NOIP Circular No 8 - 2023

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: 26-02-2023

Cir No 08/2023

The Executive Director (Per),

LIC of India, Central Office, Yogakshema,

MUMBAI,

Dear Sir,

Re: Mediclaim related issues

Every year we suggest some important changes in our Group Mediclaim policy with a view to smooth 

functioning and hassle-free servicing. We have requested you that ROOM RENT should be exclusive one 

and delete other charges and/or PROPORTIONATE DEDUCTION clause vide our detailed submission 

dtd.15-01-2023.

 We are mentioning here two cases, to show how eligible amounts are deducted by TPAs on the pretext 

of higher room rent and proportionate deduction clause:

Case 1.

CNN NO. MDI749048, Total bill amount Rs.1,47,953. Deduction amount Rs.50,036/- The deduction 

amount was mainly due to wrong interpretation of Room rent and proportionate deduction clause. On 

our intervention, helped the honorable member to prepare a representation, Rs31,000 approx. was paid 

and further representation will be made for the rest of amount.

Case No. 2.

MD ASSIST ID 4015521017, Total bill amount Rs.4,25,647/-, Deductions Rs.2,27,702/-. 

Reason for deduction, wrong interpretation of Room rent and Proportionate deduction clause. After 

representation total deduction was reduced to approximately rupees TWENTY THOUSAND from 

Rs.2,27,702.

In both the cases room rent was within the allowable limit, still TPA harassed our honorable members 

(Senior citizens). 

If the room rent is not made exclusive one and the sky high medical expenses continue, then the limit of 

Rs10,000/- for Metro, 7,500 for A category, 6000 for B category and 4000 for other cities will be 

insufficient after considering Boarding, Nursing (including injection/Drugs and Intra venous Fluid administration Expenses), DMO/RMO/CMO/RMP charges. In that case we have to be treated in general

wards only, else, have to face huge deductions mentioned in above two cases.

Hence, we reiterate our demand to delete other charges and/or PROPORTIONATE DEDUCTION CLAUSE

and ROOM RENT SHOULD BE EXCLUSIVE ONE.

Expecting your positive response,

With thanks and regards

Encl: TPA letters

 Yours Sincerely,

 General Secretary

NOIP Circular No. 7 - 2023

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: 19-02-2023

Circular No 07/2023

To,

The Chairperson,

LIC of India, Central Office,

YOGAKSHEMA, Mumbai

Dear Sir,

Re: Various Cut-off dates- A big blow on the gullible, hapless pensioners

Regarding the captioned matter, time and again we have brought to your kind notice, as to how the

various new benefits are being denied to the section of pensioners by prescribing the cut-off date for

every new benefit. Ironically, these cutoff dates are plaguing the old retirees in every aspect. No doubt,

the future retirees would be benefited. But what is the sin the earlier retirees have committed, as they

are losers of every new benefit extended to the pensioners. We are happy that LIC has been

magnanimous nowadays, in extending various new benefits and improving upon existing benefits to in-

service employees/future retirees. We, old retirees, especially above the age of 65 are the worst

sufferers. In every benefit, we are being excluded by way of cut-off dates. In the initial decades after

LIC’s coming into being, old retirees have strived a lot to make the LIC as to what it is now. Even the

Indian ethos/culture advocates- taking proper care of elderly people. Even the LIC has adopted the

slogan- ‘Yogakshemam Vahamyaham’, taking cue from the great epic Bhagavad-Gita. No doubt, LIC

cares for the Yogakshema of its policyholders, who are our masters. As a matter of equity, old retirees

too, deserve to be treated well by our great organization. That is the least we expect.

Hence, it is expected of the policy makers/rule makers to keep the above in mind, while framing new

benefits/improving the existing benefits for the employees/retirees. And also to see that the

discrimination based on the date of retirement, should be kept at bay .We are really fed up with the

plethora of cut off dates and every time a new benefit is declared, we curse our fate (cannot do anything

except this) because a large section of retirees is deprived of the benefit. We implore upon you to stop

forthwith the prescription of cut off dates for granting of benefits. This can only ensure justice, equity

and fair play to the retirees of all times.

We request you to have a cursory glance at the following few cut off dates which have marred the

fortunes of old retirees from time to time. Some more cut off dates too, might be staring at us?? Who knows.

