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State of Rajasthan - Act

Rajasthan State Accredited Journalists Medical Facility Scheme 2009

RAJASTHAN
India

Rajasthan State Accredited Journalists Medical Facility Scheme 2009

Rule RAJASTHAN-STATE-ACCREDITED-JOURNALISTS-MEDICAL-FACILITY-SCHEME-2009 of 2009

Published on 22 February 2010
Commenced on 22 February 2010
[This is the version of this document from 22 February 2010.]
[Note: The original publication document is not available and this content could not be verified.]

Rajasthan State Accredited Journalists Medical Facility Scheme 2009Published vide Notification No. F. 09(40) Sampark/2002, dated 22.2.2010No. F. 09(40) Sampark/2002. - The Governor is pleased to hereby notify the "Rajasthan State Accredited Journalists Medical Facility Scheme 2009" for accredited Journalists of Rajasthan in continuation of notification No. F.9 (37) sampark /02/281 Dated 27-05-2005 (amended from time to time), to provide Mediclaim and accidental group Insurance facility to the accredited Journalists of Rajasthan, as under: -

1.

The scheme shall be called "Rajasthan State Accredited Journalists Medical Facility Scheme 2009".

2.

This scheme shall come into force with immediate effect.

3. Eligibility.

- (i) The scheme shall apply to accredited Journalists of Rajasthan.

(ii)The scheme shall not be applicable to the accredited Journalists whose recognition has been suspended or cancelled.

(iii)The scheme shall also apply to the family members of eligible accredited Journalists and their family members include spouse and two dependent children up to the age of 21.

(iv)[ The scheme shall be optional. It is not mandatory for all accredited Journalists to opt for the scheme. He/She can continue the facility of medical diary provided vide notification No.F9(37) Sampark/02/281 Dated 27.05.2005, in addition to availing benefit under the scheme, subject to the condition that 25% of the amount of premium of mediclaim policy of rupees one lac shall be contributed by the contributed by the concerned accredited journalist.] [Substituted by Rajasthan Notification No. F. 9(40) Sampark/2002, dated 27.9.2011.]

4. Operation.

- (i) Insurer : - The insurer will be State Insurance & General Provident Fund Department which would take account of both financial and technical parameters of the proposal.

(ii)Health Service Provider: As engaged by SI&GPF Department.

5. Premium.

- (i) The annual premium will be Rs.4500 per annum per family (4000/- for mediclaim & 500/- for accidental insurance including S.T.)

(ii)The premium will be paid in proportion as 75% of Annual premium will be deposited by State Government through Journalist Welfare Fund and remaining 25% will be deposited by individual policy holders. Registration/renewal fees will also be borne by the policy holder

(iii)The insurer will complete the formalities of insurance with the individual and with the department.

(iv)The State Government shall pay the insurance amount within 45 days of submission of demand notice from the insurer.

6. Period of Insurance.

- The insurance coverage under the scheme shall be of one year from the date of commencement of the policy which could be renewed a decided by the Government.

7. Coverage.

- Coverage Details : -

1. Mediclaim coverage. Rs. 1 Lac (On floater basis).

2. Critical Illness Rs. 1 Lac (On floater basis).

3. Benefit of pre and Post hospitalization up to 10 days and 15 days respectively.

4. All pre existing diseases are covered.

5. Out door facility up to Rs. 2500/-(for per family, P.A., on floater Basis) only in government Hospitals (Reimbursement).

6. Maternity & neonatal Benefits up to 20,000/, in case of complex caesarian delivery cases up to two surviving children.

7. Boarding in only general ward of hospitals.

8. Accidental risk coverage as given below (policy issued by SIGPF).

8. Covered Medical expenses.

- (A) Room, Boarding in General Ward and Nursing Expenses as provided by the Hospital as per condition.

(B)Surgeon, Anesthetist, Medical Practitioner, Consultants, Specialists Fees.

(C)Anesthesia, Blood, Oxygen, Operation Theatre Charges, Surgical, Appliances, Medicines & Drugs, Diagnostic Materials and X-ray, Limbs implanted in the body & Cost of organs and similar expenses.

In the event of any claim/s becoming admissible under this scheme, the General Insurance Fund (State Insurance & .GPF Department, Rajasthan) will pay heads mentioned below and as are reasonably and necessarily incurred there of by or on behalf of such Insured Person, but not exceeding the Sum Insured in aggregate mentioned in the schedule hereto.

