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   >> HEALTH CARE SCHEMES | HOME |  
 

SPECIFICATION OF SCHEME BENEFITS 2013

 

Name of the Scheme

 

Mizoram State Health Care Scheme

 

 

Objective of the Scheme

 

The objective of the Scheme is to improve access of families to quality medical care for treatment of diseases involving hospitalization and surgery through an identified network of Health Care Providers. Each family shall cover all eligible family members under this Scheme.

 

Covered Benefits

 

Hospitalisation - The Scheme shall provide coverage for meeting expenses of hospitalization and surgical procedures of BPL beneficiary members up to Rs. 70,000/- per family per year subject to limits, in any of the network hospitals, after having exhausted RSBY cover of Rs. 30,000/- only. The cover shall be on family floater basis.

 

 

 

Critical Illness - A buffer floater amounting to Rs.2,00,000/-, over and above the normal cover can be availed of individually or collectively, by members of the BPL family suffering from below listed critical illness. APL families will avail benefits only under this critical illness cover within a sum insured of Rs.3,00,000/-. This buffer floater will be made available for beneficiaries with identified critical illness (excluding related ailments except where specified) as given under:

 

 

 

I.

CARDIOLOGY AND CARDIOTHORACIC SURGERY

 

 

1.

Coronary By-pass Surgery (CABG).

 

 

2.

Valve Replacement / Repair or Valvuloplasty.

 

 

3.

Correction of Congenital Heart Diseases eg. VSD, ASD, TOF, etc.

 

 

4.

Angioplasty and PTCA Stent.

 

 

5.

Permanent and Temporary Pacemaker Implantation.

 

 

6.

Surgeries for Repair of Aneurysm.

 

 

7.

Electrophysiologic Study and Radiofrequency Ablation.

 

 

8.

Pericardial Surgery & Pericardial Effusion requiring Drainage.

 

 

9.

Acute Coronary Syndrome (Unstable Angina, Myocardial Infraction).

 

 

10.

Heart Failure / Cardiogenic Shock.

 

 

 

 

 

II.

ONCOLOGY

 

 

1.

Surgical Management of all Malignant Tumours.

 

 

2.

Radiation Treatment of Malignancies.

 

 

3.

Chemotherapy / Targeted Therapy for Treatment of Malignancies.

 

 

4.

Complications and Toxicities of treatment of Malignancies.

 

 

 

 

 

III.

MEDICINES

 

 

i. NEPHROLOGY

 

 

1.

Kidney Failure.

 

 

 

 

 

 

ii. RESPIRATORY SYSTEM:

 

 

1.

Respiratory Failure.

 

 

2.

Pulmonary Thromboembolism.

 

 

 

 

 

 

iii. GI TRACT

 

 

1.

GI bleed requiring Surgical Intervention

 

 

2.

Non alcoholic Acute Pancreatitis with Complications.

 

 

 

 

 

 

iv. ENDOCRINOLOGY

 

 

1.

Diabetic Ketoacidosis.

 

 

2.

Other Metabolic emergencies (eg: Thyrotoxic Crisis, Myxoedemic Coma, Pheochromocytoma, Cushing’s Disease, etc).

 

 

 

 

 

 

v. CNS

 

 

1.

Acute Stroke - any Cerebro Vascular incident producing permanent Neurological Sequelae.

 

 

2.

Acute Myelopathies requiring Medical Board Referral.

 

 

3.

Hydrocephalus requiring Surgical Intervention.

 

 

4.

Myasthenic Crisis.

 

 

 

 

 

 

vi. HEPATOLOGY

 

 

a)

Liver Abscess requiring Surgical Intervention.

 

 

b)

Hepatic Encephalopathy.

 

 

c)

Hep B &C on Interferon / Antiviral Therapy treated only at Civil Hospital, Aizawl & Lunglei.

 

 

 

 

 

 

vii. HEMATOLOGY

 

 

1.

Complicated Cytopenias (eg : Aplastic / Hypoplastic Anaemias, Neutropenias, Thrombocytopenias).

 

 

2.

