GROUP MEDICLAIM INSURANCE POLICY (RAJ MEDICLAIM) 2020-21

GOVERNMENT OF RAJASTHAN
STATE INSURANCE AND PROVIDENT FUND DEPARTMENT
(GENERAL INSURANCE FUND)

GROUP MEDICLAIM INSURANCE POLICY (RAJ MEDICLAIM)
(01.04-2020 – 31.03.2021)

WHEREAS the insured designed in the Schedule hereto has by a proposal and declaration dated as stated in the Schedule which shall be the basis of this Contract and is deemed to be incorporated has applied to GENERAL INSURANCE FUND (hereinafter called the GIF) for the insurance hereinafter set forth in respect of Employees/Members (including their eligible family members) named in the Schedule hereto (hereinafter called the INSURED PERSON ) and has paid premium as consideration for such insurance.

NOW THIS POLICY WITNESSES that subject to the terms, conditions, exclusions and definitions contained herein or endorsed, or otherwise expressed herein the GIF undertakes that if during the period stated in the Schedule or during the continuance of this policy by renewal any insured person shall contract any disease or suffer from any illness (herein after called DISEASE) or sustain any bodily injury through accident(hereinafter called INJURY) and if such disease(s) or injury/injuries shall be required. Any such insured person, upon the advice of a duly qualified Physician/Medical Specialist/Medical Practitioner (hereinafter called MEDICAL PRACTITIONER) or of a duly qualified Surgeon(hereinafter called SURGEON) to incur hospitalization expenses for medical/surgical treatment at any Nursing Home/Hospital in Rajasthan as herein defined (hereinafter called HOSPITAL) as inpatient, the GIF will pay through TPA/GIF to the Hospital/Nursing Home or the Insured Person the amount of such expenses as are reasonably and necessarily incurred in respect thereof by or on behalf of such Insured Person but not exceeding the Sum Insured in aggregate in any one period of insurance stated in the schedule here to.

1- In the event of any claim/s becoming admissible under this scheme, the GIF shall make payment(s) through TPA to the Hospital/Nursing Home or the insured person the amount of such expenses as would fall under different heads mentioned below and as are reasonably and necessarily incurred thereof by or on behalf of such Insured Person, but not exceeding the Sum Insured in aggregate mentioned in the schedule hereto.

(A) Room, Boarding and Nursing Expenses as provided by the Hospital/Nursing Home as per entitlement of the employee mentioned in the Schedule.
(B) Surgeon, Anaesthetist, Medical Practitioner, Consultants and Specialists Fees.
(C) Anaesthesia, Blood, Oxygen, Operation Theatre Charges, Surgical Appliances, Medicines & Drugs, Diagnostic Materials and X-ray, Dialysis, Chemotherapy. Radiotherapy, Cost of Pacemaker, Artificial Limbs implanted in the body & Cost of organs and similar expenses.
(N.B.: GIF’s Liability in respect of all claims admitted during the period of insurance shall not exceed the Sum Insured per family as mentioned in the schedule)

2. DEFINITIONS:

2.1 HOSPITAL means any registered institution in or outside the state Rajasthan established for indoor care and treatment of diseases and injuries and which are :-
(a) All the Government hospitals in the State of Rajasthan “Including Ayush Treatment”.
(b) The Hospitals outside the state of Rajasthan which have been approved by the Govt. of Rajasthan (Appendix -1)
(c) Private Hospitals with in Rajasthan duly approved Govt. of Rajasthan under the Rajasthan Civil Services Medical Attendance Rules 2013 and also given the acceptance to work with GIF on CGHS Package Rates (Appendix-2 ). Those private hospitals which are added in approved list from time to time by the Government of Rajasthan and give acceptance to work with GIF on CGHS Package Rates, shall also be automatically empanelled under the scheme.
(d) If a private hospital, which is approved for treatment of State Government employees under Rajasthan Civil Services Medical Attendance Rules 2013, has not given acceptance to GIS Office to provide it’s services on CGHS packages/rates and an insured has taken treatment in such hospital, then he/she shall be paid on CGHS package, difference amount shall be borne by him/herself (i.e, insured).

2.2 “Surgical Operation’ means manual and/or operative procedures for correction of deformities and defects, repair of injuries, diagnosis and cure of diseases, relief of suffering and prolongation of life.