9. Clarification.

- I. General Insurance Fund's (State Insurance & GPF Department, Rajasthan) liability in respect of all claims admitted during the period of insurance shall not exceed the Sum Insured per family as mentioned in the schedule (Annexure-II- Mediclaim Policy).II. Day care treatment will be included (Annexure-II- Mediclaim Policy)III. Outdoor treatment will be allowed on reimbursement basis only in Government Hospital up to Rs. 2500/- (on family floater basis)

10. Definition.

- 10.1 "Scheme" means Rajasthan State Accredited Journalists Medical Facility Scheme 2009"

10.2"Accredited Journalists" means Journalist of Rajasthan having valid accredited recognition under "Rajasthan press Pratinidhi Adhiswikaran Niyam, 1995.

10.3"Government" means Government of Rajasthan.

10.4Insurer. - State Insurance & Provident Fund Department, Government of Rajasthan.

10.5Insured Beneficiaries. - All the Accredited Journalist in the State of Rajasthan with spouse and two children up to the age of 21.

10.6Commencement of Scheme. - w.e.f the date of issue of notification.

10.7Hospital. - Means any hospital for indoor care and treatment of sickness and injuries and which include : -

(a)All the Government Hospital in the State of Rajasthan (CHCs, District hospital & All Medical Collages)

(b)Private hospitals in and outside of Rajasthan which have been duly approved by the Government of Rajasthan SI&GPF Department.

(c)Referral Government hospitals outside of the state Which are super specialist hospitals duly approved by the State Government of Rajasthan.

10.8"Surgical Operation" Means manual and/or operative procedures for correction of deformities and defect, repair of injuries, diagnosis and cure of diseases, relief of suffering and-prolongation of life.

10.9Day Care Treatment Expenses : - On Hospitalization for minimum period of 24 hours are admissible. However, this time limit is not applied to daycare treatments, i.e. Dialysis, Chemotherapy, Radiotherapy, Eye Surgery, Dental Surgery in case of accidents, Lithotripsy (Kidney Stone removal), D&C, Tonsillectomy taken in the approved Hospital/Nursing Home and the Insured is discharged on the same day, the treatment will be considered to be taken under hospitalization Benefit.(Annexure-II)

10.10Outdoor Hospital facility : - In Government hospitals and reimbursement of medicines up to 2500 Rest. Per Annum per family on floater Basis from authorized medical shops including tests, X-ray done Medicare relief society.

10.11Pre Hospitalization: - Relevant medical expense incurred during period limited up to 10 days prior to hospitalization on disease/illness/injury sustained will be considered as part of claim.

10.12Post Hospitalization: - Relevant medical expenses incurred during period up to 15 days after hospitalization on disease/illness/injury sustained will be considered as part of claims subjected to a maximum share of the total costs of the hospitalization.

11. Administration of the scheme.

- co-coordinating committee at the state level would be constituted by the State Government of administer, implement, monitor and review the Insurance Scheme. The committee shall decide the proportion of premium to be paid by State Government and accredited journalists and redress the grieviances relating to this scheme.

11.1The committee at state level would be constituted as follows: -• Director & Deputy Secretary, Information & Publication Relations, Chairman.• Director, Medical and Health, Member.• Additional Director, I&PR, Member Secretary• Additional Director, Med claim, SI&PF, Member• Additional Director, Insurance, SI&PF Member.• Additional Director, GIS, SI&PF Member• Representation from Accredited Journalist.I Chairman JAARII Chairman Pink City Press club limited.III Chairman Shramjivi Patrakar SanghRepresentative of Jar

12. Enrollment of Beneficiaries.

- Data base and details will be provided by DIPR in both hard and soft copy to State Insurance & GPF Department.

13. Medical Practitioner.

- Means a person who holds a degree/diploma of a recognized institution and is registered by Medical Council of respective State of "Rajasthan". The term Medical Practitioner would include Physician, Specialist and Surgeon.

14. Qualified Nurse.

- Means a person who holds a certificate of a recognized Nursing Council and who is employed on recommendation of the attending Medical practitioner.

15.

"TPA" meats a Third Party Administrator who, for the time being is licensed by the Insurance Regulatory and Development Authority, and is engaged, for a fee or remuneration, by whatever name called as may be specified in the agreement with the GIF, for the provision of health services.

16. Cashless Facility.

- Cashless facility would be extended to the Insured in the approved hospitals for the critical ailments and the treatment requiring surgical treatments as per Guide lines issued by the GIF. It is required by the insured/hospital that the claims arising in hospitals should be intimated by cashless request form/ claim intimation form, available in the hospital, to the TPA positively. If the claim intimation does not reach the TPA the same day when the patient is admitted to the hospital then the hospital shall not be entitled for cashless facility.

17. Claim Intimation to TPA.

- It is required by the insured/hospital that the claims arising in hospitals should be intimated with claim intimation form, available in the hospital, to TPA positively. If the claim intimation does not reach the TPA the insured shall not be entitled for re-imbursement.

18. Dependent Family.

- The 'family' of the Insured shall include the Journalist, spouse and two dependent children up to the age of 21.

