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La Gazette de L' État de Poudouchéry
The Gazette of Puducherry
PART - II
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▪ 2018 } | 23 { No. 21 Poudouchéry Lundi 2 3 Avril 20 18
No. Puducherry Monday 23rd April 20 18
( 3 Vaisakha 1940 )
GOVERNMENT OF PUDUCHERRY
CHIEF SECRETARIAT (HEALTH)
(G.O. Ms. No. 12, Puducherry, dated 19th April 2018)
ORDER
Government of Puducherry has been considering the introduction
of a new Medical Benefit Scheme namely, "Contributory Medical
Benefit Scheme" as a welfare/social security measure for providing
medical facilities to "Retired Government Employees and their
Spouses and the Family Pensioners of the Government of Puducherry
for in-patient treatment through Medi-claim Insurance Policy for
treatment of prolonged illness including pre-existing diseases by
[ 395 ] 396 LA GAZETTE DE L'ETAT [P ART–II
de-notifying and withdrawing the earlier Scheme notified by reference G.O. Ms. No. 60, dated 03-08-2010 of the Chief Secretariat (Health), Puducherry
2. As such Tenders were invited through e-Tender from Public Sector Undertaking Insurance Companies to offer cashless medical Coverage of maximum of ` 3,50,000 (Rupees three lakhs and fifty thousand only) for treatment of prolonged illness and an additional ` 50,000 (Rupees fifty thousand only) for certain special cases, per annum.
3. After careful consideration, Tender Committee has recommended M/s. The New India Assurance Company Limited, Puducherry, since, the Insurance Company has been technically qualified with lowest financial bid for sum of ` 4,248 per annum with G.S.T. (` 3,600 Premium + ` 648 18% G.S.T) for the first year, subject to increase of 7.5% per annum of the premium with G.S.T. applicable from time to time for 2nd year (` 3,870 Premium + applicable G.S.T.) and 3rd year (`4,160 Premium+applicable G.S.T.) for implementation of "Contributory Medical Benefit Scheme" for a block period of three years from 01-05-2018 to 30-04-2021.
4. Accordingly, approval of the Lieutenant-Governor, Puducherry,
is hereby accorded for the following:-
(i) For de-notifying and withdrawing the earlier Scheme issued vide G.O. Ms. No. 60, dated 03-08-2010 of Chief Secretariat (Health), Puducherry and implementing a new Scheme namely, "Contributory Medical Benefit Scheme" to Retired Government Employees and their Spouses and Family Pensioners of the Union territory of Puducherry drawing pension under consolidated fund of Union territory of Puducherry by opting their willingness in their respective Pension Disbursing Authority viz. Treasuries, Banks, etc., for in-patient treatment through Medi-Claim Insurance Policy by entering into an Agreement with M/s. The New India Assurance Company Limited, Puducherry for a block period of three years from 01-05-2018 to 30-04-2021.
(ii) The 1st half of the premium amount for the first year shall be recovered from the Pensioners/Family Pensioners immediately on exercising their option to opt for the Scheme and the 2nd instalment shall be recovered after completion of six months.
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(iii) Subsequently, second and third year premium shall be recovered from the Pensioners/Family Pensioners as half yearly (during May and October) for respective years, as applicable premium with G.S.T. by the Pension Disbursing Authority (Treasuries/Banks);
(iv) The terms and conditions applicable in this regard, are
appended to this Order.
5. This issues with the concurrence of Financ Department vide their I.D. Note No. 1027/FC/FD/F4/A1/2018-19, dated 13-04-2018.
(By order of the Lieutenant-Governor)
V. JEEVA, Under Secretary to Government (Health).
————
TERMS AND CONDITIONS TO THE ORDER
Implementation Procedure for Retirement Contributory
Medical Benefit Scheme for Pensioners (Including Spouse)/
Family Pensioners
The "Contributory Medical Benefit Scheme" for Puducherry Government Pensioners (including their spouses) and the Family Pensioners shall be implemented by the Directorate of Health and Family Welfare Services, Puducherry through M/s. The New India Assurance Company Limited, Puducherry through Third Party Administrator under the control of M/s. The New India Assurance Company Limited, Puducherry for a block period of three years. The guidelines governing the Contributory Medical Benefit Scheme for Pensioners (including their spouse) and the Family Pensioners are as follows:
(1) Commencement.— The Scheme will commence from 01-05-2018
for a block period of three years i.e., up to 30-04-2021.
(2) Coverage and extent of the Scheme.— This Scheme provides Insurance coverage for Retired Employees of Government of Puducherry including their spouse and the family pensioners (spouse of the deceased employee) whose pension/family pension is paid out of the Consolidated Fund of Puducherry and who draw their pension/ family pension either directly from Treasury or through Banks, without age-limit.
