OBJECTIVE

        In order to enable and empower persons with disability to live as independently and as fully as possible, health services and their access to persons with disabilities assume a very significant role. In this context, the health insurance facility becomes important but presently such products are not easily available for persons with disabilities. In such a situation, a health insurance scheme “Niramaya” is conceived with the following objectives

 –    To provide affordable Health Insurance to persons with Autism, Cerebral Palsy, Mental Retardation & Multiple Disabilities

–    To encourage health services seeking behaviour among persons with disability

–    To improve the general health condition & quality of life of persons with disability

SCHEME & ITS COVERAGE

 The scheme envisages to deliver ‘Community based’ cover which will

–    Have a single premium across age band

–    Provide same coverage irrespective of the type of disability

–    Insurance cover upto 1.0 lakh Rs. and

–    All persons with disabilities will be eligible and included and there will be no ‘selection’

The scheme further envisages that there shall be

•          No exclusion of Pre-existing condition

•          Same cover as that for other persons

•          Services ranging from regular Medical Chekup to Hospitalization, Therapy to Corrective Surgery, Transportation

•          Conditions requiring repetitive medical intervention as an in-patient

•          Pre & Post hospitalization expenses, subject to limits

•          No pre-insurance medical tests

•          Cashless settlements only

•          Smart / Biometric cards with not only health data but also provision for other (Micro) financial data

The details of services with financial limits are as given in Annexure - ‘A’. In the first phase, the scheme will be available in the selected districts as given in Annexure - ‘B’.

ENROLMENT BENEFICIARIES

The National Trust will maintain the details of each beneficiary covered under the scheme. This will be a part of their identification and enrolment under the scheme.

ENPANELLMENT OF HEALTH SERVICE PROVIDERS

 Under the scheme, health services will be provided by a network of hospitals, nursing homes which will be duly empanelled for the scheme.  Such service provider shall be of good quality fulfilling relevant   requirements of the scheme and in case of networked hospitals, should comply with the minimum criteria as under:

• Should have at least 20 in-patient medical beds in urban centers and  5 in rural centers.
• Fully equipped and engaged in providing Medical and Surgical facilities along with Diagnostic facilities i.e. Pathological test and X-ray, E.C.G. etc for the care and treatment of injured or sick persons as  in-patient.
• Fully equipped Operation Theatre of its own wherever surgical operations are carried out
• Fully qualified nursing staff under its employment round the clock.
• Fully qualified doctor(s) should be physically in charge round the clock.
• Maintaining complete record as required on day to day basis and be able to provide necessary records of the insured patient to the Insurer or his representative as and when required.
• Using ICD and OPQS codes for Drugs, Diagnosis, Surgical procedures etc.
• Having sufficient experience in the specific identified field.

PREMIUM & STOP LOSS     

The premium shall be decided by inviting tender from the eligible insurance companies.

The premium amount for BPL category of persons with Autism, Cerebral Palsy, Mental Retardation and Multiple Disabilities will be shared by the State Govt. and Central Govt. / the National Trust. Other categories of persons may join the scheme on payment of suitable premium amount.

In case of total claims exceeding the total premium amount, the Insurance Company will cover the risk up to 120% of the total premium amount i.e. the insurance company can have a stop loss at 120% of total premium amount. Similarly in case of claims falling short of total premium amount, the Insurance Company shall pay back 90% of the savings, after deducting 20% as administrative cost.

Funding / Budget:     

IMPLEMENTATION

The entire scheme shall be implemented & monitored by the National Trust through a Third Party Nodal Agency (TPNA) with the active participation of the Local Level Committees (LLC). The Third Party Nodal Agency shall liaise with the Insurance Company, empanelled health service providers, LLCs, SNAP/SNAC of the National Trust, State Govt. and all the stakeholders concerned for awareness generation as well as for underwriting the risks and for the speedy settlement of claims.

BUDGET

In the first phase, it is expected to cover 1 lakh BPL beneficiaries for health insurance upto Rs. 1 lakh at a premium of Rs. 99/- per annum per beneficiary. The total cost of the Scheme will be as below

                                  HEALTH INSURANCE BENEFITS

List of Benefits (including pre-existing conditions)                                    Limits (Rs.)

 LIST OF DISTRICTS TO BE COVERED UNDER THE SCHEME IN FIRST PHASE

For more information contact :-

Mr. Anil Kumar

0172-2647760 ( Time 8:00 A.M to 2:00 P.M)

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