MEDICAL INSURANCE FOR STATE EMPLOYEES AND PENSIONERS
The scheme is intended to provide comprehensive health insurance coverage to all serving employees of the State Government including the High Court of Kerala who are covered under the existing Kerala Government Servants
Medical Attendant Rules [KGSMA Rules, 1960] and pensioners. This also includes newly recruited employees
and their family, part time contingent employees, part time teachers, teaching, non-teaching staff of aided
schools and colleges and their family and pensioners and their spouses and family pensioners on compulsory
basis, and all Civil Service officers serving under the Government of Kerala on optional basis.
IN FOCUS
MEDICAL INSURANCE FOR STATE EMPLOYEES AND PENSIONERS
All serving employees of State Government including teaching and non teaching staff of Aided Schools and Colleges,
employees of LSG Institutions and Universities in the State.
In this Scheme unless the context otherwise requires:
I) Additional Coverage means the additional sum insured for specified diseases.
II) Authority means Principal Secretary, Finance Department, Government of Kerala.
III) Benifits means All Serving employees of the State Government including the High Court of
Kerala and their family who are covered under the existing Kerala Government Servants Medical Attendant Rules [KGSMA Rules, 1960], part time
contingent employees, part time teachers, teaching & non-teaching staff of aided schools and colleges and their family and pensioners and their spouses and family pensioners on compulsory basis, and
all All India Service officers serving under the Government of Kerala on optional basis . In addition to the above mentioned categories, employees and pensioners of the universities which
receive Grant-in-Aid from the State Government and Local Self Government Institutions and the directly recruited personal staff of the Chief Minister, Ministers, Leader of Opposition, Chief
Whip,Speaker,Deputy Speaker, Chairmen of the Financial Committees and personal staff pensioners/ family pensioners shall also be considered as beneficiary for this scheme. Not
withstanding the above, the Authority have the discretion to include or exclude any categories of beneficiaries to / from the coverage of the Scheme at any stage of the Scheme.
IV) Cashless facility means a facility provided to the insured by the insurance company, to make
payments of treatment costs directly to the hospital in respect of treatment undergone in a network
provider, to the extent of approval given where such treatment is in accordance with the policy terms and conditions.
V) Catastrophic illness means severe illness requiring prolonged hospitalization for recovery.
These illnesses (speciality and super speciality) involve high costs for treatment and may
incapacitate the person from working, creating a financial hardship.
VI) Day Care Centre means any registered institution established for day care treatment of
illness and/or injuries or a medical setup with a hospital and is under supervision of a registered
and qualified medical practitioner and must comply with all minimum criterion.
VII) Day one means the date on which the scheme will come into force.
VIII) Dependant means those who are dependant on the employee for their livelihood.
IX) Empanelled Hospitals means those hospitals fulfilling the minimum prescribed standards and
thereby tied up as network hospitals by the insurer.
X) Enrolment means registration of beneficiaries to the scheme.
XI) Enrolment Period means the period given for the registration of the beneficiaries to the scheme.
XII) Family means all or any of the following relatives of an insured person, namely:
A. In the case of an insured employee:
(i) legal spouse of the employee (who do not have the eligibility to enrol in this scheme).
(ii)minor or adopted child/children dependant upon the
insured, till they get employed, married or attained
the age of 25 years whichever is earlier.
(iii) Physically challenged/mentally challenged children of the employee without any age restriction.
(certificate should be produced as specified in the scheme).
(iv) dependant parents of the employee .
B. In the case of insured pensioner:
Spouse (who do not have the eligibility to enrol in this scheme) and physically challenged/mentally
challenged children of the pensioner without any age restriction.(certificate should be produced as specified in
the scheme).
C.In the case of insured family pensioner.
Physically challenged/mentally challenged children of the pensioner without any age restriction. (certificate
should be produced as specified in the scheme).
XIII) Government means Government of Kerala.
XIV) Medical insurance policy is a contract between an insurer and the Government in which
the insurer agrees to provide specified health insurance cover to the employees and pensioners at a particular premium.
XV) Hospital means any institution established for in-patient care and day care treatment of illness
and/or injuries and which has been registered as a hospital with the local authorities under relevant Act, having the standards and benchmarks for hospitalisation that provides network prescribed by
IRDAI.
XVI) Hospitalisation means admission in a Hospital for a minimum period of 24 consecutive
In-patient Care hours except for specified procedures/treatments, where such admission could be for a period of less than 24 consecutive
hours.
XVII) Inpatient care means treatment for which the insured person has to stay in a hospital for more than 24 hours for a covered event.
XVIII) Insurer means Insurance Company registered under IRDAI and selected by Government of Kerala.
XIX) Insured Person means a person who has got insurance coverage under the scheme.
XX) Medical Board means standing medical board constituted by the Director of Health Services consisting of not less than 3 members.
XXI) Medical Expenses means those expenses that an Insured Person has necessarily incurred for
medical treatment on account of illness or Accident on the advice of a Medical Practitioner.
XXII) New Born Benefit means the benefit given to the new born child/children along with the insured mother.
XXIII) New born baby means baby born during the Policy Period.
XXIV) AB-PMJAY means Ayushman Bharat Pradhan Mantri Jan Arogya Yojana .
XXV) KASP means the proposed Karunya Arogya Suraksha Padhathi.
