Advice: Since the Policy has been issued by SAIL pl. contact for clarification the concerned person of your Plant / Unit or Vaani Kapoor in SAIL Corporate Office. Details are provided in the last page of this Circular.
No. PER/ITB&Med./Ren/Mediclaim
Dated:
31st December, 2014
Name of the Member
Address
Sub: Extension
of SAIL Mediclaim Scheme for period 1st January, 2015 to 31st
March, 2015
Ref: Mediclaim Index Number (MIN) Self
…….………..…… Spouse ………………….
Dear Sir/Madam,
At the outset we wish you a
very happy and fulfilling new year.
As you are aware, the
existing Mediclaim Scheme - 2014 expires on 31st December 2014. It
has been decided to extend the current SAIL Mediclaim Scheme for a period of
three months i.e. for period 1st January, 2015 to 31st
March, 2015. The benefits under the scheme being :
·
Hospitalization
coverage (IPD) upto Rs. 2.00 lacs per member with clubbing facility
between the Mediclaim member and his/her spouse, for all members.
·
The
OPD coverage, for members below 70 years of age as on 31.12.2014, is Rs.
4,000/- per member (no clubbing facility).
·
The
OPD coverage, for members who have completed 70 years of age as on 31.12.2014,
will be Rs.8,000/- per member (no clubbing facility).
It is hereby informed, that
SAIL Mediclaim Scheme has been extended with M/s National Insurance Co. Ltd.
for a period of further THREE MONTHS ONLY FROM 1ST JANUARY – 31ST
MARCH, 2015. From 01.01.2015, a
Mediclaim member can avail of the cashless/reimbursement facility under
hospitalization, as was being done earlier. OPD facility will continue to be
under reimbursement system. The administration of the Mediclaim Scheme under
cashless as well as on reimbursement basis will be done by Third Party
Administrator (TPA). The cashless facility under hospitalization will be
available in the hospitals empanelled by the TPA. For other hospitals, members
can avail of the hospitalization facility, on reimbursement basis. The claims
on account of reimbursement of OPD/IPD claims for the period will have to be
lodged with TPA. The TPA for the period
1ST JANUARY – 31ST
MARCH, 2015, will be M/s E-Meditek
(TPA) Services Ltd. Booklet of 2014 will
be valid for the period 1st January – 31st, March, 2015.
Cappings/Ceilings in the following areas will
continue:
·
Room Rent Charges
/ Procedural Charges
·
Implants/
Stents for Coronary Angioplasty
·
Lenses
for Cataract Surgery
·
Implants
for Knee/ Hip joint replacement
·
Cappings
on certain Procedures/ Packages
Members are further requested to strictly adhere to
the following:
i)
Inform/Intimate,
in writing to the TPA at least 48 hrs. prior to any elective/planned
Hospitalization/Admission.
ii) In case of Emergency
Admission/Hospitalization, the TPA to be informed in writing within 24 hrs. of
such hospitalization.
iii) Claim intimation to be considered mandatory
for both Cashless and Reimbursement claims for IPD.
iv) Claim intimation to be sent via
Letter/E-mail/Fax/Personally at TPA offices.
v) Reimbursement claims with respect to IPD to
be submitted to the TPA, within 30 days from the Date of Discharge from
Hospital.
vi) Reimbursement claims pertaining to Post
Hospitalization (IPD) treatment to be submitted to the TPA, within 30 days
after the completion of permissible post Hospitalization treatment period of 60
days.
vii) OPD Claims to be submitted to the TPA, when
the expenses exceed Rs. 2000/- per person per policy period or within 90 days
from the date of treatment, whichever is earlier.
viii)
To
facilitate payment of reimbursement of claims through ECS, members are advised
to fill in the details as indicated in the attached Form.
The premium payable for a member under 70 years of age, as on
31.12.2014 is Rs.484/- (Rupees Four Hundred Eighty Four only) per member, for a
member who is aged between 70-80 years as on 31.12.2014, premium payable is Rs.434/-
(Rupees Four Hundred Thirty Four only) per member and for members aged 80 years
or above as on 31.12.2014, the premium payable is Rs.289/- (Rupees Two Hundred
Eighty Nine only) per member. You are requested to
refer the indicative table enclosed herewith, and arrive at the premium amount
as per the date of birth of member and spouse.