2.3 Expenses on Hospitalization for minimum period of 24 hours are only admissible. However, this time limit is not applied to specific treatments, i.e. Dialysis, Chemotherapy, Radiotherapy, Eye Surgery, Dental Surgery in case of accidents, Lithotripsy (Kidney Stone removal), D&C, Tonsillectomy, Hysterectomy, Coronary Angioplasty, Coronary Angiography, Surgery of Gall Bladder, Pancreas & Bile duct, Genital Surgery, Surgery of Nose, Surgery of Throat, Surgery of Appendics, Surgery of Urinary System, Arthroscopic Knee Surgery, Laparoscopic, Therapeutic Surgeries. Any surgery under local Anaesthesia, Treatment of Fractures/ Dislocation excluding hairline fracture Contracture releases and minor reconstructive procedures of limbs which otherwise require hospitalization taken in the approved Hospital/Nursing Home and the Insured is discharged on the same day, in such cases the treatment will be considered to be taken under hospitalization benefit. This condition will also not apply in case of stay in hospital of less than 24 hours provided Explanation to the treatment is such that it necessitates hospitalization and the procedure involves specialized infrastructural facilities available in hospitals and due to technological advancement hospitalization is required for less than 24 hours only. It would be certified by concerning Doctor under whom treatment is given and vetted by TPA

2.4 CGHS packages shall be applicable in Rajasthan, as laid down by CGHS for Jaipur City and it shall be applicable (exclusive of policy clause 6.3, 9.1 and 9.2) as laid down by CGHS for various places in India. The bed charges shall be paid according to the category of employee. the diseases/ Investigation for which no Packages rate is mentioned in CGHS packages rate then it will be paid according to The “Civil Services medical attendance rules 2013” of Government of Rajasthan.

3. ANYONE ILLNESS:

Any one illness will be deemed to mean continuous period of illness and it includes relapse within 45 days from the date of discharge from the Hospital/Nursing Home where treatment has been taken. Occurrence of the same illness after a lapse of 45 days as stated above will be considered as fresh illness for the purpose of this policy.
3.1 PRE-HOSPITALISATION :-
Relevant medical expenses incurred during period up to 30 days prior to hospitalization on disease/illness/injury sustained will be considered as part of claim.

3.2 POST HOSPITALISATION :
Relevant medical expenses incurred during period up to 45 days after hospitalization on disease/illness/injury sustained will be considered as part of claims.
3.3 MEDICAL PRACTITIONER means a person who holds a degree/diploma of a recognized institution and is registered Medical Council of respective State “and stream”. The Medical Practitioner would include physician, specialist and surgeon.
3.4 QUALIFIED NURSE means a person who holds a certificate of a recognized Nursing Council and who is employed on recommendation of the attending Medical Practitioner.
3.5 MATERNITY EXPENSES BENEFIT means treatment taken in Hospital/Nursing Home arising from or traceable to pregnancy. Childbirth including normal Caesarean Section. 3.6 TPA means a Third Party Administrator who, for the time being, is licensed by the Insurance Regulatory and Development Authority, and is engaged, for a fee or remuneration, by whatever name called as may be specified in the agreement with the GIF, for the provision of health services.
3.7 CASHLESS FACILITY Cashless facility would be extended to the Insured in the private networking Hospitals for the critical ailments (Means:- 1. Coronary Artery Surgery i. Cancer iii. Renal Failure i.e. failure of both the kidneys iv. Stroke v. Multiple Sclerosis vi. Meningitis vii. Major Organ transplants like Heart, Kidney, Liver, Lung, Pancreas or Bone marrow Transplantation). However, The TPA would decide the merit of the case and it will not be claimed as a matter of right by the insured. The denial of cashless facility does not mean the denial of treatment from concerned hospital & reimbursement thereof.
3.8 CLAIM INTIMATION TO TPA – It is required by the employees that the claims arising in private hospitals should be intimated by cashless request form/ claim intimation form, available in the to the TPA positively. If the claim intimation does not reach the TPA the same day when the patient is admitted to the hospital, then the employee shall not be entitled for re imbursement.
3.9.1 Claim Intimation to TPA in case of Government Hospitals – It is not required by the employees that the claim(s) arising in Govt. Hospitals should be intimated in writing to the concerned TPA/GIF, on the same day patient is admitted in the hospital.
3.10 DEPENDENT FAMILY The family of the employee shall include the employee, his/her spouse, not more than two dependent children up to 21 years of age and dependent parents. The parents shall be regarded as wholly dependent upon the GOVERNMENT Employee, if- (a) they normally reside with the GOVERNMENT Employee at the place of his/her duty, and (b) their total monthly income from all sources does not exceed Rs.2000/- per month.
3.11 FAMILY DETAIL – Every newly recruited employee shall have to provide details of the family & photographs for preparing the database & for issuing identity cards in the prescribed form (Appendix 3) immediately after joining the service otherwise his salary bill of the designated month will not be passed by the Treasury Officer

Explanation- Details of the family means Name, Designation, DDO, Date of joining Government Service, Names of Family members, Age, Pay/ Pay Scale/Stipend.

