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 General Secretary: Ashok J. Joshi
Mob No: 9880683639 Mob No: 9561084182 & 9945104570
Date: 22-01-2025
Cir No 3/2025
The Executive Director (Per),
LIC of India, Central Office, Yogakshema,
MUMBAI,
Dear Sir,
Re. Improvement/addition in Group MediClaim policy for the year 2025-26.
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 01.04.2025. 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 including parents and
parents-in-law (for what so ever reason); to give one more option to VRS optees; and
also, to include son in law and daughter in law (as is allowed for GIPSA 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 the case of RBI Pensioners.
b. Hospital cash benefits of 1% of S.A., for a maximum of 30 days, as available in
general insurance mediclaim policy.
c. Preventive health checkup benefit, every year. This will reduce claims.
3. Increase basic Floater Sum Insured from 10 lac and 15lac to 15 lac and 20 lac with
100% contribution from LIC.
Increase Optional Total Sum Insured 75 lac to One Crore, with an option to insured
member/family Pensioner, to reduce the sum assured from the 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 class metro cities, the room rent limit has not at all increased for a long
time. This needs to 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 charges,
except 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 on the
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 that are very much part of the treatment as 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 the 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 the case of Renal Failure, Organ Transplantation and Cancer related ailments,
post hospitalization limit of 60 days is waived. We propose more life-threatening
diseases, such as Open Heart Surgery, brain, and central nervous system related
diseases, osteoporosis, spine, Veno plasty surgeries, Diabetes and the cost of Botex
injection may be included in the above list.
In the master policy, certain Cancer like treatment, post 60 days hospitalization
conditions are waived. TPA is disallowing the cost of Medicines NOT pertaining to
Cancer like drugs such as DM and HTN. These used to get reimbursed earlier.
We demand that all medicines prescribed at the time of discharge should be
reimbursed.
Chairman's relief fund exists for in service Employees. A similar fund may be created for
pensioners. In a few cases, TPA denies claim amount in total or in part. If this amount
exceeds Rs 1000, this may be reimbursed from this Fund. The maximum limit can be
fixed as per the pensioner family floater.
For some age-related problems like Alzheimer/Paralysis/Fracture/Accident, it becomes
difficult to take care of patients at home even after keeping a full-time attendant. In such
cases, the patient is kept in Day Care Centre or Asylum. The charges of such a centre
may be reimbursed on a monthly basis.
8. Cashless reimbursement through TPA.
TPA should give total cashless reimbursement, and hospitals should not be allowed to
receive any amount from Insured.
Whenever the General Insurance Council (GIC) in consultation with general and health
Insurance companies has launched CASHLESS EVERYWHERE initiative to extend the
cashless treatment at all Hospitals, our Insurer NIA should also implement the same
through the TPAs available.
In that case, we propose for abolishing or suitably modifying clause 4(a) of Policy
condition at page 14.
TPA should arrange 24×7 hours service, and their NETWORK HOSPITALS be set up
to Taluka level in the entire country.
They should settle the final bill very fast within two hours at the time of discharge of
patient and also not ask lump sum deposit amount during non-working hours/days.
Where Cashless facility is not available due to non-Empanelment in Reputed Hospitals
– (Like TATA CANCER HOSPITAL etc in Kolkata)- LIC should come forward to
advance money to the hospital on behalf of insured/Claimant and the same can be
recovered while settling the bill. This is because the treatment of cancer is costly and
reputed organisation like TATA CANCER Hospital doesn’t like to be empanelled.
9.All Zonal TPAs should coordinate among each other and provide their network
hospitals for treatment of insured members of other OTHER ZONES on a cashless
basis.
10. Examination relating to diagnostic tests without hospitalization:
The list should be more comprehensive, and the cost of the tests mentioned in the list
will become increased by at least 25%. Include sleep apnea, VTR WITH MVO/SUC test,
allergy reports, stress Thallium test, and more diagnostic tests; and conditions may be
liberalized. We propose all tests which cost Rs.1000/- or more to 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 the above tests.
11. Sub-limit Clause:
a. The present limit of cataract operations is Rs.70,000/- 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. IRDA vide Circular
IRDA/HLT/CIR/GDL31/01/2024 has clearly stated to consider AYUSH treatment at par
with other treatments w.e.f 1.4.2024. As such, we request to remove restriction of
reimbursement of 25% of sum insured and TPAs be advised to act as per the IRDA
GUIDELINES and enrol more and more network hospitals for Ayurvedic and
Homoepathy treatment and allow cashless facilities. Treatments like Shirodhara, Steam
bath, and Panchakarma should be allowed.
c. Ambulance charges be revised upward, and restrictions are removed. Ambulance
charges from hospital to home be allowed.
d. Age Related Macular Degeneration (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 is to be removed, and the actual amount be
reimbursed.
e. Psychiatric and psychometric disorders are payable up to a limit of Rs.50000/-. This
limit may be removed, and pre and post 30/ 60-day treatment charges may also be
reimbursed.
f. In case of domiciliary hospitalization or where the condition of the patient after
discharge from the hospital is such that he/she needs the services of unqualified
domestic aid/qualified nurse, full reimbursement be provided for the same for both
qualified nurses or unqualified domestic aid, as the case may be.
g. 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 caesarean 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. Vaccination and Inoculations expenses be reimbursed.
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 for inservice employees. Many retirees/pensioners visit foreign country (as their siblings are
in a 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, same should be included for reimbursement in lieu of joint
replacement.
d. Robotic surgery should be allowed wherever this facility is opted by a treating doctor.
e. Cost of hearing aids be allowed.
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 online and claim documents be allowed online through soft
(scanned) copies, instead of submitting hard copies in the OS dept., because senior
citizens cannot be expected to be mobile.
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 are included, such as sebaceous cyst surgery, in Annexture III, where
24-hour hospitalization is not mandatory.
g. Option to join the scheme be given to all i) resignees, ii) to those who resigned on
health grounds, irrespective of their date of retirement (the cutoff date prescribed is
16-1-2018).
We vehemently appeal to you to consider our suggestions/improvements and call
NOIP delegation for discussions, at the time of negotiations with New India Assurance Company Ltd., for the year 2025-26.
With thanks and regards,
Yours sincerely,
General Secretary
