A NOTE ON GROUP MEDICLAIM POLICY : 2020-21
LIC employees and Retired employees and spouse of deceased employee/retired employee are covered by Group Mediclaim policy for nearly three decades. The Spouse and dependent Children can be included by them in their policies. Over the years many improvements have taken place, with the efforts of NOIP. We give here below a gist of the Mediclaim policy for the use of our retired members. Independent Children, till their marriage, can also be included from Policy Year 2018-19.
The Group Mediclaim Policy of LIC is currently with New India Assurance Company Ltd., The same is serviced by Mumbai Divisional Office, whose address is given below :
New India Assurance Company Ltd.,
Divisional Office 120700,
8th Floor, New India Centre,
17/A, Cooperage Road, MUMBAI – 400 001.
Tel Nos: 022 - 22049763 / 22814663. email :nia120700@newindia.co.in
Person looking after Mediclaim : Smt. Dipali Kadam, AO, 022 - 22846889
Eight (8) TPAs have been enlisted by New India Assurance Co., Ltd., for 8 Zones of LIC of India through out India. For South Central Zone the TPA is Medi Assist India TPA Pvt., Ltd.,. The details of the TPA are as under :
The Policy Number will be : 12070034200400000007
Toll Free Number(dedicated for LIC) 18004191154 / 7022085000
Common Toll Free Number 18004259449
Email id lic@mediassistindia.com
Fax number 18004259559
Telephone number 18004191160
Website address www.mediassistindia.net
Contact for Claims Level 1 Smt. Ashwitha V : +91 7022970406
Contact first escalation Level 2 Smt. Usha C B : +91 9686791657
Contact Second Escalation Level 3 Smt. Shashikala G : +91 7022972053
A retired employee continues to be in the same category, even after retirement, that he was at the time of his retirement. There are three categories :
Category Basic Sum Insured Additional Optional Total Sum Insured(BSI+ASI)
III Rs.5,00,000/- 6L, 8L, 10L, 12L, 15L, 20L, 25L, 30L, 40L, 50L.
II Rs.6,00,000/- 8L, 10L, 12L, 15L, 20L, 25L, 30L, 40L & 50L.
I Rs.10,00,000/- 12L, 15L, 20L, 25L, 30L, 40L & 50L.
Premium Sharing : For BSA : 75% paid by LIC and 25% to be borne by Insured.
This sharing is for all those who are covered(spouse & dependant 2 children for in- service employees & for retired person, Spouse and disabled dependent 2 children). For ASA : 100% to be borne by Insured.
For Parents / Parents-in-Laws and Independant Children :100% borne by Insured.
The Policy document is divided into 8 parts (A to H) and contains 4 Annexures. Part A : COVERAGES
1. Reimbursement of Medical Expenses/Surgery at any Hospital/Day Care Center in India.
2. Room, Boarding expenses as provided by the Hospital including nursing charges not exceeding 1.5% of Total SI per day is payable. In Karnataka in Bengaluru the limit is Rs.7500/- (Rs.10,000/- for those who have opted for 40L / 50L SA) and at all other places it is Rs.4000/- per day. [Room rent + Boarding Charges supplied by Hospital + Nursing Charges are included].
3. However, there is NO CAPPING for admission in ICU/ICCU.
4. Surgeon, Anesthesist, Med. Practitioner, Consultants and Specialists Fees are reimbursible.
5. Relevant Lab/Diagnostic tests, Anesthesia, Blood, OT charges, Surgical appliances, Medicines, Dialysis, Chemotherapy, Radiotherapy and cost of prosthetic devices implanted like Pacemaker etc. are reimbursible.
6. Pre-hospitalisation medical expenses for a period of 30 days and Post-hospitalisation medical expenses for a period of 60 days are reimbursible.(in case of Renal failure and / or Organ Transplantation or Cancer related ailments this period may be waived).
7. Non-medical expenses are NOT covered. Annexure II gives full list of Non-medical expenses.
8. From 2019-20 International Second Medical Opinion services clause has been incorporated in the Policy (for details refer Pages 5 to 9 of Policy) for selected ailments ( see separate note).
