Ysr Bima Scheme Claim Settlement Process Status

Panchayat Raj and Rural Development Department YSR BIMA Social Security Scheme Standard Operation Procedure (SOP) for Claim Settlement Process Orders Ysr Bima Scheme 2020 claim status.

SOP for Enrolment of Leftover/New Members

  1. Registration of bread earners: The Village/Ward Volunteer or Welfare Assistant shall collect the details of beneficiary such as Rice card, Savings Bank/Jan Dhan Account number, contact number and Nominee Particulars and submit them to the nearest Bank. 
  2. Six-step validation process inbuilt in the software to be undertaken by the system, in the absence of rice card 
  3. Fill in the PMJJBY/PMSBY forms, upon eligibility and submission of the forms to the concerned bank branch by the Village/Ward Volunteers or Welfare Assistant.
  4. Sanction of premium from SERP to the pooling account of concerned bank, based on the amount quantified by SERP.
  5. Bankers shall share the information through dedicated online facility such as Deduction of premium from pooling account, credit to beneficiaries account, debit of PMJJBY/PMSBY premium and transfer of premium to the insurance companies by the concerned banks etc.
  6. Commencement of insurance cover shall be captured for each beneficiary by SERP
  7. Printing of YSR Bima cards by SERP using the budget provided by Labour Dept. and handing over of the printed cards to the beneficiary with biometric authentication. A separate SLA will be worked out by SERP to this effect.   

II. SOP for Insurance Claim Settlement Proces

Registration of claims:

Upon receipt of intimation of death/accident at the Village/Ward Secretariat level, concerned Village/Ward Volunteer (hereafter VV/WV) shall visit the house of deceased and enter the details of the family in the dedicated App.  

  • Payment of interim relief amount:

Upon verification of the death/accident, the Welfare Assistant (hereafter WA) along with concerned VV/WV shall visit the family of the deceased and handover Rs. 10,000/- for funeral expenses. She/he will collect the prescribed documents along with Bank lean form of advance payment and obtain signatures from nominee for further process.    

Submission of claim documents – Natural Deaths: 

  1. VV/WV will download the claim application and discharge voucher from the web portal and obtain the signatures from the nominee.  
  2. Panchayat secretary in case of Panchayats, Municipal Commissioner in case of Municipalities and Medical officers in case of death at hospital, will register the death and upload the death certificate to the web portal within 48 hours of claim registration.
  3. VV/WV will visit the bank branch to submit the claim application as per the below checklist: 
  4. Attested photocopy of the PMJJBY/PMSBY enrolment form of the beneficiary
  5. Account statement of the deceased showing debit of premium 
  6. Nominee bank account statement- self attested

All these documents shall be submitted to the Bank Branch manager for verification and certification.

  • VV/WV shall collect the attested documents from the bank and handover the same to the Digital Asst. as per check list.
    • Digital Asst. shall upload them to the designated web portal and WA shall verify them and forward to the concerned Bank. 
    • Upon verification of the documents uploaded, Bank Branch Manager shall push them to the concerned insurance companies for settlement. 
    • Insurance companies will verify the documents and sanction the claim amount to the nominee account within stipulated time. 
    • Branch manager can deduct Rs. 10,000/-, given for funeral expenses, from the claim amount of the nominee SB account, as per advance receipt signed by the nominee and transfer it to the CEO, SERP SB account. 
    • If the nominee does not have bank account in the Bank of deceased person, a separate nominee account will be opened to facilitate hassle-free claim settlement.
    • WA will download and hand over the claim sanction letter (provided by SERP) of the respective insurance company to the nominee following sanction of claim by the concerned insurance company. WA will further upload the acknowledgement copy received from the nominee in the web portal.
    • If any claim is rejected by the insurance company, such information of rejection along with the reasons will be intimated to the nominee by the WA.
  • Submission of claim documents – Accidental Deaths: 

In the case of accidental deaths, procedure similar to the case of natural deaths will be followed, with the below mentioned additions:

  1. Separate claim application forms and discharge vouchers are to be obtained from nominee under PMJJBY/PMSBY and state group accidental insurance policy.
  2. Copy of FIR to be uploaded by the SHO/DCRB within 2 days of claim registration. 
  3. Police inquest report to be uploaded by the SHO/DCRB within 3 days of claim registration. 
  4. Medical officer has to upload the post-mortem certificate to the web portal within 2 days of completion of post-mortem examination/claim registration. 
  5. Forensic lab reports to be uploaded to the web portal within 7 days by the concerned authority i.e. RFSL. 
  6. Medical officer has to upload final opinion certificate to the web portal within 2 days after receipt of RFSL. 
  7. SHO/DCRB has to upload the police final report within 15 days of incident.
  8. Branch manager has to verify and forward the PMJJBY claim application form, along with enclosures (soft/scanned copies) and PMSBY application form, along with enclosures (soft/scanned copies), separately to the concerned insurance companies. PMJJBY application forms are to be forwarded to the insurance company by adding the FIR copy along with the death certificate. PMSBY application forms are to be forwarded to the insurance company by adding FIR, inquest report, and post mortem report, in addition to the death certificate.
  9. WA has to upload the claim application form under the state group accidental insurance to the web portal directly
  • Submission of claim documents – Accidental Disability:
  1. In case of accidental disability claims, copy of FIR to be uploaded by the SHO/DCRB within 2 days of claim registration. 
  2. VV/WV will upload the (i) hospital discharge summary sheet, (ii) wound certificate and (iii) disability photograph within 1 week of claim registration. 
  3. SADAREM certificate to be uploaded by the Medical & Health Department within 7 days after registration for the certificate. 
  4. VV/WV will download the claim application and discharge voucher from the web portal and obtain the signatures from the nominee within the same of claim registration.
  5. VV/WV shall visit the bank branch to submit the claim application as per the checklist: (1) attested photocopy of the PMJJBY/PMSBY enrolment form of the beneficiary 2) account statement of deceased showing debit of premium to that particular account 3) nominee bank account statement  – bank account details furnished by the nominee (shall be self-attested )to the branch manager for verification and certification within 4-5 days of claim registration. 
  6. VV/WV shall collect the attested documents from the bank and handover it to the Digital Asst. as per the check list.
  7. Digital Asst. will upload them to the designated web portal. WA shall verify them and forward to the concerned Bank. 
  8. Upon verification of the documents uploaded, Bank Branch Manager shall push them to the concerned insurance companies for claim settlement. 
  9. Insurance companies will verify the documents and sanction the claim amount to the nominee account within stipulated time. 
  10. WA will download and hand over the claim sanction letter (provided by SERP) of the respective insurance company to the nominee after sanction of claim by the concerned insurance company. Welfare assistant will further to upload the acknowledgement copy received from the nominee in the web portal.
  11. If any claim is rejected by the insurance company, such information for rejection along with the reasons will be intimated to the nominee by the WA.

III. SOP for Payment of Interim Relief Amount

  1. Impressed amount for Funeral Expenses: An amount of Rs.20,000/- will be deposit in the GSWS Bank Accounts by SERP for funeral expenses through EFMS based transfer on MIS Deficit.
  2. Welfare Assistant (WA) along with concerned VV/WV will visit the deceased family and handover Rs. 10,000/- for funeral expenses.
  3. WA will collect the prescribed documents along with Bank lean form of advance payment and obtain signatures from nominee for further process.
  4. WA shall maintain the Bima register for funeral expenses payment.
  5. WA shall upload the Day to Day transactions of funeral expenses on web portal through logins by SERP.
  6. The Welfare Assistant shall upload the Books of Accounts in the web portal.
  7. SERP will release the impressed amounts to the Village/Ward Secretariats Bank accounts upon uploading the day to day transactions and Books of accounts details in web portal.

IV. Service Level Agreements (SLA)

  1. SLA for Natural Death

Roles and Responsibilities

Role of Village/Ward Volunteer:

  1. Creation of awareness to the families in his/her cluster on YSR Bima.
  2. Identification of eligible members and enroll them into the scheme.
  3. Collection of PMJJBY & PMSBY Application forms from the eligible members and submit to concern Bank Managers through Welfare Assistants.
  4. Maintain list of members covered/enrolled in YSR Bima 
  5. Distribution of Bima Identity cards to all members in his/her cluster.
  6. If any enrolled member dies either by Accident or natural death in the Volunteer Cluster area, the claim has to be registered within 1 hour. Claim details are to be informed to Village/Ward Secretariats /YSR Bima Call Centers (Zilla Samakhya), in case of any difficulty in registration of claim.
  7. Visit the bereaved family after registration of claim and verifies the claim particulars i.e. Date of death, place of death, cause of death.
  8. Pay immediate assistance of Rs. 10,000/- to the nominee as advance claim amount for funeral expenditure. 
  9. Obtain undertaking letter from nominee for deduction of Rs.10,000/- from the claim amount 
  10. Download the claim application form and discharge voucher from Web portal and obtain the signature of nominee. VV/WV will also collect Copy of ADHAAR Cards of Deceased Member and Nominee, Copy of SB Account passbook of Deceased and Nominee.
  11. Support the Nominee in opening of SB Account.
  12. Download the Death Certificate uploaded by the Panchayat Secretary / Municipal Commissioner / Medical Officer.
  13. Visit the Bank Branch where deceased member having SB Account and covered in YSR Bima to submit the following claim papers for verification and certification from Branch

