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Q. 1
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What is Pan India Cashless Medical Insurance Scheme (PICMIS) of the Institute?
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Ans.
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In order to avail the medical reimbursements towards the expenses of hospitalization (IPD), the Institute has chosen a “Pan India Cashless Medical Insurance Scheme (PICMIS)” offered by an Insurer. This is the PICMIS of the Institute.
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Q. 2
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Who are covered under PICMIS?
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Ans.
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The facility is available for the present employee (with family) and retired (Self & Spouse Only) employees of the Institute (Institute Main Account, Quasi Permanent Employees of R&D Office and Employees of Council of Wardens etc.). For more details please refer to Office Order No. IITK/Admin/MIS/2018/389 dt. 18.04.2018, IITK/Admin/MIS/2018/439 dt. 16.05.2018 and IITK/Admin/MIS/2018/441 dt. 28.05.2018.
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Q. 3
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What is the procedure to get them enrolled for Pan India Cashless Medical Insurance Scheme (PICMIS) for newly joined employee of IIT Kanpur?
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Ans.
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The employees joining the Institute will have to submit details of their dependants to the office of DOFA, office of DORD, Administration Section and COW as the case may be for coverage of the dependants.
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Q. 4
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What is the coverage value/sum insured under PICMIS?
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Ans.
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The present employee and his/her family will get a maximum coverage of ` 4.00 lakh (` 2.00 lakh base + ` 2.00 lakh from Institute buffer subject to availability of funds in the buffer) under this policy. If the expenditure is more than the ceiling limit of ` 4.00 lakh per family in the financial year 2018 – 2019, then the amount exceeding the ceiling limit, will have to be borne by the concerned employee.
The retired employee and his/her spouse only (not family) will be entitled for a maximum coverage of ` 4.00 lakh (` 2.00 lakh base + ` 2.00 lakh from Institute buffer subject to availability of funds in the buffer) under this policy. The pre 30 days and post 60 days hospitalization bills have to be submitted to TPA for reimbursement.
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Q. 5
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Who will pay the premium?
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Ans.
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No premium has to be borne by present employees. However, the contributions of retired employees covered under GPF, CPF and NPS are as mentioned in our orders IITK/Admin/MIS/2018/389 dt. 18.04.2018, IITK/Admin/MIS/2018/439 dt. 16.05.2018 and IITK/Admin/MIS/2018/441 dt. 28.05.2018. Employees retiring during the year can continue to avail the insurance till the policy expires.
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Q. 6
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Is there any top-up coverage facility under PICMIS?
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Ans.
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Beneficiaries can opt for top-up coverage. The top-up premium will have to be paid by the beneficiaries themselves as per the / applicable conditions of the insurance company policy.
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Q. 7
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What is family floater?
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Ans.
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The total sum insured (basic + buffer, if any) is available for utilization of any one or all members of the family of an employee.
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Q. 8
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Is PICMIS useful for OPD?
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Ans.
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No. The PICMIS will only reimburse the expenses towards hospitalization for a minimum period of 24 consecutive hours. However, due to advancement in medical technology, certain procedures (called day care treatments) which require less than 24 hours of hospitalization shall be covered. [Please refer to the list of permissible day care treatments.] at Office Order No. IITK/Admin/MIS/2018/389 dt. 18.04.2018, IITK/Admin/MIS/2018/439 dt. 16.05.2018 and IITK/Admin/MIS/2018/441 dt. 28.05.2018
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Q. 9
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Is there any exclusion of a particular disease?
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Ans.
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No. All diseases are covered under PICMIS. The only exclusions are the permanent exclusions, e.g., war invasion, cosmetic, vaccination & inoculation, deliberate exposure to danger, injury due to hazardous sports, sexually transmitted diseases, etc. Please refer office order no. IITK/Admin/MIS/2018/389 dt. 18.04.2018, IITK/Admin/MIS/2018/439 dt. 16.05.2018 and IITK/Admin/MIS/2018/441 dt. 28.05.2018
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Q. 10
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Is there any waiting period?
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Ans.
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There is no waiting period for any disease/treatment covered under the PICMIS. The policy will be effective from the day one i.e. 16.05.2018. Further, all pre-existing diseases are covered. However, in case of top up conditions may apply.