Hemoglobinopathies requiring Splenectomy (Thalassemia/Sickle Cell Anemia).

 

 

3.

Thromboembolic Disease (eg : DVT, Mesenteric Artery thromboembolism, Pulmonary Thromboembolism, etc).

 

 

4.

Bleeding disorders (eg : Hemophilia).

 

 

 

 

 

 

viii. CONNECTIVE TISSUE DISEASE

 

 

1.

SLE, Mixed Connective tissue disease, etc.

 

 

 

 

 

 

ix. INFECTIVE DISEASES

 

 

1.

Complicated Malaria (identified according to WHO criteria).

 

 

2.

Multi Drug Resistant Tuberculosis.

 

 

 

 

 

 

x. ORGAN TRANSPLANT :

 

 

1.

Renal / Bone Marrow / Liver/Heart / Stem Cell (for treatment of Malignancies, etc), and including ‘the’ donor only.

 

 

 

 

 

IV.

SURGERY

 

 

i. UROLOGY/NEPHROLOGY

 

 

1.

Nephrectomy and Surgery for Perinephric Abscess.

 

 

2.

Urinary Stone cases requiring surgery under GA

 

 

 

 

 

 

ii. GASTROENTEROLOGY

 

 

1.

Acute Abdomen requiring major/emergency surgery : eg – Gut Perforation, Acute Appendicitis,  Volvulus, Intussusception, Peritonitis, Intra- Abdominal Abscess, Acute Cholesystitis with Cholelithiasis etc.

 

 

2.

Pseudocyst of Pancreas requiring Surgery.

 

 

 

 

 

 

iii. NEUROLOGY AND NEUROSURGERY

 

 

1.

Life saving surgeries on Brain (eg:Intracranial Hematomas/Abscess) and Spinal Cord.

 

 

iv. PLASTIC SURGERY

 

 

1.

Treatment of major burns with complications.

 

 

 

 

 

V.

OPHTHALMOLOGY

 

 

1.

Surgery and other procedures for Detachment of Retina.

 

 

2.

Surgery for Glaucoma.

 

 

3.

Vitreous Heamorrhage, Vitrectomy.

 

 

4.

Laser treatment of Retinopathies (to SSN referred cases only).

 

 

5.

Orbital fracture and penetrating eye ball injury

 

 

7.

Intracranial blood disorders involving eye

 

 

7.

High Myopia with impending retinal damage

 

 

 

 

 

VI.

ENT

 

 

1.

Mastoidectomy.

 

 

2.

Middle Ear Disease requiring Operation in Children (excluding Intracranial Implants like Cochlear Implants, etc).

 

 

3.

Stapedectomy.

 

 

 

 

 

VII.

ORTHOPAEDIC SURGERY

 

 

1.

Joint Replacement (Hip / Knee, etc).

 

 

2.

Surgery for correction of Fractures of Bones and Joints.

 

 

3.

Arthroscopic Repair of Ligaments

 

 

4.

Major limbs amputations (legs / arms / foot) due to any diseases excluding single digits / terminal Phalanged Amputations (with Prosthesis).

 

 

5.

Correction of Locomotor disabilities due to Congenital & Acquired Contractures.

 

 

7.

PIVD with Severe Cord Compression requiring Surgery.

 

 

 

 

 

VIII.

ICU CARE

 

 

1.

Any seriously ill patient requiring ICU admission to sustain life (excluding routine post-operative patients and uncomplicated surgeries).

 

 

 

 

 

ix.

PAEDIATRICS

 

 

 

CNS

-

Meningitis / Encephalitis.

 

 

 

Respiratory System

-

Severe Pneumonia with related complications.

 

 

 

Nephrology

-

Complicated Nephrotic Syndrome.

 

 

 

 

-

ARF.

 

 

 

Newborns

-

Birth Asphyxia and related complications.

 

 

 

 

-

Preterm / VLBW requiring NICU care.

 

 

 

 

-

Congenital Malformations requiring Major Surgery.

 

 

 

 

 

X.

DERMATOLOGY

 

 

1.

Steven Johnson’s Syndrome – drug induced.