You are requested to pay your premium for renewal of your Mediclaim
membership for the period as per the procedure for premium payment, detailed in
the enclosure. The premium receipt and the renewal details as per the enclosed
format (Application Form) are to be sent to the concerned SAIL Plant/ Unit,
positively by 31st January 2015 extended by SAIL upto 28th February 2015. Your membership for the
period 1st January – 31st March, 2015 will only be
activated/renewed, once SAIL receives your filled-in Application Form along
with your premium payment receipt.
You are requested to submit all your pending
Mediclaim Bills pertaining to the year 2014 to M/s. E-Meditek TPA Services latest
by 15th January 2015 positively. The TPA for SAIL Mediclaim
Scheme-2014 will not entertain any claims
received by them after 15th January 2015.
Thanking you,
Yours sincerely,
IRP
PROCEDURE FOR PREMIUM PAYMENT
SAIL Mediclaim Scheme (extended for period :
1st January – 31st March, 2015)
I. New Payment Options
·
SAIL has a tie-up
with SBI for facilitating the medical insurance payment.
·
Premium can be
paid online through Credit Card/ATM-cum-Debit Card/Internet Banking etc.
·
Payment can also
be made at any of the SBI Branches along-with pre-filled-in, computer
generated, challans (having State Bank Collect Reference No. printed on the
challan form). The payment maybe made by the member or his/her representative
for self/spouse/both, as the case may be.
·
Facilities
/transaction charges for chosen option are detailed below at Para III in Table
A.
II.
State Bank of
India (SBI)
SBI- Collect - Link: www.onlinesbi.com
a)
On the first
screen click on the tab “State Bank Collect”.
b)
Next
Screen–check/click the box “I have read and accepted the terms
and conditions stated above” and click on the Proceed Button.
c)
Next Screen
- Select “National Capital Territory of Delhi” from
the drop-down menu for “State of
Corporate/Institution” and select “Industry”
from the drop-down menu for “Type of Corporate/Institution”.
d)
Select “Steel Authority of India
Limited” from the drop-down menu for
Industry Name and then click GO button.
e)
Next Screen - From
the drop-down menu, select either “Mediclaim Self/ Mediclaim Spouse /
Mediclaim Both”, as the case may be.
f)
Next Screen -
Enter MIN No. (Medical Index Number):-For option “Mediclaim self” or “Mediclaim
both”, enter the MIN No. of the SAIL Ex-employee. For option “spouse”
only, enter the MIN No. of the spouse.
g)
Click the “Submit”
button. Next Screen displays member details. Fields marked with * (asterix)
are mandatory/compulsory fields. Applicable amount will automatically be
displayed in the Amount field. {In case of discrepancy in applicable
premium amount, pls. contact IRP(Internal Resource Person) of your concerned
plant/unit}
h)
In the second part of the same Screen-
The person making payment may enter his/her Name, Date of Birth &
Mobile Number. This is required to reprint the challan, if the need arises.
Once done, click on the Submit button.
i)
Next Screen - All details of the member
are displayed. Please check/verify the data on this screen and then proceed to
the payment screen.
j)
The options for payment along with the
applicable transaction charges are displayed on the next screen. The applicable
transaction charges are also indicated in the table below.
k)
Members may choose to make payment
directly through Credit Card/Debit Card/ATM card/Internet Banking;
l)
Apart from the above payment options, concerned member can also take a print out of the computer
generated challan (having a pre-printed State Bank Collect Reference No.)
and use the same for making payment through cash or cheque at any of the
SBI Branches. Please note that for payment through cash or cheque, the
member is required to submit the computer generated challan (mandatory)
along with the payment.
m) On successful payment, the member shall be prompted to print the e-receipt.
However, in case of ‘challan’, there will be an option to print challan.
III. The convenience charge/ transaction charges for availing
the above services, are as follows:
Table-A-SBI
Transaction/ Convenience charges for
Payment using SB Collect option – www.onlinesbi.com
|
SBI ATM cum Debit Card
|
Debit/Credit Card (other than SBI
ATM-cum-Debit card)
|
Payment through system generated pre-filled-in
challan at SBI Branch
|
Internet Banking
|
Rs.10 per transaction
|
1.8% of transaction value + Rs.10 per transaction
|
Rs.34 per transaction
|
Rs.10 per transaction for Internet Banking of SBI.