Part B : CASHLESS / REIMBURSEMENT THROUGH TPA
1. The Insurer gives Cashless and Reimbursement facility through TPA, in the networked Hospitals only.
2. If a retired employee shifts his residence from one place to another place, the original TPA only will provide services based on Pan India network hospitals.
3. Procedure for Availing Cashless Hospitalisation Services: a) available only at TPA network hospitals. b) E-card and a Photo ID of patient to be submitted to TPA. c) If no e-card is available then a Certificate issued by OS Dept of the Division will do. d) A preauthorisation form is to be filled in completely duly signed by claimant and the treating doctor. e) All the above three requirements are to be sent to TPA on its mail id or by Fax. On receipt TPA will issue pre-authorisation letter to the Hospital. f) Bills over and above the amount paid by TPA will have to be paid by the claimant to the Hospital. g) In case TPA denies to give pre authorisation, then full bill has to be settled by the Claimant. h) However, claimant can submit the requirements for reimbursement to the TPA through OS Dept of the Division.
Part C : Diagnostic Tests without Hospitalisation
1. The following (16) Diagnostic Tests without hospitalisation are payable to the extent of the limit mentioned here in, for each insured under the policy, per person per year:
Diagnostic Test Max. payable Diagnostic Test Max. Payable
MRI charges Rs.8000/- CT Scan charges Rs.6000/-
Sonography (excluding
Maternity related) Rs.2000/- Biopsy Rs,4000/-
TMT Rs.2000/- Echo test Rs.2000/-
Gastroscopy Rs.5000/- Colonoscopy Rs.7000/-
EEG Rs.1000/- EMG Rs.2000/-
Holter Monitor Test Rs.5000/- PAP Smear Rs.750/-
Mammography Rs.5000/- PET Scan Rs.20000/-
Prostate Specific Antigen Rs.750/- Angio CT Rs.6000/-
2. Maximum amount reimbursable under this benefit is Rs.75000/- per family per year.
3. An MD doctor should have recommended the Test, giving reasons for the same.
4. Pre and Post expenses in respect of Diagnostic Tests are not reimbursable.
5. This benefit can be availed only once during the Policy year per insured per Test.
6. For MRI, CT Scan, Sonography and Biopsy the same are allowed twice during the policy period, per insured person, if done for a different Organ / Body part.
Part D : Sub-Limit Clause
1. Payment is made for admission in ICU/ICCU as part of hospitalisation bill only.
2. Bills raised by Surgeon/Asst. Surgeon/Consultant/Specialist/Anestetist directly are payable as below : a) Max. 25% of the Total Sum Insured is payable, provided a numbered Bill is given and if it is paid by Cheque. b) If paid by Cash reimbursement is restricted to Surgeon/Consultant/Specialist :
Rs.30,000/- ; Asst. Surgeon : Rs.12,000/- ;
Anesthesist : Rs.20,000/-. Provided a numbered bill is submitted for all above.
3. Claim relating to Cataract operation is Actual or Rs.60,000/- which ever is less for each eye.
4. Hospitalisation in Ayurvedic/Homeopathic/Unani hospitals is restricted to 25% of Total Sum Insured, provided it is a Govt or Recognised or accredited hospital. However, Steam Bath, Shirodhara & Panchakarma and similar Ayurvedic treatments are NOT payable except when it is part of treatment required to treat such illness / disease/injury.
5. Actual or Rs.5000/- ambulance charges (per trip) is payable for shifting the patient from Home to Hospital / from one hospital to another / from Hospital to home, on production of proper bill. For Cardiac patients Cardiac Equipped Ambulance the Charges are Rs.10,000/-.
6. In case of Organ Transplantation, hospital charges of both donor and recipient is payable, within the Total Sum Insured of the recipient. Cost of the Organ is NOT reimbursable. 7. For Lasik Laser Treatment Rs.35,000/- per eye is payable, some restrictions apply.
8. ARMD and/or treatment for retinal disease by intravitreal/intraocular injection/intervention is admissible up to Rs.1,00,000/- per member per eye per year.
9. Robotic Surgery for Malignant Cancer / Cancer, Brain & Spine only are payable.
10. For Cochlear Implant surgery (including cost of Cochlear implant), Rs.10,00,000/- per member is payable with excess of Rs.1,50,000/- to be borne by Insured member.
