Group Medical Insurance Policy for Retired Employees of WBSEDCL (201819)

1. Overview

The West Bengal State Electricity Distribution Company Limited (WBSEDCL) has long recognised the importance of providing comprehensive health security to its workforce even after retirement. In the financial year 201819, WBSEDCL introduced a Group Medical Insurance (GMI) policy specifically for retired employees and their eligible family members. This policy is administered by the companys Human Resources Department in collaboration with an approved insurance provider.

The GMI scheme is a voluntary, noncontributory (for the employee) benefit that aims to mitigate the financial burden of medical expenses, promote preventive health care, and ensure continuity of care for retirees who have contributed to the growth of the power sector in West Bengal.

2. Eligibility Criteria

The policy covers the following categories of members:

• Retired Employees of WBSEDCL who were in service on or before 31March2018.
• Spouse of the retired employee.
• Dependent children (biological, stepchildren, or legally adopted) up to the age of 21 years or up to 25 years if they are fulltime students.
• Dependent parents (both natural and inlaw) of the retired employee, provided they are financially dependent on the employee at the time of retirement.

Note: The policy does not extend to siblings, grandchildren, or any other relatives not mentioned above.

3. Coverage Details

3.1 Sum Insured

The sum insured (SI) is tierbased, depending on the grade held by the employee at the time of retirement:

3.2 InPatient Hospitalisation

• Room rent (including ICU) up to the limits specified in the policy schedule.
• All charges for surgery, anaesthesia, diagnostics, and pharmacy.
• Preand posthospitalisation expenses up to 30 days each.
• Daycare procedures as per insurers terms.

3.3 OutPatient (OP) Benefits

Annual OP benefits are provided up to INR 10,000 per member for:

• General physician consultation.
• Specialist consultation (subject to referral).
• Diagnostic tests (lab, Xray, ultrasound, etc.).
• Vaccinations and preventive health checkups.

3.4 Maternity & NewBorn Care

Only applicable to the spouse of a retired employee, subject to a onetime benefit of INR 25,000 for normal delivery and INR 35,000 for caesarean section, inclusive of newborn care for the first 30 days.

3.5 Ambulance & Transportation

Reimbursement for ambulance services up to INR 5,000 per incident, provided the patient is transferred to an empanelled hospital.

4. Key Benefits to Retirees

1. Financial Protection: Direct reimbursement of a sizable portion of medical expenses reduces outofpocket burden.
2. No Premium Outlay: The premium is fully borne by WBSEDCL, making the benefit costfree for retirees.
3. Network Hospitals: Access to a wide network of empanelled hospitals across West Bengal and major metro cities.
4. Cashless Hospitalisation: Facility to avail treatment without cash payment at the point of service, subject to network hospitals.
5. Preventive Care: Annual OP allowance encourages regular health checkups, aiding early detection of diseases.
6. Portability: Policy can be transferred to any other insurer without loss of benefits, subject to insurers terms.

5. Procedure for Filing a Claim

5.1 Cashless Claims (Network Hospitals)

1. Present the original Retiree Identity Card and a valid governmentissued ID at the hospitals insurance desk.
2. Fill out the PreAuthorization Form and obtain the insurers approval number.
3. The hospital will bill the insurer directly; the retiree pays only the amount, if any, not covered under policy limits.

5.2 Reimbursement Claims (NonNetwork Hospitals)

1. Pay the hospital bills and retain all original receipts, discharge summary, lab reports, and prescription.
2. Download the Claim Form from the insurers portal or collect it from the HR department.
3. Complete the form, attach all supporting documents, and submit within 30 days of discharge.
4. The insurer processes the claim and transfers the reimbursable amount directly to the retirees bank account.

5.3 Important Points

• Claims for preexisting conditions are payable only after the stipulated waiting period (usually 12 months).
• Duplicate claims for the same expense will be rejected.
• In case of a dispute, the retiree may approach the Internal Claims Committee of WBSEDCL.

6. Frequently Asked Questions (FAQ)

Q1: Is the policy automatically renewed each year?

Yes. The policy is renewed automatically by WBSEDCL, provided the retiree remains eligible and the necessary documentation (updated address proof, family member details) is kept current.

Q2: Can a retiree opt out of the scheme?

Retirees may voluntarily withdraw, but the withdrawal will be effective only from the next policy year, and any unclaimed benefits will be forfeited.

Q3: What is the preexisting disease clause?

Any illness diagnosed or treated within 12 months prior to the policy start date is considered preexisting. Claims for such conditions are payable only after the waiting period, unless the illness is covered under a separate rider.

Q4: Are dependent parents covered if they are staying in a different state?

Yes, provided they are financially dependent on the retiree and the required proof (pension statements, affidavits) is submitted to HR.

Q5: How can a retiree update family details?

Any change (marriage, birth of a child, death of a dependent) must be reported to the HR Department within 30 days along with supporting documents.

7. Contact Information

For further assistance, retirees may contact the Human Resources Employee Welfare Division:

• Phone: 03322455678
• Email: wbsedcl.hr@wb.gov.in
• Office: 2nd Floor, HR Block, WBSEDCL Headquarters, Alipore, Kolkata 700027

All queries related to claim status, policy documents, or eligibility clarification will be addressed within 7 working days.