4- SCHEDULE: The Schedule enclosed will be deemed to be a part of the policy.

5- EXCLUSIONS: The GIF shall not be liable to make any payment under this policy in respect of any expenses whatsoever incurred by any Insured person in connection with or in respect of:
5.1 Diagnostics/ Investigations unless followed by indoor treatment of 24 Hours.
5.2 Injury/disease directly or indirectly caused by or arising from or attributable to invasion, Act of Foreign enemy, War like operations (whether war be declared or not).
5.3 Circumcision unless necessary for treatment of a disease not excluded hereunder or as may be necessitated due to an accident, vaccination or inoculation or change of life or cosmetic or aesthetic treatment of any description, plastic surgery other than as may be necessitated due to an accident or as a part of any illness.
5.4 Cost of Spectacles and contact lenses, hearing aids
5.5 Dental treatment or surgery of any kind unless requiring hospitalization due to an incident.
5.6 Convalescence, general debility, run-down condition or rest cure, congenital external disease or defects or anomalies, intentional Self injury and use of intoxication drugs/ alcohol/poisonous substances/ Addictions.
5.7 All expenses arising out of any condition directly or indirectly caused to or associated with Human T-Cell Lymph tropic Virus Type III (HTLB-III) or Lymphadenopathy Associated Virus (LAV) or the Mutants Derivative or Variation Deficiency Syndrome or any syndrome or condition of a similar kind commonly referred to as AIDS.
5.8 Charges incurred at Hospital or Nursing Home primarily for diagnosis, X- ray or Laboratory examinations or other diagnostic studies not consistent with or incidental to the diagnosis and treatment of positive existence of presence of any ailment, sickness or injury, for which confinement is required at a Hospital/Nursing Home.
5.9 Expenses on vitamins, proteins and tonics unless forming part of treatment for injury or diseases as certified by the attending physician. 5.10 Injury or Disease directly or indirectly caused by or contributed to by nuclear weapons / materials.
5.11 Pre-existing disease of employee and his/her dependents will be covered under this scheme. 5.12 In such situations in which there are no urgency of hospitalization and treatment can be given at home and which is not pertain to section 2.3.

6. CONDITIONS–

6.1 Every notice or communication to be given or made under this Policy shall be delivered in writing at the address of the TPA/GIF office.

6.2 The premium payable under this Policy shall be paid in advance. No receipt for Premium shall be valid except on the official form of the GIF signed by a duly authorized official of the GIF. The due payment of premium and the observance and fulfilment of the terms, provisions, conditions and endorsements of this policy by the Insured Person in so far as they relate to anything to be done or complied with by the Insured Person shall be a condition precedent to any liability of the GIF to make any payment under this Policy. No waiver of any terms, provisions, conditions and endorsements of this policy shall be valid unless made in writing and signed by an authorized official of the GIF.

6.3 In case of grave emergency viz. life threatening (Means: -Coronary Artery Surgery. Vascular Surgery. Hodgkin’s Disease, Acute Retention of urine more than 24 hrs, Acute Myocardial infarction, Acute Pneumonitis, Acute Respiratory Distress, Cancer, Renal Failure i.e. failure of both the Kidneys, Stroke, Multiple Sclerosis, Meningitis, Major Organ Transplants like Kidney, Lung, Pancreas, Heart, Liver, or Bone Marrow, Accidents, Delivery, Tubal Pregnancy and Related Complication, Swine Flu, Dengue Fever, Burst Appendicitis, Pancreatitis) in which Employee has taken treatment as indoor patient in a non-empanelled private hospital, at the time of claim submission the emergent nature of hospitalization has to be established by an affidavit (Appendix-6) of the employee supported by a certificate of the treating doctor. Claim shall be paid as per CGHS package Rates of general ward up to the limit of sum assured.