Rs.15 per transaction for other banks.
|
IMPORTANT NOTES:
·
Once payment is successful and
acknowledgement / receipt has been obtained, members are required to send the
photocopy of the same along with the duly filled-in application form to the
respective IRPs of the concerned
Plant/Unit, to activate the membership for the period 1st
January – 31st March, 2015.
·
SAIL shall bear no responsibility in case
the member has filled incomplete/wrong data/details while proceeding for
premium payment for renewal for the period 1st January-31st
March, 2015.
SAIL Mediclaim Scheme for the period 1st
January – 31st March, 2015
1.0
OBJECTIVES OF THE SCHEME:
To extend the
Medical Benefits to the retired employees of SAIL and their spouses.
2.0
PERSONS COVERED
a. Retired
employees of SAIL and their spouses
b. The employees
who have taken voluntary retirement and their spouses
c. The employees
who cease to be in employment on account of permanent total disablement and
their spouses
d. The spouse of an
employee who dies in service
e. Employee who
resign from the Company at the age of 57 or above and their spouse
This scheme is
optional and those who opt for this scheme, are referred to as “members".
3.0
POLICY COVERAGE
a.
The policy covers reimbursement of Hospitalisation
and also Cashless Facility and/ or Out-Patient Department (OPD) expenses within
the prescribed limits under the policy for illness/diseases contracted or
injury/ sustained by the insured person. In the event of any claim becoming
admissible under the policy, the Insurance Company will pay to the insured
member (Reimbursement)/ Hospital (For Cashless Treatment), the amount of such
expenses as reasonably and necessarily incurred anywhere in India. For the
purpose of SAIL Mediclaim Scheme, the ex-employee and his/her spouse, to be
treated as two distinct members.
o
IPD (Hospitalization) Benefits: Rs. 2 Lakhs per member per policy period with
clubbing (floater) facility under hospitalization with his/her spouse which
means that hospitalization benefit of Rs. 2 Lakhs per member can be clubbed
between the Mediclaim members & their spouses (max. clubbed limit Rs.4
Lakhs for the extended period).
o
OPD Benefits:
o
Rs.4,000/- per
member, for members below 70 yrs. of age as on 31.12.2014
o
Rs.8,000/- per
member, for members aged 70 yrs. or above, as on 31.12.2014
Note: Persons completing 70 years of age on
01.01.2015 will also be considered for enhanced OPD. Unlike IPD facility, the
OPD facility cannot be clubbed between the ex-employee and his/her spouse.
b.
The retiring employees including their spouses who
opt for mediclaim membership are assigned a number by our plants/units. These
numbers are called Mediclaim Index Number (MIN). The system will continue to
facilitate the smooth functioning of the scheme for the period 1st
January – 31st March, 2015.
4.0
DEFINITIONS
a. Hospital/
Nursing Home means any
institution in India established for Indoor care and treatment of sickness and
injuries and which has been registered either as a Hospital or Nursing Home
with the local authorities and is under the Supervision of a registered and
qualified Medical Practitioner.
For the
purpose of O.P.D. treatment, "Hospital" shall mean:
i.
A Government Hospital,
ii.
Dispensaries/Clinics run by local Government
authority/Municipalities,
iii.
SAIL Plant Hospitals/Dispensaries
iv.
SAIL Approved Hospitals/ Nursing Homes
v.
Franchisee of major Hospitals viz. Apollo, Max,
Escorts, Fortis, etc. anywhere in India.
Note: The terms
"Hospital" shall not include an establishment which is a place of
rest, a place for the aged, a rehabilitation centre for drug addicts or
alcoholic, a hotel or a similar place.
b. HOSPITALIZATION
(IPD):
i.
Hospitalization
facility can be availed from any Hospital or Registered Nursing Home in India.
However, the Mediclaim member can avail Cashless
Facility under Hospitalization, only in Hospitals, having 50 beds or above,
which are empanelled by the Insurance Company for the purpose. However, this
minimum Bed criteria of 50 Beds, shall not apply to Single speciality Eye Care
Hospitals, for empanelment of Hospitals for Cashless treatment for eye
diseases, by the Insurance Company.
ii.