11. For Psychiatric and Psychosomatic disorder – only Hospitalisation expenses are reimbursable to the limit of Rs.50,000/-, per member per year. Pre & Post-hospitalisation expenses NOT allowed.
Part E : Maternity Expenses Benefit
1. Maternity medical expenses traceable to childbirth are reimbursable.
2. Normal Delivery : Actual or Rs.65,000/- ; Ceasarian Section : Actual or Rs.1.25 Lacs whichever is less.
3. Claim in respect of first TWO living children and / or Operations associated there with will be considered. Delivery of Twins is considered as Maternity for Single Child.
4. Reimbursement for Lawful MTP is payable, voluntary MTP expenses are NOT payable.
5. Expenses in respect of new born Child, during delivery confinement period is covered under Family Floater Sum Insured.
6. New born Child is added to the Policy of the Insured once the child is declared for insurance by the Insured and premium is paid. This however, is applicable only after the child is discharged from the Hospital.
7. Congenital Internal defects/diseases are covered. Congenital External defects/diseases are NOT covered.
8. Pre-natal and Post-natal expenses are NOT covered, unless admitted in Hospital and treatment is taken as inpatient.
Part F : EXCLUSIONS
The Group Mediclaim Policy lists 26 Exclusions. They are as under :
i. Injury/illness directly or indirectly attributable to War, invasion or warlike situation.
ii. Circumcision, cosmetic or aesthetic, plastic surgery unless required to treat illness/injury. iii. Vaccination & Inauculation. iv. Cost of Braces, eye glasses, cost of spectacles / contact lenses, hearing aids. v. All types of Dental treatments except arising out of accident. vi. Convalescence, general debility, 'run-down' condition or rest cure, obesity treatment, infertility, sterility, use of intoxicating drugs/alcohol, use of tobacco leading to Cancer. vii. Bodily injury dur to Deliberate exposure to danger, intentional self inflicted injury, attempted suicide.
viii. Treatment of any Bodily injury / illness sustained whilst or actively involved in any hazardous sports. ix. Treatment of any Bodily injury/illness sustained whilst or as a result of participating in any Criminal act.
x. Charges incurred at Hospitals primarily for Diagnosis, X-ray or Lab exams or other diagnostic studies not consistent with or incidental to the diagnosis and treatment for which hospitalised. xi. Vitamins and tonics unless forming part of injury/disease as certified by attending Doctor.
xii. Naturopathy treatment/ xiii. External and durable Medical/Non Medical equipment of any kind used for diagnosis. xiv. A) Genetic Disorders. However, treatment for THALESSIMA, Haemophilia, Sickle Cell Anemia, Hemolytic anemia, myeloma requiring Hospitalisation are covered with Pre & Post Hospitalisation both as inpatient and OPD subject to a max of 75% SI.
B) Stem cell implantation / Surgery. (i) Restricted to HSCT for certain Cancers of Blood, Bone marrow to the extent of 75% of the SI. (ii) Stem Cell transplantation treatment for Cerebral Palsy and multiple Scerosis covered max of 50% of SI. xv. Treatments taken outside India. xvi. Experimental / unproven treatment.
xvii. Change of treatment from one system to another, unless recommended by treating Doctor under whom the treatment is taken.
xviii. Any other charges except Registration/Admission charges & GST/Surcharges.
xix. Treatment such as RFQMR, Ozone Therapy, ECP, EECP, Hyperbaric Oxygen Therapy are admissible only as Hospitalisation expenses. xx. Voluntary Medical Termination of Pregnancy. xxi. Acupressure, Acupuncture, Magnetic therapies. xxii. Treatment arising from or traceable to miscarriage, abortion or complications. Except abdominal operation for extra uterine pregnancy. xxiii. Lasik Laser treatment to get rid of Spectacles or contact lenses unless the treatment is for keratotomy of insured having more than (-4) refractive error, recurrent corneal erosion, nebular opacities, non healing ulcers. Refer clause D section 7. xxiv. Physiotherapy, pre or post-hospitalisation is restricted to Rs.40,000/- per person per year.
Treatment taken in Physiotherapy centres or at clinic only payable. However, if the patient is permanently or temporarily disabled, with prescription of Doctor Physiotherapy taken at home is payable, minimum 15 are required. xxv. Congenital external Defect / diseases / deformities. xxvi. Any expenses relating to cost of items detailed in Annexure II.
