08-03-10:

New Medical Scheme for Central Government Employees and Pensioners

Government introduce a new Medical Scheme for Central Government Employees and Pensioners as in the name of Central Government Employees and Pensioners Health Insurance Scheme (CGEPHIS).Some key points regarding the scheme:-
BENEFICIARIES:
CGEPHIS shall be compulsory to new Central Government Employees who would be joining service after the introduction of the Health Insurance Scheme.
and who would be retiring from the service after the introduction of the Insurance Scheme.
CGEPHIS would be available on voluntary basis for the following:
Existing Central Government Employees and Pensioners who are already CGHS beneficiaries. In this case they have to opt out of CGHS scheme. They will also have the option of choosing both CGHS and Insurance policy. In such case the total insurance premium has to be borne by the member.
Existing Central Government Employees and Pensioners who are not CGHS beneficiaries but are covered under CS (MA)
INSURANCE COVERAGE:
In-patient benefits – The Insurance Scheme shall pay all expenses incurred in course of medical treatment availed of by the beneficiaries in an Empanelled Hospitals/ Nursing Homes (24 hours admission clause) within the country, arising out of either illness/disease/injury and or sickness.
NOTE: In case of organ transplant, the expenses incurred for the Donor are also payable under the scheme.
Pre & Post hospitalization benefit: Benefit up to 30 days Pre Hospitalization & up to 60 days Post Hospitalization respectively which would cover all expenses related to treatment of the sickness for which hospitalization was done.
FAMILY SIZE:
Serving/Retired Employees: Self, Spouse, Two dependent children and up to Two Dependent Parents. New born shall be considered insured from day one till the expiry of the current policy irrespective of the number of members covered subject to eligibility under maternity benefit.
Any additional dependent member in addition to above [Sr. No. 5 (1)] can be covered under the Scheme by paying the fixed amount of premium. This additional full premium shall be borne by the beneficiary.
IDENTIFICATION OF FAMILY:
Beneficiaries shall be identified by a “Photo Smart Card” issued by the insurer to all beneficiaries which would have all personal details, medical history, policy limits etc. of the CGEPHIS members. This card would be used across the country to access Health Insurance Benefits. The photograph embedded in the chip of the Smart Card will be taken as the proof for determining the eligibility of the beneficiaries.
SUM INSURED AND BUFFER / CORPORATE SUM INSURED
SUM INSURED:

The Scheme shall provide coverage for meeting all expenses relating to hospitalization of beneficiary members up to Rs. 5, 00,000/- per family per year in any of the Empanelled Hospital/Nursing Home/Day Care Unit subject to stated limits on cashless basis through smart cards. The benefit shall be available to each and every member of the family on floater basis i.e. the total reimbursement of Rs. 5.00 lakh can be availed by one individual or collectively by all members of the family.
Entitlements for various types of wards: CGHS beneficiaries are entitled to facilities of private, semi-private or general ward depending on their pay drawn in pay band / pension. These entitlements are amended from time to time and the latest order in this regards needs to be followed. The entitlement is as follows:-
Pay drawn in pay band/Basic Pension - Entitlement

Rs. 13,950/-(up to)……………………………… General Ward

Rs. 13,960/- to 19,530/- …………………… Semi-Private Ward

Rs. 19,540/- and above ……………………… Private Ward
CASHLESS ACCESS SERVICE:
The Insurer has to ensure that all CGEPHIS members are provided with adequate facilities so that they do not have to pay any deposits at the commencement of the treatment or at the end of treatment to the extent as the Services are covered under the Scheme. The service provided by the Insurer along with subject to responsibilities of the Insurer as detailed in this clause is collectively referred to as the “Cashless Access Service.”
The services have to be provided by the Empanelled Hospitals/Nursing Homes/Day Care Clinics to the beneficiary based on Photo Smart Card authentication only without any delay. The beneficiaries shall be provided treatment free of cost for all such ailments covered under the Scheme within the limits/sub-limits of defined package rates and sum insured, i.e., not specifically excluded under the scheme.

ENROLMENT PROCESS:The process of enrolment shall be as under:

Serving Employees:

1. Departments and offices will call for options from employees to join voluntary CGEPHIS with or without existing CGHS/CS (MA) benefits.
2. Head of Department of the Administrative Ministry/Department would be the contact point for the Insurance Companies.
3. Enrolment forms giving details about self and family and authorization to the department for recovery of premium on a monthly basis would be consolidated by the Administrative Ministry / Department. The data of the beneficiary and dependent members to be covered along with 2 recent passport size photo and copy of enrolment form will be forwarded to Insurance Company on monthly basis.
4. Insurance Company will issue Smart Cards on the basis of information received of the beneficiaries for enrolment.
5. Such Smart Cards along with the enrollment kit shall be sent by the insurers directly to the insured persons at their respective mailing addresses at insurer’s cost within 7 days.
Insurance Premium:-

The beneficiary will have to pay an annual premium which will be determined after the formal introduction of the Scheme. It will vary according to the grade pay of the officer. The estimated annual premium for a standard family size will be in the range of Rs.8000 to Rs.12000 p.a. It is however proposed to be subsidized by the Government to a considerable extent.