When
treatment/surgeries such as Dialysis, Chemotherapy, Radiotherapy, Opthalmic
Surgeries(Cataract/Glaucoma Surgeries etc.), Lithotripsy, Laproscopic
surgeries, Microsurgery etc., is taken
in the Hospital/Nursing Home and the insured is discharged on the same day, the
treatment will be considered to be taken under Hospitalization Benefit Section.
Indicative List of such procedures is enclosed.
iii.
In
addition to the indicative list of Day-care procedures, any other surgeries / procedures agreed to by
SAIL, Insurance Company and TPA, requiring less than 24 hours hospitalization
will also be considered under hospitalization.
c. OPD
TREATMENT: OPD Means
treatment taken as an out-patient in any Govt. Hospital/SAIL Plant Hospital or
SAIL approved Hospital/ Nursing Home. The
Charges incurred for treatment taken from Registered Medical Practitioners or
other than SAIL approved Hospital/Nursing Home will not be reimbursed. The
Medicine should be prescribed by the Doctors on the letter heads of the
hospital. Even though a medical practitioner is attached to any of the
Govt. / SAIL plant hospital or SAIL approved hospital and if the treatment is
taken by him/her privately, the OPD Claim amount will not be reimbursed, under
any circumstances.
d. Claim Settlement - The claims under SAIL
Mediclaim Scheme are to be settled and recommended amount to be paid within 15
days of submission of all claim documents.
e.
MEDICAL
PRACTITIONER: Means a
person who holds a degree / diploma of a recognized institution and is
registered by Medical Council of respective State of India. The term Medical Practitioner
would include Physician, Specialist and Surgeon.
f.
QUALIFIED
NURSE: Means a person who
holds a certificate of a recognized Nursing Council and who is employed on
recommendations of the attending Medical Practitioners.
5.0
HOSPITALISATION
BENEFIT
Reimbursement:
Reimbursement of actual charges upto Rs. 2,00,000/- per member per policy
period (with clubbing facility between employee & spouse) is permissible. Claim under hospitalization benefit shall be
admissable only when the patient is admitted in a hospital for a minimum
period of 24 hours. Hospitalization expenses for Ayurvedic/Homeopathic/Unani
Treatment are admissible only when the treatment is taken in a Government
Hospital/Medical College Hospital.
Pre-hospitalization: Relevant
medical expenses incurred during the policy period, upto 30 days prior to the
hospitalization specifically for that particular disease/ illness, for which
hospitalization has taken place, shall be considered as part of claim under
hospitalization. However, during
pre-hospitalization period, medicines prescribed under regular OPD treatment
for diseases/ illness not related to the said hospitalization, shall not be
reimbursable under hospitalization claims.
Post-hospitalization: Relevant medical expenses incurred during the policy period, upto 60
days after the hospitalization, specifically for that particular disease/
illness for which hospitalization had taken place, shall be considered as part
of claim under hospitalization. However,
during post-hospitalization period, medicines prescribed under regular OPD
treatment for diseases/ illness not related to the said hospitalization, shall
not be reimbursable under hospitalization claims.
Cashless:
Insurance Company/ TPA shall offer Cashless Service to
the Insured, where treatment can be obtained without payment, subject to the
terms and conditions of the policy, from empanelled hospitals. Insurance
Company/ TPA to settle the hospital bills directly on behalf of Insured.
6.0
OPD BENEFIT
6.1
Under
no circumstances, the clubbing (Floater basis) of individual OPD limits of Rs.
4000/- or Rs. 8000/- (as the case may be) per member per policy period, will be
permitted.
6.2
OPD
treatment if availed in SAIL Plant Hospitals, the members are not required to
pay any expenses. SAIL Plant Hospitals will make claims for any Treatment given
to the member.
6.3
Dental
Treatment can also be availed of within the existing limit under O.P.D.
treatment. Cost of dentures will not be reimbursed.
6.4
Preventive
Health Check-ups & Ophthalmic consultations for refractory error will be
covered under OPD Benefits only.
6.5
In
case of expenses on Eye Treatment, cost of spectacles/contact lenses shall not
be reimbursed.