Manager;

  • Claim application form
    • Discharge Voucher
    • Death certificate
    • Copy of SB A/c passbooks of Deceased and Nominee
    • Copy of ADHAAR Cards of Deceased and Nominee.
    • Copy of FIR, Inquest Report, Post Mortem Examination Report will be submitted along with PMSBY Claim Application form in case of Accidental Death.
  • Distribution of claim sanction letter to the nominee after sanction of claim.

2. Role of Village/Ward Welfare & Education Assistants 

  1. Responsible for enrolment of all eligible members into YSR Bima.
  2. Submission of PMJJBY and PMSBY Application forms of all members enrolled into YSR Bima to the concerned Bank Branch where Members having SB A/c. Acknowledgement of PMJJBY/ PMSBY application to be maintained.
  3. Distribution of YSR Bima ID Cards to the members enrolled into the scheme.
  4. Visit the bereaved family on the same day of incident and extend moral support and to pay Rs. 10,000/- immediate assistance  
  5. Monitoring of Claims registered in the Village / WardSecretariat  
  6. Downloading claim sanction letter and distribute it to the Nominee through Village / Ward Volunteer.

3. Role of Branch Manager:

  1. Maintain the PMJJBY and PMSBY application forms of all the members enrolled in the scheme.
  2. Issuing certified copy of PMJJBY and PMSBY Application form to the VV/WV for the claim registered.
  3. Issuing certified SB Account statements of Deceased and Nominee to the VV/WV for the claims registered.
  4. Receiving of claim application form, discharge voucher, death certificate, Aadhar cards of deceased and nominee from nominee to verify the death details and to sign on claim application for processing of claim at insurer level.
  5. Handing over certified copies of claim papers to VV/WV for scanning and uploading to the web portal.
  6. Forwarding scanned claim document to the insurance company for processing of claim. In case of accidental claims, PMJJBY and PMSBY application forms to be forwarded to the concerned Insurance Agencies.
  7. Deducting Rs. 10,000/- from nominee SB A/c based on the undertaking letter of nominee submitted by the VV/WV.
  8. Transfer of Rs. 10,000/- to the CEO, SERP SB A/c after sanction of claim amount towards adjustment of immediate assistance paid to the nominee for funeral expenditure.
  9. Coordinating with Insurance Company for processing and sanction of claim within 15 days.
  10. If any requirement from the Insurance company, such requirement to be submitted to the Insurance Company for sanction of claim.

4. Role of District level YSR Bima Call Centre:

The call centre will be supervised by the President, Zilla Samakhya and PD, DRDA. 

Monitoring of Registration of claims registered by VV/WV on day to day basis.

  1. Registration of claims in case of non-availability of VV/WV in any cluster.
  2. Follow up with Line Departments for upload of Certificates (i.e. Death Certificate, FIR, Inquest Report, Post Mortem Examination Report, RFSL Report, Final Opinion Report, Police Final Report, Family Member Certificate) for submission of claim documents.
  3. Scrutiny of documents uploaded by the Line Departments.
  4. Follow up with VV/WV to upload claim documents as per SLA.
  5. Follow up with Branch Managers for issuing certified copies of claim papers for upload of claim document throughVV/WV
  6. Monitoring of Bank wise / Insurance company wise claims status.
  7. Monitoring of requirements called by Insurance Agencies and ensures attending all requirements.
  8. Forwarding of Accidental Claim documents under State Group Accident Policy to the National Insurance Company.

5. Role of Insurance Agency:

  1. Maintain the Logins provided to the Insurance Company to access the claim documents forwarded by Bank Managers.
  2. Downloading of claim documents on day to day basis using login ID from the web portal for processing of claims as per the scheme guidelines.
  3. Uploading of claims status in the web portal on day to day basis.

