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Saturday, June 28, 2014

Tamil Nadu Order - MEDICAL AID – New Health Insurance Scheme, 2014 for Pensioners (including spouse) / Family Pensioners

 MEDICAL  AID – New Health Insurance Scheme, 2014 for Pensioners (including spouse) / Family Pensioners – Provision of Health Care Assistance to the Pensioners (including spouse) / Family Pensioners through the United India Insurance Company Limited, Chennai – Implementation – Orders – Issued
Government of Tamil Nadu


2014

MANUSCRIPT SERIES
FINANCE [Pension] DEPARTMENT
G.O.Ms.No.171, Dated 26th June 2014.
(Jaya, Aani-12, Thiruvalluvar Aandu-2045)

ABSTRACT

MEDICAL  AID – New Health Insurance Scheme, 2014 for Pensioners (including spouse) / Family Pensioners – Provision of Health Care Assistance to the Pensioners (including spouse) / Family Pensioners through the United India Insurance Company Limited, Chennai – Implementation – Orders – Issued.

Read:-
 G.O.Ms.No.462, Finance (Pension) Department, dated 27-12-2013.
-oOo-
ORDER:

In the Government Order read above, orders have been issued for launching a New Health Insurance Scheme, 2014 to provide health care assistance to the Pensioners (including spouse) / Family Pensioners on a CASHLESS basis, with provision to avail assistance upto rupees two lakh for a block period of four years and to implement the scheme through the Director of Treasuries and Accounts, Chennai after selection of a suitable Public Sector Health Insurance Company through National Competitive Bidding.


 2. Based on the Government Order read above, the Secretary to Government (Expenditure), Finance (Pension) Department was nominated as Tender Inviting Authority and Tender Accepting Authority. The Commissioner of Treasuries and Accounts and the Director of Medical and Rural Health Services were also nominated as Members of the Committee for selection of a Public Sector Health Insurance Company through National Competitive Bidding. Accordingly, the Tender Inviting Authority has called for Open Tender by issue of Notice Inviting Tender on 24.01.2014. The Tender Accepting Committee, on 18-02-2014, has recommended to  select the United India Insurance Company Limited, Chennai to implement the New Health Insurance Scheme, 2014 for Pensioners (including Spouse)/Family Pensioners.

3. After careful consideration, the tender has been awarded to the United India Insurance Company Limited, Chennai and the said Company has since entered into an agreement with the Government of Tamil Nadu for implementation of the New Health Insurance Scheme, 2014 for Pensioners (including Spouse) / Family Pensioners for a block period of four years from 1-7-2014 to 30-6-2018. This scheme shall also be administered through a Third Party Administrator under the control of United India Insurance Company Limited, Chennai. The payment of premium shall be regulated as per the terms and conditions of the agreement between the Insurance Company and Government of Tamil Nadu.

4. The Government also direct that the implementation of the New Health Insurance Scheme, 2014 for Pensioners (including spouse) / Family Pensioners shall be administered by the Director of Treasuries and Accounts, Chennai-600 015. The implementation procedure outlined in Annexure-I to this order shall be adopted.

5. The Pensioners / Family Pensioners shall uniformly subscribe a sum of Rs.150/- per month to the New Health Insurance Scheme, 2014. The subscriptions recovered from the Pensioners / Family Pensioners shall be credited into the following Revenue Receipt Head of Account.

“0075.00. OTHER MISCELLANEOUS GENERAL SERVICES
          800. Other Receipts
            BY. Subscription from Pensioners / Family
                   Pensioners towards New Health Insurance
                   Scheme (NHIS), 2014.
                  [D.P.C. 0075 00 800 BY 0004]”

6. The Government of Tamil Nadu shall pay the insurance premium along with the service tax to the Insurance Company on behalf of all the Pensioners / Family Pensioners as per the terms and conditions of the agreement entered into by the Government with the Insurance Company through the Director of Treasuries and Accounts. The expenditure on payment of insurance premium including service tax shall be debited to the following Head of Account under Demand No.50. Pension and Other Retirement Benefits:

“2075.00. MISCELLANEOUS GENERAL SERVICES
         800. Other Expenditure
              I. Non-Plan
             IJ. New Health Insurance Scheme, 2014 for
                  Pensioners / Family Pensioners.
            10. Contributions.
              2. Insurance Premium
                    [D.P.C. 2075 00 800 IJ 1022]”


 7. The Director of Treasuries and Accounts, Chennai shall be the estimating, reconciling and controlling authority for the head of accounts opened in this order. The Director of Treasuries and Accounts, Chennai shall open the above Head of Accounts in their books of accounts.

