Medisep Phase 2 to come into effect from Feb. 1

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Phase II of the Medical Insurance Scheme for State Employees and Pensioners (Medisep) will come into effect from February 1, Finance Minister K.N. Balagopal has announced.

In what would come as a major relief for the beneficiaries, the monthly premium, which had earlier been fixed at ₹810 for Phase II and which had been a major grouse for all beneficiaries, has now been fixed at ₹687 (this is minus the 18% GST).

The total annual premium payable for a beneficiary and his/her dependents will be ₹8,244. The Oriental Insurance Company will implement Phase II also.

The revised scheme in Phase II offers an enhanced basic insurance coverage from ₹3 lakh to ₹5 lakh. All existing beneficiaries, including government employees, service and family pensioners, employees and pensioners of universities and local self-government institutions and their dependents will be covered under the revised scheme also.

Beneficiaries will be happy to note that the government has removed the provision that knee replacement and hip replacement surgeries may be performed only in government hospitals. Beneficiaries can opt for these surgeries in private hospitals also.

A provision has also been included to allow reimbursement under Medisep for treatments undertaken at Sree Chitra Tirunal Institute for Medical Sciences and Technology and JIPMER, if these institutions are not empanelled under the scheme.

Treatment packages based on the nationally approved Health Benefit Package 2022, with enhanced rates have been newly included in the scheme and this it is hoped, will encourage more hospitals to empanel under the scheme.

Cashless inpatient treatment will be available at all empanelled hospitals. A total of 2,516 medical and surgical packages have been included in the revised scheme. The room rent has been fixed at up to ₹5,000 per day. The Government pay-ward room rent has been capped at ₹2,000 per day. The revised scheme ensures simultaneous coverage for both surgical and medical packages.

For medical packages, separate amounts will be fixed for high-cost medicines and investigations, which will be provided along with the basic rate. For diseases requiring continuous treatment, such as dialysis and chemotherapy, a one-time registration facility will be provided on the insurance portal to ensure free treatment.

The additional coverage for ten critical organ transplant surgeries will continue in Phase II as well. For this purpose, the insurance company has earmarked ₹40 crore for two years. It has also been agreed that when the revised scheme enters its second year, a 5 % increase will be allowed in treatment package rates.

In emergencies like road accidents, heart attacks and strokes, beneficiaries may seek treatment at hospitals which are not empanelled under the scheme. The insurance company will reimburse the expenses incurred. Ten additional treatments have also been included under this reimbursement benefit.

A 24×7 call centre facility will be available throughout the year. A three-tier grievance redressal mechanism has been put in place. Representatives of the Kerala Private Hospital Association and the Indian Medical Association will also be included in the grievance redressal system. Detailed information on packages and the complete list of hospital networks will be made available on the website.