Punjab Government Employees and Pensioners Health Insurance Scheme (PGEPHIS) Notification for Cashless Health Insurance scheme
New Cashless Health Insurance scheme introduced to Punjab State Govt Employees. Details of the terms and conditions furnished below
GOVERNMENT OF PUNJAB
DEPARTMENT OF HEALTH AND FAMILY WELFARE
(HEALTH – V BRANCH)
Dated, Chandigarh the:-20.10.2015
The Governor of Punjab is pleased to introduce a Cashless Health Insurance Scheme hereinafter referred as Punjab Government Employees and Pensioners Health Insurance Scheme (PGEPHIS) to cover indoor medical treatment expenses. specified daycare procedures and treatment of chronic diseases as specified or to be specified by State Government. The scheme will be applicable to all the Government serving employees (whether covered under old or new pension scheme) and pensioners on compulsory basis. However, the scheme will be optional for All India Service Officers, Serving & Ex-MLAs, Serving & Ex-Judicial officers including Judges of Punjab & Haryana High Court. The premium of the main member as well as dependent(s) (as defined in the State Services (Medical Attendant Rules) [CS(MA)] Rules, 1940) will be paid by the State Government.
2. In case husband and wife both are in Punjab Government job or one of them is retiree from Punjab Government, either one of them is eligible for the scheme. However, in case any employee/pensioner is taking medical reimbursement (as a dependent of spouse) from other source he/she will not be eligible under this scheme.
3. The PGEPHIS will cover all the entitlements as specified under the State Services (Medical Attendant Rules) [CS(MA)] Rules, 1940 The scheme will ensure cashless all Indoor medical treatment, Pre & Post hospitalization, specified as denned. Day Care procedures, (requiring less than 24 hours hospitalization) and OPD medical expenses relating to chronic diseases up to a sum of Rs. 3.00 lacs per family per year on floater basis. Medicines for chronic diseases will also be made available on cashless basis from designated stores and hospitals in every district and block. All pre existing diseases will be covered.
4. The treatment can be taken by any enrolled beneficiaries in Government or in empanelled Hospitals in Punjab, Chandigarh and NCR Area (Gurgaon, Noida and Delhi). Further details of the scheme can be seen on website www.pbhealth.gov.in. No reimbursement will be available to employee/pensioner in the Punjab, Chandigarh and Panchkula, where cashless treatment is available. However, reimbursement can. be taken by employee/pensioner for medical treatment taken in any other State in India in exceptional circumstances, in such circumstances, the insurance company will reimburse the bill of the employee up to Rs. 3.00 lacs as per the package. rates defined under the scheme.
5. Since this cashless medical treatment is made available to employee/pensioner through Insurance Company there are certain treatments which are not covered under Health Insurance as per the Insurance Regulatory and Development Authority of India (IRDA). Details of such exclusions are available in the scheme uploaded on the website of Health Department of Punjab i.e. www punjabhealth.gov.in. The-reimbursement of such exclusions will be made available to employees/pensioners as per existing policy and State Services (Medical Attendant Rules) [CS(MA)] Rules, 1940 as amended from time to time through Treasury route.
6. Any treatment taken abroad will not be covered under this scheme. Any public servant/pensioner will have to take overseas insurance cover before going abroad. Premium of such insurance cover will be borne by employee/pensioner. In case, any public servant is. going on Government tour, premium of such overseas insurance will be borne by the State Government
7. The State Government through tendering process has selected Oriental Insurance Company Chandigarh. The Insurance Company will make the buffer of Rs.25.00 crores for meeting out expenses over and above Rs. 3.00 lacs and Cashless Insurance to any employee / pensioner will be available beyond Rs.3.00 lacs subject to the availability of the buffer. On the exhaustion of the buffer, the Cashless reimbursement more than Rs.3.00 lacs will not be available to any employee/pensioner. In such circumstances, the Insurance Company will inform the employee/pensioner that further treatment shall not be on cashless but reimbursement basis as per the existing pattern at PGI/AIIMS rates The concerned ODO will seek the reimbursement from concerned Civil Surgeon/Directorate of Health & Family Welfare who will examine the bill as per the entitlement of the claimant as per State Services (Medical Attendant Rules) [CS(MA)] Rules, 1940 If that particular bill(s) as per the entitlements) is less than Rs: 3.00 lacs then no amount will be reimbursed to the employee and if the bill(s) is more than Rs. 3.00 lacs then additional amount will be reimbursed to the employee through Treasury Route.
8. Enrollment under this scheme will start from immediate effect and will be completed by 31.12.2015 and the benefits under this scheme will start from 1.1.2016 and will be available up to 31.12.2016 initially Every employee/pensioner will ensure his/her enrollment along with dependents before 15.12.2015 enabling .the Insurance Company to deliver the enrolled insurance cards up to 31.12.2015. No fresh enrollment of the Serving Employees and Pensioners shall be allowed after the date of expiry of Enrollment Period except for any exceptional circumstances or in case of any employee who has joined the service after the enrollment period, under such circumstances. coverage as well as payment of premium of such employees/pensioners shall be allowed on pro-rata basis
9. The enrollment forms for the employees/pensioners and option form for the category mentioned in Para-3 of the Notification will be available after 15 10 2015 on website www.pbhealth.gov.in along with the procedure to fill such forms. A copy of the forms will be made available to all the DDOs. The forms can be filled online as well as offline but have to be submitted in hardcopy through ODO to Insurance Company The Insurance Company will collect the filled forms from ODO and handover the Insurance Cards of the main member and dependent(s) to the ODO for onward delivery to the employee/pensioner Every employee/pensioner will be notified regarding enrollment with Unique Insurance ID Numbers. In case of misplacement of the card/non availability or the card this Unique Insurance ID can be used for taking treatment in the designated hospitals.
10. The employees and pensioners on whom the scheme will be applicable and those who have opted for PGEPHIS, will be entitled for fixed medical allowance as per the existing pattern to cover their routine OPD expenditure
11. Any employee/pensioner can take any information /clarification regarding enrollment, benefits available under the scheme, exclusions, list of enrolled private as well as government hospitals. process to be followed tor lodging claim with Insurance Company or with State Government by dialling toll free medical helpline number “104” Any complaint regarding enrollment treatment, reimbursement, Insurance Company and Hospitals can be lodged also on toll free helpline number “104”. The complaint will be redressed in a time bound manner
12. The Punjab Health Systems Corporation will operate this Scheme. This will involve enrolments and other operational issues like, crawl of requisite funds, release of payment to the insurance company on the basis of the enrollments and monitoring this scheme.
13. A similar scheme can be adopted by the Boards, Corporations and Public Sector Undertakings of Punjab Government for its Employees & Pensioners in consultation with the State Government in Finance Department.
14. This is issued in accordance with the approval granted by the Cabinet in its meeting held on 17 .9.2015 conveyed to the Health Department by the General Administration Cabinet Affairs Branch vide ID 1/180/2015-1 Cabinet/529618/1, dated 18.9.2015.
Hussan Lal, IAS
Secretary Health & Family Welfare