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esi notifications
ESIC
Notifications/Circulars
Super Speciality
Treatment under ESI Scheme
Copy of Ref No. 24736/ESI/G1/2004 dated 10.6.04
of
the Director of Medical and Rural Health Services (ESI) Chennai-6
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Sub : ESI Scheme - Medical care to insured persons/ family members – package
deal for speciality and super speciality treatment – certain instructions –
issued.
Ref : Govt. lr. Ref. No. 14669 /L1/2003 dated 16.4.04 and 25.5.04 labour and
Employment Department, Chennai.
The Government have decided to introduce package deal for speciality and
super speciality treatment to Insured Persons and their family members as
imparted under the Central Government Health Scheme – Arrangements are being
made to enter into a memorandum of agreement with the private medical
institutions, which have given their willingness to treat the insured
persons and their family members under the package deal.
The list of empanelled private medical institutions and approved diseases
will be communicated shortly. The insured persons/ beneficiaries, in need of
such a treatment may be referred to any one of the empanelled medical
institutions for the disease noted against them. The package deal system
will come into effect from 1st July, 2004.
If any insured person desires to avail of the treatment under the package
deal, procedure to be followed is :-
1. The insured person shall approach the ESI Dispensary to which he/she is
attached, and the Medical Officer shall issue a referral letter to the IP to
approach the concerned empanelled medical institution.
2. If the IP/beneficiary
need medical attention during the non working hours of the concerned ESI
Dispensary, they may directly approach the nearest ESI Hospital for getting
referral letter. If there is no ESI Hospital situation nearer to the IP’s
place of living, the IP shall approach the nearest Govt. Hospital for
getting referral letter.
3. In the case of an
emergency the IP/beneficiary can get Medical attention just by producing
his/her ESI identity card at the designated private medical institution,
shall produce necessary referral letter and other relevant documents within
48 hours. (If any case referral letter is a must to avail treatment under
package deal)
4. The IP/beneficiary shall
produce the referral letter along with the ESI Identity Card at the
designated private medical institution and avail the treatment without
paying any amount from out of his/her pocket. However any facility, other
than the items included in the package deal shall be borne by the
IP/beneficiary.
5. While referring the
IP/beneficiary to the concerned Empanelled Medical institution, Medical
Officer incharge has to verify whether the IP/beneficiary is eligible for
treatment.
6. The IP shall produce all
the relevant documents (as indicated in the referral letter ) demanded by
the designated hospital and extend his/her co-operation to the hospital
authorities.
7. The designated hospital
after imparting treatment to the IP/beneficiary shall raise the claim bill
directly to the Directorate where it will be settled.
At present the following treatments are included in the package deal.
| Sl. No. |
Procedure |
| I |
CARDIOLOGY & CARDIO
THORACIC SURGERY |
|
a) Coronory By-Pass Surgery
CABG |
|
b) Valve Replacement |
|
c) Correction of Congenial
Complex Heart Diseases |
|
d) Coronory By-Pass Surgery
Post Angioplasty |
|
e) Coronory Balloon
Angioplasty |
|
f) Balloon Angioplasty in the
Valvotomy |
|
g) Open Heart Procedure |
|
h) Mitral Valvotomy |
|
i) Open itral Valvotomy |
|
j) Mitral Valve
Replacement |
|
k) Aortic Valve Replacement |
|
l) Double Valve Replacement |
|
m) Total correction of
Tetrology of Fallots |
|
n) Permanent Pacemaker
implementation |
| II |
ORTHOPAEDIC SURGERY |
|
1. Total Hip Replacement |
|
2) Total Knee Replacement |
|
a)
Open Reduction & Internal fixation of long bones |
|
3) Amputation of legs:
a) Below knee |
|
b)
Above knee |
| III |
NEPHROLOGY/UROLOGY |
|
1) Renal Transplantation |
|
2) Lithotripsy |
|
3) Peritoneal Dialysis
Procedure per sitting |
|
4) Haemodialysis Procedure per
sitting |
|
5) Nephroureterctomy |
| IV |
ONCOLOGY |
|
1) Surgical Management of
Malignancy (Cancer) |
|
a) Radial
Masectomy |
|
b) Total
Thyroidectomy |
|
c)
Transurethrel Resection of Prostate |
|
2) Laser or Radiation
Treatment of Cancer |
|
3) Chemotherapy - Per day |
|
4) Total Cystectomy |
| V |
NEUROLOGY |
|
1) Emergency Life Saving
operation on brain and spinal cord |
|
2) Advanced specialized
operation on brain and spinal cord such as cerebrovascular surgery, skull
base surgery, deep seated tumour of brain, syntactic surgery |
| VI |
OPTHALMOLOGY |
|
1) Any cataract surgery with
or without intraocular Lens(IOL) ECCE/ICCE |
|
2) Glaucomo Surgery (Goniotomy) |
|
3) Scleral Bulking Retinal
Detachment Surgery |
|
4) Keratoplasty |
|
5) Laser Treatment (Xenon Arc
Laser) |
|
6) Vitrectomy |
|
7) Fundus Flurescein (Angiography
of Retina) |
|
8) Orbitotomy |
|
Draft format of referral letter to the issued
by the Medical Officer Incharge, ESI Dispensary to the Insured Person while
referring him to empanelled Private Medical Institution to avail
treatment under Package deal.
