NATIONAL ORGANISATION OF INSURANCE PENSIONERS
Regn No.PN 4769 (Regd under Indian T U Act, 1926)
(Affiliated to Bharateeya Mazdoor Sangh)
BMS Office, Vishwakarma Bhavan, 185, Shaniwar Peth, Pune 411030.
President: T.C. Gunesh Kumar Working President: Vilas V. Purkar General Secretary: Ashok J. Joshi
Mob No: 9880683639 Mob No: 9922166599 Mob No: 9561084182 & 9945104570
Date: 15-01-2023
Circular 02/2023
The Executive Director (Per),
LIC of India, Central Office, Yogakshema,
MUMBAI,
Dear Sir,
Re. Improvement/addition in Group MediClaim policy for the year 2023-24.
We wish you and all staff members a VERY HEALTHY AND HAPPY NEW YEAR.
We reiterate below some of our long pending demands regarding Group mediclaim
policy.
Shortly discussions may start at your end with the New India Assurance company Ltd.,
for renewal of the Policy wef 01.04.2023. Hence, we felt it appropriate to place our
reminder request for your kind consideration and taking up with NIA.
1. One time option for inclusion in the Policy for all left out cases (for what so ever
reason), also to include son in law and daughter in law (as is allowed for GIC retirees).
2. ADD ON COVERES:
a. Reimbursement of OPD TREATMENT. Retirees and pensioners may be allowed
OPD EXPENSES.
Else, a separate Policy for OPD may be chalked out as in case of RBI Pensioners.
b. Hospital cash benefits 1% of S.A., for maximum 30 days, as available in general
mediclaim policy.
c. Preventive health checkup benefit, every year. This will reduce claims.
3. Increase basic Floater Sum Insured from 5lac, 6lac and 10lac to 10lac, 15lac and
20lac with 100% contribution from LIC.
Increase Optional Total Sum Insured 75 lac to One Crore, with an option to Insured
member/family Pensioner, can reduce the sum assured from next annual renewal date.
4. Coverages:
a. Room rent should be based on S.A, since the Insured pays the same premium
irrespective of his place of stay (whether Metro/City/Village).
For other than A and B cities, the Room rent limit is not at all increased for a long time.
This should go up.
We suggest Rs.12,500/- room rent per day up to 30 Lacs and Rs.15,000/- for 40 Lacs
and above Sum Assured.
b. Presently NURSING CHARGES are also included in the Room rent. The same
should be reimbursed separately (not as a part of room rent).
c. If one gets admitted in a room with higher rent than eligibility, then all other chargesexcept Medicine and Implants- are reduced proportionately. Our request is, in such
cases, Room rent should be reduced proportionately and all other charges are paid in
full.
5. Please delete " *However the following expenses are not payable” mentioned in page
no.4, clause 7 a, b and c as most of the items mentioned are payable as per the
annexture II (item no.75,76,134,84,96,102,155,12, 78, 45, 56 91,23, 87, 104, 189, 78,
12,91,23,135,15,149,58,150,198), some items are used by Doctors for Diagnosis and
Ambulatory devices, is very much part of the treatment as it is advised by treating
doctor. They are not used for personal comfort. Hence unless this part is deleted, it will
create contradiction and confusion, which leads to wrong settlement of claim.
We also request you to overhaul the annexture II and allow more items as payable.
Item no129 Mortuary charges be increased from 24 hours to 48 hours.
6. Pre and post hospitalization Medical expenses be allowed 60/120 days.
7. In case of Renal Failure, Organ Transplantation and Cancer related ailments, pre and
post hospitalization limit of 30/60 days is waived. We propose more Life-Threatening
diseases, such as Open Heart Surgery, Brain and Central Nervous system related
diseases, Osteoporosis, Spine surgeries, cost of Botex injection, may be included in
above list.
8. Cashless Reimbursement through TPA.
TPA should give total Cashless Reimbursement and Hospital should not be allowed to
receive any amount from Insured.
TPA should arrange 24×7 hours service and their NETWORK HOSPITALS should not
ask lump sum deposit amount during non-working hours/days.
