We have the pleasure in sending "SALIENT FEATURES OF GROUP MEDICLAIM POICY" in attachment for your guidance. The same has been prepared by Sri Partha Chatterjee, our member.
Subir Kumar Mazumder
GENERAL SECRETARY
LIC RETIRED CLASS-I OFFICERS' ASSOCIATION,
KOLKATA
click here to read or see below
Subir Kumar Mazumder
GENERAL SECRETARY
LIC RETIRED CLASS-I OFFICERS' ASSOCIATION,
KOLKATA
click here to read or see below
Salient Points of Mediclaim Policy for Retired Officers/Employees of LICI.
by Partha Chatterjee
Sl no
|
Description
|
Details of benefit
|
1
|
Policy No for WZO and CO Area
|
12070034150400000001
|
Policy No for CZO Area
|
12070034150400000002
| |
Policy No for NZO Area
|
12070034150400000003
| |
Policy No for NCZO Area
|
12070034150400000004
| |
Policy No for ECZO Area
|
12070034150400000005
| |
Policy No for EZO Area
|
12070034150400000006
| |
Policy No for SCZO Area
|
12070034150400000007
| |
Policy No for SZO Area
|
12070034150400000008
| |
2
|
Name of the Insured
|
LICI, CO. YOGAKSHEMA, Mumbai-400021
|
3
|
Name of the Insurer
|
The New India Assurance Company LTD
|
4
|
Location of the Insured Persons
|
Anywhere in India
|
5
|
Policy period
|
01.04.2015-31.03.2016
|
6
|
Basic floater Sum Insured
|
3.0L,4.0L,6.0L
|
7
|
Optional SA on Floater Basis
|
4.0,5.0,6.0,8.0,10.0,12.0,15.0,20,.0 LAKHS
|
8
|
TPA for WZO & CO/ CZO/NZO
|
MD India Health care services (TPA) Pvt.Ltd, Web site:www.mdindiaonline.com, email:customercare@mdindia.com,
Toll free Tel no:18002335588
|
TPA for NCZO
|
Raksha TPA Pvt. Ltd.
Web site:www.rakshatpa.com
email:jyotiawasthi rakshatpa.com
Toll free Tel no:18001039533
| |
TPA for EZO / ECZO
| ||
TPA for SCZO
|
Medi Assist India TPA Pvt.Ltd.
Web site: www.mediassistindia.com
email: lic@mediassistindia.com
Toll free Tel no: 18004191160
| |
TPA for SZO
|
Vidal Health TPA Pvt.Ltd.
Web site: www.vidalhealthtpa.com
email: lic@vidalhealthtpa.com
Toll free Tel no/ Tamilnadu:18004257595
| |
9.
|
List of Hospitals covered under network of TPA
|
It is available on respective TPA's website and also in LIC's intranet website
|
10
|
Procedure for availing CASHLESS facility
|
i)
Cashless hospitalization can be available only at TPA's network of hospitals.
ii)
Pre admission authorization to the Hospital/NH by TPA is essential.
iii)
In case of change of residence outside Zone original TPA will provide services based onPAN India's network hospital. |
11
|
Documents required
|
i)
E-Card of patient issued by TPA & any photo identity card such as employee ID Card, PAN, Driving License, Voter ID, Passport, Aadhar Card, School/College ID Card or any other photo ID Card by State/Central Government.
ii)
In absence of TPA ID Card Certificate by respective OS Deptt will do. |
12
|
Room Rent / Boarding Expenses limit
|
1.5% of total SA (Basic+ Additional) per day subject to maximum Rs7, 500/- for A Class cities; Rs 5,000/- for B Class cities; Rs4, 000/- for C class cities. ( Reimbursement will be reduced proportionately in case limit exceeds)
However in case of ICU/CCU there is no capping/ ceiling on ICU/ICCU Expenses.
|
13
|
Expenses relating to Diagnostics Tests without hospitalizations.
Restrictive conditions:-
1)
The Maximum limit 65,000/- for the family during the Policy Year
2)
MD or EQUIVALENT Doctor must advice for the same
3)
In case of prescription by Govt Hospital, the above condition can be waived.
4)
Allowed for only once per insured in a policy year |
Diagnostics Tests Maximum amt payable
MRI Charges Rs8000/- each insured
CT Scan Charges Rs5000/- each insured
Sonography Rs2000/- each insured
Biopsy Rs3,000/- each insured
Tread Mill Test Rs1200/- each insured
Echo Rs1500/- each insured
Gastroscopy Rs4000/- each insured
Colonscopy Rs6000/- each insured
EEG Rs1000/- each insured
EMG Rs2000/- each insured
Holter Monitor Rs5000/- each insured
PAP SMEAR Rs750/- each insured
PSA(Prostate Specific Rs750/- each insured
Antigen)
Mammography Rs5000/- each insured
|
14
|
ORGAN TRANSPLANT
|
Hospitalisation expenses (excuding the cost of the organ) during the course of organ transplant to the insured person
|
15
|
LASIK LASER TREATMENT
|
Maximum amount payabe Rs.35000/- per eye
|
16
|
MATERNITY BENEFIT
|
Maximum 65000/- for Normal Delivery
Maximum 125000/- for Caserian section Delivery
Lawful Medical Termination of pregnancy included.
|
17
|
Limitation of 24 Hrs. hospitalisation.
|
Not applicable for certain surgeries , procdures and eye surgeries.
|
18
|
Pre and post hospitalisation expenses.
|
30 days and 60 days respectively. The above limitaions may be waived in cases of renal failure snd/or organ transplantation.
|
19
|
Surgeon/Anesthetists Payment
|
Restricted to 25% of SA. Payment must be paid by cheque and numbered bill and not receipt on letter head is required. However fees paid by cash may be reimbursed up to following limit, provided numbered bill is obtained.
Surgeon Rs 30,000/-
Assistant Surgeon Rs12,000/-
Anesthetists Rs20,000/-
|
20
|
Limit for payment on cataract
|
Rs60,000/- for each eye( all inclusive) or actual cost, whichever is less.
|
21
|
Ambulance charges
|
Limited to maximum Rs5,000/- per insured.
|
22.
|
Dental treatment
|
Not allowed, except arising out of accident.
|
23
|
Dependent children
|
Insurance cover is restricted to Retired employee, spouse, dependent male children up to 25 years of age dependent female children unmarried, widow and divorcee residing with the insured parents and having income less than Rs3,500/- per month.
|
24
|
Submission of claim
|
Must be submitted within 20days from discharge of the Hospital.
|
25
|
Settlement of claim
|
The Insurer must settle the claim, including rejection within 30 days from receipt of the last document. Once claim is settled by TPA fund will be transferred to LICI within seven working days.
|
26
|
Claim intimation forms
|
Claim form, Doctor/consultant's prescription,
Discharge Summary/Discharge card, Bills cash memo and money receipts, pathological test reports, Surgeon's certificate, attending Doctor's bill and receipt and claimant' s details
|
In case of any doubt/dispute and further clarification, please refer original circulars