398 LA GAZETTE DE L'ETAT [P ART–II
(3) Enrolment.— Enrolment shall be made by the Pensioners and the Family Pensioners by opting their willingness in their respective Pension Disbursing Authority viz., Treasuries, Banks, etc. Further, if husband and wife both are Pensioners they can get enrolled separately under the Scheme and claim shall be restricted to the amount insured by each.
(4) Geographical-Limit.— Coverage available anywhere in India
through Third Party Administrator (TPA).
(5) Nodal Officer.— The Director of the Health and Family Welfare is the Nodal Officer for "Contributory Medical Benefit Scheme" for entering into Agreement with M/s. The New India Assurance Company Limited, Puducherry. The Director of Accounts and Treasuries, Puducherry, is the Authorised Officer for recovery of premium from the Pensioners/Family Pensioners in Treasury/Sub-Treasury/Associated Banks in Puducherry and Outlying Region and Union territory of Puducherry Pensioners receiving pension in other States and issue of Identity Card to the Policy holders.
(6) Sum assured and additional sum assured.— The Government Pensioner (including spouse)/Family Pensioners shall avail cashless medical coverage on floater basis of maximum sum of ` 3,50,000 (Rupees Three lakhs and fifty thousand only) for treatment under hospitalisation (including pre-existing diseases) and an additional ` 50,000 (Rupees fifty thousand only) for six critical illnesses viz., Cancer, Kidney Failure requiring Transplantation, Major Organ/Bone Marrow Transplantation, Cochlear Implants, Multiple Injury due to Accidents, and Major Spinal Surgery/Stabilisation of Spine Surgery.
(7) Premium.— The Pensioners/Family Pensioners shall uniformly pay the insurance premium of ` 4,248 per annum with G.S.T. (` 3,600 Premium + 648 – 18% G.S.T.) for the first year, subject to increase of 7.5% per annum of the premium with G.S.T applicable from time to time for 2nd year (` 3,870 Premium + applicable G.S.T.) and 3rd year (` 4,160 Premium + applicable G.S.T.) from 01-05-2018 to 30-04-2021.
Any differences/excess in G.S.T. at a later date shall be paid by the Government of Puducherry to the Insurance Company after collecting the same from the beneficiary Pensioners and Family Pensioners.
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(8) Payment of premium to the Insurance Company.— The
payment of premium for the first year shall be 45% of the 1st half
yearly premium initially paid to the Insurance Company and the
remaining 5% or the actual premium shall be paid/adjusted after
finalising and disbursement of Identity Cards to the Pensioners/Family
Pensioners. Further, 2nd instalment for the 1st year, 50% shall be paid
at the inception of the 2nd half year.
As far as 2nd and 3rd year are concerned, 45% of the adhoc
payment of 1st half yearly premium shall be paid initially and the
remaining 5% shall be paid as per the data provided by the Insurance
Company after exclusion of employees who were expired during the
previous year and also inclusion of new Pensioners at the commencement
of next year. Further, 2nd instalment for the 2nd and 3rd year, 50%
shall be paid at the inception of the 2nd half year.
The premium to the Insurance Company shall be payable by the
Government through the Nodal Officer viz., the Director of Health and
Family Welfare Services, Puducherry after due verification. Further,
any excess premium if any, paid by the Government of Puducherry shall
be refunded by the Insurance Company.
As far as newly Retired Employees are concerned annual
premium of the respective year shall be covered in full for the prorata
period also after obtaining option from them.
(9) Accredited treatments and surgeries and coverages.— The
accredited treatments and surgeries for availing assistance under the
Contributory Medical Benefit Scheme for Pensioners (including
spouse)/Family Pensioners shall cover all hospitalisation including
pre-existing illnesses and the Day Care Procedures as per Insurance
Regulatory Development Authority (IRDA) Regulations. Further, permanent
exclusions and Non-Medical expenses during hospitalisation shall be
excluded as per IRDA Regulations. The beneficiaries are entitled for
availing treatment as many times as necessitated as in-patient till the
coverage of insured amount. The Scheme shall cover hospitalisation
as in-patient only and does not cover out-patient treatment or
reimbursement. Clear list of diseases covered and exclusions in the
Insurance Scheme are available in http://health.puducherrv.gov.in.
400 LA GAZETTE DE L'ETAT [P ART–II
(10) Room rent.— The Room, Boarding and Nursing Charges not exceeding 1% of the sum Insured per day or actuals whichever is less. ICU/ICCU expenses not exceeding 2% of sum insured per day or actuals whichever is less.