8. The Director of Treasuries and Accounts shall send proposals to Government for sanction of release of insurance premium including service tax payable to the Insurance Company from time to time as per the terms and conditions of the agreement.

9. The Director of Treasuries and Accounts, Chennai shall submit annual report to the Government in the month of July every year.

(BY ORDER OF THE GOVERNOR)

K.SHANMUGAM
PRINCIPAL SECRETARY TO GOVERNMENT.


Annexure-I
IMPLEMENTATION PROCEDURE FOR NEW HEALTH
INSURANCE SCHEME, 2014 FOR PENSIONERS (INCLUDING
SPOUSE) / FAMILY PENSIONERS.

The New Health Insurance Scheme, 2014 for Pensioners (including spouse) / Family Pensioners shall be implemented by the Director of Treasuries and Accounts, Chennai-15 through the United India Insurance Company Limited, Chennai-600 006 / Third Party Administrator under the control of United India Insurance Company Limited, Chennai for a block period of four years. The guidelines governing the New Health Insurance Scheme, 2014 for Pensioners (including spouse) / Family Pensioners are as follows:

1. COMMENCEMENT:

The scheme will commence from 1-7-2014 for a block period of four years i.e. upto 30-6-2018.

2. ENROLMENT:

The enrolment of the Pensioners / Family Pensioners under the New Health Insurance Scheme, 2014 for Pensioners (including spouse) / Family Pensioners shall be compulsory.

3. EXTENT OF THE SCHEME:

(a) The scheme shall be applied to the following categories of existing/future Pensioners / Family Pensioners whose pension / family pension is paid out of the Consolidated Fund of Tamil Nadu and who draw their pension / family pension either directly from the Pension Pay Office, Chennai / District Treasury / Sub-Treasury through Banks under Pension Pilot Scheme or directly from Banks under Public Sector Bank Scheme:-

(i) State Civil Pensioners / Family Pensioners.

(ii) Teacher Pensioners / Family Pensioners.

(iii) Pensioners / Family Pensioners of All India Services belonging to the Tamil Nadu Cadre.

(iv) Pensioners / Family Pensioners of the State Government Employees who had drawn lumpsum payment on absorption in Public Sector Undertakings / Autonomous Bodies / Local Bodies / Co-operative Institutions and have become entitled to restoration of 1/3rd commuted portion of pension as well as revision of the restored amount.

Note: The State Government Employees who were permanently absorbed in the State / Central Owned Corporations, Boards and Autonomous Bodies whose terminal benefits were already settled for the service rendered under the State Government are not eligible under this scheme

 (v) Divisible Family Pensioners where family pension is granted to more than one family members.

(vi) Ex-Gratia Pensioners / Family Pensioners.

(vii) Pensioners / Family Pensioners who are in receipt of Special Pension under Extraordinary Pension Rules, Tamil Nadu and Compassionate Allowance.

(viii) Provisional Pensioners as provided in rules 60, 66, 69 & 69-B of Tamil Nadu Pension Rules, 1978.

(ix) Pensioners / Family Pensioners of former Travancore-Cochin State who drawing their pension on 1st November, 1956 in the Treasuries situated in the areas transferred to Tamil Nadu State on that date i.e. Kanniyakumari District and Shencottah  Taluk of Tirunelveli District.

(b) This scheme is also applicable to the Government Pensioners / Family Pensioners of the above categories who are getting pension / family pension from the Treasuries / Sub-Treasuries and under the Public Sector Bank Scheme outside the State.

4. OPTION TO BE EXERCISED FOR CERTAIN CASES:

(a) The scheme is compulsory for all Pensioners / Family Pensioners. The following categories of Pensioners / Family Pensioners alone are entitled to exercise their option at the time of submitting the prescribed Form appended in the Annexure-IV to this order to the authorities concerned:

i) All India Service (AIS) Pensioner.
ii) A Pensioner who is a recipient of All India Service (AIS) Family Pension.
iii) If the spouse of the Pensioner is a State Government Employee.
iv) If both Husband and Wife are Pensioners.
v) If a Pensioner is also a Family Pensioner.
vi) If an individual draws more than one Family Pension.

