The Benefits within this scheme, to be provided on a cashless basis to the Beneficiaries up to the limit of their annual coverage, package charges on specific procedures and subject to other terms and conditions outlined herein, are the following:
The scheme shall provide coverage for meeting expenses of hospitalization for medical and/or surgical procedures including maternity benefit, to the enrolled families and up to Rs.60,000 per family per year subject to limits, in any of the government hospitals and private hospitals and nursing homes. The benefit to the family will be on floater basis, i.e., the total reimbursement of Rs.60,000 can be availed of individually or collectively by members of the family per year.
Pre-existing conditions/diseases are to be covered from day one, subject to the exclusions given in Annexure 8.
Coverage of health services related to surgical nature shall also be provided on a basis.
The Insurer shall provide coverage for the following treatments/procedures:
ii) Parenteral Chemotherapy
iv) Eye Surgery
v) Lithotripsy (kidney stone removal)
vii) D & C
viii) Dental surgery following an accident
ix) Surgery of Hydrocele
x) Surgery of Prostrate
xi) Gastrointestinal Surgeries
xii) Genital Surgery
xiii) Surgery of Nose
xiv) Surgery of Throat
xv) Surgery of Ear
xvi) Surgery of Urinary System
xvii) Treatment of fractures/dislocation (excluding hair line fracture), Contracture releases and minor reconstructive procedures of limbs which otherwise require hospitalization
xviii) Laparoscopic therapeutic surgeries
xix) Identified surgeries under General Anesthesia
xx) Any disease/procedure mutually agreed upon.
Pre and post hospitalization costs up to 1 day prior to hospitalization and up to 5 days from the date of discharge from the hospital shall be part of the package rates.
Maternity and Newborn Child Coverage will be covered as per details provided below:
This means treatment taken in hospital/nursing home arising from childbirth including normal delivery / caesarean section and/ or miscarriage or abortion induced by accident or other medical emergency subject to exclusions given in Annexure 8.
Newborn child shall be automatically covered from birth up to the expiry of the policy for all the expenses incurred in taking treatment at the hospital as in-patient. This benefit shall be a part of basic sum insured and new born will be considered as a part of insured family member till the expiry of the policy subject to exclusions given in Annexure 8.
Above shall be covered from day one of the inception of the scheme and normal hospitalisation period for both mother and child should not be less than 48 hours post delivery.
The maximum benefit allowable under this clause will be up to Rs.4,500/- subject to limits under table of benefits. This benefit shall be a part of basic sum insured. Government of Goa can revise these rates based on the costs structure in their State, however, the ratio of cost of caesarean and normal deliveries will be as prescribed in Annexure 6.
The charges for medical/ surgical procedures/ interventions under the Benefit package will be no more than the package charge agreed by the Parties, for that particular year. The same can be amended by mutual consent for the next year. Provided that the Beneficiary has sufficient insurance cover remaining at the time of seeking treatment, such listed services will not be subject to pre-authorization by the Insurer. The list of common procedures and package charges is set out in Annexure – 6 to this tender document, and will also be incorporated as an integral part of service agreements between the Insurer and its empanelled service providers. [States and Insurer to review Annexure – 6 to check on suitability of list and package charges by procedure].
Procedures which are not on the list set out in Annexure – 6 to this tender document would still be included as Benefits under this scheme, but will be subject to a pre-authorization procedure, as per Clause – 14(2). As part of their regular review process within the Co-ordination Committee, the Parties shall review information on common unlisted procedures and seek to introduce them into the listed package with appropriate package charge.