Final Rvsd His 8.03.13
Transcript of Final Rvsd His 8.03.13
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HEALTH INSURANCE SCHEME FOR CBEC EMPLOYEES
BACKGROUND:
As an outcome of the all India Conference of Chief Commissioners and Directors
General, 2012, four Break-Away Groups were constituted for parallel discussion on different
issues. The Break-Away Group-IV deliberated on Staff Welfare. One of the recommendations
made by this group was to explore corporate style tie-up with good hospitals in every major city
for effective treatment of Departmental employees and their families. The suggestions are as
reproduced below:
TIE-UP WITH GOOD HOSPITALS
The existing CGHS facilities particularly in metros have been restrictive/non-existent to fulfill
genuine needs of the employees. It is desirable that department should explore corporate style tie-up
with good hospitals in every major city, for effective treatment of our officers and their families. The
difference between the CGHS entitlement and negotiated fees of the hospital can be met either by
Welfare Fund or through an insurance agency scheme suitably negotiated for the whole service to
leverage better rates.
In pursuance of the above recommendation, a new Health Insurance Scheme is proposed (in
addition to the existing facilities under CGHS/CSMA Rules) for the government employees
working under CBEC.
A. NAME OF THE SCHEME: Health Insurance Scheme of CBEC. The office of DGHRD will actas the Nodal Agency of the welfare scheme.
B. COVERAGE OF THE SCHEME:The Health Insurance Scheme will provide Cashless access to Health care facilities to 55,000
working employees of CBEC and his/her family { family as defined under the CGHS/CS (MA)
Rules, 1944 and the guidelines issued by Central Government from time to time} thereby enabling
access to healthcare facilities for In-Patient department (IPD) i.e. Hospitalization in over 3,000
hospitals / nursing homes which are empanelled/recognized under CGHS/CSMA Rules across
the country with an Annual Checkup of the Government Employee once in a year. Initially the
new scheme will be for two years as a pilot project, for providing a health insurance cover to
every employee of CBEC and his/her family worth Two Lakh rupeesfor one year at a time from
the date of contract. The insurance cover will include all pre-existing diseases. However the
OPD facility will continue to be provided through the CGHS scheme, as per the CGHS/CSMA
Rules.
C. SCOPE OF THE SCHEME:1. The working employees of CBEC and his/her family (herein after referred to as the
employee), can avail the medical benefits on actual expenses incurred by him/her and
without the restriction of the CGHS price sub-limits (but restricted to up to the cover of
Rs. 2 lakh per annum).
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2. The government employee (including his/her family) can avail the benefits worth themedical insurance cover of Rs. 2.00 lakh in a year. Thereafter, treatment can be
obtained under CGHS/CSMA Rules on the previous (existing) pattern.
3. The treatment will be on cashless basis i.e without any upfront payment to be made bythe individual to the hospital.
D. FINANCING:It is proposed that the Scheme may be financed completely from the Welfare Fund and
100% of the premium for the health insurance cover will be paid by the Central Govt. on behalf
of the CBEC employee.
E. ANTICIPATED PREMIUM:The Health insurance Cover will be upto Rs. 2.00 Lakh p.a. on family floater basis for allAilments including Critical Illness ** (Without CGHS Limits /Cap)
*Exemption from Service Tax has been granted to a few Govt. Sponsored Welfare Schemes videNotification no. 25/2012- Service Tax dtd. 20.06.12 issued by Min. of Finance, Department Of
Revenue, Govt. of India. CBEC may like to consider similar exemption for the proposed HIS
Scheme for CBEC employees too.
** Critical illness includes following ailments: Cancer, Coronary artery bypass surgery,
neurological surgery, First heart attack, Kidney failure, Multiple sclerosis, Major organ
transplant, Stroke, Aorta graft surgery, Paralysis & Primary pulmonary arterial hypertension.
F. ELIGIBILITY OF BENEFICIARIES:1. All employees of CBEC (of all Groups/Cadres) and their family (as defined under the
CGHS rules) shall be insured.
2. The employees to be insured shall be from those already enrolled under CGHS/CSMAhaving a valid CGHS Card or the certificate issued under CSMA Rules. The data of new
employees will be sent to the HRD duly certified by the Head of the Department
periodically.
Particulars Amt. (Rs.)
i) Net premium payable ( Excl. S.Tax) 15.00 croresii) Insurance Company liability per annum 15.30 crores
iii) * Service Tax @12.36% on Premium 1.85 crores*
iv) Net Premium Payable (incl. S.Tax) 16.85 crores
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3. New entrants on appointment/ marriage/ birth shall also be eligible.G. ADVANTAGES OF THE NEW HEALTH INSURANCE SCHEME :
1. Cashless Health care treatment for all employees in over 3,000 hospitals / nursinghomes across the country.
2. The employee can avail the medical benefits on actual expenses incurred by him/herwithout the restriction of the CGHS price sub-limits (but restricted up to the cover of Rs.
