Dependants of employees and pensioners.

Medical Insurance For State Employees

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) Benefits 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.