(11) Ayurveda/Homoeopathy/Unani.— The expenses incurred for Ayurvedic/Homeopathic/Unani are admissible upto 25% of sum insured provided the treatment for illness or injury taken in a Government/ National Ayush Mission approved Centres excluding Centres for Spa, Massage and Health Rejuvenation Procedures, subject to those Hospitals agree for cashless payment.
(12) Approved H o s p i ta ls .— T h e h o s p i t al s a p p r o v e d b y M/s. The New India Assurance Company Limited, Puducherry/Third Party Administrator under control of M/s. The New India Assurance Company Limited, Puducherry for undergoing accredited treatments/ surgeries anywhere in India should be Registered as a Hospital with Competent Authorities under the Clinical Establishment (Registration and Regulation) Act, 2010 (or) under the enactments specified under the Schedule of the section 56(1) of the said Act and will be made available in the websites of the Directorate of Health and Family Welfare Services, Puducherry and in M/s. The New India Assurance Company Limited, Puducherry.
Any addition and deletion of Approved Hospitals under this Scheme is to be issued with the consent of the Director of Health and Family Welfare Services, Puducherry and the same have to be updated/ uploaded in the website of Directorate of Health and Family Welfare Services, Puducherry http://health.puducherrv.gov.in. and M/s. The New India Assurance Company Limited, Puducherry and also communication shall be sent to all the beneficiaries by e-mail.
(13) Identity Cards.— (i) The New India Assurance Company/ Third Party Administrator shall arrange to issue the Identity Cards to the Pensioners/Family pensioners covered under this Scheme with the details of spouse within the stipulated period of 60 days.
(ii) The Director of Accounts and Treasuries concerned shall be responsible to arrange to furnish the data of the Pensioners and Family Pensioners in the Prescribed Form to issue Identity Cards to the beneficiaries. The Director of Accounts and Treasuries shall also be 401
PART–II] LA GAZETTE DE L'ETAT
responsible to surrender the Identity Cards of such of those Pensioners/ Family Pensioners who die in harness to M/s. The New India Assurance Company Limited, Puducherry.
(iii) If, there is any difficulty in getting identity cards, by the Pensioners and Family Pensioners, a representation shall be submitted to the Director of Accounts and Treasuries, Puducherry. The representation received shall be sent to M/s The New India Assurance Company Limited, Puducherry/Third Party Administrator under control of M/s. New India Assurance Company Limited, Puducherry for redressal and the process shall be completed within the period of 10 working days.
(iv) In case of loss of Identity Card, a duplicate Identity Card shall be obtained by Pensioners/Family Pensioners on payment of the amount mentioned by the Director of Accounts and Treasuries, Puducherry and the process shall be completed within the period of 15 working days.
(v) The Director of Accounts and Treasuries, Puducherry, shall be the sole Authority to sort out the discrepancies as and when brought to notice by the Pensioners/Family Pensioners concerned regarding issue of Identity Cards.
(14) Procedure to be followed for availing medical assistance.— The procedure to be followed at the time of admitting Pensioners (including spouse)/Family Pensioners for accredited treatments/ surgeries are as follows:
(i) The hospitals approved by M/s. The New India Assurance Company Limited, Puducherry/Third Party Administrator under this Scheme alone shall be applicable for availing the benefits.
(ii) The approved Hospitals shall be approached by beneficiaries for all types of treatment/surgeries to be undertaken on Cashless basis, so that pre-authorisation is given by M/s. The New India Assurance Company Limited, Puducherry/Third Party Administrator under the control of M/s. The New India Assurance Company Limited, Puducherry.
(iii) In case of critical illnesses treatments/surgeries undertaken in the listed hospitals of M/s. The New India Assurance Company Limited, Puducherry/Third Party Administrator, approval have to be obtained for settlement on Cashless basis by the Pensioner/Family Pensioner during the period commencing from the date of treatment/ surgeries as in-patient to the date before discharge from the hospital.
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(iv) For claim assistance, the Pensioners/Family Pensioners shall contact through Toll Free Helpline No. 1800 2335693 [24 Hours] of the Third Party Administrator under the control of M/s. The New India Assurance Company Limited, Puducherry and also shall contact Coordinators of the Third Party Administrator under this Scheme through contact numbers.
(v) Further, if there is any grievances for availing medical assistance, Pensioners/Family Pensioners shall contact Nodal Officers of the following order viz., (i) Third Party Administrator, (ii) M/s The New India Assurance Company Limited (iii) Directorate of Accounts and Treasuries and (iv) Directorate of Health and Family Welfare Services. The list of State-wise/Area-wise coordinators and Nodal Officers under the Contributory Medical Benefit Scheme and their contact numbers are available in http://health.puducherry.gov.in.
(vi) The Identity Card of the Pensioners/Family Pensioners issued by M/s The New India Assurance Company Limited, Puducherry/ Third Party Administrator shall be produced to the approved hospitals for the accredited treatments/surgeries.