6.6
OPD
Claims to be submitted by the Mediclaim member, to the TPA when the expenses exceed Rs. 2000 per person per policy
period or within 90 days from the date of completion of the treatment,
whichever is earlier.
6.7
In
case of treatment of ear, cost of hearing aid is not reimbursable.
7.0
MANDATORY CLAIM INTIMATION/ SUBMISSION:-
7.1 Claim
Intimation for Hospitalization treatment on Cashless/ Reimbursement basis
i) The Mediclaim member shall be required to
inform / intimate, in writing, the Insurance Agency / TPA at least 48 Hrs Prior
to any elective / planned Hospitalization / Admission.
ii) In case of Emergency Admission /
Hospitalization, the Insurance Company / TPA, to be informed by the Mediclaim
member, in writing within 24 hrs of such hospitalization.
iii)
The
Claim Intimation by the Mediclaim member, is mandatory for both Cashless &
Reimbursement claims.
iv)
Claim
Intimation can be sent via Letter/ Email/ Fax/ Personally delivered at TPA
offices.
The
above must be adhered to, so that the claims are not rejected
7.2
Claim Submission for Hospitalization
treatment on Cashless/ Reimbursement basis
i. The reimbursement claims with respect to
IPD/ Hospitalization to be submitted to the TPA within 30 days from the Date of
Discharge from the Hospital.
ii. The reimbursement claims pertaining to Post
Hospitalization (IPD treatment), to be submitted to the TPA within 30 days
after the completion of permissible post Hospitalization treatment period of 60
days.
The
above must be adhered to, so that the claims are not rejected
8.0
Cappings
in Mediclaim
Scheme:
8.1
Cappings
in the area of room rent charges, the Implants/Stents used under various
procedures like cataract surgery, coronary angioplasty, joint related disorder
requiring knee/hip joint replacement excluding the associated procedure charges
under the Scheme will be as given below:
a) Maximum
entitlement of room to be restricted to:
o
For Metro Cities (Hyderabad, NCR,
Bangalore, Mumbai, Chennai, Kolkata) - Ceiling of 2%, i.e Rs.4000/- of the sum
insured per member or a single AC non-deluxe room per day, whichever is lower,
o
For non-metro cities which are State
capitals - Ceiling of 1.5%, i.e Rs.3000/- of the sum insured per member or a
single AC non-deluxe room per day, whichever is lower,
o
For rest of the country - Ceiling of 1%,
i.e Rs.2000/- of the sum insured per member or a single AC non-deluxe room per
day, whichever is lower;
In case a member goes for a higher
category room, the consultation charges/ investigation charges/ procedural
charges/ surgical Charges/ package rates etc. shall be limited to actuals or as
per their corresponding rates for single AC non-deluxe room of the concerned
hospital, whichever is lower.
b) Ceiling
rates for different types of Intra Ocular Lens (IOL) Implants to be as per
actuals or Rs. 10,000/- whichever is lower and shall be reimbursable in
addition to the package rates for cataract surgery procedure. It should be mandatory for the operating
surgeon of all hospitals to attach the empty IOL sticker, bearing the signature
and stamp of the operating surgeon on it alongwith the bill in support of the
type of IOL used containing its batch number. Incase the same is not followed,
the claim with regards to IOL implant, may be rejected.
c) Ceiling
rates for different types of Coronary Stents to be as per the actuals or the
rates as mentioned below, whichever is lower.
S.No.
|
Name
of Drug Eluting Stent /
Bare
Metal Stent
|
Ceiling
Rate
|
1.
|
Cypher Stent
|
Rs. 95000 + VAT
|
2.
|
Taxus Stent
|
Rs. 67300 + VAT
|
3.
|
Element Stent
|
Rs. 95000 + VAT
|
4.
|
Endeavor
|
Rs. 85000 + VAT
|
5.
|
Xience V EECSS
|
Rs. 95000 + VAT
|
6.
|
Yukon choice
|
Rs. 55000 + VAT
|
7.
|
Pronova
|
Rs. 50000 + VAT
|
8.
|
Supralimus
|
Rs. 55000 + VAT
|
9.
|
Bare Metal Stent
|
Rs. 45000 (all
inclusive)
|
Ceiling rates for Coronary Stents
other than the Stents mentioned above, to be as per actuals or Rs. 95000/- plus
VAT, whichever is lower.
d) A
maximum of three Coronary Stents shall be permitted on the advice of the
specialist, of which not more than two shall be of Drug Eluting Stents (DES).