Cut off date Benefit

1) 01-11-1993 Pension updation not effected till date whereas future retirees get

updated pension till their date of retirement

2) 01-08-1997 100% neutralization of DR, earlier retirees getting truncated DR

3) 01-04-2011 Mediclaim option not given thereafter to join the scheme

4) 16-06-2018 Continuation of coverage of Mediclaim to PF optees resigning on the

reason of self illness

5) 01-04-2018 GIS (Group Insurance Scheme) to retirees

6) 01-12-2021 Conversion of extended cadre loan (housing) into Basic Loan (new name

for cadre loan.

We request you to remove the above cut off dates, wherever feasible and which are within your

powers, so that old retirees can take a pleasant sigh and feel blessed.

We anticipate your positive response,

With thanks and regards,

 General Secretary

Circular 1 - Pending issues

 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: 11-01-2023

Circular 01/2023

The Executive Director (Personnel),

LIC of India, Central Office, Yogakshema,

MUMBAI

Dear Sir,

Re: Pending issues

You may please recall our meeting held with you on 19-10-2022, wherein we discussed various pending

issues. We are yet to get the expected positive response from you regarding some of the following

major issues.

1) Reckoning ADO’s period of retired development officers for calculation of gratuity and

pension

We had urged you to issue clarificatory circular regarding this issue, after you regretted to

consider the period spent on apprentice by the development officer, for the calculation of

gratuity and pension. The earlier letter by the Chief (Personnel) in this regard, clearly says that

ADO’s period (training period) is to be considered for calculating gratuity; and Pension Rules

1995, provide for considering the period spent on training for calculation of pension. As such,

we once again implore upon you to issue a clarificatory circular in this regard to the operating

offices forthwith and oblige.

2) GIS to all the retirees irrespective of date of retirement- Please refer to our earlier letter dtd.

15-11-2022. We once again request you to offer GIS to all the retirees irrespective of the date of

retirement, since the entire premium would be borne by the retiree.

3) Exclusive App for the pensioners- We were thankful to you for having acceded to our request

for an exclusive App for the pensioners. We request for the early release of the same.

4) One more option to join the group Mediclaim scheme- As discussed in detail, one more option

to left over retirees may please be given to join the scheme, at least from 1-4-2023.

5) Exclusive Portal for the pensioners- On the similar lines of an App for pensioners, we request

you to take steps to design and develop an exclusive portal for the pensioners, to cater to their

various needs.

In anticipation of positive response from your end,

Thanking you,

 General Secretary

Circular 02/2023 - Improvement/addition in Group MediClaim policy for the year 2023-24.

 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 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 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