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Q. 11
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Is there any upper limit for the reimbursement?
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Ans.
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The upper limit is the sum insured (basic + buffer subject to availability). Otherwise, as such, the disease covered under PICMIS has no upper limit for reimbursement. There are certain treatments that are not usually covered in any medical insurance policy are covered under the PICMIS.
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Q. 12
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On top of treatment cost, what are the other expenses reimbursable under PICMIS?
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Ans.
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The treatment cost including doctor’s fee and required drugs and investigation expenses are reimbursable as per Insurers norms, Institute Policy and category of entitlement. Please refer office order no. IITK/Admin/MIS/2018/389 dt. 18.04.2018, IITK/Admin/MIS/2018/439 dt. 16.05.2018 and IITK/Admin/MIS/2018/441 dt. 28.05.2018.
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Q. 13
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Who will process the reimbursement claims?
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Ans.
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The Insurer shall engage an agency called Third Party Administrator (TPA) through which the reimbursement claims will be processed.
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Q. 14
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How does the Insurer/TPA recognize a member of PICMIS?
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Ans.
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The ID-Card may be downloaded from RAKSHA TPA website under the link https://www.rakshatpa.com/log_main_new.jsp?id=policy including all family members who are covered under the policy of the PICMIS. This ID-Card along with Institute ID Card / Adhaar Card shall be used for any hospitalization and reimbursements. Alternately the card can also be obtained from ID Cell of the Institute by paying ` 100/- only per card.
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Q. 15
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What is the claim procedure?
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Ans.
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The hospitalization of members which is duly informed/pre-authorized to/by TPA are eligible for reimbursement. For which, the member shall submit a duly filled claim form (in the prescribed format) to TPA along with the original documents.
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Q. 16
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Should anyone be informed about any hospitalization?
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Ans.
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Yes, TPA shall be informed regarding any hospitalization for which reimbursements are expected. In case of planned hospitalization.
Raksha Health Insurance TPA Pvt. Ltd.,
807, 8th Floor Cyber Height,
Vibhuti Khand, Gomti Nagar,
Lucknow – 226 010
Toll free no. - 18001801444
Contact No. 8090046595 / 8090046594
Cashless – 08881673411 / 011-66173411 / 011-45823411
Website : https://www.rakshatpa.com/
Email:
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- The present employees residing in Kanpur will have to seek referral from Health Centre, IIT Kanpur for all planned hospitalization cases. However, in case of any emergency, the patient can be taken directly to the hospital and post referral must be taken from the Health Centre, IIT Kanpur within 24 hours of admission to the hospital.
- The present employees residing outside Kanpur may avail facility directly from the hospital where they are residing after seeking advice / referral from their treating doctor & intimate the same to Health Centre, IIT Kanpur attaching the advice / referral of treating doctor within 3 days of hospitalization but before discharge. Also inform to RAKSHA TPA through the contact details as given.
- Retired employees need not seek any referral from Health Centre, IIT Kanpur. However, they have to inform RAKSHA TPA.
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Q. 17
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Is there any restriction on the hospitals to get the treatment?
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Ans.
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No. Any Institution in India established for indoor care and treatment of sickness and injuries and which has been registered either as hospital or nursing home with the local authorities and is under the supervision of a registered and qualified medical practitioner will be considered.
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Q. 18
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What are network hospitals and their advantages?
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Ans.
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The Insurer/TPA has tie-up with some hospitals across the country called the network hospitals. The members of PICMIS can have cashless treatment in the network hospitals. The Insurer/TPA shall directly pay the entitled medical expenses to the network hospitals. In case of treatment in a hospital which is not empanelled ‘OR’ in case of any emergency where networked hospitals are not available ‘OR’ for all government hospitals, the claim will be reimbursed as per entitlement on submission of all documents. All reimbursement claims will be routed through Health Centre, IIT Kanpur for verification of referral. Health Centre, IIT Kanpur will send the bills to the respective Accounts Section of employees concerned to check the admissibility of claims for onward submission to the Insurance Company. On receipt approved of the amount of against the claim from the insurance company, the said amount will be transferred to the account of the claimant. If claim is not submitted (and also verified to the concern hospital and doctor along with RAKSHA TPA claim form which is available on RAKSHA TPA website www.rakshatpa.com) within 30 days from the date of discharge the same will not be processed for reimbursement by the TPA / Insurance Company / Institution.
