Group Health Insurance Scheme for Retired Employees

                                                            

Annexure-I

Group Health Insurance Scheme for Retired Employees

1.                 Background

          As per 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.

2.                 Scope of the Scheme and Coverage:

2.1              The 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.

 

2.2              Coverage under the Scheme would be available in the following cases also:

 

2.2.1       Widows/ Widowers of those employees who died while in service, without any minimum Service requirement;

 

2.2.2       Widows/ Widowers of ex-employees as at paras-2.1 & 2.2.1 who had died after leaving the Company.

 

2.2.3       In 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 in HAL.

 

2.2.4       Widows/ Widowers of those ex-employees who become members of the Scheme would continue to be eligible for benefits under the Scheme.

 

2.3              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.

 

2.4              The 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.

 

2.5              The general term ‘retired employees’ would be used under the Scheme to denote the beneficiary.

 

3.                 Overall Insurance Coverage under the proposed Policy

 

3.1              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).

 

3.2              The coverage provided shall be without any entry and exit age limits.

 

3.3              Pre-existing illnesses will be covered under the Policy.

 

3.4              There will also be no waiting period. Similarly, all diseases would be covered from the inception of the Policy.

 

3.5              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 (TPA).

 

3.6              Medical Coverage under the Policy:

3.6.1       In case of hospitalization for any illness or injury, the Policy would cover the following:

a)     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.

b)     Professional Charges of Doctors, Surgeons, Anesthetists, Medical Practitioners, Consultants, Specialists etc.

c)     Ambulance expenses.

d)     Medical and Diagnostic Tests and other related expenses.

e)     Medicine & drugs expenses

f)       Pre and Post Hospitalisation expenses to the extent which would be specified.

3.7              Out Patient Treatment Coverage:                      

3.7.1       OPD 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. 

4.                 Administration of the Scheme

 

4.1.           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.

 

4.2.           Network Hospitals:

 

4.2.1.     The Insurance Company will have Network Hospitals where treatment can be availed, at least in 50% of the Districts in 20 or more States.

 

4.2.2.     Cashless facility will be available at network hospitals.

 

  • Beneficiary 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.

 

5.                 Detailed Scheme

5.1     Detailed Scheme with all applicable Terms & Conditions etc., will be notified, after the Insurance Company, TPA and the Scheme are finalized.

 

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