Photos of Surat conference 13 & 14 September 22

A NOTE ON GROUP MEDICLAIM POLICY : 2022-23

 A NOTE ON GROUP MEDICLAIM POLICY : 2022-23
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 theefforts of NOIP. We give here below a gist of the Mediclaim policy for the use of our retired members.
Independent Children, till their age 45 (whether married or unmarried / employed or not), can also beincluded from current Policy Year. Every year the Insurer will do a review of Premium to be paid basedon Claims experience.
For Retirees the premium recovery from Pension commences from February Pension payable on 1stMarch and for in-service employees recovery starts from March Salary.
The Group Mediclaim Policy of LIC is currently with New India Assurance Company Ltd., The sameis 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 :nia.120700@newindia.co.in
SDM is Sri P N Ajulraj & his mobile Number is +91 9447155123; 022-22892776;
email id : ajulraj.pn@newindia.co.in;
Person looking after Mediclaim : Smt. Meghna Dixit, AO, 022 – 22846889
email id : meghna.dixit@newindia.co.in;
Eight(8) TPAs have been enlisted by New India Assurance Co., Ltd., for 8 Zones of LIC of Indiathrough out India. The Zone wise list of TPAs are below with Toll Free Number dedicated to LIC :
Sl No. ZONE T P A Policy Number
1 West Zone & C O MD India Healthcare Services TPA Pvt
Ltd., Toll Free No(LIC):1800 209 7600
12070034220400000001
www.mdindiaonline.com
2 Central Zone Health India Insu. TPA Services Pvt Ltd.,
Toll Free No(LIC):1800 226 970
12070034220400000002
www.healthindiatpa.com
3 Northern Zone Good Health Insurance TPA Ltd.,
Toll Free No(LIC):1800 102 8673
12070034220400000003
www.ghpltpa.com
4 North Central Zone Raksha TPA Pvt Ltd.,
Toll Free No(LIC):1800 180 1555
12070034220400000004
www.rakshatpa.com
5 East Central Zone Vipul Medcorp Insurance TPA Pvt Ltd.,
Rajeev Agarwal : 9931107825
Toll Free No(LIC):1800 102 7477.
12070034220400000005
www.vipulmedcorp.com
6 Eastern Zone Heritage Health TPA Pvt Ltd.,
Toll Free No(LIC):1800 102 4547
12070034220400000006
www.heritagehealthservic
e.com
7 South Central Zone Medi Assist India TPA Pvt Ltd.,
Toll Free No(LIC):1800 419 1154
12070034220400000007
www.mediassist.in
8 Southern Zone Vidal Health TPA Pvt Ltd.,
Toll Free No(LIC):1800-425-6268(Ker)
1800-425-7595 (T N)
12070034220400000008
www.vidalhealthtpa.com
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 : 12070034220400000007
Toll Free Number(dedicated for LIC) 7022085000 / 1800 419 1154
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, 75L.
II Rs.6,00,000/- 8L, 10L, 12L, 15L, 20L, 25L, 30L, 40L, 50L, 75L.
I Rs.10,00,000/- 12L, 15L, 20L, 25L, 30L, 40L, 50L & 75L..
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 persons, Retired employee, Spouse &
disabled dependent 2 children (CO/PER/ER-A/CL 14 dtd. 22-06-2013).
For ASA : 100% to be borne by Insured. For Parents / Parents-in-Laws, Dependant
children 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. For “A” Class cities the limit is Rs.7500/- (Rs.10,000/- forthose who have opted for 40L / 50L SA) and at all other places it is Rs.4000/- per day. [Roomrent + Boarding Charges supplied by Hospital + Nursing Charges (includingInjection/Drug & intravenous Fluid administration charges) + DMO/RMO/CMO/RMPcharges of the Hospital, are included].
Propotionate Deduction Clause : If one chooses a higher room rent category than he is eligible, then Proportionate deduction will be applicable on Associate Medical Expenses.
However, this clause is NOT applied to i) Cost of Pharmacy and consumables, ii) Cost of
Implants and Medical Devices and iii) Cost of Diagnostics.
3. However, there is NO CAPPING / CEILING for admission in ICU/ICCU.
4. Associate Medical Expenses : Surgeon, Anesthetist, Med. Practitioner, Consultants andSpecialists Fees, Anesthesia, Blood, Oxygen. OT charges and procedure charges such asDialysis, Chemotherapy, Radiotherapy and similar expenses.
5. Cost of Pharmacy such as Medicines, Drugs, Surgical appliances and Consumables, Cost ofImplants and Medical Devices including prosthetic devices implanted during surgical proceduresuch as Pacemaker, Cost of Diagnostics such as Relevant Laboratory/Diagnostic tests,Diagnostic Materials such as X-rays and other similar expenses are reimbursable.
6. Pre-hospitalisation medical expenses for a period of 30 days and Post-hospitalisation medicalexpenses for a period of 60 days are reimbursable (in case of Renal failure and / or OrganTransplantation or Cancer related ailments this period may be waived. The only conditionis that the Reimbursement amount on each occasion should not be less than Rs.10,000/-).
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 incorporatedin 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 provides Cashless and Reimbursement facility through TPA. Cashless is availablein the networked Hospitals only. For Reimbursement admission in any Hospital will do.
