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La Gazette de L' État de Poudouchéry
The Gazette of Puducherry
PART - II
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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
2018 }
| 23 {
No. 21 Poudouchéry
Lundi
23
Avril
2018
No.
Puducherry
Monday
23rd
April
2018
( 3 Vaisakha 1940 )
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LA GAZETTE DE L'ETAT
[PART–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.
397
PART–II]
LA GAZETTE DE L'ETAT
(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.
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LA GAZETTE DE L'ETAT
[PART–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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PART–II]
LA GAZETTE DE L'ETAT
(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.
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LA GAZETTE DE L'ETAT
[PART–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
Hospitals.— The
hospitals
approved
by
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.
402
LA GAZETTE DE L'ETAT
[PART–II
(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.
403
PART–II]
LA GAZETTE DE L'ETAT
(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
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LA GAZETTE DE L'ETAT
[PART–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