SAMAJWADI KISAN & SARVHIT BIMA YOJNA

Transcription

1 Your link to good health PARAMOUNT HEALTH SERVICES & INSURANCE TPA PVT. LTD. Registered & Head Office: Plot No. A-442, Road No. 28 M.I.D.C. Industrial Area, Wagale Estate,Ramnagar,Vitthal Rukmani Mandir,Thane (W), Maharashtra Phone:+91(22) FAX:(022) /55 Web: AN OVERVIEW SAMAJWADI KISAN & SARVHIT BIMA YOJNA UTTAR PRADESH BO : 72, Faizabad Road (1 st & 2 nd Floor), Near Mahanagar Railway Crossing, Mahanagar, Lucknow Phones: +91(522) , 277, 377 & 477 Helpdesk Website- Regional Office:D-39,Okhla Industrial Area,Phase-I,NearDD Motors,N.Delhi Phone :+91(11) FAX : Website :

2 SAMAJWADI KISAN & SARVHIT BIMA YOJNA 1. Background Directives issued by Government of Uttar Pradesh to All District Magistrates for implementation of Scheme. References: 1. Chief Secretory, Uttar Pradesh - Letter no. 681/Ka.Ni. -6/20B(4)/2015 dated 15/09/ Chief Secretory, Uttar Pradesh - Letter no /Institution of Finance/ K-24/ dated 20/06/16 3. Director General, Institutional Finance, Insurance & Externally Aided Project,UP- Letter no /K-24/ dated 25/07/ Objective of the Scheme Financial support to the families of Uttar Pradesh covered under the Scheme through Insurance a. Accidental Death or Disability of the Head of the Family/Bread Earner b. Post-accidental Medical Treatment of Head of the Family/Bread Earner & his/her family members. 3. Beneficiaries All Farmers of U.P. as per Revenue Records or Khasra//Khatauni without any income limit Landless farmers & persons engaged in allied Agriculture activity Others - Roaming families, Forest workers, Riksha pullers, Porters, Businessmen / Retailers & others not covered by any other Govt. scheme & having annual family income less then Rs.75000/-. 4. Age Limit Minimum age 18 years & Maximum age 70 years. 5. Documents of Eligibility 1. Land Revenue records (khasra / khatuni) in case of Farmer 2. Income proof certificate issued by Tehisildar (not older than one year) except in case of (a) BPL Card holders (b)beneficiaries of Samajwadi Pension Scheme (c) Farmers 3. Family details certificate- any one of below mentioned- (a) Copy of family register (b) Ration card (c) Certificate issued by SDM / Class 1 Magistrate

3 4. Age Proof certificate- any one of below mentioned- (a) High school certificate (b) Bank account passbook (c) Voter ID/ copy of Voter List (d) Certificate issued by Nagar nigam / Block Development Officer (e) Ration Card (f) Driving Licence/ Adhar Card/ Passport 5. Address Proof Khasra/Khatauni /Income Certificate/Adhar Card 6. Salient Feature of the scheme 1. Personal Accident Insurance Benefit to Head/Bread Earner of the Family (Rs. 5.0 Lakhs = 100% Sum Assured) a. Death due to accident or Permanent Total Disablement or permanent mental disorder or Permanent damage of % body parts or loss of both eyes, Permanent dumbness or complete damage to lower jaw or chewing incapacity b. Complete Deafness (both ears) - 75 % c. Permanent damage to one body part or loss of 1 eye - 50 % 2. Post accident Medical Treatment benefits to Head/Bread Earner of the family & his/ her family members a. Emergency Medical Treatment Treatment sought in nearest Primary Health Centre or Registered Hospital with minimum 10 beds facility Reimbursement of treatment Expenses upto Rs.25000/- b. Cashless Facility Cashless Treatment upto Cashless Medical treatment at Rs. 2,50,000/- inclusive of Empaneled Hospital/Trauma Centre Rs.25000/-Medical Expenses having more than 30 Beds incurred in Treatment c. Artificial Limb Replacement On need basis to Head of Family/ Maximum Rs. 1,00,000/- Bread Earner & family members 7. Term of Insurance cover One year from 14the Sep'2016 ; time 10:00 AM which shall be extended on annual basis for 3 years + 3 years.