(b) In respect of categories (i) to (iii) above, the subscription shall be recovered only from the Pensioners / Family Pensioners who has opted to avail the benefits under this scheme. In respect of categories (iv) to (vi) above, the subscription shall be recovered from one of the Pensioner / Family Pensioner as per the option exercised.

(c) If no such option is received from the above said categories on or before the completion of one month from the date of issue of this order, it shall be construed that the above said categories of Pensioners / Family Pensioners are willing to enroll themselves under this scheme. The option once exercised shall be final.

5. ACCREDITED TREATMENTS AND SURGERIES:

(a) The accredited treatments and surgeries for availing assistance under the New Health Insurance Scheme, 2014 for Pensioners (including spouse) / Family Pensioners are listed in Annexure-II to this order.

(b) The coverage shall also include pre-existing illnesses which have been included in the accredited treatments and surgeries list.

6. APPROVED HOSPITALS:

(a) The hospitals approved by the United India Insurance Company Ltd., Chennai / Third Party Administrator under control of United India Insurance Company for undergoing accredited treatments / surgeries are listed in Annexure-III to this order.

(b) The additional list of approved hospitals to be included and list of deleted hospitals, if any covered under this Scheme will also be updated and hosted in the websites of Government of Tamil Nadu in Finance Department (www.tn.gov.in), the Treasuries and Accounts Department (www.tn.gov.in / karuvoolam) and the United India Insurance Company Limited, Chennai / Third Party Administrator (www.tnnhis2014.com) for ready reference from time to time on receipt of the same from the United India Insurance Company Limited, Chennai.

(c) The assistance will not be extended for any other treatment / surgeries undertaken other than those in the accredited treatments / surgeries / approved hospitals annexed to this order.

7. MEDICAL ASSISTANCE:

(a) The Pensioners (including spouse) / Family Pensioners can avail medical assistance upto a limit of Rupees Two Lakhs in a block period of four years from 1-7-2014 to 30-6-2018 on a CASHLESS basis for the accredited treatments / surgeries in the hospitals approved by the United India Insurance Company / Third Party Administrator under this Scheme.

(b) The benefit will be on a floater basis with a total coverage upto Rupees Two Lakhs individually or collectively for Pensioner (including spouse) and Family Pensioners during the said block period of four years with no restriction on the number of times of availing the accredited treatments / surgeries in the hospitals approved by the United India Insurance Company / Third Party Administrator under this Scheme.

(c) The scope of the scheme shall be to provide coverage for the eligible expenses incurred by the Pensioners (including spouse)/Family Pensioners on behalf of himself / herself or spouse for the accredited treatments and surgeries listed out in Annexure-III to this order.

(d) The United India Insurance Company / Third Party Administrator shall ensure that the patient i.e. Pensioners / Family Pensioners and spouse of the Pensioner who are eligible under this Scheme are given coverage for accredited treatments / surgeries including pre-existing illnesses in the approved hospitals upto the limit of Rupees Two Lakhs over a period of four years commencing from 1-7-2014.

(e) The Pensioners (including spouse) / Family Pensioners under this Scheme will not have to make any payment for the approved cost to the hospitals upto the limit of Rupees Two Lakhs. The hospitals approved by the United India Insurance Company / Third Party Administrator under this Scheme shall extend treatment to the Pensioners (including spouse) / Family Pensioners on a CASHLESS basis.

8. SUBSCRIPTIONS:

(a) A sum of Rs.150/- (Rupees One Hundred and Fifty only) per month shall be recovered as subscription from the pension / family pension of the Pensioner / Family Pensioner payable from the month of July 2014.
(b) In respect of Pensioners / Family Pensioners who drawing pension / family pension from the Pension Pay Office, Chennai / District Treasuries / Sub-Treasuries, the subscription shall be recovered by the Pension Disbursing Officers directly and credited into the relevant Revenue Receipt head of account as indicated in para-5 of the G.O.