2 lakh in a year).
3. The employee can avail the cashless IPD benefits worth Rs. 2.0 lakh per year.Thereafter, he/she can obtain the treatment under CGHS/CSMA Rules on the previous
(existing) pattern.
4. An annual Medical check-up will be conducted by the insurance company for allemployees of CBEC (of all Groups/Cadres).They will be required to conduct the tests as
prescribed under the CGHS norms. Thus there will be gross saving on the expenditure
incurred from the medical funds at present.
5. No upfront payment to be made by the Govt. employee and thereby no medicalreimbursement claims will be required to be filed by the employees until the limit of
health cover is exhausted.
6. Saving on human resources dedicated at present for processing the claims, since all theclaims will be processed by the insurance company and will be settled directly by them
with the empanelled hospitals.
H. BENEFITS:a. 100% Premium shall be paid by CBEC on behalf of all the employees.b. The Health Insurance Scheme shall be for a period of 2 years for the individuals w.e.f.
the date of agreement between CBEC and Health Insurance Service provider.
c. The insured members can claim Medical benefits worth Rs. 2.0 lakh per annum underthe Health Insurance cover. The health insurance cover will replace the medical
benefits provided from the Welfare Fund by DGHRD under the welfare schemes and
the service provider will bear the cost of treatment up to the cover limit of Rs. Two
lakh. However expenses over and above the Rs. 2.0 lakh cover may be considered by
the Governing Body on a case to case basis.
d. Employee to utilize the medical cover of up to Rs. 2.0 lakh under the new healthinsurance scheme first. Thereafter, (beyond this limit of 2 lakh), further treatment can
be continued from CGHS, on reimbursement basis, under the existing CGHS/ CSMA
Rules.
e. In case of death of the employee due to accident, the education fees up to maximum ofRs. 3,000/- per month will be paid by the insurance company for the Dependent
children for the academic year.
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f. Treatment in higher category of accommodation than the entitled category is notpermissible under this scheme. If it happens, at the discretion of the card holders then
the cardholder is liable to pay the extra expenses to the Hospital directly.
g. Cost of implants, if any, over and above the package rates will also be borne by theinsurer.
h. Pre-existing diseases shall be covered.i. In case of death due to accident, expenditure of carriage of dead body to be borne by
the insurance company up to Rs.10,000/-
j. Free annual Medical check-up for all employees of CBEC as per tests prescribed underthe CGHS norms.
k. Pre & Post hospitalization benefits can be availed under the insurance cover for up to07 days and up to 15 days respectively.
l. The insurance cover will also include minor surgeries which do not requirehospitalization (such as Cataract etc.) i.e involving only one-day or less than 24 hours
treatment.
m. All the benefits/procedures will be on the pattern of the CGHS scheme wherever notmentioned.
I. EXCLUSIONS :1. Any dental treatment or surgery which is corrective, cosmetic or of aesthetic
procedure, including wears and tears etc.2. Sex change.3. Vaccination.4. Those insured persons who are already having two or more living children will not be
eligible for Maternity benefit.
5. Pre-natal and post-natal expenses, unless admitted in the Hospital/Nursing Home andtreatment is taken there.
6. Any type of OPD treatment.J. ENROLMENT:
I. Identification to be as per existing CGHS membership.II. The health insurance cover shall be for a period of two years subject to midterm review
at the end of the first year of contract.
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III. The entire 100% annual insurance premium shall be borne by the Central GovernmentCBEC per annum along with the Service Tax, as applicable on behalf of all the
employees.
IV. The insurance companies shall be selected through a transparent process and shallenter into a contract with the Department, through DGHRD, for implementation of thescheme.
V. Each insurance company shall be awarded the contract at the lowest rate of premiumoffered by it (being the L1 bidder).
VI. With this background, technical and financial bids will be invited from all insurancecompanies dealing with health insurance and licensed by Insurance Regulatory and
Development Authority (IRDA) for implementation of the Health Insurance Scheme for
working employees of CBEC and their families.
VII.