19. Beneficiaries.

- The policy covers the Journalist family as defined above.

20.

I.D. Card Will be issued by SIGIF/DIPR along with the name of family members.

21. Enrollment of the Private Hospital.

- The criteria for Empanelling private hospital would be as per (Annexure IV- mediclaim policy)

22. Schedules.

- The Schedules enclosed will be deemed to be a part of the scheme (Annexure-I-V mediclairn policy)

23. Maternity Benefit.

- Spouse & Accredited female journalist shall be entitled for this benefit. The benefit shall be as under :-

(i)Spouse Rs.20 Thousand per case per year.

(ii)Accredited female journalist Rs. 50 Thousand per case per year.

Note : - (i) This benefit will be available up to two survived children

(ii)9 months waiting period shall be applied in case of spouse this will not be applicable in case of accredited female journalists.

Neo/post natal cover shall be part of maternity benefit limit.

24. Accidental risk cover.

(a)Deaths: - The capital sum insured will be paid if the death of the insured person is within a period of twelve months from the date of bodily injury and such injury be the direct cause of the death of insured person.

(b)Permanent Total Disablement (PTD): - If such injury shall cause irrecoverable losses such as -

(c)Sight of both or single eye, Physical separation of two entire hands or two entire feet or one entire hand and one entire foot then the capital sum insured will be given as per the policy issued by SI&GPF

(d)In case of loss of use of two hands, feet or eyes or one hand and one foot, or eye, the capital sum insured will be given as per the accidental insurance policy issued by SI&GPF

Permanent Partial Disablement (PPD): - If such injury shall cause physical separation loss of use of body parts like -Loss of toes, loss of hearing, loss of fingers, loss of thumb, loss of little, middle index finger, loss of metacarpus and any other permanent partial disablement the capital sum insured will be given as per the accidental insurance policy issued by SI&GPF

(e)Carriage of dead bad : - Expenses incurred for transportation of insured's dead body to the place of residence (due to accident) subject to a maximum of 5% of sum insured.

1. Natural death (on medical reasons) : - In case of death from other medical reasons (during hospitalization) the capital sum injured will be paid to the legal nominee of injured without any refund of the premium.

2. Pre existing diseases be covered under the scheme

25. Exclusions.

- 1. Conditions that do not require hospitalization

2. Congenital external diseases

3. Drug and Alcohol Induced illness

4. Sterilization and Fertility Related procedures

5. Vaccination

6. War, Nuclear Invasion

7. Suicide

8. Naturopathie Un Ani, Siddha, Aruveda.

9. Outdoor treatment which is not included in day care treatment

10. Dental treatment

26. Terms & Conditions.

- Every notice or communication to be given or made under this scheme shall be delivered in writing at the address of the TPA/GIF office.

26.1The premium payable under this Policy shall be paid in advance. No receipt for Premium shall be valid except on the official form of the /SI&GPF signed by a duly authorized official of the/GIF. The due payment of premium and the observance and fulfillment of the terms provisions conditions and endorsements of this policy by the Insured Person in so far as they relate to any thing to be done or complied with by the Insured Person shall be a condition precedent to any liability of the GIF to made any payment under this Policy. No waiver of any terms, provisions, condition an endorsements of this policy shall be valid unless made in writing and signed by an authorized official of the GIF.

26.2Upon the happening of any event which may give rise to a claim under this Policy notice with full particulars shall be sent to the TPA/GIF immediately and in case of emergency Hospitalization with in 24 hours from the time of Hospitalization.

26.3All supporting documents relating to the claim must he tiled with TPA/GIF within 7 days from the date of discharge from the hospital. In case of post-hospitalization, treatment (limited to 15 days), all claim documents should be submitted within 7 days after completion of such treatment.

26.4The Insured Person shall obtain and furnish the TPA/GIF with all original bills, receipts verifications and other documents upon which a claim is based and shall also give the TPA/GIF such additional information and assistance as the TPA/GIF may require in dealing with the claim.

26.5Any medical practitioner or an officer authorized by the TPA/GIF shall be allowed to examine the Insured Person in case of any alleged injury or disease requiring Hospitalization when and so often as the same may reasonably be required on behalf of the TPA/GIF.19. The GIF shall not be liable to make any payment under this policy in respect of any claim if such claim be in any manner. fraudulent or supported by any fraudulent means or device whether by the Insured Person or by any other person acting on his behalf.

26.6If at the time when any claim arises under this Policy, there is in existence and other insurance (other than Cancer Insurance Policy in collaboration with India Cancer Society), whether it be effected by or on behalf of any Insured Person in respect of whom the claim may have arisen covering the same loss, liability, compensation , costs of expenses, the GIF shall not be liable to pay or contribute more than its rate able proportion of any loss, liability, compensation costs or expenses The benefits under this Policy shall be in excess of the benefits available under Cancer Insurance Policy.

