PROJECT REPORT FOR SERVICING THE SCHEME

Transcription

1 SAMAJWADI KISAN & SARVHIT BIMA YOJNA A PROJECT BY GOVT. OF UTTAR PRADESH DIRECTORATE OF INSTITUTIONAL FINANCE, INSURANCE & EXTERNALLY AIDED PROJECT PROJECT REPORT FOR SERVICING THE SCHEME Raksha TPA An ISO Co

2 Contents 1. Objective of the Scheme 2. Beneficiary 3. Eligibility 4. Family Cover 5. Family Composition 6. Documents for Eligibility 7. Salient Features 8. Nomination 9. Insurance Cover 10. Claim Settlement Guidelines

3 1. Objective of the Scheme Samajwadi Kisan & Sarvhit Bima Yojna has been prepared with the aim of providing social security to the economically weaker sections of the society. The Scheme has below two features: 1. Personal Accidental insurance benefit up to a maximum of INR 5 Lakhs to the Head of the Family/ Bread Earner (Policy holder) of the covered family. 2. Post accidental medical treatment benefit to Head of the Family/ Bread Earner/ family members as follows: a) Primary medical treatment benefit (on need basis) up to a maximum of INR 25,000/- (INR Twenty Five Thousand) b) Medical treatment benefit up to a maximum of INR 2,50,000/- (Two Lakh Fifty Thousand) (inclusive of primary medical treatment benefits of INR 25,000, wherever applicable) c) On need basis, artificial limb replacement up to a maximum of INR 1,00,000 (One Lakh) Note: The aforementioned amount of INR 2.5 Lakhs for Maximum Accidental Medical treatment cover is inclusive of primary medical treatment benefits of INR 25,000, wherever applicable and exclusive of maximum of INR 1 Lakh for artificial limb, as the case may be. Insurance Company (ies) shall provide insurance cover as per the provisions of the Scheme. 75 districts of Uttar Pradesh/ 3 Crore beneficiaries have been divided into 10 Clusters Various insurance companies shall be allotted these Clusters by the Tender Committee. The Scope of Work of Insurance Company (ies) includes

4 2. Beneficiary The Scheme is applicable for the residents of the State of Uttar Pradesh as per eligibility 3. Eligibility All farmers of Uttar Pradesh (without any income limit), Landless farmers, those related to Agriculture related activities, (Fishery, milk producing, pig farming, goat farming, Bee keeping etc.) nomadic/ roaming families, businessmen (who are not covered under any other Governmental Scheme), forest workers, retailers, Rickshaw pullers, porters and those engaged in other activities who are residents of rural or urban areas whose annual income is less than INR 75,000/- and age limit in between 18 to 70 years shall be eligible for this Scheme. During the currency of the Scheme, if a person attains the age of 18 years or a person crosses the age of 70 years, that person shall also be covered. Employees of Central Government, State Government, Public Sector Units (PSU) of Central Government or State Government, Financially aided Organizations, Private Sector, Autonomous Bodies/ Public Undertakings/ Corporations/ Boards and Authorities who are covered under any insurance scheme shall not be covered under the Samajwadi Kisan & Sarvhit Bima Yojna Scheme. Any beneficiary who is covered under any accidental insurance scheme operated by any of the department of State Government shall not be eligible under the Samajwadi Kisan & Sarvhit Bima Yojna Scheme. The Connotations/Meaning used under this RFP for the eligibility purpose are as follows: Farmer: Account holders/ co-account holders as per the revenue records or khasra/ Khatauni with minimum age of 18 years and maximum age of 70 years. Landless farmer and person engaged in allied activities related to agricultural activities means: Those landless families of rural areas who are directly or indirectly associated with agriculture related activities. Others: Head of the Family/ Bread earner other than farmers having age between 18 years to 70 years and whose family income is less than INR 75,000 per annum shall be eligible under the Scheme. 4. Family Cover 1. Personal Accidental insurance benefit up to a maximum of INR 5 Lakhs to the Head of the Family/ Bread Earner (Policy holder) of the covered family