(c) In respect of Pensioners / Family Pensioners who drawing pension / family pension directly from Banks under Public Sector Bank Schemes, the subscription shall be recovered by the Branch Manager of the bank concerned and the amount recovered shall be sent to the Director of Treasuries and Accounts, Chennai by means of a Demand Draft along with details of Name / PPO No. of the Pensioners / Family Pensioners. The Director of Treasuries and Accounts, Chennai shall credit the subscription into the relevant Revenue Receipts Head of Account as indicated in para-5 of the G.O

(d) In respect of the State Government Pensioners / Family Pensioners who are getting pension / family pension from the Treasuries / Sub-Treasuries and under the Public Sector Bank : 8 : Scheme outside the State shall send their subscription at the rate of Rs.150/- per month (i.e. Rs.1800/- in one lumpsum for every year on or before 31st July) for a block of four years commencing from 1-7-2014 to 30-6-2018 directly to the Director of Treasuries and Accounts, Chennai by means of a Demand Draft. The filled in Form prescribed in Annexure-IV to this order may also be sent along with Demand Draft. The Director of Treasuries and Accounts, Chennai shall credit the subscription into the relevant Revenue Receipts Head of Account as indicated in para-5 of the G.O.

(e) In respect of Provisional Pensioners, the subscription shall be recovered by the Disbursing Officers concerned directly and credited into the relevant revenue receipts head of account. The Pay and Accounts Officers / Pension Pay Officer, Chennai / Treasury Officers / Sub-Treasury Officers from whom provisional pension is drawn shall ensure that the subscription is being recovered towards this scheme.

(f) In respect of Divisible Family Pensioners, the subscription shall be recovered from each of the Family Pensioners separately.

(g) The Pension Disbursing Officers including the Branch Manager of the Bank concerned shall be held responsible for the prompt recovery of the subscription and remittance every month.

(h) The Pension Disbursing Officers including the Branch Manager of the Bank concerned should also send a monthly report to the Director of Treasuries and Accounts, Chennai about the deductions and remittances made towards subscription of New Health Insurance Scheme, 2014 for Pensioners (including spouse) / Family Pensioners along with Pensioners / Family Pensioners.

(i) In the case of Divisible Family Pensioners, each of the Family Pensioners have to subscribe to the New Health Insurance Scheme, 2014 separately.

9. SUBMISSION OF FORM:

(a) The Pensioners / Family Pensioners / Provisional Pensioners at the time of retirement / sanctioning of Family Pension / Provisional Pension as the case may be, shall submit their filled in Form prescribed in Annexure-IV to this order to the following authorities:-

i) Pensioners/Family Pensioners              
attached to pension pay office, Chennai              
Pension  pay Officer, Chennai.
ii) Pensioners/Family Pensioners attached to Treasuries sub-Treasuries
District Treasury Officer/sub- Treasury Officer concerned
iii) Pensioners/Family Pensioners under the public sector Bank scheme.
Branch Manager of Bank concerned
iv) Pensioners/Family Pensioners drawing outside State.
The Director of Treasuries and Accounts, Chennai.
v) Provisional Pensioners
Pay and Accounts Officers / Pension pay Officer, Chennai/ Treasury Officers/ Sub-Treasury Officers concerned for Self-Drawing Officers.
Head of Office / Pay Disbursing Officers concerned for Non-Self Drawing Officers.

(b) The authorities concerned shall scrutinise the Forms and furnish the certificate to the effect that the applicant is a Pensioner / Family Pensioner drawing pension / family pension through his/her office and that the monthly subscription amount is being recovered from the pension / family pension and credited into the revenue receipts head of account. A copy of the same may be furnished to the Pensioners / Family Pensioners duly signed by the authorities concerned. In respect of Pensioners / Family Pensioners drawing pension/family pension outside State, a copy of the same may be sent to the Pensioners / Family Pensioners duly signed by the Director of Treasuries and Accounts, Chennai.

(c) The Pension Drawing Officers including Branch Manager of Banks concerned shall send the Forms directly to the United India Insurance Company, Chennai / Third Party Administrator under the control of United India Insurance Company with due acknowledgement.

10. IDENTITY CARDS:

(a) The identity cards for availing treatment under New Health Insurance Scheme, 2014 for Pensioners (including spouse)/ Family Pensioners will be issued by the United India Insurance Company through the authorities concerned where pension / family pension are received based on the data provided by the authorities concerned. In respect of Pensioners / Family Pensioners drawing pension / family pension outside the State, the Director of Treasuries and Accounts, Chennai shall arrange to send the identity card directly to the pensioners / family pensioners outside the State.