One has to go through them carefully. Lot of claims are rejected as they come under Exclusions.
Part G : Definitions
Thirty seven definitions are given under this part for the terminologies used in the Policy. Important ones are Domiciliary Hospitalisation, who are covered under the Policy, what is Day Care Center etc.,. A dependent is one whose monthly income is not more than Rs.10,530/-. In case of Parents and Parents -in-Laws the income of both should be considered to decide eligibility. This income limit is applicable from 01-04-2020. The Income Limit to decide the dependency is reviewed every year.
Part H : Conditions
1. Notice of Hospitalisation to be given to TPA through OS Dept., of the Division within 7 days.
2. Claim with all the requirements to be submitted to TPA through OS Dept., of the Division within 20 days of the date of discharge.
3. The Insurer may ask for Physical Examination of the Insured, in respect of whom claim is preferred, by a Doctor specified by the company.
4. When claim is repudiated, the TPA has to inform the reasons for repudiation.
5. Mid-term inclusion of employee / dependent not allowed. Exception is New born child and recruitment of the employee.
6. Insurer has to settle / reject the claim within 30 days of the receipt of last document.
7. Hospitalisation falling in to two policy years, then the Date of Admission, which will be in the previous policy year will be taken into account. The Sum Insured under the new policy will not be available for the claim (including Pre and Post Hospitalisation expenses). Claims are settled on per event basis.
8. Claim Documents :
a) Claim form duly completed and signed.
b) Prescriptions and original Cash bills for purchase of drugs/medicines.
c) Original Discharge Summary / Card.
d) Original Numbered Bill / Cash Memo and Money Receipts.
e) Diagnostic / Pathological Test Reports (Original or Attested)
f) Surgeon's certificate stating nature of operation performed.
g) Attending Doctor's/ Consultant's/ Specialist's/ Anesthesist's Bill and receipt and certificate regarding diagnosis.
h) Contact number, email id and correspondence address of the Claimant.
All the above requirements are to be sent to TPA. Also an authorisation to the TPA/Company to obtain Medical and other records from any Hospital, lab or other agency.
GRIEVANCE REDRESSAL
For any grievances Claimant can approach this authority on the following address :
Grievance Cell, The New India Assurance Co., Ltd.,
Mumbai Regional Office III, 3rd Floor, 17/A Cooperage Road, MUMBAI – 400 001.
INSURANCE OMBUDSMAN : Claimant can also approach Insurance Ombudsman on the following address for SCZ employees / Pensioners :
Insurance Ombudsman,
Office of the Insurance Ombudsman,
6-2-46, 1st Floor, Moin Court,
A.C. Guards, Lakdi-ka-pool, HYDERABAD, 500 004.
Tel No:040-65504123. Fax :040-23376599.
Email : insombudhyd@gmail.com
ANNUXURE I
Gives list of “A” & “B” class cities. In our Zone Bengaluru and Hyderabad(including Secunderabad) are A class cities. Vishakhapatnam and Vijayawada are B class cities. All others are C class cities.
ANNEXURE II
Contains list of Non-medical items which are either NOT PAYABLE or partly payable. The list runs into 11 pages containing 198 items. I only list below the items which are payable either partly or fully.
Item No. Details of the Items Suggestions Item No. Details of the Items Suggestions
12 Razor Payable when used for Operation site
Preparation. 15 Belts / Braces Payable for thorasic or lumbar spine surgery.
23 Disposable Razors Payable. 31 Leggings Payable in bariatric or Vericose Vein surgery.
45 CLINIPLAST Payable during
Hospitalisation. 46 Crepe Bandage Payable during
Hospitalisation.
47 Curapore --- do --- 49 DVD, CD charges Payable.
51
52
53 Face Mask
Flexi Mask
Gauze soft Payable during
Hospitalisation. 54
56 Gauze
Hansaplast /
Adhesive Bandage Payable during
Hospitalisation.
58 Slings Reasonable cost of One sling for Upper Arm fracture. 66 Psychiatric &
Psychosomatic disorders. Payable refer to D (11).
