Suggestion: Group Mediclaim Policy for Employees

This is further to the discussion we had during the Information Sharing Session on 27.02.2017 and feedback you sought on the Group Mediclaim Policy for Employees and a mail reminder dated 02.03.2017 on the same by Asst. Secretary (ER).

1-TheCompulsory Family Floater Sum Insured should be as under:



{Remarks} – Since the floater scheme SA being increased to 30 lakhs, the loading on HCPT funds has been considerably reduced and the accrued benefits should percolate down to the  class3 & 4 employees in the form of enhanced Basic SA and subsidized premium on the increasedSA).


2-NewGroup Mediclaim Policy should contain all features of the ‘’ Premier Mediclaim Policy’’ issued on 09/02/2017 by The New India Assurance Co. Ltd. [Special features of the Scheme attached herewith)

Few Special features are as follows:-

a) OPD Expenses for Dental treatment, health check-up, medicines etc.

b) Psychiatric treatment and psychosomatic illness coverage up to 5 lacs.)

c ) Obesity treatment coverage up to 5 lacs.

It is suggested that keeping intact the better features of the current scheme new features covering the health care needs of the employees containing in the above “Premier MediclaimPolicy” could be incorporated in the new Group Mediclaim Policy.

[3] New Policy should cover all the family members as desired by the employees. It is a well known fact that in the Indian Society, the responsibility as a guardian extends beyond one’s own family and parents/in-laws. Similarly, in case of any physically/mentally challenged member, dependent unmarried sister/widow, living with the employee as declared by him/her
should be covered. So when the employee is ready to bear the premium (even if it is without subsidy), his/her social obligation should be honored, as long as even any other such
members who are elderly/child financially dependent on being orphaned & stays along with
employee as per his/her declaration.
[4] Mediclaim cover should continue on the children as long as they are financially dependent irrespective of age, and till they are gainfully employed and are covered under such scheme under employment.
[5] Subsidized Premium should cover to the third child in case of second delivery
twins or first delivery triplets. [This may appear rarer of the rarest case but there are employees who have been deprived the subsidy to such third child]
[6] Subsidized Premium should also be extended to the Pensioners/Retirees/VRS
Employees and also to the spouse of the deceased employees.
[7] The expenses of the Corporation in case of HCPT have now reached the minimal.
These crores of rupees can be rightly utilized for betterment of the Staff Group Mediclaim Scheme.
[8] The TPA appointed should be a single entity across LIC as it will ensure proper,
timely and better co-ordination for Mediclaim Settlement, with a well equipped staff to ensure
24 x 7 service.
[9] The caps on individual items like room rent, nursing charges etc. should be
removed and the claim settled should be considering the overall limit. Charges like Registration, Generator charges and other miscellaneous charges should be paid to the employees.

[10] Exclusions mentioned on page no. 17/18 as well as in Annexure II starting
from page 32 of the Staff Group Mediclaim Policy` 2016-17 should be removed.
[11] Expenses relating to Diagnostic Tests without Hospitalization should be permitted not only once during the policy year but THRICE. The consulting fees as well as the medicine cost after the Diagnostic Tests should also be paid.

[12] OPD/Domiciliary hospitalization benefits should cover diseases like Diarrhea,Viral fever, Urinary Tract Infection, stone in kidney, swelling prostate etc….
[13] The re-imbursement of the expenses relating to Diagnostic Tests without
Hospitalization in case of CT Scan charges is at present Rs. 5000/- each insured. But practically, this charge varies from Rs. 7000/- to 8000/- depending upon the type of CT
scan. So the amount of CT scan re-imbursement without hospitalization should be enhanced to a maximum of Rs. 8000/- each insured.
[14] Vaccination is not as like as taking vitamin tablets. Vaccination is essential
particularly for the children and now-a-days vaccination up to the age of 5 years requires lacs of rupees. So vaccination should not be a part of exclusion in the policy conditions.
[15] Nearsightedness or farsightedness of eyes is undoubtedly a type of problems of eyes which is treated with adequate amount of lens power. Giving eyeglasses or spectacles is its treatment. So re-imbursement of eyeglasses or spectacles is justified which is prevalent in RBI and some other organizations. It should not be a part of exclusion.
[16] Excluding Dental treatment is a gross injustice to the insured. It is said that tooth decay does more than affecting our smile. If untreated, it may lead to severe infections in our body. If untreated, bacteria from the teeth and gums can affect our overall health in
many ways which is heard in some cases to be a cause of developing heart disease or increased risk of Dementia etc. So under no circumstances, dental treatments like RCT, capping etc. should be treated as /4/ exclusion in policy condition.
[17] Existing conditions to be noted :

(a) There is provision of taking re-imbursement for 30 days’ of pre-hospitalization expenses and 60 days’ of post-hospitalization expenses.

(b) Claim must be submitted to TPA within 20 days of the date of Discharge
from the Hospitals. Findings: If an insured person submits his/her hospitalization bill after 20 days of the date of discharge, he/she can be able to submit bill for maximum 20 days’
post hospitalization expenses only. But he or she is eligible for re-imbursement of remaining 40 days’ post hospitalization expense also. But procedures for claiming the post-hospitalization after submission of Discharged claim should be made transparent by TPA.
[18] For cashless treatment, no extra billing should be imposed by the TPA as per their MOU of capping of reimbursement with the Hospitals.
[19] 24 Hours Group Accident Policy: Compensation of Rs. 10000/- on weekly basis  should be restored. [Previously Rs.5000/- was admissible]
We hope that our suggestions for a beneficial Group Mediclaim Policy to our
employees and their family/dependents will be seriously look in to for the coming financial year.
Thanking you.

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