !ame

!cheme or chan"e the !cheme &/ +a/in" the a++lica&le

annual in!urance +remium from their o,n !ource!7

Dther im+ortant in!truction!



2a6 Dnetime o+tion !hall &e "iven to eli"i&le +a!t retiree! ?

!urvivin" !+ou!e! of decea!ed em+lo/ee! ? retiree! of

SBI' e-SBS and e-SBIN to @oin the 0rou+ Mediclaim

1olic/-3B4 durin" the +eriod )#7)#7()#$ to 9#7)97()#$7

2&6 Eli"i&le a++licant! ,ho are ,illin" to @oin 0rou+

Mediclaim 1olic/-3B4 are advi!ed to vi!it the 31ortal for SBI

Retired Em+lo/ee!4 and clic on 3Re"i!tration for 0rou+

Mediclaim 1olic/-B4 ,hich ,ill &e availa&le ,7e7f7

)#7)#7()#$ and a++l/ online on or &efore 9#7)97()#$7

2c6 In ca!e the online +roce!! i! not read/ &/ )#7)#7()#$'the eli"i&le a++licant! !hall fill u+ the a++lication formmanuall/ &/ do,nloadin" the !ame from 31en!ioner!4

1ortal4 or +h/!ical collection and!u&mit to the +en!ion+a/in" &ranch alon" ,ith ( late!t @oint +hoto"ra+h!of !elf and the !+ou!e7

2d6 Dnline ? Dffline admi!!ion +roce!! for +re-)#7)#7()#$

retiree!?!+ou!e! of decea!ed em+lo/ee! 5 +en!ioner!!hall remain o+en till 9#!t March' ()#$7 1lea!e note that

the Ban !hall not &e re!+on!i&le for an/ dela/ in recei+t

of the a++lication for ,hat!oever rea!on!7

2e6 Eli"i&le ne, retiree! ? !+ou!e! of decea!ed em+lo/ee!

,ill @oin the 1olic/ 3B4 ,ithin three month! from the date

retirement ? death &/ +a/in" the +remium from their o,n

!ource! on +ro-rata &a!i! 7

2f6 All addition! of mem&er! and famil/ mem&er! ,ould &e

on +a/ment of +remium on +ro-rata &a!i!' In ca!e' !ome

mem&er! @oin the !cheme !ometime after the main ma!ter

+olic/ ha! &een ince+ted' the/ ,ould @oin &/ +a/in" the

+ro-rata +remium and full Sum In!ured ,ill &e availa&le

to the mem&er and hi! ? famil/ till the ex+ir/ of the

+olic/7



2"6 In!urance cover for mem&er! ,ho +a/ the +remium

durin" #!t da/ of the month to #:th da/ of the month

,ill commence from #$th da/ of the month7 Similarl/'

in!urance cover for mem&er! ,ho +a/ the +remium

durin" #*th da/ of the month to the !econd la!t da/ of the

month' ,ill commence from #!t da/ of the next month7

2h6 1remium amount alon" ,ith !ervice tax for the #!t /ear

and !u&!euent rene,al! ,ill &e +aid to the United India

In!urance Co7 Ltd7 &/ de&it to the +en!ion account?other

account 2in ca!e of 1. o+tee of e-SBS' e-SBIN 5 mem&er!

of N1S6 of the a++licant7 The a++licant !hall "ive mandate

? authoriation to thi! effect to the Ban and maintain

!ufficient &alance in the account till the +remium i!

de&ited7

The Annual 1remium +a/a&le i! !u&@ect to chan"e from time to time

a! fixed &/ the In!urance Com+an/ ever/ /ear7

2l6 The term! and condition! of the !cheme and &enefit!

availa&le under the +olic/ are !u&@ect to chan"e from time to time a!

decided &/ the Ban ever/ /ear7

A11LICATIDN .DRM

.DRMAT

Affix coloured @oint

+hoto"ra+h

of the mem&er and!+ou!e



Chief Mana"er 2HR6

State Ban of India'

Fonal office'

GGGGGGGGGGGGGGGGGGGGGGGGGG

%ear Sir'

SUB .amil/ .loater 0rou+ Health In!urance 1olic/ for SBIRetiree!

I am intere!ted in @oinin" the .amil/ .loater 0rou+ Health In!urance1olic/ 3B4 of State Ban of India and furni!h the reuired information

a! under

Sl7

1articular!

Remar!

)#17. Index No7

)( Name

)9Name of theBan

SBI?e-SBS?e-SBIN

):

%ate of @oinin"the Ban

)*%ate of confirmation in



!ervice

)$%ate of

Retirement

);Retired a!

Clerical?Su&-!taff?M0S-I?MM0S-II?MM0S-III?SM0S-I?SM0S-?TE0S-I?TE0S-

II?TE0SS-I?TE0SS-II

)=A"e 2in /ear!6 a!on the date of

retirement

)< 0ender

i7 Male

ii7

.emale

#) T/+e

i7

1en!ioner

ii7

.amil/ 1en!ioner

## Cate"or/i7 SBI retiree! on com+letion of

+en!iona&le !ervice in the Ban7



ii7 Mem&er! of National 1en!ion

S/!tem on com+letion of () /ear! of confirmed !ervice in the Ban7

iii7 S+ou!e of SBI em+lo/ee ,hodied ,hil!t in !ervice or afterretirement7

iv7 1re-mer"er retiree! of e-SBS

and e-SBIN on com+letion of +en!iona&le !ervice in the concerned

Ban7

v7 Survivin" !+ou!e! of +re-mer"er retiree! ?decea!ed em+lo/ee!

of e-SBS and e-SBIN7

vi7 Exi!tin" mem&er of SBIREMBS'e-SBS REMBS and e-SBINREMBS7

#(Whether

di!char"ed ?

di!mi!!ed ?removed ?

com+ul!oril/retired ?

terminated from

!ervice7 2Tic6

e! ? No

#9Whether Rule#<296 ,a!

invoed on

attainin" the a"eof retirement

2If /e!' +lea!e

furni!h thedetail! of the

di!ci+linar/ ca!e'date of it!

conclu!ion and

e! ? No



+enalt/' if an/

im+o!ed 6

#:

%ate of Birth

dd?mm?//

#*%ate of %eath 2in

ca!e of decea!edem+lo/ee ?