However, DES shall be permitted only for patients where re-stenosis will
involve high risk to patient’s life i.e
i)
Osteal/Proximal LAD lesions;
ii)
Stenosis of a coronary artery, which is
giving collaterals to another blocked artery, thus supplying a large area of
myocardium; and,
iii)
Stenting of restenotic lesions after
previous angioplasty.
It is essential for the hospital to
quote the batch number when a Coronary Stent of any type (ordinary metal/Drug
Eluting Stent) is implanted in the case of a beneficiary. In addition to this,
the outer pouch of the Stent packet alongwith the sticker on it on which the
details of the stent are printed shall also be enclosed with the medical bill
for claiming reimbursement. In case hospital has not given the batch number and
/ or outer pouch of the stents in a particular case, the claim with regards to
the implant, may be rejected.
e) Ceiling
rates for different types of Knee and Hips implants, to be as per the actual rates
or the rates as mentioned below, whichever is lower.
i)
Maximum ceiling for Knee implant to be Rs 75000/- (including cost of Bone
cement)
ii)
Maximum ceiling for Hip implant to be Rs 75000/- (including cost of Bone
cement)
f) In
addition to the aforementioned cappings on Implants/ Stents, the following
cappings on procedures/ packages as given below, shall also be applicable:
S. No.
|
Disease/ Treatment
|
Cappings
|
1.
|
Hernia repair
|
Rs. 40000
|
2.
|
Cholecystectomy
|
Rs. 45000
|
3.
|
Haemorroidectomy
|
Rs. 25000
|
4.
|
Appendicetomy
|
Rs. 35000
|
5.
|
Hysterectomy
|
Rs. 45000
|
The above cappings/ ceilings are
applicable on ‘per Hospitalization’ basis and only for cases where there are no
complications/multiple diseases. Moreover, Pre-Hospitalization &
Post-Hospitalization claims pertaining to the above treatments do not come
under the purview of the aforementioned cappings.
9.0
IMPORTANT EXCLUSIONS: Under SAIL Mediclaim Scheme, the Insurance
Company shall not be liable to make any payment in respect of any expenses
whatsoever incurred by the insured person in connection with:
i)
Any Disease/ complication caused due to
alcohol intake.
ii)
Any disease/ injury caused by War/Nuclear
Weapons/Radiations / Breach of Criminal law.
iii)
Circumcision, cosmetic or Plastic Surgery
unless necessitated by an accident or as a part of any disease/ illness.
iv)
Cost of dentures, hearing aid, spectacles,
cost of glasses/ contact lenses etc.
v)
Convalescence, general debility,
"Run-down" condition or rest cure, congenital diseases or defects,
sterility, venereal diseases, intentional self injury and use of intoxicating
drugs.
vi)
The Hospitalization charges in which
Radiological/ Laboratory investigations/ other diagnostic studies have been
carried out which are not consistent with or incidental to the diagnosis of
treatment of positive existence or presence of any ailment, sickness or injury
for which confinement at any Hospital/ Nursing Home, has taken place.
vii)
Expenses on vitamins and tonics unless
forming part of treatment for injury or disease as certified by the attending
physician.
viii)
Treatment traceable to pregnancy/ child
birth, voluntary medical termination of pregnancy during first 12 weeks of
conception.
ix)
Naturopathy Treatment.
x)
External and/ or durable Medical/
Non-Medical equipment of any kind used for diagnosis and/ or treatment including
CPAP, CAPD, Infusion pump etc. Ambulatory devices, i.e walker, crutches, belts,
collars, caps, splints, slings, braces, stockings etc., of any kind. Diabetic
foot wear, Glucometer/ Thermometer and similar related items etc., and also any
medical equipment which subsequently used at home etc.
xi)
Any kind of service charges, attendant
food charges, surcharges, admission fees/ registration charges &
Non-Medical expenses levied by the Hospital.
xii)
Treatment for age related Macular
degeneration with Injection Avastin/ Lucentis/ Macugen.
xiii)
Cytotron Therapy
xiv)
Ozone Therapy
xv)
Enhanced External Counter Pulsation
Therapy (EECP)
xvi)
Robotic Surgery/ Robotically assisted
surgery
xvii)
Any unproven therapy
xviii)
Ayurvedic treatment if it is not an active
line of treatment.
xix)
Rejuvenation therapy/ Massage/ Panchkarma
xx)
Stem cell Transplantation except
Haemopoetic Stem Cell Transplant/ Bone Marrow Transplant
Misuse of Scheme: Stringent action to be taken against
individuals found to be misusing the system/guilty of any fraudulent activity,
viz. debarring member from Mediclaim membership, blacklisting hospitals,
initiating suitable legal action etc., as deemed fit by SAIL Management.
