TN New Health Insurance Scheme : Emergency care on re-imbursement basis in Non-Network Hospitals
Government of Tamil Nadu
2018
FINANCE [Salaries] DEPARTMENT
G.O.(Ms).No.391, Dated 10th December 2018.
(Vilambi, Karthigai-24, Thiruvalluvar Aandu-2049)
ABSTRACT
Medical Aid – New Health Insurance Scheme, 2016 for Employees – Provision of assistance for the treatments/surgeries covered under the said Scheme on re-imbursement basis in Non-Network Hospitals in case of Emergency Care – Guidelines to implement the clause “Emergency Care” – Orders – Issued.
Read:-
1. G.O.Ms.No.202, Finance (Salaries) Department, dated: 30-06-2016.
2. G.O.Ms.No.222, Finance (Pension) Department, dated: 30-06-2018.
3. G.O.Ms.No.292, Finance (Salaries) Department, dated: 03.09.2018.
4. Letter received from Principal Secretary/Commissioner of Treasuries and Accounts, Rc.No.22006/2018/ NHIS – 2, dated: 26.09.2018.
ORDER
In the Government Order first read above, orders have been issued for the implementation of New Health Insurance Scheme, 2016 for Employees during the block of four years from 01.07.2016 to 30.06.2020.
2. In the Government Order second read above, orders have been issued for the implementation of the New Health Insurance Scheme, 2018 for Pensioners (including Spouse) / Family Pensioners with a new clause providing assistance for the treatments / surgeries covered under the scheme in case of emergency care on re-imbursement basis in Non-Network Hospitals.
3. In the reference 3rd cited, the Government have sanctioned funds towards the additional premium for extending the new clause “Emergency Care” to the beneficiaries under New Health Insurance Scheme, 2016 for Employees.
4. The Government after careful consideration has decided to issue guidelines to extend the medical assistance to the subscriber of New Health Insurance Scheme, 2016 for Employees for the treatments / surgeries covered under the scheme in case of emergency care on re-imbursement basis in Non-Network Hospitals subject to Eligible Medical Expenses and Ceiling Criteria where there will be no cashless facility available.
5. The Guidelines for implementation of New Health Insurance Scheme, 2016 for employees and the procedure to be followed by the Beneficiaries for availing Medical Assistance under this Scheme are as detailed below:
(1) In case of Planned Hospitalisation: The Beneficiaries seeking medical assistance under this Scheme shall approach the Network Hospitals only for the approved treatments and surgeries to be undertaken on CASHLESS basis so that pre-authorisation is given by the Insurance Company / Third Party Administrator under the control of the Insurance Company.
(2) In case of Emergency Care : The Beneficiary seeking medical assistance under this Scheme shall approach either Network Hospital for the approved treatments and surgeries to be undertaken on CASHLESS basis or Non-Network Hospital for the approved treatments and surgeries to be undertaken on reimbursement basis. The Beneficiary has to pay the medical expenses first directly to the hospital and then seek cash reimbursement for the approved treatments and surgeries undertaken subject to Eligible Medical Expenses and Ceiling Criteria. There will be no cashless facility applicable in Non-Network Hospital.
(3) The Scheme is that ordinarily the employee /eligible family members is required to avail CASHLESS facility in Network Hospital (to the extent of Eligible Medical Expenses and Ceiling Criteria under the Scheme) and pay for non-medical expenses directly to the hospital.
(4) In case, an employee /eligible family members undergoes emergency treatments/surgeries not covered under this Scheme in either Network Hospital or Non-Network Hospital, no claim can be filed under the New Health Insurance Scheme. However, they shall be eligible for claim to the extent permissible under the Tamil Nadu Medical Attendance Rules and the G.O.Ms.No.1023, Health and Family Welfare Department, dated 17-06-1980. It may be noted that the Tamil Nadu Medical Attendance Rules requires that treatment in private hospitals should not be resorted to except in cases of emergencies. Clause 2(3) of the aforesaid Government Order states that in genuine cases of emergency, the claims will be restricted to the expenditure that would have been incurred had the patient taken treatment in a Government hospital excepting diet charges. For claims under Tamil Nadu Medical Attendance Rules, the Beneficiaries may apply to the authority in the department in which the Government employee is working.
(5) In case, an employee/eligible family members avails treatments/surgeries in Non-Network Hospital where there is no emergency, the employee /eligible family members shall not be entitled to reimbursement under the New Health Insurance Scheme.
(BY ORDER OF THE GOVERNOR)
K.SHANMUGAM
ADDITIONAL CHIEF SECRETARY TO GOVERNMENT