5 2. Post accidental medical treatment benefit shall be provided to Head of the Family/ Bread Earner/ family members as follows: a) Primary medical treatment benefit (on need basis) up to a maximum of INR 25,000/- (INR Twenty Five Thousand) b) Medical treatment benefit up to a maximum of INR 2,50,000/- (Two Lakh Fifty Thousand) (inclusive of primary medical treatment benefits of INR 25,000, wherever applicable) c) On need basis, artificial limb replacement up to a maximum of INR 1,00,000 (One Lakh) Note: The aforementioned amount of INR 2.5 Lakhs for Maximum Accidental Medical treatment cover is inclusive of primary medical treatment benefits of INR 25,000, wherever applicable and exclusive of maximum of INR 1 Lakh for artificial limb, as the case may be. 5. Family Composition Below individuals shall be considered as family members under the Samajwadi Kisan & Sarvhit Bima Yojna Scheme: a) Head of the Family/ Bread earner (Male/ Female) b) Husband/ Wife of Head of the Family/ Bread earner c) Unmarried daughter d) Dependent Son e) Dependent parents of unmarried son (where unmarried person is Head of the Family/ Bread Earner) f) Dependent parent of Head of the Family/ Bread Earner (only in cases where husband is the Head of the Family) Note: Parents of Wife shall not be covered. 6.Documents for Eligibility The Eligibility of the beneficiary shall be determined on the basis of the following documents or on the basis of Samajwadi Kisan & Sarvhit Bima Care Card:- 1. Land-revenue records (Khasra/ Khatauni, in case of Farmers including co-owner), (Farmers are not required to submit Income certificate) 2. Income certificate issued by Tehsildar and should not be older than 1 year from the Scheme start date and should be as per relevant State Government orders. Income Certificate shall not be required in below cases a. B.P.L card holder b. Beneficiaries of Samajwadi Pension Scheme

6 c. Farmer (Owner/ Co-owner) 3. Family details certificate (any one of the below) a. Copy of family register b. Ration card c. Certificate issued by Sub-divisional magistrate (SDM)/ Class-1 magistrate 4. Age certificate (any one of the below) a. High School certificate b. Bank account passbook c. Voter ID card/ copy of voter list d. Age certificate issued by Nagar Nigam/ Block Development office e. Passport f. Driving License g. Aadhar Card h. Ration Card 5. Address Proof (As applicable) a. Khasra/ Khatauni b. Income Certificate 7. Salient Features of the Scheme 1. Cashless facility Head of the Family shall be provided Samajwadi Kisan & Sarvhit Bima Care Card (as provided in Annexure 15). The beneficiary shall be entitled to get cashless medical treatment at Empaneled Hospitals of up to INR 2.5 Lakhs (inclusive of primary medical treatment benefits of INR 25,000, wherever applicable and exclusive of maximum of INR 1 Lakh for artificial limb, as the case may be) 2. Personal Accidental insurance Following are the classification: a. Sum Assurance of 5 lakhs: Benefit of sum assured of INR 5 Lakh shall be given in case of accidental death or permanent disability or permanent and incurable mental disorder or Permanent damage to two (2) body parts/permanent blindness (both eyes) or Permanent disability to one body part and Permanent blindness in one eye) or Permanent dumbness or Complete damage to lower jaw or Complete loss of chewing capacity b. 75% of sum assured (5 Lakh): In case of Complete deafness (both ears) c. 50% of sum assured (5 Lakh): In case of permanent damage to one body part or Permanent blindness to one eye.

7 Note: The aforementioned amount of INR 2.5 Lakhs for Maximum Accidental Medical treatment cover is inclusive of primary medical treatment benefits of INR 25,000, wherever applicable and exclusive of maximum of INR 1 Lakh for artificial limb, as the case may be. 3. Post-accidental benefits to Head of the Family/ Bread Earner and his/her family members: a. Benefit up to INR 2.5 Lakhs to Head of the Family/ Bread Earner and his/ her family member for post-accidental medical treatment b. Artificial limb replacement on need basis to Head of the Family/ Bread Earner and his/her family member(s) up to a maximum of INR 1 lakh It would be mandatory for the beneficiary to send the physical copies of claim form with all the details and Documents to the Insurance Company for claim settlement. Also, the claim shall be required to be submitted electronically on Insurance Company website/data Center with scanned copies of all relevant documents (as per the prescribed claim form). 4. The beneficiary shall also remain covered under the Scheme in case of accidental death/ physical disability outside Uttar Pradesh. 8. Nomination facility As per the prescribed application form for Samajwadi Kisan & Sarvhit Bima card, a nominee is required to be nominated so that the claim benefits can be provided to the nominee under the personal accidental insurance in case of death of the Head of the Family/ Bread Earner. However, in case there is no nomination, the claim amount shall be paid to legal heir(s). 9. Insurance Cover The scheme shall provide benefits to the Family / Bread Earner in case of Personal Accident and to Head of the Family / Bread Earner and his / her family members in case of Post Accidental Medical Facility and Artificial Limb (on need basis). The Scheme has two major benefits as follows : PERSONAL ACCIDENTAL INSURANCE Only head of the family / Bread Earner is covered under Personal Accidental Insurance. Accident includes Train / Road / Airplane Accident, Any collision, injury due to falling, Gas Leakage, death due to snake / scorpion / Mongoose / Lizard bite, death or disability due to cylinder blast, explosion, dog bite, death or injury due to wild animal bite or attach, burning, drowning swept away in flood, loss of Hand / Leg in any incident, poison etc.