26.7If and when the Insured has submitted his/her family details to the concerned State Insurance District office and identity cards have been issued to the insurer, then only he/she shall be entitled for cashless facility.

26.8The Policy may be renewed by mutual consent. The GIF shall not however be bound to give notice that it is due for renewal and the GIF may at any time cancel this Policy by sending the Insured 30 days notice by registered letter at the insured's last known address and in such event the GIF shall refund to the insured a pro-rata premium for unexpired Period of Insurance. The GIF shall however, remain liable for any claim, which arose prior to the date of cancellation. The Insured may at any time cancel this Policy and in such event the GIF shall allow refund of premium at GIF's short period rate only (Table given here below) provided no claim has occurred up to the date of cancellation.

26.9If any dispute or difference shall arise as to the quantum to be paid under the policy (liability being otherwise admitted) such difference shall independently of all other questions be referred to the decision of a sole arbitrator, to be appointed in writing by the parties or if they cannot agree upon a single arbitrator within 30 days of any party invoking arbitration, the same shall be referred to a panel of three arbitrators, comprising of two arbitrators, one to be appointed by each of the parties to the dispute/difference and the third arbitrator to be appointed by such two arbitrators and arbitration shall be conducted under and in accordance with the provisions of the Arbitration and Conciliation Act, 1996. It is clearly agreed and understood that no difference or dispute shall be referable to Arbitration as herein before provided, If the GIF has disputed or not accepted liability under or in respect of this Policy. It is hereby expressly stipulated and declared that it shall be a condition precedent to any right of action or suit upon this policy that award by such arbitrator/arbitrators of the amount of the loss or damage shall be first obtained.

26.10If the TPA, as per terms and conditions of the policy or the GIF shall disclaim liability to the Insured for any claim hereunder and if the Insured shall not within 12 calendar months from the date or receipt of the notice of such disclaimer notify the TPA/GIF in writing that he does not accept such disclaimer and intends to recover his claim form the TPA/GIF then the claim shall for all purposes be deemed to have been abandoned and shall not thereafter be recoverable hereunder.

26.11All medical/surgical treatments under this policy shall have to be taken in approved hospitals in and outside Rajasthan and admissible claims thereof shall be payable in Indian currency. Payment of claim shall be made through TPA/GIF to the Hospital/Nursing Home or the Insured Person as the case may be. The list of approved hospitals is available at (Annexure 2).

26.12In case of death of insured during policy period the names of family members to be continued till expiry of the policy.

26.13hi case of Group accidental insurance all conditions as laid down under accidental insurance policy at annexure shall be applicable.

27. Empanelment of hospitals.

- Hospitals and other health facilities with desired infrastructure for inpatient and day care services will need to be empanelled. All government hospitals may be empanelled. The criteria for empanelling private hospitals and health facilities would be as decided by SIGPF department.

28. MOU with Network Hospitals.

- The SIGPF department shall enter in to an agreement with all the hospitals empanelled under the scheme. The third party administrator State Government will be a part of this agreement as supervisor and nodal agency. A provision will be made in the MOU of non compliance/default clause while signing them.

29. Payment of premium.

- 75% of Annual premium as decided by SIGPF will be deposited by State Government through JWF and remaining 25% will be deposited by individual policy holders. Registration/renewal fees will also be borne by the policy holder.

30. Cashless Transaction.

- It is recommended that for each hospitalization the transaction shall be cashless for all health services in the insured package. Accredited Journalist will go to hospital and come out without making any payment to the hospital.

31. Claim Settlement.

- The insurance company shall settle the claims of the hospitals within 15 days of receipt of the bills along with the discharge progress will be scrutinized and reviewed by State Government time to time. District PRO/District SIGPF officer will play the role of coordinator at district level for the scheme.In the case of accident the insured shall be required to furnish the following for or in support of a claim -

(a)Duly completed claim form

(b)Doctors Report

(c)Police report whenever necessary

(d)Death certificate, wherever necessary

(e)Medical bills, wherever applicable. They insured shall give immediate notice in writing to the insurance company.

32. Standardization of formats.

- The Committee constituted for administration of the insurance scheme will standardize various formats used for cash less transactions and discharged summary billing pattern & other reports.

1. Package Rates. - Rates will be on floater basis as decided by the Committee constituted for administration and SIGPF department.

33. Grievance redressal mechanician.

- There would be committees at the State and District level to be constituted by Pr. Sectary 1 & P. R., to monitor, co-ordinate and redress the grievances related to the scheme.

34. Expenditure.

- 75% expenditure account of premium shall be charged to 'Journalists Welfare Fund' and 25% will be desited by individual policy holders.

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State of Rajasthan - Act