(b) The United India Insurance Company / Third Party Administrator shall update the details of each Pensioners (including spouse) / Family Pensioners provided by the authorities concerned and arrange to issue new Identity Cards within the stipulated period with abstract of the details of Pensioners (including spouse) / Family Pensioners to get signature from the Pensioner / Family Pensioners.

(c) Prior to issue of Identity Cards by the United India Insurance Company, Chennai / Third Party Administrator, the Pensioners (including spouse) / Family Pensioners can avail treatment by furnishing a copy of the filled in Form prescribed in Annexure-IV submitted by the Pensioner / Family Pensioner and duly attested by the authorities.

(d) During the interim period of preparation and distribution of the new Identity Cards, the United India Insurance Company / Third Party Administrator shall accept copy of the filled in Form prescribed in Annexure-IV submitted by the Pensioner / Family Pensioner to the authorities concerned as valid identity for the purpose of availing benefits under this Scheme. This arrangement will be applicable only for such interim period, till the Identity Cards are made available.

(e) The United India Insurance Company / Third Party Administrator shall arrange to issue the new Identity Cards to the Pensioners / Family pensioners covered under this Scheme with the details of spouse within the stipulated period of 60 days. The United India Insurance Company / Third Party Administrator shall also arrange to issue the Identity Cards to the new Pensioners / Family Pensioners as and when the details of the Pensioners / Family Pensioners are furnished to the United India Insurance Company / Third Party Administrator. The authorities concerned shall be responsible to arrange to furnish data in the Form prescribed in the Annexure-IV to this order and get Identity Cards for their Pensioners / Family Pensioners. The authorities concerned shall also be responsible to surrender the Identity Cards of such of those Pensioners / Family Pensioners to the United India Insurance Company who die in harness.

(f) If there is any difficulty in getting identity cards, a representation may be submitted to the Director of Treasuries and Accounts, Chennai through Pension Pay Officer, Chennai and in other districts to the District Treasury Officers at the District Headquarters including Branch Manager of the Banks concerned. The representation received shall be sent to the United India Insurance Company for redressal.

(g) The Director of Treasuries and Accounts, Chennai-15 shall coordinate and monitor the progress of the work of the United India Insurance Company / Third Party Administrator for issuance of new Identity Cards to the Pensioners / Family Pensioners. Further, the United India Insurance Company / Third Party Administrator shall arrange to issue the Identity Cards to the Pensioners / Family Pensioners within the stipulated time.

(h) The data furnished by the Pensioners / Family Pensioners shall be the property of the State Government and should not be used by the authorities concerned for any other purpose without the prior permission of the Government of Tamil Nadu.

(i) The softcopy of the updated database of Pensioners / Family Pensioners shall be handed over to the Government of Tamil Nadu in Finance (Pension) Department, as and when the data compilations are completed and also to the Director of Treasuries and Accounts, Chennai-15 on monthly basis for calculation of actual annual premium.

(j) All the Pensioners (including spouse) / Family Pensioners covered under this Scheme shall get new Identity Card within the stipulated period without fail for availing medical assistance on a CASHLESS basis under this Scheme. In case of loss of Identity Card, a duplicate Identity Card can be obtained on payment of Rs.50/- by Pensioners / Family Pensioners to the United India Insurance Company / Third Party Administrator through authorities concerned. In turn, the authorities concerned shall arrange to obtain and issue the same to Pensioners (including spouse) / Family Pensioners within the stipulated time.

(k) The Director of Treasuries and Accounts, Chennai shall be the sole authority to sort out the discrepancies if any in the implementation of this scheme as and when brought to notice by the Pensioner / Family Pensioners concerned.

11. PROCEDURE TO BE FOLLOWED FOR AVAILING MEDICAL ASSISTANCE:

The procedure to be followed at the time of admitting Pensioners (including spouse) / Family Pensioners for accredited treatments / surgeries are as follows:

(a) The hospitals approved by the United India Insurance Company / Third Party Administrator under this Scheme alone should be approached for availing the benefits.