6.4 Insured shall show their identity to the empanelled hospitals and fill up a prescribed form at the time of admission to take treatment at CGHS rates/packages. Forms are available at reception counters of all empanelled hospitals (Appendix-5). If an insured person(s) do/does not show his/her identity and takes treatment without filling prescribed form then it is possible that hospital may charge their actual rates. In such cases, GIF shall reimburse only on CGHS rates/ packages, difference amount shall be borne by the insured. 6.4 6.5

6.5 All supporting documents relating to the claim must be filed with district unit of SIPF department within 90 days from the date of discharge from the hospital. In case of post-hospitalisation, treatment (limited to 45 days), all claim documents should be submitted within 90 days after completion of such treatment.

6.6 The Insured Person shall obtain and furnish the district unit of SI&PF department with all original bills, receipts verifications and other documents upon which a claim is based and shall also give such additional information and assistance as the TPA/GIF/ district unit of SI&PF department may require in dealing with the claim.

6.7 Any medical practitioner or an officer authorized by the TPA/GIF shall be allowed to examine the Insured Person in case of any alleged injury or disease requiring Hospitalization when and so often as the same may reasonably be required on behalf of the TPA/GIF.

6.8 The GIF shall not be liable to make any payment(s) under this policy in respect of any claim(s) if such claim be found in any manner fraudulent or supported by any fraudulent means or device whether by the Insured Person or by any other person acting on his behalf.

6.9 If at the time when any claim arises under this Policy, there is in existence any other insurance (other than Cancer Insurance Policy in collaboration with Indian Cancer Society), whether it be effected by or on behalf of any Insured Person in respect of whom the claim may have arisen covering the same loss, liability, compensation, costs or expenses, the GIF shall not be liable to pay or contribute more than its rateable proportion of any loss, liability, compensation costs or expenses. The benefits under this Policy shall be in excess of the benefits available under Cancer Insurance Policy.

6.10 If and when the Employee has submitted his/her family details to the concerned TPA/GIF and identity cards have been issued to the insurer, then only he/she shall be entitled for cashless facility.

6.11 The Policy may be renewed by mutual consent. The GIF shall not however be bound to give notice that it is due for renewal and the GIF may at any time cancel this Policy by sending the Insured 30 days’ notice by registered letter at the insured’s last known address and in such event the GIF shall refund to the insured a pro-rate premium for unexpired Period of Insurance. The GIF shall however, remain liable for any claim, which arose prior to the date of cancellation. The Insured may at any time cancel this Policy and in such event the GIF shall allow refund of premium at GIF’s short period rate only (Table given here below) provided no claim has occurred up to the date of cancellation.

6.12 in case if any dispute or difference arises as to the quantum to be paid under the policy (liability  being otherwise admitted) such difference shall independently of all other questions be referred to the decision of a sole arbitrator to be appointed in writing by the parties or if they cannot agree upon a single arbitrator within 30 days of any party invoking arbitration, the same shall be referred to a panel of three arbitrators, comprising of two arbitrators, one to be appointed by each of the parties to the dispute/difference and the third arbitrator to be appointed by such two arbitrators and arbitration shall be conducted under and in accordance with the provisions of the Arbitration and Conciliation Act, 1996.

It is clearly agreed and understood that no difference or dispute shall be referable to arbitration as herein before provided, if the GIF has disputed or not accepted liability under or in respect of this Policy.

It is hereby expressly stipulated and declared that it shall be a condition precedent to any right of action or suit upon this policy that award by such arbitrator/arbitrators of the amount of the loss or damage shall be first obtained.

6.13 If the TPA, as per terms and conditions of the policy or the GIF shall disclaim liability to the Insured for any claim hereunder and if the Insured shall not within 12 calendar months from the date or receipt of the notice of such disclaimer notify the TPA/GIF in writing that he does not accept such disclaimer and intends to recover his claim form the TPA/GIF then the claim shall for all purposes be deemed to have been abandoned and shall not thereafter be recoverable hereunder.

6.14 All medical/surgical treatments under this policy shall have to be taken in approved hospitals in 6.15 and outside the state of Rajasthan and admissible claims thereof shall be payable in Indian currency. Payment of claim shall be made through TPA/GIF to the Hospital/Nursing Home or the Insured Person as the case may be. The list of approved hospitals is available at (Appendix 2).

6.15 In case of death of insured during policy period then the names of family members to be continued till expiry of the policy.