 

 

 

 

 

XI.

PSYCHIATRY

 

 

1.

Psychiatric Emergencies (eg : Manic / Ac Psychotic Disorder).

 

 

 

 

 

XII.

OBS AND GYNAECOLOGY

 

 

1.

Emergency life saving operations (eg : Ruptured Ectopic Pregnancies, DUB, Twisted Ovarian Cyst, etc).

 

 

2.

LSCS complicated by Rupture Uterus, Re-opening of Abdomen.

 

 

 

 

 

XIII.

DENTAL SURGERIES

 

 

1.

Post Traumatic Maxillofacial fractures requiring Surgery.

 

 

 

 

Eligibility of Beneficiaries

 

1.

Any non- Government Servant (Central or State) or their dependents who is a bonafide citizen of India and residing in Mizoram, with the Head of the Family thereby being in the Voters list or the Head of the Family having Voter ID Card shall be eligible to be covered under this Scheme, irrespective of age. The Scheme will also cover dependents of Government Servants (Central or State), who are not covered under the existing Medical Attendance Rules such as Grandchild, daughter / son-in-law, overage children, sister / brother, uncle / aunty, niece / nephew, etc. The Scheme will also cover personnel and their dependents working under the Government of Mizoram eg: Contracts, Muster roll, etc who are not entitled to medical reimbursement under the existing rule in force. The Scheme will not cover persons and their dependents working under church organizations and who can thus be eligible for claiming their medical reimbursements their respective church organization

 

 

 

 

 

2.

Coverage under the Scheme would be provided for all family and their members as per the photo ID Card / Smart Card issued to them. Prior to issue of Photo ID Card / Smart Card, copy of enrollment form with Voter ID may be used as proof of coverage.

 

 

 

 

3.

Family – A family would be defined as anyone living under one roof, irrespective of their relationships and duly ascertained by the Family Ration Card. Any addition / deletion of family members e.g. death, birth, divorce, marriage, adoption etc. the same will have to be recommended by the concerned Health Worker / Medical Officer / Senior Medical Officer / Chief Medical Officer and certified by the Mizoram State Health Care Society.

 

 

 

 

4.

Proposed Payment of Premium: The family members will be restricted to 5 members for APL families, while for BPL families, this number limit will not be applicable. Payment of premium for a family of 5 or families whose number is above 5, payment of Premium may is as below:

 

Table III: Details of Premium Payment

BPL, family members

Less than 5

APL

APL, family members less than 5

APL, Additional family member more than 5

Nil

Sum insured up to Rs. 1 lakh

Rs.500/-

Rs. 100 per additional member

Sum insured up to Rs. 2 lakhs

Rs.750/-

Rs. 200 per additional member

Sum insured up to Rs. 3 lakhs

Rs.1,000/-

Rs. 300 per additional member

 

Dependents

 

The dependents should be living in the same household. “Dependents” are those who depend upon the Head of the household for their basic subsistence / care.

 

 

 

 

Insured Benefits

 

Pre-existing conditions to be covered, subject to minimal exclusions as per clause 19.

 

 

 

 

Transport Allowance

 

Provision for transport allowance as part of the sum insured will be allowed for the patient along with one attendant by any public service vehicle at the rate as may be fixed by the State Transport Authority from time to time. In case of an emergency / exceptional case, hiring of private vehicle may also be allowed, provided it is duly certified by the Medical Officer i/c of the Hospital. The cost of travel that would be reimbursable for a patient that has to be shifted from residence to hospital in case of admission in Emergency or from one Hospital / Nursing Home to another Hospital / Nursing Home for better medical facilities. Expenses for travel (Fares only) would have a ceiling of Rs. 1,000/- within the State and Rs. 10,000/- for travel outside the State per claim. Reimbursement for travel outside the State would be considered for treatment of named Critical Illnesses only. Further, only the lowest fare available for the journey shall be considered for reimbursement.