XXVI) Period of Contract means three years from the date of signing of MoU/Agreement.
XXVII) Period of Insurance means three years from the date of signing of MoU/Agreement between the Government and Insurer.
XXVIII) Pre-existing disease is a medical condition/disease that existed before the
commencement of the insurance coverage obtained from the health insurance policy.
XXIX) Pre-hospitalization Post hospitalisation Medical Expenses means medical expenses
incurred during pre-defined number of days preceding/succeeding the hospitalisation of the
Insured Person. 30 days before hospitalisation and 60 days after discharge.
XXX) Premium means the payment made on behalf of the insured persons as consideration for
the policy. The Premium of the employee shall be deducted from their salary in monthly instalments
and the premium of the pensioner shall be met from their medical allowance.
XXXI) Policy plan period means the three year period from the date which the scheme starts.
XXXII) Provider Network means hospitals or health care providers enlisted by an insurer, to provide medical services to an insured by cashless
facility.
XXXIII) State Nodal Cell means the implementation and monitoring mechanism for MEDISEP under the Authority.
XXXIV) Sum Assured mean the total benefit coverage provided by the insurer.
XXXV) CGHS means Central Government Health Scheme.
XXXVI) HDU means High Definition Unit.
XXXVII) ICU means Intensive Care Unit.
ELIGIBILITY OF BENIFICIARIES
i) All serving employees of State Government including teaching and non-teaching staff of Aided
Schools and Colleges by remitting prescribed premium. In addition to the above mentioned categories, employees of the universities which receive Grant-in-Aid from the State Government
and Local Self Government Institutions and the directly recruited personal staff of the Chief
Minister, Ministers, Leader of Opposition and Chief Whip, Speaker, Deputy Speaker and the Chairmen
of the Financial Committees shall also be considered as beneficiary for this scheme.
ii) Newly appointed employees who joined service during the policy period of three years shall join
the scheme by remitting the premium from the month of joining and can avail Rupees Two Lakh
per annum as Basic Sum Insured.
iii) Part time Contingent employees/pensioners and part time teachers/pensioners subject to
remittance of prescribed premium. The part-time contingent pensioners/family pensioners and Exgratia
Pensioners/family pensioners should execute an authorisation for deducting the prescribed
monthly premium from their monthly pension.
iv) All service pensioners including teaching and nonteaching
staff of aided schools and colleges by deduction of entitled medical allowance. In
addition to the above mentioned categories pensioners of the universities which receive Grantin-
Aid from the State Government and Local Self Government Institutions and the directly recruited
personal staff pensioners/family pensioners shall also be considered as beneficiary for this scheme.
ENROLMENT OF BENIFICIARY
i) The beneficiaries must mandatorily fulfil their enrolment procedure as prescribed by Government
within the duration of enrolment Period.
ii) Enrolment of such beneficiaries shall not be allowed after the expiry of the enrolment period.
iii) In case of pensioners the prescribed enrolment procedure shall be followed as specified by Government from time to time.
iv) The database of beneficiaries will be maintained by the State Nodal Cell and will be shared with the
selected insurer for initiating the enrolment process. The enrolment of the beneficiaries and
issuance of ID cards would be undertaken by the insurer.
v) The date of expiry of policy shall be co-terminus for
all the beneficiaries.
vi) Insured will have the option to change the details regarding dependant beneficiary.
vii) Every employee/pensioner will be notified regarding enrolment with Permanent Employee Numbers/Pension Payment Order Number.
viii) The empanelled Hospitals/Nursing Homes/Day Care Clinics and the beneficiaries shall have the access to the dedicated website to see their relevant information.
FAMILY ENROLMENT
The Scheme shall cover a family and dependants as follows.
A. In the case of an insured employee:
(i) legal spouse of the employee (who do not have the eligibility to enrol in this scheme).
ii) minor or adopted child/children dependant upon the insured, till they get employed, married or
attained the age of 25 years whichever is earlier.
(iii) Physically challenged/mentally challenged child/children of the employee without any age
restriction.(certificate should be produced as specified in the scheme).
iv) dependant parents of the employee.
B. In the case of insured pensioner:
Spouse (who do not have the eligibility to enrol in this scheme) and physically challenged/mentally
challenged child/children of the pensioner without any age restriction. (certificate should be produced as specified in the scheme).
C. In the case of insured family pensioner:
Physically challenged/mentally challenged child/children of the pensioner without any age restriction.
(certificate should be produced as specified in the scheme).
ADDITION & DELETION OF FAMILY MEMBERS
The Scheme shall cover a family and dependants as follows.
A. In the case of an insured employee:
(i) legal spouse of the employee (who do not have the eligibility to enrol in this scheme).
ii) minor or adopted child/children dependant upon the insured, till they get employed, married or
attained the age of 25 years whichever is earlier.
(iii) Physically challenged/mentally challenged child/children of the employee without any age
restriction.(certificate should be produced as specified in the scheme).
iv) dependant parents of the employee.
B. In the case of insured pensioner:
Spouse (who do not have the eligibility to enrol in this scheme) and physically challenged/mentally
challenged child/children of the pensioner without any age restriction. (certificate should be produced as specified in the scheme).
C. In the case of insured family pensioner:
Physically challenged/mentally challenged child/children of the pensioner without any age restriction.
(certificate should be produced as specified in the scheme).