(b) The approved Hospitals shall be approached for the accredited treatments / surgeries to be undertaken on CASHLESS basis so that pre-authorisation is given by the United India Insurance Company / Third Party Administrator under the control of the United India Insurance Company Limited, Chennai. In case of emergency only, the approval of the United India Insurance Company / Third Party Administrator for the accredited treatments / surgeries undertaken in the approved hospitals shall be obtained for settlement on CASHLESS basis by the Pensioner / Family Pensioner during the period commencing from the date of treatment / surgeries as in-patient to the date before discharge from the hospital.

c) For claim assistance, the Pensioners / Family Pensioners may contact through Toll Free Helpline No.1800 233 5544 [24 Hours] of the Third Party Administrator under the control of United India Insurance Company Ltd. and also may contact Coordinators of the Third Party Administrator under this scheme through Phone Numbers. Further, if there is any grievances for availing medical assistance, Pensioners / Family Pensioners may contact Nodal Officers of the United India Insurance Company Limited through Phone Numbers. The list of District wise/Other State Co-ordinators and Nodal Officers under the New Health Insurance Scheme, 2014 for Pensioners (including spouse) / Family Pensioners are listed out in Annexure-V.

(d) The Identity Card of the Pensioners / Family Pensioners issued by the United India Insurance Company / Third Party Administrator or by production of the copy of Form prescribed in Annexure-IV shall be produced to the approved hospitals for the accredited treatments / surgeries. This arrangement of production of the copy of Form in Annexure-IV in lieu of Identity Card will be applicable only for such interim period, till the Identity Cards are made available.

(e) This Scheme is on a CASHLESS basis and no payment for approved cost need to be made by the Pensioners (including spouse) / Family Pensioners to the approved Hospitals. Claims for reimbursement of the payment, if any made shall not be entertained.

(f) The eligible charges which are entitled to under this Scheme should be ascertained for the accredited treatments / surgeries from the hospitals approved by the United India Insurance Company / Third Party Administrator should not be allowed to charge any excess amount.

(g) Any claim in deviation of the above procedure for reimbursement is liable to be rejected.

12. REDRESSAL OF GRIEVANCES:

(a) Any complaints about difficulty in availing accredited treatments / surgeries, non-availability of facilities, bogus availment of treatment for ineligible individuals, etc., shall be submitted to the Pension Pay Officer, Chennai and other districts to the District Treasury Officers at the District Headquarters. The complaints received shall be placed for decision of an Empowered Committee at District Level headed by the District Collector, having the Joint Director of Medical and Rural Health Services Department and the Pension Pay Officer, Chennai / District Treasury Officer concerned as the case may be and a official representative of the United India Insurance Company as member. In respect of Pensioners / Family Pensioners drawing pension / family pension directly from Banks under Public Sector Bank Schemes, the complaints if any shall be sent to the Director of Treasuries and Accounts, Chennai.

(b) An appeal against the decision of the District Level Empowered Committee may be preferred by the Pensioners / Family Pensioners to the State Level Empowered Committee headed by the Director of Treasuries and Accounts and having the Director of Medical and Rural Health Services as Member Secretary and an official representative nominated by the United India Insurance Company as members.

(c) The appeals shall be filed with the Director of Medical and Rural Health Services, the Member Secretary of the State Level Empowered Committee who shall place the appeals for a decision of the said Committee.

(d) Any dispute arising out of the implementation of this Scheme which remain unresolved at the State Level Empowered Committee shall be referred within fifteen days of award of State Level Empowered Committee to a High Level Committee, comprising of the Secretary to Government (Expenditure), Finance (Pension) Department, the Secretary to Government, Health and Family Welfare Department and the representative of the United India Insurance Company nominated for the purpose.

(e) The Civil Courts situated in Chennai shall have exclusive jurisdiction over any dispute, which remain unresolved by the above procedure and nothing aforesaid, shall prejudice the rights of the Government of Tamil Nadu to approach any other forum for dispute resolution permissible under Law.

13. The United India Insurance Company, Chennai shall furnish a Monthly / Quarterly / Annual report to the Government of Tamil Nadu in Finance (Pension) Department with the details of the number of claims (hospital wise), and the total amount disbursed (treatments and surgeries wise) and also to the Director of Treasuries and Accounts, Chennai-15. The Director of Treasuries and Accounts, Chennai-15 shall furnish a Annual report to the Government every year.










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