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Q. 19
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How to contact the TPA?
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Ans.
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TPA can be contacted on the phone numbers given on RAKSHA website/Toll Free Number. The TPA shall provide a helpdesk at the Institute on regular basis. At present, the helpdesk is opened twice a week on Tuesday and Friday (from 3.00 PM to 5.00 PM) at Health Centre, IIT Kanpur.
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Q. 20
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In case of any difficulty whom to contact in the Institute?
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Ans.
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Health Centre has established an Insurance Cell for resolving various pre and post hospitalization reimbursement problems of the policy during office hours / working days. In case of hospitalization beneficiary has to contact to RAKSHA TPA.
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Q. 21
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I approached a network (or even a non-network) hospital for a medical emergency. The hospital kept me in observation for a while and after some diagnosis, they observed that the hospitalization is not required. Will these expenses be paid/reimbursed by PICMIS?
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Ans.
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No. PICMIS only covers the expenses towards hospitalization for 24 hrs or certain day care procedures. TPA may be referred for clarifications regarding hospitalization and reimbursements. List of day care are given in office order no. IITK/Admin/MIS/2018/389 dt. 18.04.2018.
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Q. 22
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What is the procedure to get treatment outside Kanpur?
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Ans.
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It is the same across the country. The Insurer/TPA shall have their offices in all major cities to deal with the cases.
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Q. 23
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Who is the current Insurer, Policy No. & current policy period?
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Ans.
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The New India Assurance Co. Ltd. 127/2, W-1 Mangalam Complex, Saket Nagar,
Kanpur-208 014. Current Policy Number is – 42220634180400000001. Current Policy period is from 16.05.2018 To 15.05.2019.
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Q. 24
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What is the role of beneficiary in case of non-cashless hospitalization?
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Ans.
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Beneficiaries responsibility is to collect all original bills from the hospital (bills, report, discharge summary and card, if any etc.) and also get these verified from the concern hospital and doctor along with RAKSHA TPA claim form which is available on RAKSHA TPA website www.rakshatpa.com
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Q. 25
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What is the role of all beneficiaries for pre and post hospitalization?
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Ans.
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All medical expenses relating to pre hospitalization (30 days) and post hospitalization (60 days) shall have to be claimed from M/s New India Assurance Company / Raksha TPA. Bills, prescription and investigation reports in original along with claim form need to be submitted for payment. Institute shall not reimburse the Pre (30 days) & Post (60 days) hospitalization bills. Bills have to be submitted within 30 days from the date of discharge positively failing which no reimbursement will be available.
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Q. 26
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Who is eligible for buffer & what is the distributary of buffer to serving and retired employee?
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Ans.
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Patient getting treatment in entitled category shall only be eligible for Buffer subject to availability if need arises. Buffer is bifurcated between retired and serving employee in ratio of 20:80. However, the same will be reviewed periodically and suitable adjustments will be made. Preference for release of buffer shall be as per Institute policy.
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Q. 27
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Should all the papers be obtained from hospital before discharge?
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Ans.
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YES!! Please refer office order no. IITK/Admin/MIS/2018/389 dt. 18.04.2018, IITK/Admin/MIS/2018/439 dt. 16.05.2018 and IITK/Admin/MIS/2018/441 dt. 28.05.2018.
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Q. 28
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Is top up allowed?
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Ans.
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Yes top up is allowed. However, the top up insurance is a normal insurance wherein the waiting period will apply. For eg. in case of joint replacement surgery the beneficiary has to wait for 4 years. The top up premium invariably had to be borne by the beneficiary. Institute liability is only up to ` 4.00 lakh (` 2.00 lakh base + ` 2.00 lakh from Institute buffer subject to availability of funds in the buffer).
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Q. 29
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What to do in case insurance card is not available?
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Ans.
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Insurance card is already available on the web page of RAKSHA TPA https://www.rakshatpa.com/log_main_new.jsp?id=policy.
All the data had been uploaded. Even otherwise, the Institute Photo ID card along with Adhaar Card and Policy No. is sufficient to avail facilities all over India on Cashless basis. In case of non-cashless, Adhaar is sufficient and bill will be reimbursed as per norms.
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