6. Role of Project Director, DRDA.

  1. Overall monitoring and supervision of the operations of YSR Bima Call Centers.
  2. Coordinate with all Line Departments (Police Dept, DCRB, RFSL, Medical & Health Dept., Panchayat Raj & Rural Development Dept, Municipal Administration & Urban Development Dept.) for issue of certificates under SLA
  3. Conduct periodical meetings with line departments, under the Chairmanship of the District Collector  
  4. To undertake grievance redressals.

VI. YSR Bima Monitoring & Review Committees

State Level Monitoring Committee:

  1. Principal Secretary to Govt., PR&RD        -Chairman
  2. Principal Secretary to Govt., LFB&IMS  -Co- Chairman
  3. CEO, SERP                                            -Member Convener
  4. Special Commissioner of Labour, A. P  – Member
  5. MD, MEPMA                                       -Member
  6. Commissioner, Panchayat Raj Dept, A. P -Member
  7. Commissioner, MA&UD Dept, A. P    -Member
  8. Commissioner, Civil Supplies Dept, A. P -Member
  9. Director & Commissioner, GSWS Dept  -Member
  10. Additional Director General of Police         -Member
  11. Director, Medical Education      -Member
  12. Convener, SLBC, AP         -Member
  13. Representatives of the Insurance Companies 

The Committee shall meet at monthly intervals and review the progress in implementation of the Scheme district wise and Bank wise and submit a report to the Government before 15th of every month with specific observations and recommendations, if any, to improve the performance.

District Level Monitoring and Review Committee:

  1. District Collector                       –Chairman
  2. PD, DRDA                                        – Member Convener
  3. Joint Collector (Asara & welfare)  – Member
  4. Superintendent of Police            -Member
  5. District Medical & Health Officer  – Member
  6. Deputy Commissioner of Labour  -Member
  7. PD, MEPMA                              –Member
  8. CEO, Zilla Parishad                  –Member
  9. District Panchayat Officer                  –Member
  10. President, Zilla Samakhya                 –Member
  11. Commissioners of Municipalities  –Member
  12. LDM                                                  –Member
  13. Representatives of the Insurance Companies

The Committee shall meet at monthly intervals and review the progress in implementation of the Scheme and submit a report before 5th of every month to the Special Commissioner of Labour, under copy to the Government in LFB &IMS Department.

VII. Grievance Redressal:

Any grievances related to (i) registration of Beneficiaries, (ii) enrolment of beneficiaries into the scheme and (iii) registration of claims may be addressed to Deputy Commissioner, Labour Dept. In case of settlement of claim if any dispute arises against any Insurance agencies the individual can file a complaint before District Consumer Forum or Insurance Ombudsman only. 

VIII. Management Information System

SERP will be create a dedicated “YSR Bima” web portal to capture all information pertaining to YSR Bima claim enrolment, registration, processing and settlement. All reports pertaining to enrolment details, insurance company wise registered, settled, rejected & balance reports will be made available through the MIS. 

Detailed stages and modules involved in MIS are as follows:

Registration of claims:

a. Death Intimation Module: 

i. Facilitation of receipt of death intimation via Toll free phone number, district call centre phone numbers, to telephone operator for claim registration. ii. The calls reception recording will be stored and made available to access for further process.   

b. Claim Registration Module:

i. Facilitation of claim registration at district call centre and village/ward secretariat via operator login and village/ward welfare assistance login.

  • Confirmation of Incident and payment of interim relief amount:

a. Intimation to VV/WV Module:

i. Within claim registration module the respective VV/WV shall be assigned or can be selected based on availability for verification of incident 

b. Interim relief payment Module:

  1. Facilitation of auto deduction of 10,000/- Interim relief from allocated budget VV/WV wise 
    1. Facilitation of android app for VV/WV and village/ward volunteers to capture the picture of 10,000/- Interim relief handover to nominee with geographical location capturing. 
    1. Facility to update nominee details via android app 
  2. Nominee Details:

a. Nominee change Module:

i. Provision to change the nominee with reason and support documents to VV/WV and call centre.

Document required -Family member certificate  ii. Changed nominee verification with 2 level authentications by Accountant and APM

b. Nominee bank details Module:

i. Nominee bank entry provision with 3 levels authentication by operator, accountant and APM.