67 Eye Surgery for refractive error correction. Payable refer D (7). 70 Admission /
Registration Char. Payable.
75 Ward & Theatre booking Charges. Payable under OT
Charges. 76 Arthroscopy &
Endoscopy Instru. Rental Charged by
Hosp. Payable.
77 Microscope Cover Payable under OT ch. 78 Surgical Blades, Harmonic Scalpel, Shaver. Payable during
Hospitalisation.
79 Surgical Drill Payable during Hosp. 80
81 Eye Kit
Eye Drape Payable under OT charges.
82 X-ray Film Payable as Radiology Charges. 83 Sputum Cup Payable during
Hospitalisation.
84 Boyles Apparatus Charges. Payable during
Hospitalisation. 85 Blood grouping & donors matching. Part of cost of Blood.
86
87 Antiseptic or disinfectant lotion.
Band aids, bandages, sterile injections, needles, syringes.
Payable during
Hospitalisation.
88
89
90
91
93 Cotton
Cotton Bandage Micropore/ surgical tape
Blade
Torniquet.
Payable during hospitalisation.
94 Ortho/Gynaec bundle. Part of Dressing
Charges. 95 Urine Container. Payable during hospitalisation.
96
97 Luxury tax
HVAC Actual Govt., charges payable as part of Room rent. 98
99 House Keeping ch. Service Charges where Nursing Ch. also charged. Within room rent eligibility, payable.
100 TV & AC charges. Part of Room charge. 101 Surcharges. Payable.
102
106 Attendant charges. Blanket Part of Room charge. 105 Extra Diet of
Patient. Diet provided by hosp.
is payable.
118 Cost of Medicine on Discharge. Payable as posthospitalisation. 129 Mortuary Charges. Payable upto 24 hrs. Shifting ch not paid.
134 CPAP/CAPD equipments. Rental payable during hospitalisation. 135 Infusion pump – cost. Payable during hospitalisation.
149 Lumbosacral Belt. Payable for surgery of Lumbar Spine. 150 Nimbus, Water or Air Bed. Payable for any ICU patient for more than 3 days in ICU,
Paraplegia/quadriplegi a patients @ Rs.200/- per day.
154 Abdominal binder. Payable in post-surgery for major Abdominal operations. 155 Betadine, spirit, hydrogen peroxide ,disinfect ions etc Payable if prescribed.
158 Sugar free tabs. Sugar Free variant of Medicines payable. 159 Creams, Powders, Lotions. Payable if prescribed.
160 Digestion gels. Payable if prescribed. 161 ECG electrodes. One set every second day is payable.
162 Gloves All types of Gloves
Payable during
hospitalisation 163 HIV Kit Payable Pre-surgery screening.
164 Listerine,
antiseptic mouth wash. Payable when prescribed. 165
166 Lozenges
Mouth Paint Payable when prescribed.
167 Nebulization Kit. Payable if used during hospitalisation. 168
169
170 Novarapid
Volini, Analgesic Zytee Gel Payable when prescribed.
171 Vaccination charges. Post bite vaccination charges payable. 180
182
185 Exam. Gloves. Mask
Oxygen Mask Payable during hospitalisation.
187 Pelvic traction belt Payable in case of PIVD requiring traction. 194 Ambulance charges. Payable. Refer D (5).
195 Tegaderm / Vasofix Safety. Payable. Max. 3 in 48 hrs, then 1 in 24 hrs. 196 Urine Bags. Payable where medically necessary.
Max 1 per 24 hrs.
198 Stockings. Payable for case like CABG etc., 68 Treatment for STD & HIV/AIDS. Payable. Deleted from Exclusions this year.
ANNEXURE III
List of 189 surgeries / procedures, for which 24 hour Hospitalisation is not necessary. The list runs into 6 pages. Any other Surgery / Procedures agreed by New India / TPA which requires less than 24 hours hospitalisation due to advancement in Medical Technology can be considered.
ANNEXURE IV
Gives list of Ombudsmen with their Addresses. Ombudsman address for our Zone (Karnataka, Andhra and Telangana states) is given above.
A separate Note on International Second Medical Opinion services will be prepared and sent.
Compiled by
05-05-2020 C T JOSHI
Mobile : +91 9731955044 email id : joshi.chidambart@gmail.com
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