 

 

 

 

 

Relevant medical expenses incurred for the period up to 1 clear day prior to hospitalization and up to 10 clear days from the date of discharge from the hospital shall be part of the benefit. This pre-hospitalization coverage would also include all pre-admission investigations pertaining to the particular hospitalization and not subject to the 1 clear day pre-hospitalization coverage and duly certified by the treating doctor. However, in cases of organ transplantation patients, post hospitalization coverage would be extended up to 30 clear days.

 

 

 

 

Maternity and New Born Benefit:

 

a.

This means treatment taken in Hospital / Nursing Home arising from childbirth including normal delivery / caesarean section and / or miscarriage or abortion induced by accident or other medical emergency except voluntary medical termination of pregnancy.

 

 

 

 

b.

Newborn child shall also be covered from day one up to the expiry of the Policy and expenses incurred for treatment taken in hospital as in-patient. This benefit shall be a part of basic sum insured and new born will be considered as a part of insured family member till the expiry of the policy. However, hospitalization prior to delivery can be taken under medical procedures and will not be included under this benefit.

 

 

 

 

c.

The maximum benefit allowable under this benefit will be up to Rs. 10,000/- . For complicated cases such as Cesarean Section, the amount covered will be subject to actuals, provided certification from the treating doctor is included in the claim. This benefit shall be a part of basic sum insured.

 

 

 

 

 

Note:

 

i.

For the Policy period, new born will be provided all benefits under the Scheme and will NOT be counted as a separate member.

 

 

 

 

ii.

Verification for the new born can be done by any of the existing family members who are getting the Scheme benefits.

 

 

 

Minimum period of hospitalization:

 

The minimum period for which a beneficiary is admitted in the hospital as inpatient and stays there for the sole purpose of receiving the necessary and reasonable treatment for the disease / ailment contracted / injuries sustained under the Scheme shall be at least 24 hours

 

 

 

Day Care Procedures:

 

Given advances in treatment techniques, many health services formerly requiring hospitalization can now be treated on a day care basis.  Examples of such services which are included for coverage under hospitalization benefits are:

 

 

Dialysis

 

 

Parenteral Chemotherapy

 

 

Hepatitis B

 

 

Hepatitis C

 

 

Drug Resistant TB

 

 

Radiotherapy

 

 

Epilepsy

 

 

Eye Surgery

 

 

Lithotripsy (Kidney stone removal)

 

 

Tonsillectomy

 

 

D&C (not MTP)

 

 

Dental Surgery following an accident

 

 

Hysterectomy

 

 

Surgery of Hernia

 

 

Surgery of Hydrocele

 

 

Surgery of Prostrate

 

 

Gastrointestinal Surgery

 

 

Genital Surgery

 

 

Surgery of Nose

 

 

Surgery of Throat

 

 

Surgery of Ear

 

 

Surgery of Appendix

 

 

Surgery of Urinary System

 

 

Treatment of Fractures / Dislocation (excluding hair line fracture), Contracture releases and minor reconstructive procedures of limbs which require hospitalization

 

 

Laparoscopic Therapeutic Surgeries

 

 

Any surgery under General Anaesthesia

 

 

Any disease / procedure mutually agreed upon by the Society and the Insurance Company / TPA before treatment

 

 

 

 

The above listed procedures can also be treated / claimed under normal hospitalization benefits.

 

 

 

Fraudulent Bills / Claims:

 

If fraudulent bills are detected from beneficiaries, hospitals or Government Staffs, the following actions will be initiated:

 

 

 

 

 

For Beneficiaries: the fraudulent claim/s will be rejected and further claims from the particular family will not be entertained for the current Policy period or as may be determined b the Executive Committee.

 

 

 

 

 

For Hospitals: the bills of the hospitals will be out rightly rejected. Further, if the hospital is found to be directly attributable to the false claims as referred to in the Specification of Scheme Benefits or included later under the clause, the concerned hospital will be de-panelled.

 

 

 

 

 

For Government Staff working in Hospitals, etc: Appropriate Government proceedings will be initiated against them.

 

 

 

Benefit Exclusions

 

Common exclusions from the benefits would include:

 

 

 

 

Conditions that do not require hospitalization or that can be treated at home or conditions that do not fall under Day Care Procedures specified in paragraph 16.