2. If a retired employee shifts his residence from one place to another place/employee istransferred out of Zone, the original TPA only will provide services based on Pan Indianetwork hospitals.
3. Procedure for Availing Cashless Hospitalisation Services: a) available only at TPA networkhospitals. b) E-card and a Photo ID of the patient to be submitted to TPA. c) If no e-card isavailable then a Certificate issued by OS Dept of the Division will do. d) A pre authorisationform is to be filled in completely duly signed by claimant and the treating doctor. e) All theabove three requirements are to be sent to TPA on its mail id or by Fax. On receipt TPA will
issue a 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 refuses to give pre
authorisation, then the 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
(A)
1. The following (16) Diagnostic Tests without hospitalization 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.8500/- CT Scan charges Rs.6500/-
Sonography (excluding
Maternity related)
Rs.2500/- Biopsy Rs.4500/-
TMT Rs.2000/- Echo test Rs.2000/-
Gastroscopy Rs.5500/- Colonoscopy Rs.7500/-
EEG Rs.1000/- EMG Rs.2000/-
Holter Monitor Test Rs.5000/- PAP Smear Rs.1500/-
Mammography Rs.5500/- PET Scan Rs.20000/-
Prostate Specific Antigen Rs.750/- Angio CT Rs.6500/-
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.
(B)
FACILITY OF TELE CONSULTATION
From current Policy Year facility of Tele Consultation has been provided by the Insurer Free of Cost.
To avail this facility is made available to all persons insured under the Family Floater Mediclaim
Policy. The facility is available 24x7 through MediBuddy (MB) Application of MediAssistIndia TPA
Pvt Ltd., To avail this facility one has to activate MB Gold in MediBuddy App.
The flow chart is as follows :
1. Download MediBuddy App (about 42MB) from Playstore / Appstore.
2. Click on “I have Corporate Account” and Log-in giving your SR Number viz 123456@LIC
click on proceed it will ask you to keyin Password : your DOB in DDMMYYYY format.
3. Key in your Mobile Number. You will receive an OTP. Key in the OTP for verification.
4. Click on MB Gold Banner. Click on Activate sponsored annual subscription. It is FREE for LIC
employees / Retirees and their Family Members.
5. Click on “Talk to Doctor”. Choose your Doctor’s Speciality and enter your health symptoms.
6. You will receive a call from the Doctor shortly.
(C)
FACILITY OF MEDICAL EXAMINER
The Insurer has provided a facility of Placing a Medical Examiner at each Zonal Head Quarters and at
Central Office for consultation by Employees / Retired employees on all working days between 11-00
am to 4-00 pm FREE OF COST. However, this facility is NOT available for dependent/independent
Family members.
Details of Medical Examiner placed at Hyderabad for SCZ is Dr. Syed Mukthar Mohiuddin,
MBBS,MD. Who will be available in CRM department of Zonal Office, Hyderabad.
He can also be contacted on Phone Number : 040-23230346 on all working days between 11-00
am to 4-00 pm for consultation.
Part D : Sub-Limit Clause
1. Payment is made for admission in ICU/ICCU as part of hospitalization bill only.
2. Bills raised by Surgeon/Asst. Surgeon/Consultant/Specialist/Anesthetist directly are payable as
below : a) Max. 25% of the Total Sum Insured Max of Rs.10.00.000/- 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/- ;
Anesthetist : Rs.20,000/-. Provided a numbered bill is submitted for all above.
inclusive of all charges excluding Service Tax.
4. Hospitalization 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/-
for admission to the Hospital only.
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, Heart & 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/- ; Caesarian Section : Actual or Rs.1.25 Lacs
whichever is less (Payable only if expenses are incurred as in-patient in Hospital).
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, even if the Child is shifted to another Hospital. However,
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 due 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 treatment for 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 (-4) and above 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 a prescription of Doctor Physiotherapy taken at home
is payable, minimum 15 are required. The pre & post Hospitalization of 30/60 days shall not
be applicable for patients who are totally and permanently disabled/paralyzed.
xxv. Congenital external Defect / diseases / deformities.
xxvi. Any expenses relating to the 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.11,790/-. In case of Parents and Parents
-in-Laws the income of both should be considered to decide eligibility. The Income Limit to decide thedependency 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.
Phone Nos : 022-22822604 / 22821833 /22892701.
Head Office of NIA : customercare.ho@newindia.co.in
seniorcitizencare.ho@newindia.co.in
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 Payable during 85 Blood grouping & Part of cost of Blood.
Charges. Hospitalisation. donors matching.
