Rajiv Gandhi Jeevandayee Arogya Yojana (RGJAY) would be implemented throughout thestate of Maharashtra in phased manner for a period of 3 years. The insurance policy/coverageunder the RGJAY for the eligible beneficiary families in 8 districts of Phase I will be in forcefor an initial period of one year from the date of commencement of the policy (“Phase I”).The extension of period of the policy will be subject to review and renewal of the policy on ayearly basis which will be based on the quality of experience and performance as well asannual IRDA renewal. Notwithstanding, anything to the contrary mentioned elsewhere in thisRFP the memorandum of understanding will be co – terminus with the insurancepolicy/coverage which is for a term of 1 year from (From 00.00 hrs. of 02.10.2011 toMidnight of 01.10.2012 for Phase-I). Based on the quality of experience and performance ofthe RGJAY the State Government may at its sole discretion and without any obligation extendthe RGJAY to cover the whole state.1. NAME OF THE SCHEME:Name of the scheme is Rajiv Gandhi Jeevandayee Arogya Yojana (RGJAY).2. OBJECTIVE :To improve access of Below Poverty Line (BPL) and Above Poverty Line (APL) families(excluding White Card Holders as defined by Civil Supplies Department) to quality medicalcare for identified specialty services requiring hospitalization for surgeries and therapies orconsultations through an identified network of health care providers.2.a. BENEFIT:The scheme would provide 972 surgeries/therapies/procedures along with121follow uppackages in following 30 identified specialized categories:GENERAL SURGERY1ENT SURGERY2
OPHTHALMOLOGY SURGERY3GYNAECOLOGY AND OBSTETRICS SURGERY4ORTHOPEDIC SURGERY AND PROCEDURES5SURGICAL GASTRO ENTEROLOGY6CARDIAC AND CARDIOTHORACIC SURGERY7PEDIATRIC SURGERY8GENITOURINARY SYSTEM910 NEUROSURGERY11 SURGICAL ONCOLOGY12 MEDICAL ONCOLOGY13 RADIATION ONCOLOGY14 PLASTIC SURGERY15 BURNS16 POLY TRAUMA17 PROSTHESES18 CRITICAL CARE19 GENERAL MEDICINE20 INFECTIOUS DISEASES21 PEDIATRICS MEDICAL MANAGEMENT22 CARDIOLOGY
23 NEPHROLOGY24 NEUROLOGY25 PULMONOLOGY26 DERMATOLOGYSi gnature & stamp of Insurance Agency27 RHEUMATOLOGY28 ENDOCRINOLOGY29 GASTROENTEROLOGY30 INTERVENTIONAL RADIOLOGYDetailed list of surgeries and therapies falling under above specified categories and theirpackage rates are given at Appendix 1 a and that of follow up package are given at Appendix1 b of Part-IV of the document.3. BENEFICIARY FAMILIES:Families holding yellow ration card, Antyodaya Anna Yojana card (AAY), Annapurna cardand orange ration card from eight districts viz. Gadchiroli, Amravati, Nanded, Solapur, Dhule,Raigad, Mumbai city and Suburban Mumbai. The families with white ration card holdingwould not be covered under the scheme. The beneficiary families would be identified throughthe “Rajiv Gandhi Jeevandayee Health Card” issued by the Government of Maharashtra orbased on the Yellow and Orange ration card issued by Civil Supplies Department. The totalnumber of beneficiary families in the state would be around 2,04,30,527; out of whichapproximately 49 Lakh families in the 8 districts are to be covered under the scheme in firstphase as on the date of publishing of the Request for Proposal (RFP) document. District wiseprofile of the beneficiary families is given below:DistrictsPopulation
*Approximate number ofPhase-IBeneficiary Families1Gadchiroli9702941828892Amravati26071605594733Nanded28762595439614Solapur3849543830011Dhule17079473976745Raigad22079295662316
Mumbai City333803148207378Mumbai Suburban86404191340828261975824903140Total* Based on data furnished by Civil Supplies department as on 31.05.2010.The total number of beneficiary families for each District is an indicative estimate and mayvary. The number of the final beneficiary families for each district will be given within onemonth of signing MOU. The total premium payable would be based on this final figure ofeligible beneficiary families.4. HEALTH CARDSAll eligible families in these districts shall be provided with Rajiv Gandhi JeevandayeeArogya Yojana Health Cards in due course of time. These Health Cards will be used foridentification of Beneficiary families in the family under the Scheme. Family Health Cardswill be prepared by using data from valid yellow or orange ration cards coupled with Aadhaarnumbers issued by UID authorities. As an interim measure till the issuance of health cards, thevalid Orange/Yellow Ration Card with Aadhaar number or in case Aadhaar number notavailable, any Photo ID card of beneficiary issued by Govt. agencies (Driving license,Election ID,) to correlate the patient name and photograph would be accepted in lieu of healthcard.5. FAMILY:
Family means members as listed and photographed on the Rajiv Gandhi Jeevandayee ArogyaYojana Health Cards or holding valid Orange/Yellow Ration Card.6. IDENTIFICATION:Health card issued by Govt. of Maharashtra/Rajiv Gandhi Jeevandayee Arogya YojanaSociety or valid Orange/Yellow Ration Card with Aadhaar number if Health card is not issuedwould act as a tool for beneficiary identification for availing the health insurance facility. TheSi gnature & stamp of Insurance Agencyfollowing actions would be undertaken by Network hospitals in case of the possibleexceptional situations:Requirement for benefitAadhaar number and in case Aadhaar number nottaken any Photo ID card issued by Govt. ( Drivinglicense, election identity card with photograph) toNo Health Card with beneficiary, butcorrelate the patient name & photographValid Yellow or Orange Ration Card(In instance of emergency admission, provisionalwith name of beneficiary is availablepreauthorization may be given subject to confirmationof it against submission of valid photo identity cardissued by Govt. before discharge.)Children born after issue of card i.e.Photograph of child with either parent along withname and photo not available on health
Health card/ valid Yellow or Orange ration card ofcard or on valid yellow/Orange rationparent and Birth certificate issued by authorized office.cardName is there in Yellow or Orange Not eligible for benefit packageRation Card and matches with name in (The yellow /Orange ration card is cancelled afterphoto identity. But the card is invalid as verification by department but still the family isit does not match with the digitized list.holding it)Exceptional Situation7. PRE EXISTING DISEASES:All Diseases under the proposed scheme shall be covered from day one. A person sufferingfrom disease prior to the inception of the policy shall also be covered under approvedprocedures for that disease.8. SUM INSURED ON FLOATER BASIS:The Scheme shall provide coverage for meeting all expenses relating to hospitalization ofbeneficiary up to Rs. 1,50,000/- per family per year in any of the Empanelled Hospital subjectto Package Rates on cashless basis through Health cards or valid Orange/Yellow Ration Card.The benefit shall be available to each and every member of the family o n floater basis i.e. thetotal annual reimbursement of Rs. 1.5 lakh can be availed by one individual or collectively byall members of the family.In case of renal transplant surgery, the immunosuppressive therapy is required for a period of1 year. So the upper ceiling for Renal Transplant would be Rs. 2,50,000 per operation as anexceptional package exclusively for this procedure. The cases are likely to be very few and
well controlled by Human Organ Transplant Act 1994. The claims related to this have to besettled by Insurer.9. PAYM ENT OF PREMIUM:Rajiv Gandhi Jeevandayee Arogya Yojana Society / Government of Maharashtra will pay inadvance the insurance premium in installments on behalf of insured beneficiary families to theInsurance Company as mentioned in clause 10 of Memorandum of Understanding (MOU) oras decided by the Society or GoM.10. PERIOD OF INSURANCE & PERIOD OF AGREEMENT:The insurance coverage under the scheme for the beneficiary families in 8 districts of Phase Ishall be in force for an initial period of one year from the date of commencement of the policy(From 00.00 hrs. of 02.10.2011 to Midnight of 01.10.2012 for Phase-I).The period of MOU/agreement shall be for three years with effect from 02.10.2011; subject toreview and renewal of policy on yearly basis based on the quality of experience andperformance as well as annual IRDA renewal. Based on the quality of experience andperformance of the scheme, the State Government/ Society may extend the scheme to coverthe whole state.