01/04/16
Chairman,
SAIL, New Delhi.
Dear Sir,
The SAIL Mediclaim Policy for 2015-16, as was well known, lapsed yesterday. Now the problem for the SAIL Retirees starts as it will be impossible to understand how to proceed for availing Healthcare facilities including hospitalisation for major treatment under option for Cashless. And this will affect our lives for months and months together. In spite of our several requests and reminders to initiate negotiation on Mediclaim policy formulation and selection of Insurance Company etc, at least 3 to 4 months before, there is not much of a change. We reached the day without a policy to safeguard us.
Since there is no representation of Retirees in such negotiations and policy formulation bodies in SAIL the end result is a half cooked Policy prepared by those who can never understand the Retirees problems. The Insurance Co. and the TPA have their own axe to grind with SAIL silently looking over our agony from a distance.
Sir, I may like to mention for your information and understanding that no SAIL initiative has been visible in conduct and operation of the SAIL Mediclaim Policy in the past when chips are down and retirees life is in danger. No Office concerned with retirees issues /IPR in SAIL Corp Office or SAIL's Plants/ Units knows what and how to advise on such occasions. Our request to you to invite us for a meeting with you has not been responded positively causing more gap in information exchange and problem solving.
In view of this I request you to please get the policy formulated and implemented without cappings and take reference from our recommendations/ suggestions copied below (between orange lines). We may be contacted for clarification, if necessary.
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Healthcare Issues – Suggestion for Improvement
Ø To accept and enforce the guiding principle of the Healthcare including mediclaim insurance “that it is a matter of life and death leaving no chance for a repeat performance. So the benefit of doubt should always be in favour of the patient and there can be no room for laxity of any kind or slow action at any time at either end of the network of SAIL, Insurance Co., the TPA and the patient.”
Ø To consider the Healthcare of the retirees to be at par with those for the current employees.
However, if SAIL decides to continue with the present arrangement of healthcare through mediclaim insurance it must develop a formula for incorporation of annual price rise in healthcare.
i. To increase OPD coverage of Rs.20,000/-per annum jointly in respect of retired employee and spouse on floater basis.
ii. To raise the upper limit to Rs. 4 lacs for Cashless treatment/ IPD reimbursement for each member under floating (combining) facilities (existing in RINL) and withdrawal of all cappings.
iii. To pay total subscription for renewal of mediclaim membership, to make permanent I-card by SAIL, to complete negotiations and settling of terms and conditions with Insurance Co. & the TPA by March end 2016 and to issue Guidebook etc by mid-April.
iv. Renewal of lapsed mediclaim: Anytime and every time with a nominal charge.
v. Upgradation of the present Medical facilities with review of present Medical Scheme and Malfunctioning of TPA.
a) In view of the fixed upper limit of cost of treatment the Capping becomes redundant and hence needs to be withdrawn.
b) Best serving Hospitals for OPD and Indoor Cashless Treatment need be listed and retained without break in-between. All Govt Hospitals also must be recognized for OPD purposes. TPA must ensure that admission to a Hospital against cashless facility during the tenure is not denied
c) However, in rare case of exigencies the TPA may withdraw recognition to a Hospital listed for OPD or Cashless treatment but only by circulating a one month’s notice in advance to all the SAIL Mediclaim Members/ Spouse.
d) The TPA/ Insurer must ensure settlement of all Bills for Re-imbursement within 15 days.
e) The TPA / Insurer must not exceed a maximum of 3 hours for approving treatment and release of payment after treatment for cases of Cashless treatment.
vi. Settlement of Mediclaim related Grievances - Role of Ombudsman.
vii. In case of widows/ widowers of the member total coverage should be allowed in case he/she agrees to make full premium.
viii. Renewal of Yearly Mediclaim policy : The Yearly Scheme may please be finalized at least two months before the year is over i.e. within March and the booklet should be made available to the members latest by the last week of March every year by SAIL instead of leaving the matter entirely with the TPA.
ix. The procedure for filing claim in case of deceased person should be formulated and incorporated in the booklet.
x. In case of settlement of disputes, name of the officer with designation, official address contact number etc to whom such cases are being referred should be clearly spelt out
xi. Registered Association/ Society should be authorized to deal on behalf of mediclaim members.
xii. Inclusion of various tests like MRI etc. and therapy (like "CYTOTRON Therapy"), Accentrix injection for Macular Eye disease and gadgets required for absolute fitness of the Retirees and their spouse should be listed under IPD/ cashless treatment.
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With warm regards,
--
Dr.V.N.Sharma, Chairman
For & on behalf of
Federation of Retired SAIL Employees (Regd)
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