8 The policy has sub-components as follows : Accidental Death : The Insurance company shall pay the nominee / legal heir a sum of INR 5 Lakh (100% of sum assured) in case of accidental Death of the Head of the Family / Bread Earner. Disability due to Accident : The Insurance Company shall pay the Head of the Family / Bread Earner on his / her accident as per the below matrix : S.No. Personal Accident Cover Compensation as % of Sum Assured * 1 Permanent Complete Disability Permanent & Incurable mental disorder Permanent damage to two(2) body parts Permanent blindness (both eyes) Permanent disability in a body part and permanent blindness in one eye) 6 Permanent dumbness Complete damage to lower jaw Complete loss of chewing capacity Complete deafness (both ears) Permanent damage to one body part Permanent blindness (one eye) POST ACCIDENTAL MEDICAL TREATMENT Under this classification of the scheme, the Head of the Family / Bread Earner and his / her family members are covered during the currency of the Insurance term for Post Accidental Medical Treatment and Artificial Limb replacement (on need basis). The Scheme involves insurance cover to the Head of the Family / Bread Earner / family members as per the below matrix. S.No. Coverage Sum Insured (INR) 1 2 Primary Treatment after Accitdent at Primary Health Centre Medical Treatment at Hospitals / Trauma Centre after Primary Medical Treatment 0.25 Lakh 2.25 Lakh 3 Artificial Limb as required 1.00 Lakh

9 9. Claim Settlement Guidelines The Insurance Company (ies) shall process the claim application submitted by the beneficiaries. The claims settlement shall also be done in case the Samajwadi Kisan and Sarvhit Bima card for the beneficiary has not been issued. The Process of Claims in case of Personal Accidental Insurance Process of claims in case of Personal Accidental Insurance prior to issuance of card: a) In case of accidental death or physical disability (as the case may be), Head of the Family / Bread Earner / Nominee / Legal Heir (as applicable) shall submit the claim documents through Common Service Centre / Outlets to Insurance Company. b) It would be mandatory for the beneficiary to send the physical copies of the claim form with all the details and documents to the Insurance company for claim settlement. Also, the claim shall be required to be submitted electronically on Insurance Company website / data centre with scanned copies of all the relevant documents (as per the prescribed claim form). c) The Claim are to be made within three months (but not later than one month of end of the Insurance period). In case the claims are not made within the above time frame, then District Magistrate shall have the right to excuse the delay for claim submission for additional one month. d) Head of the Family / Bread Winner / Nominee / Legal Heir (as applicable) shall submit claim form (available on Insurance Company website) with scanned copies of below documents (as applicable) : 1. Khasra / Khatauni Certificate (including co-owner in case of farmer). 2. Age Certificate 3. F.I.R. / G.D. copy / Certificate issued by S.D.M. (if applicable) 4. Death Certificate 5. In case of disability, certificate issued by Chief Medical Officer (C.M.D.) / Committee designated for this purpose. 6. Legal Heir certificate (only in controversial cases). 7. Income Certificate (in case of non-farmer) The Claim forms shall also be available on website of Mukhyamantri Banking and Bima Helpline 1520.