  • Claim Document Download: 

a. Claim form generation Module: 

i. On claim registration the system prefilled claim form will be made available in VV/WV login

b. Documents from Line Departments Module:

i.     Facilitation of logins to line departments Panchayat secretary 

Municipal Commissioner 

Andhra Pradesh Vaidya Vidhana Parishad

Directorate of Medical Education

District Hospital, Area Hospital of Medical and

Health

  • SCRB, DCRB, SHO Police Department

ii. Document request notification to respective line department officer via SMS on claim registration. iii. The dashboard and Task section of line department login will be updated on each claim registration for respective document request 

iv. The document upload provision made available to close the document request pending.  

c. Documents verification and download Module:

  1. Provision at call centre login to verify and download or revert with reason for line department documents received.
    1. Verified and accumulated document will be made available to VV/WV for download 
  2. Bank Visit: 

a. Banker attestation Module: 

i. Banker attested and certified claim document upload provision shall be made available to VV/WV call centre.

b. Document verification Module: 

i. Call Centre 3 levels verification and forwarding of claim document by operator APM, DPM

  • Insurance companies: 

a. Login:

i.              Logins of all insurance will be facilitated with

Dashboard and task sections  

b. Download task:

  i.     Provision to download claims individually or bulk 

c. Claims status update:Provision to update claim as settled 

Provision to update claims as rejected 

Provision to call for requirement  

Requirement / Rejection 

a. Requirements upload and verification Module  

  1. Insurance company requirements and rejection made available to VV/WV / secretariats 
    1. Verification of uploaded requirement by operator, APM, at call centre 

b. Reupload to Banks and insurance:  

  1. The requirement uploaded will be made available to banker under repeat section in respective logins 
    1. The requirement uploaded will be made available to Insurance under repeat section in respective logins 
  • Interim relief Adjustment for settled claims: 

a. State accounting Module: 

                            i.          Uploading of statement of 10,000 credits made to

SERP account from nominee account  ii. Uploading data of 10,000 deductions made at nominee accounts 

iii.          Realtime reconciliation of deductions and credits in backend 

b. District / Secretariat accounting Module: 

i. Auto generation of proceeding to adjust advance paid by district call centre / village/ward secretariats. ii. Reconciliation of proceeding and bank transaction statement towards district call centre/village/ward secretariats.

  • Claim sanction letters 

a. Generation of sanction letter: 

i. Auto generation of sanction letter on settlement of claim and made available at Village / ward secretariats 

b. Collection of acknowledgment: 

                            i.     Provision to upload acknowledgement

  1. Status details for redressal

a. Policy Search:

i. Policy Search Provision shall be made available to all call centres, secretariats logins for policy status details with claim code / UID / account number  

b. Claim search:

i. Claim Search Provision shall be made available to all call centres, secretariats logins for claims status details with claim code / UID / account number  

c. DBT details:

i. DBT details Provision shall be made available to all call centres, secretariats logins for DBT details with claim code / UID / account number  

  1. Monitoring:
    1. Public dashboard in Bima portal for real time claims registration, document uploaded, claim settlement, requirement and rejections monitoring for today and accumulated.  
    1. Monitoring report on calls received, number of calls attended, number of calls rejected District wise, operator wise 
    1. Day wise Claims registration monitoring report District wise,

Mandal wise, secretariat wise 

  • Same Day Registration, Rs.10,000 Paid, Below 7Days

Upload Details 

  • Call Centre staff perforation wrt claim registration, document upload and verification.
    • Age wise policy and claims ratio, percentage and death rate 
    • Claims intimated to VV/WV / volunteer SLA deviation report 
    • No of 10,000/- advance payment made and not made 
    • Progress and Delay in 10,000/- adjustment 
    • Interim relief 10,000 /- reconciliation done and pending report 
    • Interim relief circulation bottleneck in interim relief release analysis and status 
    • Nominee details changed report 
    • Pending for verification of nominee reports 
    • Nominee mobile number verification and validation 
    • Nominee bank details entry pending report 
    • Verification pending of nominee bank details geographical wise, operator wise.
    • Claims pending at Line department, day wise, SLA wise 
    • Document upload pending geographical wise, operator wise.
    • Document verification pending level wise, district wise 
    • Claims pending at bank for certification out of SLA
    • Insurance company claims download pending company wise 
    • Claims pending at Insurance company for settlement with in and out of SLA
    • Claim settlement, requirement and rejection percentage 
    • Requirement claims pending at call centre 
    • Requirement claims pending at banker and insurance for settlement. 
    • Sanction letter delivery status report geographical wise, operator wise. 

The SERP is nodal organization for overall implementation of YSR Bima, including coordination with multiple stakeholders, strategic planning & operations, monitoring management & information systems and maintenance of software.

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