Thiruvananthapuram: The Kerala State Cabinet has approved the second phase of the MEDISEP (Medical Insurance Scheme for State Employees and Pensioners). In this phase, the basic insurance coverage will be increased from ₹3 lakh to ₹5 lakh. Over 2,100 treatment procedures across 41 speciality categories will now be included in the basic treatment package.

Two procedures that were earlier included under the catastrophic package in Phase I — Cardiac Resynchronisation Therapy (CRT with Defibrillator – ₹6 lakh) and ICD Dual Chamber – ₹5 lakh — which had been removed, will now be re-included under additional packages. Knee replacement and hip replacement surgeries will now be part of the basic benefit package.

The revised scheme will also offer 10 packages for critical/organ transplant-related treatments. To support this, the insurance company must set aside a corpus fund of ₹40 crore for two years. Up to 1% of the base insurance coverage (ie, ₹5,000/day) will be available as room rent and for pay wards in government hospitals, room rent reimbursement will be up to ₹2,000/day.

The Cabinet has also given in-principle approval to include employees and pensioners from public sector undertakings, boards, corporations, autonomous institutions and cooperatives — who are not covered under ESI benefits — in the second phase of the MEDISEP scheme.

The policy period will now be reduced from three years to two years. There will be a revision in premium rates and package costs in the second year. Only technically qualified public sector insurance companies that participated in the first phase will be eligible to participate in the tender process for Phase II.

Changes in Phase II

  • In addition to the existing three emergency procedures (heart attack, stroke, and road accidents) eligible for reimbursement at non-empanelled hospitals, 10 more emergency treatments will be added.
  • One-time registration on the insurance portal will be allowed for recurring day care treatments like dialysis and chemotherapy
  • Medical and surgical packages can now be combined and approved simultaneously.
  • Pre-hospitalisation and post-hospitalisation expenses will be covered for 3 and 5 days, respectively.
  • A three-tier grievance redressal mechanism will be established — at district, state and appellate authority levels.
  • QR code integration will be added to the MEDISEP cards to enable faster access to beneficiary information.
  • The insurance company must draft a Standard Operating Procedure (SOP) to take strict action against hospitals that breach contract terms. Oversight by the Clinical Establishment Authority will be utilised to curb exploitative practices such as overbilling in private hospitals.

Performance in Phase I (So far)

  • 1,052,121 claims processed, totalling ₹1,911.22 crore
  • 2,256 organ transplant treatment claims – ₹67.56 crore
  • 1,647 reimbursement claims – ₹9.61 crore
  • Total amount released to the insurance company (including 18% GST) – ₹1,950 crore
  • Actual premium (excluding GST) – ₹1,599.09 crore