REFERRAL LETTER
| 1. Name of the Insured
Person |
: |
| 2. Insured Person No. |
: |
| 3. Name of the Patient |
: |
| 4. Relationship of the
Insured Person |
: |
| 5. Name of the
organisation in which insured person is working |
|
| 6. Whether the Insured
Person in the Live list |
: |
| 7. Whether the Insured
Person is eligible for Medical Benefit |
: |
| 8. Whether the
treatment period is within the eligible Medical Benefit period
(certificate must be obtained from Branch office) |
: |
| 9. Pay Certificate of
the Insured Person (current month) |
: |
| 10. Whether the
Insured Person has availed any assistance for the treatment from
Hon'ble Prime Minister's Relief Fund/Hon'ble Chief Minister's Relief
Fund/ Employer/Others |
: |
| 11. Nature of disease
( as recommended by specialist) |
: |
| 12. Whether the
treatment is available by ESI Hospital |
: |
| |
|
| |
MEDICAL OFFICER INCHARGE
ESI DISPENSARY |
UNDERTAKING BY INSURED PERSON
I fully understand the rules governing the
medical benefits extended to ESI Insured Persons under the package deal. I
undertake to settle the bills pertaining to the treatment imparted by the
empanelled medical institution, in the event, I am not eligible avail the
medical benefit in any way. I also undertake to pay any charge levied by the
empanelled hospital for any additional facility availed by me over and above
the facility included in the treatment package.
Station:
Date :
SIGNATURE OF THE INSURED PERSON
UNDERTAKING BY MEDICAL OFFICER INCHARGE
All the above particulars furnished are
true/correct. The Insured Person has signed the undertaking before me. The
Insured Person is eligible to avail medical benefit under the ESI Rules.
Station:
Date :
SIGNATURE OF THE MEDICAL OFFICER INCHARGE
The following private
Hospitals have executed
Memorandum of agreement.
| 1. |
Appollo Hospital, Greams Road,
Chennai |
| 2. |
Mahatma Eye Hospital,
Thiruchirapalli |
| 3. |
Miot Hospital, Manapakkam,
Chennai |
| 4. |
Prem's Eye Clinic, Bazaar
Road,Saidapet, Chennai-15 |
| 5. |
Sugam Hospital, T.H.Road,
Chennai-19 |
| 6. |
Lalitha Hospital, Cross Cut
Road, Coimbatore |
| 7. |
The Eye Foundation, RS
Puram,Coimbatore |
| 8. |
AG Eye Hospital, Puthur,
Trichy |
| 9. |
Sheela Clinic, East Power
House Road, Coimbatore |
| 10. |
Kongunadu Hospital Private
Ltd, Tatabad, Coimbatore |
| 11. |
KG Hospital, Coimbatore |
| 12. |
Harvey Health Care Limited,
TTK Road, Chennai |
| 13. |
Bejan Singh Eye Hospital,
Nagercoil |
| 14. |
The Institute of Orthopaedic
Research and Accident Surgery, Madurai |
| 15. |
Dr. J. Mathias Hospital,
Nagercoil |
| 16. |
Sooriya Hospital, Chennai. |
| 17. |
Dr. Agarwals Eye Hospitals
Ltd., Cathedral Road, Chennai-86 |
| 18. |
Vizhiagam Eye Hospital,
Sivaganga |
| 19. |
Shanmuga Hospitals and Salem
Cancer Institute, Salem |
| 20. |
Sri Kavery Medical
Centre(TRichy) Pvt Ltd. Trichy |
| 21. |
Joseph Eye Hospital, Trichy |