INDICATIVE LIST OF DAY CARE PROCEDURES
1.
Suturing
- CLW -under LA or GA
2.
Surgical
debridement of wound
3.
Therapeutic
Ascitic Tapping
4.
Therapeutic
Pleural Tapping
5.
Therapeutic
Joint Aspiration
6.
Aspiration
of an internal abscess under ultrasound guidance
7.
Aspiration
of hematoma
8.
Incision
and Drainage
9.
Endoscopic
Foreign Body Removal - Trachea /- pharynx-larynx/ bronchus
10.
Endoscopic
Foreign Body Removal -Oesophagus/stomach /rectum.
11.
True
cut Biopsy - breast/- liver/- kidney-Lymph Node/-Pleura/-lung/-Muscle
biopsy/-Nerve biopsy/-Synovial biopsy/-Bone/ trephine biopsy/ pericardial
biopsy
12.
Endoscopic
ligation/banding
13.
Sclerotherapy
14.
Dilatation
of digestive tract strictures
15.
Endoscopic
ultrasonography and biopsy
16.
Nissen
fundoplication for Hiatus Hernia /Gastro esophageal reflux disease
17.
Endoscopic
placement/removal of stents
18.
Endoscopic
Gastrostomy
19.
Replacement
of Gastrostomy tube
20.
Endoscopic
polypectomy
21.
Endoscopic
decompression of colon
22.
Therapeutic
ERCP
23.
Brochoscopic
treatment of bleeding lesion
24.
Brochoscopic
treatment of fistula /stenting
25.
Bronchoalveolar
lavage & biopsy
26.
Tonsillectomy
without Adenoidectomy
27.
Tonsillectomy
with Adenoidectomy
28.
Excision
and destruction of lingual tonsil
29.
Foreign
body removal from nose
30.
Myringotomy
31.
Myringotomy
with Grommet insertion
32.
Myringoplasty
/Tympanoplasty
33.
Antral
wash under LA
34.
Quinsy
drainage
35.
Direct
Laryngoscopy with or w/o biopsy
36.
Reduction
of nasal fracture
37.
Mastoidectomy
38.
Removal
of tympanic drain
39.
Reconstruction
of middle ear
40.
Incision
of mastoid process & middle ear
41.
Excision
of nose granuloma
42.
Blood
transfusion for recipient
43.
Therapeutic
Phlebotomy
44.
Haemodialysis/Peritoneal
Dialysis
45.
Chemotherapy
46.
Radiotherapy
47.
Coronary
Angioplasty (PTCA)
48.
Pericardiocentesis
49.
Insertion
of filter in inferior vena cava
50.
Insertion
of gel foam in artery or vein
51.
Carotid
angioplasty
52.
Renal
angioplasty
53.
Tumor
embolisation
54.
TIPS
procedure for portal hypertension
55.
Endoscopic
Drainage of Pseudopancreatic cyst
56.
Lithotripsy
57.
PCNS
(Percutaneous nephrostomy)
58.
PCNL
(percutaneous nephrolithotomy)
59.
Suprapubic
cytostomy
60.
Tran
urethral resection of bladder tumor
61.
Hydrocele
surgery
62.
Epididymectomy
63.
Orchidectomy
64.
Herniorrhaphy
65.
Hernioplasty
66.
Incision
and excision of tissue in the perianal region
67.
Surgical
treatment of anal fistula
68.
Surgical
treatment of hemorrhoids
69.
Sphincterotomy/Fissurectomy
70.
Laparoscopic
appendicectomy
71.
Laparoscopic
cholecystectomy
72.
TURP
(Resection prostate)
73.
