Su-Swastha Yojna - Sikkim

“Su-Swastha Yojna” is the Employees' Health Services Scheme by the Department of Health & Family Welfare, Government of Sikkim. The scheme is envisioned and launched by the Honourable Chief Minister of Sikkim Shri Prem Singh Tamang. The scheme aims to provide healthcare services to employees of the Government of Sikkim and their dependent family members for a cashless benefit covering hospitalizations across top-tier hospitals in India.

Vision: “Su-Swastha Yojna” underlines the vision of the Chief Minister of Sikkim to put the healthcare of our employees and their families as the top priority. Today healthcare quality, accessibility, and costs have taken center stage in discussions. Su-Swastha Birtus brings quality healthcare to easy accessibility of its members utilizing technology innovation and good governance practices.

Mission: Su-Swastha Yojna is on a mission to set an example in delivering comprehensive healthcare coverage by focusing on a combination of excellence of care, the convenience of accessibility, and a people-centric experience in their journey from sickness to health.

Values: Su-Swastha Yojna runs on values that we believe are foundational to the service we envision providing employees and their families in easing their pain and discomfort when they are in need of healthcare.

In the first phase of launch in April 2021, the Su-Swastha Yojna aims to cover regular employees in service of the Government of Sikkim and dependent family members up to a maximum of 5 dependents in a scheme that provides 10 lacs of cover to the family per year.

The scheme renews every year and new benefits are planned to be added as further phases of the Yojna are implemented.

 

Benefits

• Cashless admission and discharge across network hospitals take away the hassle of arranging funds when someone needs to get admitted at a hospital.
• Best healthcare accessible to beneficiaries by empanelment of top-tier hospitals and Institutes in India.
• Assurance of quality of care, with the Su-Swastha Facilitation Center keeping oversight of medical care provided by hospitals for the beneficiaries.
• Transparent billing with standardization of tariff with hospitals based on infrastructure and quality of care provided.
• Communication with patient and family at each step of care.
• The beneficiary members as per rules can avail of the benefits of Su-Swastha Yojna in any of the 400+ empaneled hospitals within the Su-Swastha Yojna network of providers.
• 10 lacs base cover + 10 lacs additional critical care coverage for the family- irrespective of the number of dependents in the family.
• The scheme covers hospitalization expenses for periods of more than 24 hrs for in-patient treatment.
• The scheme covers road Ambulance Expenses-Expenses incurred for transportation of the Beneficiary by private ambulance service from home/one hospital to another hospital. 3500 per hospitalization to a maximum of 3 times a year.
• All pre-existing diseases are covered from day 1 of completing enrolment.
• Post-hospitalization- Medical Expenses incurred up to 30 days from the date of discharge from the hospital.
• This scheme also covers special conditions, treatments and implants, Vehicular accidents, and Trauma.
• Coverage for Delivery Maximum ₹ 50,000- newborn baby cover limit up to include.
• The scheme covers daycare Dental and Ophthalmic treatment inclusive of implants.
• Organ Donor Expenses-Expenses incurred for organ transplantation from the Donor to the recipient Su Swastha beneficiary are payable provided the claim for transplantation is payable.



Eligibility

1. All employees of the Sikkim government appointed against the regular Post from the date of joining the regular post.

2. A central government servant or a government servant of any other state while on deputation to the Government of Sikkim.

3. A maximum of 5 family members can be added to one employee as dependents.

4. A family member dependent on the employee from the following relationships:

• Parents of the primary member or spouse (step-parents are excluded)

• Legally wedded spouse (husband/ wife) of primary beneficiary member; a legally divorced spouse cannot be added as a dependent. When both spouses are government regular employees they can choose to enroll separately as the primary members of Su-Swastha Yojna OR as dependent on the other spouse.

• Children, biological or legally adopted, of the primary beneficiary member as below:

a. Unemployed unmarried male child up to the age of 30 years.

b. Unemployed unmarried female child up to any age.

c. Unmarried unemployed child suffering from certified mental or certified physical disability preventing gainful employment of either gender up to any age till the tenure of employment of primary beneficiary member.

* Disability means blindness, hearing impairment, locomotor disability, mental retardation, mental illness, or any other illness or disability certificate by the com patent authority or medical board.

• Unmarried and unemployed biological brother and/or sister age 30 years

• Unmarried and unemployed biological brother and/or sister suffering from certified mental or certified physical disability preventing gainful employment of up to any age till the tenure of employment of primary beneficiary member.

5. The employee must enroll himself /herself before adding dependents to the scheme.



Note 01: A maximum of five (5) dependents can be added for a primary member or employee to the list of dependents mentioned above; in no case can more than 5 dependents be added to a primary member. However, any combination of family members from the list of eligible dependents above can be used to constitute and enroll 5 dependents in the scheme.



Note 02: In no case can the enrolment/membership for a dependent continue if the primary member is not enrolled in the scheme; if the primary man has exited the scheme due to causes including but not limited to death, retirement, termination, or resignation, the cover of benefit for dependents automatically stops.



Note 03: Primary member can add or remove a dependant anytime during the tenure of the membership without requiring the consent of the dependant for such removal.



Note 04: The responsibility of truth in the declaration of dependent family members is of the employee and action may be taken against the employee if information regarding the dependent is found to be untrue.



Note 05: Su-Swastha Yojna is primarily a cashless benefits scheme covering beneficiaries for medical hospitalizations across empanelled hospitals only across India.



Note 06: Cashless benefits cannot be availed if the beneficiary is admitted electively or in a medical emergency in a non-empanelled hospital across India, in or outside the state of Sikkim.





