Health Insurance Scheme for Retired Employees
Health Insurance Scheme for Retired Employees
the Post Retirement Medical Assistance Scheme-2004 notified vide
Personnel Circular No. 664 dated 5.8.04 prevailing in the Company,
retired employees and spouses are extended limited Medical Benefits,
from HAL Hospitals/ Dispensaries. Considering that retired employees
would be residing across the country, it is proposed to provide
medical facilities to retired employees & their spouses, through a
Group Health Insurance Scheme, so that they can avail Medical
benefits throughout the Country.
Scope of the Scheme and Coverage:
Scheme would cover ex-employees who have superannuated, opted for
Voluntary Retirement/ Optional Retirement or terminated on account
of continued ill-health, after rendering a minimum service of 15
years in the Company, and their spouses.
Coverage under the Scheme would be available in the following cases
Widows/ Widowers of those employees who died while in service,
without any minimum Service requirement;
Widows/ Widowers of ex-employees as at paras-2.1 & 2.2.1 who had
died after leaving the Company.
respect of ex-employees who joined the Company from other PSUs/
Govt., the Service rendered by them in other PSUs/ Govt. would be
reckoned for computing the minimum service requirement of 15 years
Widows/ Widowers of those ex-employees who become members of the
Scheme would continue to be eligible for benefits under the Scheme.
Employees who would Superannuate, opt for Voluntary Retirement/
Optional Retirement, whose Services are terminated on account of
continued ill health and who would fulfill to minimum Service
requirement of 15 years, after the date of introduction of the
Scheme and their spouses would be eligible to join the Scheme.
Similarly, Widows/ Widowers of employees who die while in service
would also be eligible to join the Scheme.
Scheme would not be applicable in the following cases:
Ex-Employees who were dismissed/ who had absconded from Service
Ex-Employees who do not fulfil the minimum Service eligibility
criteria indicated above
Ex-Employees who are covered under Medical Benefit Schemes
provided by the employer of his/her spouse/ children etc.
general term ‘retired employees’ would be used under the Scheme to
denote the beneficiary.
Insurance Coverage under the proposed Policy
Insurance coverage under the Policy will be on a Family Floater
basis. The total coverage will be per Family. The coverage can be
used for both the retired employee & spouse or only for the retired
employee or only for the Spouse, as per requirement. Family for this
purpose would mean only the retired employee and his/ her spouse,
both or the survivor. In case any retired employee is unmarried, the
family would mean only the retiree (The Sum Insured will be
notified alongwith the approved Scheme).
coverage provided shall be without any entry and exit age limits.
Pre-existing illnesses will be covered under the Policy.
There will also be no waiting period. Similarly, all diseases would
be covered from the inception of the Policy.
Cash Less Facility would be available for the beneficiaries.
However, where such a facility cannot be availed by the
beneficiaries, reimbursement of actual expenditure in the scope of
the policy would be made available by the Third Party Administrator
Medical Coverage under the Policy:
case of hospitalization for any illness or injury, the Policy would
cover the following:
Room charges, ICU charges, nursing expenses, anaesthesia, blood,
oxygen, operation theatre charges, surgical appliances, dialysis,
chemotherapy, radiation-therapy, Angioplasty, CABG, cost of
pacemaker, artificial limbs and similar other expenses. Restriction
to these charges, if any, to be specified individually.
Professional Charges of Doctors, Surgeons, Anesthetists, Medical
Practitioners, Consultants, Specialists etc.
Medical and Diagnostic Tests and other related expenses.
Medicine & drugs expenses
and Post Hospitalisation expenses to the extent which would be
Out Patient Treatment Coverage:
expenses subject to the ceiling which will be notified, would be
availed by the beneficiaries from Network Hospitals only, with
cashless facility. In cases where cash less facility cannot be
availed, reimbursement of actual expenditure incurred shall be made
available, by the TPA.
Administration of the Scheme
Scheme will be administered through a Third Party Administrator (TPA),
recommended by the Insurance Company. Insurance E-cards would be
issued by TPA to all members. TPA will be the intermediary between
retired employees, Insurance Company & Hospitals.
Insurance Company will have Network Hospitals where treatment can be
availed, at least in 50% of the Districts in 20 or more States.
Cashless facility will be available at network hospitals.
need to fill "Pre authorization Form" available in the network
hospital to get an authorization from TPA. This authorization
along with a copy of the card issued by TPA is to be given to the
Network Hospital at the time of admission. TPA will authorize
"Cashless Service" at the Network Hospitals in all cases eligible
under the insurance policy.
In case of
Denial of "Cashless Service" for any reason, the treatment can be
continued by paying for the Services and the claim can be sent to
TPA for processing reimbursement.
Detailed Scheme with all applicable Terms & Conditions etc., will be
notified, after the Insurance Company, TPA and the Scheme are
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