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Medisep

01 February 2022

Medisep - Overview

• Cashless Insurance scheme for Kerala Government Employees & Pensioners
• About 4 Lakh Kerala Govt. Employees & Pensioners eligible for the scheme
• Premium per annum for a family is Rs.4800
• Total Premium can reach up to Rs. 200Cr. /Annum
• Sum Insured Rs. 3Lakhs per Annum, Rs.1.50Lakhs fixed Sum Insured and Rs.1.50 Lakhs Floater which can be carried forward to next year – if not exhausted completely
• For Catastrophic Illnesses, corpus sum insured of Rs.35 Cr. for three years
• Pre and Post Hospitalization of 15days each.
• Beneficiary details: -
  

  Insured Employee, Spouse and Minor or adopted child/children dependent upon the insured, till they get employed, married, or attained the age of 25 years whichever is earlier (Physically challenged/mentally challenged child/children of the employee without any age restriction)

  For Insured Pensioner, Spouse and physically challenged/mentally challenged child/children of the pensioner without any age restriction.

Hospital Categorization

1. General Purpose Hospitals-Healthcare provider having 25 or more beds with the following specialities : General Medicine, General Surgery, Obstetrics and Gynaecology, Paediatrics, Orthopaedics, ENT, Dermatology, ICU and Critical Care units
2. Speciality and Super Speciality Hospitals- Hospitals having 50 or more beds can be empanelled as a speciality hospital, provided they have at least 10 beds earmarked for the speciality. The specialities include Cardiology, Cardiovascular and Cardiothoracic surgery, Genito Urinary Surgery, Gastroenterology, Ophthalmology, Pulmonology, Poly Trauma & Critical Care, Plastic Surgery, Neurosurgery, Neurology, Paediatric Surgery, Nephrology, Rheumatology, Endocrinology etc.
3. Hospitals for Transplant Surgery: Hospitals with experience in conducting transplant surgeries (Kidney, Liver, Heart Transplant etc.)

Benefit Package Rate & Hospital Classification

Hospitals without any quality accreditation can charge the base package rate, whereas hospitals with NABH/NQAS entry level can charge additional 5% of base package rate. Hospitals with NABH are eligible to charge 10% over the base rate.

Hospitals with full accreditation (Accredited Rates), where there is an increase of 10% over the base package price, the incremental 10% is to borne by the beneficiary.

Procedure Charges

The package cost includes all cost components related to medical consultation and treatment, pre hospitalization expenses, medicine and consumables, diagnostic and laboratory investigations, doctor, and nursing charges, discharge medicines and post hospitalization review if required.

Room charges can be charged over and above the package rates but as per the days of stay agreed for the procedure. In case of complications or extension of stay beyond package days, additional days room charges can be charged- provided approval for extension of stay is obtained. But there is hardly any clarity on whether hospital will get cost of medicine/consumables/investigation/procedure etc. during extended stay.

Implant Cost

Certain procedures require single or multiple implants, the cost of which is variable. Hence the implant cost is separate from the procedure costs, wherever it is applicable.

The cost of the implants will be based on the maximum ceiling price fixed by the National Pharmaceutical Authority of India (NPPA).

Room Charges

For General Ward up to Rs.1000; For Semiprivate Ward up to Rs.1500 and Private Ward up to Rs 2000.

In case the hospital room rent is less than the specified room rent, only the actual rates applicable for each category room can be claimed. If the beneficiary opts for the higher category room than the one specified in the policy, difference amount is to be borne by the beneficiary.

Medical Management Cases

The package rate offered include medical management cases also and rent can be charged separately.

If admission extend beyond the agreed days of stay, approvals to be initiated for the same.

Claim Settlement TAT

Claim settlement TAT is 15 Days.