Kerala MEDISEP Coverage Raised to Five Lakh Rupees; Expanded Benefits and Stricter Hospital Oversight Introduced

Thiruvananthapuram: The Kerala government has approved the second phase of MEDISEP, the state-run medical insurance scheme for government employees and pensioners. The revised policy increases the basic insurance coverage from three lakh rupees to five lakh rupees, with expanded medical coverage and stronger monitoring of private healthcare providers.

The new phase brings over two thousand one hundred procedures across forty-one specialised treatment categories into the basic treatment package. Two high-cost cardiac treatments excluded in the first phase — Cardiac Resynchronisation Therapy with defibrillator (worth six lakh rupees) and ICD Dual Chamber (worth five lakh rupees) — will now be included under the additional benefit package. Knee and hip replacement surgeries are also being moved into the basic benefit package.

Ten new treatment packages for critical and organ transplant cases will be introduced, with the insurance company required to set aside a corpus fund of forty crore rupees for two years to cover such cases.

The room rent allowance has been revised to one percent of the total insurance coverage, allowing up to five thousand rupees per day. In government hospitals, pay ward charges will be covered up to two thousand rupees per day. The cabinet has also granted in-principle approval to include employees and pensioners from public sector undertakings, boards, corporations, cooperative institutions, and local self-government bodies who are not eligible for Employees' State Insurance benefits.

The scheme's policy period has been shortened from three years to two years. In the second year, there will be an increase in both the premium and package rates. Only public sector insurance companies that were technically qualified and participated in the first phase will be allowed to bid in the second phase.

Emergency medical treatments in non-empanelled hospitals — which were earlier limited to heart attack, stroke, and road accidents — will now cover thirteen specific conditions. Reimbursement will be allowed for treatment under these defined emergency situations.

Day-care procedures requiring frequent hospital visits, such as dialysis and chemotherapy, will now be allowed through one-time registration on the MEDISEP insurance portal. Combined approvals will be given when both surgical and medical treatments are involved. Pre-hospitalisation expenses will be covered for up to three days and post-hospitalisation expenses for up to five days.

A three-tier grievance redressal mechanism will be introduced at the district level, state level, and appellate level. MEDISEP cards will be upgraded with a QR code for faster access to beneficiary data. Insurance providers will also implement a Standard Operating Procedure to penalise hospitals that breach contract terms. To prevent overcharging and exploitation by private hospitals, the services of the Clinical Establishment Authority will be enlisted.

As of July first, under the first phase of the scheme, over ten lakh fifty-two thousand claims were settled, amounting to one thousand nine hundred eleven crore rupees. Of this, sixty-seven crore rupees were paid out for two thousand two hundred fifty-six organ transplant claims, and nine crore rupees for one thousand six hundred forty-seven reimbursement claims.