10 e) Post-mortem report shall not be required in such cases where dead body could not be found due to drowning or being swept away in flood. In such cases Certificate issued by SDM shall be deemed sufficient. f) In case of death of the Head of the Family / Bread Earner due to any wild animal bite, postmortem report / certificate issued by doctor of local primary health centre shall be deemed sufficient and the claim shall not be rejected on ground that Viscera report not being submitted. g) In case of death of Head of the Family / Bread Earner in an accident, Certificate issued by doctor of local Primary Health Centre attestation or attestation by District Chief Medical Officer (C.M.O.) will have to be submitted. h) In case of physical disability to Head of the Family / Bread Earner in an accident certificate issued by Chief Medical Officer (C.M.O.) / Committee designated for this purpose will have to be submitted. i) Head of the Family / Bread Winner / Nominee / Legal Heir (as applicable) while filling the claim shall also furnish his /her bank details including : 1. Bank Name 2. Account Number 3. I.F.S.C. Code 4. A copy of Bank Account Passbook 5. The Insurance Company shall make the claim payments to the Bank Accounts Electronically. j) If electronic payments cannot be made due to unavoidable reasons, claim payment is to be made through cheque which is to be provided to Head of the Family / Bread Winner / Nominee / Legal Heir (as applicable) within 15 days. k) In case of any discrepancies are found in the claim or if any controversy arises, the claim shall be investigated and the report shall be presented to the concerned committee (headed by District Magistrate).

11 The Committee shall include : 1. District Magistrate 2. Chief Development Officer 3. Chief Medical Officer 4. Sub-Divisional Magistrate 5. District Level Officer, National Saving Representatives of the Insurance Company shall also be invited. The committee shall take decision on all the discrepant / controversial claims. The Insurance Company shall be bound to adhere to the decision taken by the Committee and make the payment within one month. In such cases, Insurance Company shall submit a cheque of amount payable to the District Magistrate who will hand over the cheque to the concerned Head of the Family, Bread Winner / Nominee / Legal Heir (as applicable) within 15 days. Claim Process for Personal Accidental Insurance after Care Card is issued: a) The IT Company issuing Card shall provide details of the Care Cards issued by it to the monitoring cell / data centre. The card shall be issued to the Head of the Family / Bread Earner of each beneficiary family and care card no. shall be assigned to it. Based on the care Card No. beneficiary shall be identified by the data centre / insurance company / hospitals. b) Head of the Family / Bread Winner / Nominee / Legal Heir (as applicable) shall submit claim for physical disability or death through common service centres by filling the claim form available on website of insurance company / data centre. c) The Claim are to be made within three months (but not later than one month of end of the Insurance period). District Magistrate shall have the right to excuse the delay for claim submission for additional one month. Head of the Family / Bread Winner / Nominee / Legal Heir (as applicable) shall submit claim form (available on Insurance Company website) with scanned copies of below documents (as applicable) : 1. Khasra / Khatauni Certificate (including co-owner in case of farmer. 2. Age Certificate

12 3. F.I.R. / G.D. copy / Certificate issued by S.D.M. (if applicable) 4. Death Certificate 5. In case of disability, certificate issued by Chief Medical Officer (C.M.O.) / Committee designated for this purpose. 6. Legal Heir certificate (only in controversial cases). 7. Income Certificate (in case of non-farmer) The Claim forms shall also be available on website of Mukhyamantri Banking and Bima Helpline e) Post-mortem report shall not be required in such cases where dead body could not be found due to drowning or being swept away in flood. In such cases Certificate issued by SDM shall be deemed sufficient. f) In case of death of the Head of the Family / Bread Earner due to any wild animal bite, postmortem report / certificate issued by doctor of local primary health centre shall be deemed sufficient and the claim shall not be rejected on ground that Viscera report not being submitted. g) In case of death of Head of the Family / Bread Earner in an accident, Certificate issued by doctor of local Primary Health Centre and in case of certificate issued by Private Doctor then Sr. Medical Officer of Local Primary Health Centre attestation or attestation by District Chief Medical Officer (C.M.O.) will have to be submitted. h) In case of physical disability to Head of the Family / Bread Earner in an accident certificate issued by Chief Medical Officer (C.M.O.) / Committee designated for this purpose will have to be submitted. i) Head of the Family / Bread Winner / Nominee / Legal Heir (as applicable) while filling the claim shall also furnish his /her bank details including : 1. Bank Name 2. Account Number 3. I.F.S.C. Code 4. A copy of Bank Account Passbook 5. The Insurance Company shall make the claim payments to the Bank Accounts Electronically.