6.16 Entitlement category for boarding/accommodation in the Hospital:-

* Pay scale means basic pay (including grade pay) /fixed remuneration

Note: Actual boarding / accommodation charges of hospital rate shall be applicable but these

charges cannot be more than CGHS packages rates, indicated as above. If insured takes treatment in higher category other than his entitlement, the reimbursement of cost of treatment will be made according to his category as prevalent in the hospital.

6.17 Pre-existing discase of employee and his/her dependents (as per section 3.10) will be covered under this scheme.

6.18 Medical examination of the GOVERNMENT Employee or any member of his family shall not be a condition for issue of Mediclaim Policy.

6.19 A female employee can get the Mediclaim coverage either for her parents or Parents in law in case they are dependent on her and their monthly income is less than Rs. 2000/- and they are residing with her generally.

6,20 A master policy has been issued & copy of policy has been provided to all Drawing & Disbursing officer of State Government. It is required from every DDO that they would bring in notice of all the newly recruited employees regarding terms & condition of the policy. It is also expected that every newly recruited employee must have gone through the terms & conditions of the policy from their concerned DDOS. 6.21 This Policy is available at website : www.sipf.rajasthan.gov.in

7. HIGH CLAIMS RATIO LOADING (MALUS)

The total premium payable at the time of renewal of the Group Policy will be loaded at the following scale depending upon the incurred claims ratio for the entire group insured under the Group Mediclaim Insurance Policy for the preceding three completed years excluding the year immediately preceding the date of renewal, where the Group Mediclaim Policy has not been in force for the three completed years, such shorter periods of completed years, excluding the year immediately preceding the date of renewal will be taken in to account.

Note:

1. High Claim loading (Malus) will be applicable to the Premium at renewal of the Policy depending on the incurred claims Ratio for the entire Group Insured.
2. Incurred claim would mean claims paid plus claims outstanding in respect of the entire group insured under the policy during the relevant period.

9 MATERNITY EXPENSES BENEFIT EXTENSION: (Wherever applicable)

9.1 The maximum benefit allowable under this clause will be up to Rs. 50,000/- per family per year restricted to two living children. This amount is including sum-assured of Rs. 3,00,000 per family per annum.

9.2 The Maternity benefits under this policy are categorized into three :
I Maximum limit under normal delivery : Rs. 10000/
II Maximum limit under caesarean delivery: Rs. 20000/-
III Maximum limit under delivery related complications (Including child care) Rs. 50000/ –

9.3 Special conditions applicable to Maternity expenses Benefit Extension:
I. These Benefits are admissible only if the expenses are incurred in Hospital/Nursing Home as in-patients in Rajasthan.
II A waiting period of 9 months is not applicable for payment of any claim relating to normal delivery or caesarean section or abdominal operation for extra uterine pregnancy. The waiting period may be relaxed only in case of delivery, miscarriage or abortion induced by accident or other medical emergency.
III Claim in respect of delivery for only first two children and/or operations associated therewith will be considered in respect of any one Insured Person covered under the policy or any renewal thereof. Those Insured Persons who are already having two or more living children will not be eligible for this benefit.
IV Expenses incurred in connection with voluntary medical termination of pregnancy during the first 12 weeks from the date of conception are not covered.
V Pre-natal and post-natal expenses are not covered unless admitted in Hospital/Nursing Home and treatment is taken there.
VI Mother and Newly born child would be single unit for 3 days from the date of delivery.
VII Indoor Treatment of Sterility/ Infertility shall be payable up to the limit of 20,000/- in a policy year.

10. PAYMENT OF CLAIM–

10.1 The insured shall submit the online claim’ on the departmental web portal (www.sipf.rajastha.gov.in) through his ’employee id’. Only ‘online’ claims shall be accepted. No offline claim shall be accepted. Details of online claim submission procedure can be seen on department website www.sipf.rajasthan.gov.in.
10.2 The insured shall submit the hard copy of claim form through DDO to the district unit of SI&PF department in the prescribed Performa (Appendix 4).
10.3 For Re-imbursement photo will be pasted by the concerned employee (if he doesn’t possess the identity card) which will be duly verified by the treating doctor/ DDO so as to confirm the identity of the Patient.
10.4 Cashless facility will not be provided if the identity cards have not been obtained by the policy holder.
10.5 Payment of claim shall be made through TPA/GIF to the Hospital or to the Insured Person as the case may be normally within 30 days from the date of receipt of completed claim proposals by the TPA.