 

 

 

 

i.

Sterilization and Fertility related procedures.

 

 

 

 

ii.

Circumcision unless necessary for treatment of a disease not excluded hereinabove or as may be necessitated due to an accident.

 

 

 

 

iii.

Vaccination or Inoculation.

 

 

 

 

iv.

Change of life or cosmetic or aesthetic treatment of any description other than as may be necessitated due to an accident or as a part of any illness.

 

 

 

 

v.

Cost of spectacles, contact lenses and hearing aids.

 

 

 

 

vi.

Dental treatment or surgery of any kind unless requiring hospitalization.

 

 

 

 

vii.

Convalescence, general debility, ‘run-down’ condition or rest cure.

 

 

 

 

viii.

Congenital external diseases, except where intervention is required to maintain the functionality of the individual.

 

 

 

 

ix.

Sterility, venereal or sexually transmitted diseases.

 

 

 

 

x.

Intentional self-injury, unlawful activity associated injury (intentional/unintentional), suicide and direct consequence of use of intoxicating drugs/alcohol.

 

 

 

 

xi.

All expenses arising out of any condition, directly or indirectly, caused to or associated with human T-Cell Lymphotropic Virus type III (HTLV III) or Lymphadinopathy Associated Virus (LAV) or the Mutants Derivative or Variations Deficiency Syndrome or any Syndrome or condition of a similar kind commonly referred to as AIDS / HIV, if otherwise treatable under Mizoram State Aids Control Society (MSACS) Programme.

 

 

 

 

xii.

Charges incurred at Hospital or Nursing Home primarily for diagnostic, X-ray or laboratory examinations or other diagnostic studies not consistent with or incidental to the diagnosis and treatment of the positive existence or presence of any ailment, sickness or injury, for which confinement is required at a Hospital / Nursing Home or at home under domiciliary hospitalization as defined.

 

 

 

 

xiii.

Expenses on vitamins and tonics unless forming part of treatment for disease or injury as certified by the Medical Practitioner.

 

 

 

 

xiv.

Domiciliary Treatment, Naturopathy Treatment.

 

 

 

 

xv.

Disease or injury directly or indirectly caused by or arising from attributable to war, invasion, act of foreign enemy, warlike operations (whether war be declared or not), disasters (man made, natural).

 

 

 

 

xvi.

Disease or injury directly or indirectly caused by or contributed to by nuclear weapons / materials.

 

 

 

Rates

 

The rates will include Bed charges (General Ward only), Nursing, diet charges, Surgeons, Anesthetists, Medical Practitioner, Consultants Fees, Anesthesia, Blood, Oxygen, O.T. Charges, Cost of Surgical Appliances, Medicines and Drugs, Cost of Prosthetic Devices, implants, X-Ray and Diagnostic Tests, etc as notified by the Government of Mizoram and will be applicable for all medical/surgical cases for hospitals within the State of Mizoram vide No.A.17014/7/07-HFW, Dt. 22nd July, 2008.   For hospitals outside Mizoram, rates will be as per current CGHS rates will be adhered. Costs of drugs would be as per distributor prices.

 

 

 

Specific Provisions for the Scheme

 

Enrolment Procedure

 

 

 

 

a)

Beneficiary enrollment is the responsibility of the Mizoram State Health Care Society. Enrollment period will be opened for 2 months in each district only and beyond this period, enrollment would not be opened whatsoever.

 

 

 

 

b)

Enrollment of the Head of the Family in the current electoral roll or having Voter ID Card of the State published by the Election Commission of India shall be used as proof of eligibility for enrollment under the Scheme.

 

 

 

 

c)

For BPL families, a Certificate / Card as proof thereof issued by GoM authorized Department (identified from time to time) and certified by a Gazetted Officer or Health Worker in remote villages of the Government of Mizoram has to be attached.

 

 

 

 

d)

Coverage under the Scheme would be provided for all family and their family members as per the Enrollment / Photo ID Card.