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
post-hospitalisation.
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
,disinfections 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 for
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
Novarapid
Volini, Analgesic
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 on page 6.A NOTE ON INTERNATIONAL SECOND MEDICAL OPINION SCHEME
The Family Floater Medi Claim Policy for LIC employees / retirees envisages International Second
Medical Opinion scheme from 2019-20 year policy. For the current year also the same has been
continued. This facility is available FREE OF COST to the employee/retiree. This scheme is available
in the Policy Document from Page 5 to Page 9. Let us discuss in brief about this service.
1. An insured under the Policy is entitled to have an expert opinion from World Leading Medical
Center (WLMC) that specialises in the medical condition with which the member is diagonised.
2. This year this facility is provided through MDIndia Healthcare Networx Pvt. Ltd., whose
address and contact details are given below :
Name & Address of this Service
Provider.
MDIndia Healthcare Networx Pvt Ltd.,
S.No.46/1, E-space, A2 Building,
2
nd Floor, Pune Nagar Road,
Vadgaonsheri, PUNE-411 014.
MAHARASHTRA.
EMAIL ID 2ndmedicalopinion@mdindianetwrox.com
Mobile No/Whatsapp No. +91 9607017817
3. For obtaining this facility the Service provider has to be contacted on the above mobile number
or by Email to the above email address by the member, who is eligible to receive the facility
during working hours of New India Assurance company.
4. Once intimation is received, the service provider with members diagnosis by attending
Physician along with Qualifying Medical Condition, will list the best in the world THREE
WLMC's who are expert in diagonising and treating that particular illness. The service provider
will work directly with Attending Physician to collect and assemble all Medical Records for
onward transmission to WLMC.
5. The expert in WLMC will verify the correctness of the Diagnosis on going through the Records
presented. Also it will send the originally proposed treatment plan, treatment options,
international standards of care, newly available and proven treatment approaches.
6. The Opinion will be sent to the Member and attending Physician in writing within 10 working
days. If the service provider fails to obtain the required medical records, then it is the
responsibility of the member to collect the same.
7. The service provider will pay for all costs of Medical Second Opinion process.
8. All benefits under this Program are available only when the Member (Insured) is diagonised
with one or more of the following 17 Medical Qualifying Condition.
9. Qualifying Medical Conditions :
A. Open and Close Heart Surgery including CABG.
B. Cardiac ailments neessitating :
1. Pacemakers (including biventricular Pacemakers).
2. AICDs with or without biventricular pacemakers.
3. Radiofrequency ablation.
4. Device closures of ASDNSD/PDA etc. with Valvulopasty(BNV/BAV/BPU).
5. Valve replacements.
C. Angioplasties :
1 Coronary and Peripheral (including Carotid/Renal/Aorto-iliac).
2 Including Stent Implantation (with drug-eluding stents).
D. Cerebra or Vascular Strokes/Paralysis due to any cause.
E. Neurosurgery / Ailments requiring Brain Surgery.
F. Major operations of the spine and vertebrae including correction of congential spinal
deformity.
G. Renal diseases / Failure / Kidney transplants / Dialysis.
H. Malignancy including Leukaemia.
I. Lung Surgery :
1. Lobectomy.
2. Pneumonectomy.
3. Decortication.
4. Removal of Mediastint Tumours.
J. Encephalitis (viral), Visual / Hearing loss.
K. Gall Bladder / Pancreatic Calculi or Nesidioblastosis.
L. Diseases of the Liver leading to failure or transplantation.
M. Surgery of portal hypertension.
N. Organ transplants.
O. Aplastic Anaemia.
P. Cerebral Palsy.
Q. Mysthenia Gravis.
10. Following Exceptions are there where International Second Medical Opinion is not available :
When a Member has not received a Diagnosis – Member must receive official daignosis
from his/her treating Physician. This is pre-requisite for reference to WLMC.
Member has not been evaluated by treating Physician in the last 12 months. Recent
Medical reports are required by WLMC to give treatment recommendations.
If a member has developed an Acute or life threatening condition. There is no point in
waiting for Second Opinion.
Where physical evaluation of the patient is required. Certain cases require physical
evaluation (eg. Mental illness) in such cases remote second medical opinion will not be
given.
This is only a gist in short. For further details policy document should be referred.
Compiled by
VIJAYAPUR
02-06-2022
C T JOSHI.
Mobile : +91 9731955044
email id : joshi.chidambart@gmail.com
3. Claim relating to Cataract operation is Actual or Rs.60,000/- whichever is less for each eye,
expenses in respect of new born child of independent children are not covered.