Varicose
vein stripping or ligation
74.
Excision
of dupuytren's contracture
75.
Carpal
tunnel decompression
76.
Excision
of granuloma
77.
Arthroscopic
therapy
78.
Surgery
for ligament tear
79.
Surgery
for meniscus tear
80.
Surgery
for hemoarthrosis/pyoarthrosis
81.
Removal
of fracture pins/nails
82.
Removal
of metal wire
83.
Incision
of bone, septic and aseptic
84.
Closed
reduction on fracture, luxation or epiphyseolysis with osetosynthesis
85.
Suture
and other operations on tendons and tendon sheath
86.
Reduction
of dislocation under GA
87.
Cataract
surgery
88.
Excision
of lachrymal cyst
89.
Excision
of pterigium
90.
Glaucoma
Surgery
91.
Surgery
for retinal detachment
92.
Chalazion
removal (Eye)
93.
Incision
of lachrymal glands
94.
Incision
of diseased eye lids
95.
Excision
of eye lid granuloma
96.
Operation
on canthus & epicanthus
97.
Corrective
surgery for entropion & ectropion
98.
Corrective
surgery for blepharoptosis
99.
Foreign
body removal from conjunctiva
100. Foreign body removal from cornea
101. Incision of cornea
102. Foreign body removal from lens of the eye
103. Foreign body removal from posterior chamber
of eye
104. Foreign body removal from orbit and eye
ball
105. Excision of breast lump /Fibro adenoma
106. Operations on the nipple
107. Incision/Drainage of breast abscess
108. Incision of pilonidal sinus
109. Local excision of diseased tissue of skin
and subcutaneous tissue
110. Simple restoration of surface continuity of
the skin and subcutaneous tissue
111. Free skin transportation, donor site
112. Free skin transportation recipient site
113. Revision of skin plasty
114. Destruction of the diseases tissue of the
skin and subcutaneous tissue
115. Incision, excision, destruction of the
diseased tissue of the tongue
116. Glossectomy
117. Reconstruction of the tongue
118. Incision and lancing of the salivary gland
and a salivary duct
119. Resection of a salivary duct
120. Reconstruction of a salivary gland and a
salivary duct
121. External incision and drainage in the
region of the mouth, jaw and face
122. Incision of hard and soft palate
123. Excision and destruction of the diseased
hard and soft palate
124. Incision, excision and destruction in the
mouth
125. Surgery to the floor of mouth
126. Palatoplasty
127. Transoral incision and drainage of
pharyngeal abscess
128. Dilatation and curettage
129. Myomectomies
130. Simple Oophorectomies
131. Coronary Angiography
132. Dental Surgery (following Accident)
133. Hysterectomy
134. Laproscopic Therapeutic Surgeries
Any other surgeries / procedures agreed to
by SAIL, Insurance Company and TPA, requiring less than 24 hours
hospitalization will also be considered under Hospitalization.
Renewal Premium for SAIL Mediclaim Scheme
(1st January – 31st March, 2015)
INDIVIDUAL
PREMIUM AMOUNTS
|
|
AGE OF
MEDICLAIM MEMBER (AS ON 31.12.2014)
|
RENEWAL
PREMIUM AMOUNT PER MEMBER
|
|
BELOW 70
YRS
|
484
|
|
B/W 70-80
YRS
|
434
|
|
80 YRS
& ABOVE
|
289
|
|
|
|
|
CALCULATION
OF RENEWAL PREMIUM FOR
SAIL
MEDICLAIM SCHEME
|
|
AGE OF
MEDICLAIM MEMBER (AS ON 31.12.2014)
|
AGE OF
MEMBER SPOUSE (AS ON 31.12.2014)
|
TOTAL
PREMIUM FOR BOTH MEMBERS
|
BELOW 70
YRS
|
BELOW 70
YRS
|
968
|
B/W 70-80
YRS
|
918
|
80 YRS
& ABOVE
|
773
|
B/W
70-80 YRS
|
BELOW 70
YRS
|
918
|
B/W
70-80 YRS
|
868
|
80 YRS
& ABOVE
|
723
|
80 YRS
& ABOVE
|
BELOW 70
YRS
|
773
|
B/W
70-80 YRS
|
723
|
80 YRS
& ABOVE
|
578
|