If the utilization of total accrued premium received from the Central Government(CBEC) does not reach 80% of the actual pay-out made towards claims settlement then
the differential balance amount (i.e. 80% of total premium paid by CBEC minus the
actual pay-out in claims settled) shall be rolled over and adjusted in the premium
payable by CBEC for the next year. However, in the second year, such differential
amount, if any, will be refunded to CBEC by the Insurance Company, within one month
of the expiry of the contract period, failing which the insurance company is liable to
refund the said amount with interest @ 10% p.a. and a penalty of Rs. 50 lakh. Insurance
company shall submit claims MIS as per CBEC requirements.
K. DISPOSAL OF CLAIMS:a. All hospitalizations in all locations shall be on cashless basis which means the
beneficiary doesnt have to pay any cash charges upfront.
b. The actual expenses incurred on the treatment will be paid in full by the insurancecompany uptil the insurance cover limit of Rs. Two lakh per employee.
c. Once the insurance cover limit for IPD treatment is exhausted (i.e. the 2.0 lakh cover),the employee can seek further treatment from CGHS directly on the earlier (existing)
pattern as per the CGHS /CSMA Rules/Scheme.
d. The insurance company is liable to provide the facilities of medical cover once theenrollee is admitted just before the date of expiry of the contract/insurance cover
period, provided the cover amount is not exhausted.
e. In case any claim is found untenable, the Insurer shall communicate reasons to theNodal Agency for this purpose with a copy to the beneficiary. Insurer will file a report to
the Nodal Agency explaining reasons for denial of each claim periodically and these
reports shall be reviewed by the D.G.(HRD) on monthly/quarterly basis.
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L. MODALITIES OF IMPLEMENTATION:1. Cadre Controlling Officers office would be the contact point for the Insurance Companies.
The data related to employees will be provided by the Head of the Department to the
Insurer ( duly verified from the Service Book) with copy to the Nodal Agency.
2.
The valid CGHS Card or the filled in Enrolment forms will be given by the Department tothe Insurance Company within 60 days from the date of entering the contract.
3. The enrollment in the first year should be completed by the insurer within 60 days andthe insurance cover will become effective for complete one year (excluding the 60 day
period) for all those enrolled uptil that date. However the insurance cover period for those
enrolled after 60 days will reduce to that extent. Therefore the onus of providing the
verified data to the service provider within 60 days is on the department. The enrolment
of new entrants will continue throughout the year.
4. Insurance Company will issue Smart Cards to the employees along with the list of theNetworked Hospitals, the benefits and the contact details of their persons with toll-free
number of their help centre.
5. If the card is lost within the policy period then beneficiary can get a new card issued bypaying to the insurer, a pre-defined fees agreed by the Nodal Agency.
6. Publicity shall be given by the Insurer and the Nodal Agency through website, AdvisoryCommittee Members and Circulars and through Workshops and Kiosk/help centers by the
Insurance Company in Zonal Head Quarters.
7. The details of the Scheme and further amendments, if any, as well as enrolment formwould be put up on the web-site of DG (HRD) and of all Commissionerates.
8. Insurance Company will also provide the Application Performa through their website andthe Head of the Department/empanelled Hospitals/Nursing Homes/Day Care Clinics and
the beneficiaries can access the website to see the relevant information. All relevant data
shall be uploaded on the insurers website on a read-only access and a link shall beprovided to the DG (HRD).
9. The Insurer shall provide Management Information System (MIS) reports regarding theenrolment, admission, claim settlement and such other information regarding the Services
to the Nodal Agency monthly. Nodal Agency will also monitor data related to enrolment
etc. available through their website.
M.MID TERM REVIEW:A mid-term review of the Scheme will be carried out by a Review Committee, headed by DG
(HRD), CBEC, at Delhi, with the following composition, for making recommendations to the
Board for continuation/ extension of the Scheme:
1. Director General, HRD, CBEC Chairperson2. Any Zonal Chief Commissioner (co-opted by DG, HRD) Co-Chairperson3. Addl. Director General (I&W), DGHRD Member4. Addl. Director General (EMC), DGHRD Member
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5. Addl. Director (I&W), DGHRD Member-Secy.
N. GRIEVANCE REDRESSAL:a. In case of any grievance faced by the beneficiary, a Grievance Redressal Committee
(GRC), headed by a Zonal Chief Commissioner, will be constituted to settle the grievances
and settle the disputes on the claims, if any.
b. The Grievance Redressal Committee (GRC), will comprise of the following members:1. Zonal Chief Commissioner Chairperson2. Executive Commissioner at Zonal Hqr. Member3. Additional Commissioner, CC Unit Member-Secretary4. Authorized Representative of
Health Insurance Service provider Member
c. The GRC will meet periodically as decided by the Chairperson of the GRC.d. The decision of the Grievance Redressal Committee (GRC) will be final and binding on all.
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