(vii) The arrangement of production Authorization Letter in lieu of Identity Card shall be applicable only for such interim period, till the Identity Cards are made available. In initial stage, till the Identity Card is issued by the Third Party Administrator, the claim procedure to be followed in the event of hospitalization is that the enrolled persons/spouse have to obtain a Certified Enrollment with Photo Identity Proof from Directorate of Health and Family Welfare Services, Puducherry/Directorate of Accounts and Treasuries, Puducherry. After the issuance of Identity Card, the Hospitalisation procedure will become simpler.
(viii) This Scheme is on a CASHLESS basis and no payment for approved cost need to be made by the Pensioners (including spouse)/ Family Pensioners to the approved Hospitals. Claims for reimbursement of the payment if any, made shall not be entertained.
(ix) The eligible charges which are entitled to under this Scheme shall be ascertained for the accredited treatments/surgeries from the hospitals approved by M/s The New India Assurance Company Limited, Puducherry/Third Party Administrator shall not be allowed to charge any excess amount.
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(x) Rejection of claims shall be done by Third Party
Administrator with the consent of M/s. The New India Assurance
Company Limited, and the Directorate of Health and Family Welfare
Services, Puducherry and they have to convey their rejection.
(15) Modification or alteration of the agreement.— Either of
the parties to the agreement by giving advance notice of at least three
months before the expiry of a particular year, may propose modification
or alteration of any or all the terms of this agreement at the end of
each year and in the event that such modification or alteration is
accepted in writing by the other party, the agreement shall stand
modified or altered to that extent.
(16) Cancellation.— Either of the parties agree to cancel this
agreement for breach of terms and conditions under this agreement at
anytime during its currency with thirty days advance written notice to
that effect. In the event of such cancellation, the Insurance Company
will be liable to settle all the claims till the effective date of such
cancellation and shall refund to the Government of Puducherry, the
advance premium received for the remaining part of the year.
(17) Banning of Hospitals.— Where any fraudulent claim
becomes directly attributable to a hospital included in the networked
hospitals under this Scheme, the said hospital shall be removed and
excluded under the Scheme by the Insurance Company and shall be
excluded from the list of approved networked hospitals for the purpose
the Scheme.
(18) Penalty clause.— Failure to abide by the terms of the
Scheme as per the terms of this agreement and as stipulated in the
tender document will attract penalty as may be determined by the
Government of Puducherry, subject to the minimum of five times the
amount of the expenditure incurred by the Government of Puducherry
or beneficiary due to non-compliance.
(19) Redressal of grievances.— Any complaints about difficulty
in availing accredited treatments/surgeries, non-availability of facilities,
bogus availment of treatment for ineligible individuals, etc., shall be
submitted to the Committee, comprising of the Director of Health and
Family Welfare Services, Puducherry, the Director of Accounts and 404 LA GAZETTE DE L'ETAT [P ART–II
Treasuries, Puducherry and official representative of M/s. The New India Assurance Company Limited, Puducherry. The complaints received shall be placed for decision. The Civil Courts situated in the Union territory of Pondicherry shall have exclusive jurisdiction over any dispute, which remain unresolved by the above procedure and nothing aforesaid, shall prejudice the rights of the Government of Puducherry to approach any other forum for dispute resolution permissible under Law.
(20) Profit sharing.— The New India Assurance Company Limited, Puducherry, shall furnish a Monthly/Quarterly/Annual report to the Director of Health and Family Welfare Services with the details of the number of claims (hospital-wise), and the total amount disbursed (treatments and surgeries-wise) and also to the Director of Accounts and Treasuries, Puducherry. The Director of Accounts and Treasuries shall furnish a Annual report to the Government through Director of Health and Family Welfare Services, Puducherry every year.
All the benefits under the Health Insurance Policy shall cease the moment the overall claims under the policy reaches 120% of the actual premium paid excluding the Service Tax in respect of all the persons who are covered under the Scheme. The overall claim shall be arrived at after taking into account, all the expenses relating to bills paid and liable to be paid towards the Hospital/Service providers, medicines and implants purchased all connected expenses for the treatment of the beneficiaries under this Scheme.
The Insurer at the end of the policy period shall set apart 20% of the premium amount (excluding Service Tax) towards its administrative cost and the balance amount adjusted towards the claims payment received from the network hospitals. If, there is any surplus after such adjustments mentioned above, the Insurer shall refund 90% of such surplus to the Authority i.e., Government of Puducherry.
V. JEEVA, Under Secretary to Government (Health).
online publication at "http://styandptg.puducherry.gov.in" Published by The Director, Government Press Printed at: Government Central Press, Puducherry. Posted at: Puducherry HPO on every Tuesday