4 8. Identification of Beneficiaries Head/Bread Earner of each beneficiary family would be issued a Samajwadi Kisan & Sarvhit Bima Care Card by an IT Company under supervision of Government which shall carry Unique Identification Number of the Head of Family / Bread Earner/ family members/nominee/legal heirs. 9. Bima Care Card Bima Care Card shall carry a. Name of the Scheme Samajvadi Kisan & sarvhit Bima Yojana b. LOGO OF UP Government as watermark /hallmark in background c. Photograph of Head of family d. Finger Prints e. Necessary data in respect of dependents of Family & f. Category of Beneficiary such as Farmer, Landless workers & others 10. Family composition a. Head of the family / Bread earner (Male/Female) b Spouse (Husband/wife) of Head of family/ Bread earner c. Unmarried daughter d. Dependent Son. e. Dependent parents of unmarried son who is Head of family / bread earner f. Dependent parent of Head of the family / bread Earner (only in cases where Husband is Head of the family) 11. Eligibility Criteria of Hospitals/Service Providers a. Emergency Medical Treatment Primary Health Centers & Registered Hospitals with minimum 10 beds b. Cashless Facility in Major Hospitals /Trauma Centre a. Hospitals having minimum 30 Beds facility b. Availability of Oxygen gas supply c. Availability of 24hrs Power Supply (Electricity/ Generator) d. ICU unit 12. Empanelment of Network Hospitals Documents to be executed/furnished for empanelment- 1) MOU between Hospital & Paramount Healthcare Management Pvt Ltd. 2) MOU between Hospital & Paramount Health Services & Insurance TPA Pvt Ltd. 3) Addendum MOU between Hospital and PHS in term of Samajwadi Kisan & Sarvhit Bima Yojna 4) Fully filled Hospital Detail Form Duly signed & sealed by Hospital 5) Self attested copy of valid and effective Registration certificate issued

5 by Chief Medical Officer of the District 6) PAN card of Hospital / Proprietor 7) NEFT details of Bank Account for Electronic Payment 8) Cancelled cheque leaf of Bank account 9) Photographs of Hospital 13. Claim Process for Personal Accident Claims Accidental Death or Disability claim to be submitted by Claimants through Common Service Centers by filling claim form available on website of the Insurance Company followed by submission of following documents- 1. Prescribed Claim Form of Insurance Company 2. Scanned copy of Bima Care Card/Khasra/Khatauni 3. Age Proof Certificate 4. FIR/GD Copy/Certificate issued by SDM 5. Death Certificate/disability certificate issued by CMO /committee 6. Legal Heir certificate in case of controversy 7. Income certificate in case of Non-Farmer 14. Claim Process for Post-accidental Medical Treatment a. Emergency Medical Treatment In case, Primary Treatment sought from nearest Primary Health Center or Registered Hospital with 10 beds facility, payment of such treatment expenses shall be made by Injured Person/Family & will submit claim for reimbursement from Insurance Company/TPA with following documents- 1. Prescribed Claim Form Of Insurance Company 2. Scanned copy of Bima Care card or any other proof of beneficiary i. Prescribed Claim Form Of Insurance Company ii. Scanned copy of Bima Care card or any other proof of beneficiary iii. Case History card iv. Line of treatment/prescription v. Details of Procedure/surgery carried out vi. Diagnostic test reports & Bills related to treatment vii. Medicine Bills of treatment on CGHS Rates viii. Discharge Certificate with prescription of Medicines ix. Beneficiary Bank name, Account No. & IFSC code/canceled cheque leaf for payment of claim in Bank account of Beneficiary b. Cashless Facility in Major Hospitals /Trauma Centre Immediately upon injured person being brought to Network Hospital/Trauma Centre, Hospital shall - (a) Attend the injured person for required Medical treatment pending the formalities in compliance to Supreme Court Directives (b) Convey to TPA with proof of Beneficiary & estimate of expenses

6 seeking Pre - Authorization to extend Cashless Facility (c) Medical facility covered for injured in-patients 1. Patient Registration Fee 2. Diagnostic Medical test related to treatment 3. Breakfast/ food / water for beneficiary during Hospitalization. 4. Bed charges 5. Medical treatment /surgery(operation) / Limb replacement 6. Ambulance facility / rent of ambulance (if paid) 7. Medicine expenses during Hospitalization. 8. Medicine expenses 15 days from date of discharge from Hospital 9. Providing Artificial Limb, if required (d) Central Government Health Scheme Rates shall be applicable (e) Beneficiary is free to avail Medical treatment from any of designated Hospital (f) In case, an injured beneficiary is referred to another District due to non- availability of Medical treatment /Artificial limb in Home districti. Such Medical expenses incurred shall be paid by Home District Company. ii. The Beneficiary shall inform Home Insurance Company before seeking Medical treatment in other than Home District. iii. The Hospital providing Medical treatment / Artificial limb shall submit the claim to beneficiary s Home insurance Company. 15. Procedure of payment to Network Hospitals Hospital, having received Pre - Authorization from TPA, shall submit the Claim bill to TPA on CGHS Rates within 1 month after discharge of patient with following original documents/scanned copies & Insurance Company shall make Electronic payment to Hospital within 1 month of receipt of claim bill - 1. Scanned copy of Bima Care card or other proof of beneficiary 2. Case History card 3. Line of treatment/prescription 4. Details of Procedure/surgery carried out 5. Diagnostic test reports & Bills related to treatment 6. Medical Bills of treatment on CGHS Rates 7. Discharge Certificate with prescription of Medicines advised/provided to patient for next 15 days, if any 8. NEFT details of Hospital (Bank name, Account No. & IFSC code) 16. Grievance Redressal Mechanism Any Grievance related to Samajwadi Kisan & Sarvhit Bima Yojna can be filed on 'Mukhyamantri Banking & Bima Helpline No. 1520