 

 

 

 

e)

The period for enrolment would be from the date of commencement of enrolment for a period of 60 days only, beyond which it would not be possible to enroll. Enrolment period would be widely publicized.

 

 

 

 

f)

Enrollment under the Scheme at the time of hospital admission within the enrolment period will also be considered.

 

 

 

Cashless Access Service

 

a)

Within the limits of coverage, BPL beneficiaries only shall be provided cashless treatment for all conditions, illness or disease covered under the Scheme. The Health Care Provider shall be reimbursed according to the packaged cost specified in Paragraph 18.

 

 

 

 

b)

For APL beneficiaries, the facility of cashless treatment shall be restricted only to Critical Illnesses as listed in Paragraph 4. The basis of reimbursements shall be limited to the rates specified in Paragraph 18.

 

 

 

The Mizoram State Health Care Society shall formulate Rules and Procedures relating to the following:

 

a.

Pre-authorization requirements, when applicable.

 

b.

Access to network and out-of-network providers.

 

c.

Emergency care and treatment of beneficiaries.

 

d.

Any other matter as may be deemed necessary by the Mizoram State Health Care Society.

 

 

 

Referral of Patients from Mizoram to Hospitals outside the State:

 

The existing Medical Boards constituted by the Government of Mizoram at Aizawl and Lunglei will be utilized under the Scheme for referring cases outside the State of Mizoram. However, Final Authority shall lie with the Society and the recommendations of the Boards for utilization of hospitals referred by it will not be binding on the Mizoram State Health Care Society.  The Mizoram State Health Care Society may recommend other hospitals with similar facilities but providing the same treatment at lower rates as negotiated by the Society.

 

 

 

Eligible Health Care providers

 

i.

Both public and private health care providers which provide hospitalization and/or daycare services, with desired infrastructure would be eligible for inclusion under the Scheme, subject to such requirements for empanelment as accepted by the Mizoram Health Care Society.

 

 

 

 

ii.

All Government Hospitals (including Primary and Community Health Centers) will be automatically eligible for empanelment under the Scheme. However, claims from beneficiaries taking treatment at Government Hospitals would only be allowed for expenses incurred by them on drugs, consumables, etc., purchased from the market (on production of Cash Memos / Bills) and on minimal investigation / laboratory charges levied by the Government Hospitals (on production of Cash Memos / Bills / Receipts). Expenses such as Diet, Nursing, Bed Charges, Doctor Consultation, Surgical Charges and other expenses which the Government Hospitals provide free will not be payable under the Scheme

 

 

 

Empanelment of Private Hospitals for Inpatient and Day Care Services:

 

Hospitals and other Health Facilities shall be empanelled that conform to the eligibility criteria as detailed below:

 

a)

It has a minimum of 15 beds.

 

 

 

 

b)

It is equipped with properly functioning of Computer, Telephone and Fax facilities

 

 

 

 

c)

It is fully equipped and engaged in providing medical and / or surgical care, including a Pharmacy and Laboratory and Diagnostic Services that could handle at least testing of clinical (blood and urine) specimens, X-rays and ECG

 

 

 

 

d)

The facilities undertaking Surgical Operations have a fully equipped Operating Theatre which it owns and is located on the premises of the facility

 

 

 

 

e)

The facility employs fully qualified Doctors and Nursing Staff on a 24 hour a day basis

 

 

 

 

f)

The facility employs fully qualified laboratory technicians

 

 

 

 

g)

The facility has the requisite system and procedures of maintaining patient’s records required to be provided to the patient or his representative, the Insurance Company / TPA, Government / Nodal Agency as and when required

 

 

 

 

h)

The facility preferably agrees to packaged costs for each identified medical / surgical intervention/procedures provided as covered benefits under the Scheme

 

 

 

 

i)

The Hospital should be in a position to provide following additional benefits to the BPL beneficiaries related to identified systems:

 

 

 

 

 

i.

Free OPD consultation.

 

 

 

 

 

 

ii.

Fixed / agreed discounts on diagnostic tests and medical treatment   required where hospitalization is not required.

 

 

 

         

 

 

 
 

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