9.All Zonal TPA's should co-ordinate among each other and provide their network
hospitals for treatment of insured member of other OTHER ZONES, on cashless basis.
10. Examination relating to Diagnostic Tests without hospitalization:
List should be more comprehensive and the cost of the tests mentioned in the list be
increased by at least 25%, Include Sleep Apnea, allergy reports and more diagnostic
tests; and conditions may be liberalized. We propose all tests which cost Rs.1000/- or
more be reimbursed along with doctor’s fees. MD DOCTORS ARE NOT AVAILABLE IN
RURAL/REMOTE CENTERS or at the time of emergency situations. Hence conditions
may be relaxed and MBBS DOCTORS be allowed to prescribe for above tests.
11. Sub-limit Clause:
a. Present limit of Cataract Operations is Rs.60,000/- per eye which is not reasonable.
Limit should be removed and reimburse full cost of treatment and cost of spectacles.
b. AYUSH:
As per Government policy, Ayush treatment is to be promoted and our Insured
members are very much inclined to it. As such, we request to liberalize the conditions,
remove restriction of reimbursement of 25% of sum insured and TPAs be advised to
enroll more and more network hospitals for Ayurvedic and Homeopathy treatment and
allow cash less facilities. Treatment like Shirodhara, steam bath and Panchakarma
should be allowed.
c. Ambulance charges be revised upward and restrictions are liberalized. Ambulance
charges from Hospital to home be allowed.
d. Age Related Macular Degermation (ARMD) and treatment for retinal diseases by
intravitreal/intra occular injection/intervention are admissible only up to 1 lakh per
member per eye per year, which is very insufficient. Our members are facing hardship
because of the ceiling. The ceiling limit to be removed and actual amount be
reimbursed.
e. Psychiatric and psychometric disorders are payable up to a limit of Rs.50000/- as per
Chapter D (11). Whereas the same is shown as Not payable under Serial no.66 of
Annexure II. It is contradictory, needs correction. The limit of Rs.50000 be removed.
f. Pre and post hospitalization Physiotherapy limit of 40,000 be removed and limit of
30/60 days pre and post hospitalization expenses be waived, allow Physiotherapy
treatment at home for all such patients as per the advice of treating Doctor.
12. MATERNITY EXPENSES BENEFITS: Normal and caesarian delivery benefit cap
be removed and expenses other than hospitalization also be reimbursed.
13. EXCLUSION CLAUSE, list contains 26 items, this should be overhauled to reduce
as much as possible.
a. Reimbursement of all types of dental treatment and costs of dentures, root canal
treatment be reimbursed.
b. Now HCPT reimbursement is allowed for treatments taken outside India. Many
retirees/pensioners visit foreign country (as their siblings are in foreign country).
Reimbursement of expenses incurred in Hospitalization treatment out of India should be
included in the policy (removed from exclusions).
c. PRP (Platelet Rich Therapy)- This is less expensive and less painful compared to
joint replacement surgery,mshould be included for reimbursement in lieu of joint
replacement.
d. Robotic surgery be allowed wherever this facility is opted by a treating doctor.
14. General:
a. Senior citizens be given preferential treatment by TPA AND NIA.
b. Insisting for KYC for each and every claim should be dispensed with. (Since all
claims are processed through D.O.)
c. Submission of Claim form is to be allowed by TPA through soft copies, instead of
hard copies.
d. PPN must not be made applicable by NIA for LIC policy holders/members under our
MediClaim policy.*
e. A and B class cities for mediclaim purpose should be on the basis of CCA cities as
applicable in LIC.
f. More diseases be included, such as, Sebaceous cyst surgery, in Annexture III where
24 hours hospitalization is not mandatory.
g. Option to join the scheme be given to all resignees who resigned on health grounds,
irrespective of their date of retirement (the cut off date prescribed is 16-1-2018)
We vehemently appeal to you to consider our suggestion/improvements, and call NOIP
delegation for discussions, at the time of negotiations with New India Assurance
Company Ltd., for the year 2023-24.
Thanking you,
Yours Sincerely,
General Secretary