+en!ioner6

dd?mm?//

#$Addre!! for

communication

Hou!e No7

Street No7

Neare!t Landmar

1o!t Dffice

1olice Station

Cit/

State

1in Code

#;Landline No7

2,ith ST% code6

#=Mo&ile No7

#<Email I%



()Name of S+ou!e

2if an/6

(#%ate of Birth of

S+ou!e

dd?mm?//

((Name of di!a&led

Child ? Children2if an/67

2Attach valid

di!a&ilit/certificate i!!ued

&/ medicalofficer not &elo,

the ran of CivilSur"eon6

Sl

Name of the di!a&led

child

%ate of Birth

dd?mm?//

dd?mm?//

dd?mm?//

(9Name of the

+en!ion?famil/+en!ion +a/in"

&ranch

Name of the Branch

Code No7

(:1en!ion AccountNo7 2## di"it6

(*I.SC Code

($Sum In!ured

o+tin" for

21lea!e tic the

a++ro+riate

Scheme6

Sl

Scheme

Sum

In!ured

In!urance

1remium

#

A

R!7 97))

lac

R!7 *'*;;?-

JSTJSBC



ST K Service Tax

SBC K S,achh

Bharat Ce!!

(

B

R!7 :7))

lac

R!7 ;'(=(?-

JSTJSBC

9

C

R!7 *7))

lac

R!7 <'(=*?-

JSTJSBC

:

%

R!7 ;7*)

lac R!7 #('$;;?-

JSTJSBC

*

E

R!7 #)7))lac R!7 #$'<)(?-

JSTJSBC

$

.

R!7 #*7))

lac R!7 (*'9*9?-

JSTJSBC

;

0

R!7 ()7))

lac R!7 99'=):?-

JSTJSBC

=

H

R!7 (*7))lac R!7 :('(**?-

JSTJSBC



%eclaration of Nominee?!

I' Mr7?Mr!7?M!7 GGGGGGGGGGGGGGGGGGGGG ' a retired em+lo/ee ?!+ou!e of the decea!ed em+lo/ee ? +en!ioner of the Ban do here&/

a!!i"n the mone/ +a/a&le &/ United India In!urance Co7 Ltd7 inca!e of m/ death to Mr7 ? Mr!7? M!7 GGGGGGGGGGGGGGGGGGGGGGGGG

Relation GGGGGGGGGGGGGG and further declare that hi!?her recei+t

!hall &e !ufficient di!char"e of the com+an/7

%e&it Authorit/

I am a,are that I alon" ,ith m/ !+ou!e and di!a&led child?children

,ill &e eli"i&le for a health in!urance cover of R!7 GGGGGGGG lac under

the .amil/ .loater 0rou+ Health In!urance +olic/7 I here&/ authoriethe Ban to de&it the annual in!urance +remium amount of R!7

GGGGGGGGG to m/ +en!ion ? famil/ +en!ion account No7 GGGGGGGGGGGGGGG no, and to rene, the +olic/ ever/ /ear &/

de&itin" the rene,al +remium a! communicated &/ the in!urance

com+an/ to m/ a&ove account ,ithout further reference to me unle!!

m/ inten!ion not to rene, the +olic/ i! informed to at lea!t onemonth in advance of the rene,al date7 I undertae to ee+ !ufficient&alance in m/ a&ove account for de&itin" current in!urance ? rene,al

+remium failin" ,hich the +olic/ ma/ not &e i!!ued ? rene,ed7

1lace

%ate

Si"nature of Retired Em+lo/ee ? S+ou!e

.or office u!e onl/

Certified that Shri ? Smt7 GGGGGGGGGGGGGGGGGGGGGGG i! a retired



em+lo/ee ? !+ou!e of the retired ? decea!ed em+lo/ee of the Ban

and he ? !he ha! remitted the in!urance +remium a! +er the follo,in"

detail!

Tran!action No7

GGGGGGGGGGGGGGG

%ate GGGGGGGGGGGGGG

Amount GGGGGGGGGGGGGG

State Ban of India

Name of the .or,ardin" Branch 2Code No76

1lace

%ate

GGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGG

Si"nature of the Branch Mana"er ,ith !eal

ACONDWLE%0EMENT



2to &e "iven to the a++licant &/ the &ranch receivin" the .orm6

Received from

Shri?Smt7GGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGG

GG

A++lication for mem&er!hi+ of .amil/ .loater 0rou+ Mediclaim 1olic/

3B4 alon" ,ith the draft No7 GGGGGGGGG dated GGGGG for

R!7GGGGGGGGGGGGGGG i!!ued &/ GGGGGGGGGGGGGGGGGGGG and dra,n

onGGGGGGG GGGGGGGGGGGGGGGGGGGGGGGfor on,ard !u&mi!!ion to

Admin Dffice7

%ate GGGGGGG

Branch GGGGGG Stam+ of the Branch

Si"nature of the officer receivin" the form

Documents

Sbi New Health InsurSBI NEW HEALTH INSURANCE SCHEMEance Scheme