13 j) If electronic payments cannot be made due to unavoidable reasons, claim payment is to be made through cheque which is to be provided to Head of the Family / Bread Winner / Nominee / Legal Heir (as applicable) within 15 days. k) In case of any discrepancies are found in the claim or if any controversy arises, the claim shall be investigated and the report shall be presented to the concerned committee (headed by District Magistrate). The Committee shall include : 1. District Magistrate 2. Chief Development Officer 3. Chief Medical Officer 4. Sub-Divisional Magistrate 5. District Level Officer, National Saving Representatives of the Insurance Company shall also be invited. The committee shall take decision on all the discrepant / controversial claims. The Insurance Company shall be bound to adhere to the decision taken by the Committee and make the payment within one month. In such cases, Insurance Company shall submit a cheque of amount payable to the District Magistrate who will hand over the cheque to the concerned Head of the Family, Bread Winner / Nominee / Legal Heir (as applicable) within 15 days. Claim Process in case of Post Accidental Treatment and Artificial Limb (on need basis): Post Accidental Treatment and Artificial Limb (on need basis):prior to issuance of card: Following documents shall have to be submitted to the Insurance Company by the Claimant : 1. Khasra / Khatauni, (in case of Farmers) 2. Income Certificate (in case of non-farmer) 3. Family details certificate (as mentioned in 2.2.7) 4. Age Certificate (as mentioned in 2.2.7)

14 b) Under this components of the scheme, the beneficiary can claim upto INR 25,000 for post accidental medical treatment at hospitals with ten beds, upto INR 2.5 Lakhs (Inclusive of primary medical treatment benefits of INR 25,000, wherever applicable and exclusive of INR 1,00,000 for artificial limb (on need basis) through Bima Care Card) c) Following Medical Facilities are covered under the scheme : 1. Patient Registration Fees 2. Treatment related medical test 3. Breakfast / Food / Water for beneficiary during medical admission. 4. Bed Charges 5. Medical Treatment / Operations / Limb Replacement. 6. Ambulance facility / rent of ambulance (if paid) 7. Medicine expenses during medical treatment at hospital. 8. Medicine expenses till 15 days from discharges from the hospital. 9. Providing artificial limb (if required) d) C.G.H.S. Rates shall be applicable for Medical Treatment. e) The beneficiary is free to avail medical treatment from any of the designated hospitals. f) In case of an injured beneficiary is referred to another district (due to non-availability of medical treatment / artificial limb in-home district). The Insurance company of home district shall pay the medical expenses incurred. The beneficiary shall the inform the home Insurance Company before medical treatment / Artificial Limb. The hospital providing med. Treatment / artificial limb shall submit the claim to beneficiary home Insurance Company. g) In case of emergency, Insurance Holder can get primary medical treatment at any hospital, but the treatment rates shall remain the same as in case of Central Government Health Scheme and payment shall be made as per prescribed rules under Samajwadi Kisan & Sarvhit Bima Yojna.

15 Post Accidental Treatment and Artificial Limb (on need basis) In case Care Card is issued: a) The beneficiary can claim upto INR 25,000 for post accidental medical treatment at hospitals with ten beds, upto INR 2.5 Lakhs (Inclusive of primary medical treatment benefits of INR 25,000, wherever applicable and exclusive of INR 1,00,000 for artificial limb (on need basis) through Bima Care Card) (Note : The aforesaid amount of INR 2.5 Lakhs for Maximum Accidental Medical Treatment cover is inclusive of Primary Medical Treatment benefits of INR 25,000, wherever applicable and exclusive of maximum of INR 1Lakh for artificial Limb, as the case may be) b) Following Medical Facilities are covered under the scheme : 1. Patient Registration Fees 2. Treatment related medical test 3. Breakfast / Food / Water for beneficiary during medical admission. 4. Bed Charges 5. Medical Treatment / Operations / Limb Replacement. 6. Ambulance facility / rent of ambulance (if paid) 7. Medicine expenses during medical treatment at hospital. 8. Medicine expenses til 15 days from discharges from the hospital. 9. Providing artificial limb (if required) c) C.G.H.S. Rates shall be applicable for Medical Treatment. d) The beneficiary is free to avail medical treatment from any of the designated hospitals. e) In case of an injured beneficiary is referred to another district (due to non-availability of medical treatment / artificial limb in-home district). The Insurance company of home district shall pay the medical expenses incurred. The beneficiary shall the inform the home Insurance Company before medical treatment / Artificial Limb. The hospital providing med. Treatment / artificial limb shall submit the claim to beneficiary home Insurance Company. h) f) In case of emergency, Insurance holder can get primary medical treatment at any hospital, but the treatment rates shall remain in the same as in case of Central Govt. Health Scheme and

16 payment shall be made as per prescribed rules under the Samajwadi Kisan & Sarvhit Bima Yojna.