| 22. |
Meenakshi Mission Hospital and
Research Centre, Madurai |
| 23. |
PSG Hospital, Coimbatore |
| 24. |
Madras Medical Mission,
Chennai |
| 25. |
Kidney Care Centre, Madurai
Road, Tirunelveli |
| 26. |
Kovai Medical Centre and
Hospital, Avinashi Road, Coimbatore |
| 27. |
Quality Care Hospital, Ellis
Road, Madurai |
| 28. |
Sri Ramachandra Hospital,
Porur, Chennai |
| 29. |
Maruti Hospital, Tennur,
Trichi-17 |
| 30. |
Appollo Hospital, KK Nagar,
Madurai |
| 31. |
Mani Hospital (P) Ltd. Theni |
|
Annexure II
Package Rates
| Sl. No. |
Procedure |
Proposed Rates (in Rs) |
| I |
CARDIOLOGY & CARDIO
THORACIC SURGERY |
|
|
a) Coronory By-Pass Surgery
CABG |
126000 |
|
b) Valve Replacement |
126000 |
|
c) Correction of Congenial
Complex Heart Diseases |
126000 |
|
d) Coronory By-Pass Surgery
Post Angioplasty |
126000 |
|
e) Coronory Balloon
Angioplasty |
83700 |
|
f) Balloon Angioplasty in the
Valvotomy |
76500 |
|
g) Open Heart Procedure |
126000 |
|
h) Mitral Valvotomy |
38250 |
|
i) Open itral Valvotomy |
115000 |
|
j) Mitral Valve
Replacement |
120000 |
|
k) Aortic Valve Replacement |
126000 |
|
l) Double Valve Replacement |
126000 |
|
m) Total correction of
Tetrology of Fallots |
126000 |
|
n) Permanent Pacemaker
implementation |
10000 + cost of pacemaker |
| II |
ORTHOPAEDIC SURGERY |
|
|
1. Total Hip Replacement |
61200+ implant |
|
2) Total Knee Replacement |
81900+ implant |
|
a)
Open Reduction & Internal fixation of long bones |
10000 |
|
3) Amputation of legs:
a) Below knee |
7650 |
|
b)
Above knee |
10700 |
| III |
NEPHROLOGY/UROLOGY |
|
|
1) Renal Transplantation |
103300 |
|
2) Lithotripsy |
10000 |
|
3) Peritoneal Dialysis
Procedure per sitting |
1000 |
|
4) Haemodialysis Procedure per
sitting |
1500 |
|
5) Nephroureterctomy |
12000 |
| IV |
ONCOLOGY |
|
|
1) Surgical Management of
Malignancy (Cancer) |
|
|
a) Radial
Masectomy |
15000 |
|
b) Total
Thyroidectomy |
15000 |
|
c)
Transurethrel Resection of Prostate |
15000 |
|
2) Laser or Radiation
Treatment of Cancer |
20000 |
|
3) Chemotherapy - Per day |
500+ cost of drugs |
|
4) Total Cystectomy |
20000 |
| V |
NEUROLOGY |
|
|
1) Emergency Life Saving
operation on brain and spinal cord |
40000 |
|
2) Advanced specialized
operation on brain and spinal cord such as cerebrovascular surgery, skull
base surgery, deep seated tumour of brain, syntactic surgery |
40000 |
| VI |
OPTHALMOLOGY |
|
|
1) Any cataract surgery with
or without intraocular Lens(IOL) ECCE/ICCE |
7200 |
|
2) Glaucomo Surgery (Goniotomy) |
6300 |
|
3) Scleral Bulking Retinal
Detachment Surgery |
10800 |
|
4) Keratoplasty |
10800 |
|
5) Laser Treatment (Xenon Arc
Laser) |
1500 |
|
6) Vitrectomy |
10800 |
|
7) Fundus Flurescein (Angiography
of Retina) |
800 |
|
8) Orbitotomy |
9000 |
|
sd/-
Director of Medical and Rural Heatlh
Services(ESI)
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