Exclusions

Gov. of Sikkim shall not be liable to make any payments under Su-Swastha in respect of any expenses whatsoever incurred by the insured person in connection with or in respect of:



1. Advances of any amount are not covered in Su-Swastha Yojna since the Yojna functions as a cashless service for its members.
2. Intentional self-injury is not included.
3. Use of intoxicating substances, substance abuse, drugs/alcohol, smoking, and tobacco chewing, and illnesses resulting due to such abuse is excluded.
4. Venereal Diseases and Sexually Transmitted Diseases are excluded.
5. Injury/disease directly or indirectly caused by or arising from or attributable to war, invasion, act of a foreign enemy, warlike operations (whether war be declared or not).
6. Injury or disease directly or indirectly caused by or contributed to by nuclear weapons/materials.
7. Expenses incurred on weight control services including surgical procedures such as Bariatric Surgery and /or medical treatment of obesity.
8. Expenses incurred on High-Intensity Focused Ultra Sound, Uterine Fibroid Embolisation, Balloon Sinoplasty, Enhanced External Counter Pulsation Therapy and related therapies, Chelation therapy, Deep Brain Stimulation, Hyperbaric Oxygen Therapy, Rotational Field Quantum Magnetic Resonance Therapy, VAX-D, Low-level laser therapy, Photodynamic therapy, and such other therapies similar to those mentioned under this exclusion.
9. Charges incurred on diagnostics that are not consistent with the treatment for which the insured is admitted in the hospital/nursing home. Admission is primarily for diagnostic purposes with no positive existence of sickness/ disease/ailment/injury and no further treatment is indicated.
10. Items for post-operative home-based therapies and aides such as crutches, wheelchairs cushions and walking sticks, braces, oxygen cylinders, and accessories for use of the residence and other aids of similar nature are excluded.
11. Expenses on vitamins and tonics unless forming part of treatment for injury or disease as certified by the attending Physician of the hospital where the insured underwent treatment.
12. Cosmetics, diapers, oral hygiene products, talcum powder and toiletries are not covered.
13. Unconventional, Untested, Unproven, Experimental therapies.
14. Stem cell Therapy, Autologous derived Stromal vascular fraction, Chondrocyte Implantation, Procedures using Platelet Rich Plasma, and Intra articular injection therapy.
15. Oral Chemotherapy, Immuno-therapy, and Biologicals, except when administered as an in-patient, when clinically indicated and hospitalization warranted.
16. All types of Cosmetic, Aesthetic treatments of any description, all treatments for Priapism and erectile dysfunctions, and Change of Sex.
17. Plastic surgery (other than as necessitated due to an accident or as a part of any illness)
18. Hospital record charges and other charges
19. Inoculation or Vaccination (except for post–bite treatment and for medical treatment for therapeutic reasons).
20. Dental treatment or surgery (in excess of what is specifically provided) unless necessitated due to accidental injuries and requiring hospitalization.
21. Hospital registration charges, admission charges, telephone charges, and other charges.
22. Any hospitalizations which are not Medically Necessary / do not warrant Hospitalization
23. Other Excluded Expenses as detailed and periodically revised as in the website www.suswastha.sikkim.gov.in
24. Any claim arising out of Accidents that the beneficiary has caused

i. intentionally or

ii. by committing a crime/involved in it or

iii. as a result of/in a state of drunkenness or addiction (drugs, alcohol).

25. Pre-hospitalization Expenses are NOT admissible by Su-Swastha unless they are included in the package of a procedure defined and agreed upon with the hospital during empanelment contracting. When pre-hospitalization is included in the package of admission and procedure, no separate bill or invoice can be raised by the hospital or beneficiary member against such pre-hospitalization expenses.

26. Beneficiary engaging in Air Travel unless he/she flies as a fare-paying passenger on an aircraft properly licensed to carry passengers. For the purpose of this exclusion, Air Travel means being in or on or boarding an aircraft for the purpose of flying therein or alighting therefrom.

27. Travelling Allowance for attendants, patients, and escorts shall not be covered by Su-Swastha Yojna. Such allowances may be covered by Rules 54 and 55 of the Travelling Allowances Rules of the Government of Sikkim. Please refer to these rules to avail of traveling allowances as applicable.

28. Accidents that are results of war and warlike occurrence or invasion, acts of foreign enemies, hostilities, civil war, rebellion, insurrection, civil commotion assuming the proportions of or amounting to an uprising, military or usurped power, seizure capture arrest restraints detainments of all kings princes and people of whatever nation, condition or quality whatsoever.

29. Participation in riots, confiscation or nationalization or requisition of or destruction of or damage to property by or under the order of any government or local authority.

30. Any claim resulting or arising from or any consequential loss directly or indirectly caused by or contributed to or arising from:

• Ionizing radiation or contamination by radioactivity from any nuclear fuel or from any nuclear waste from the combustion of nuclear fuel or from any nuclear waste from combustion (including any self-sustaining process of nuclear fission) of nuclear fuel.
• Nuclear weapons material-The radioactive, toxic, explosive or other hazardous properties of any explosive nuclear assembly or nuclear component thereof.
• Nuclear, chemical, and biological terrorism.



Application Process

Online

Offline

Step 01: Digital enrolment via an online process can be done by accessing enrolment forms on the website and filling it out directly online. https://suswasthasikkim.com/login/employee



Step 02: There are two parts of the application. First, the employee must fill and submit part 1 of the form which is to enroll himself/herself in the scheme. Then he/she should fill and submit part 2 of the form.



Step 03: Both forms have mandatory documents to be attached for each member like the passport-size photo, Voter’s Card, Aadhar card and proof of relationship for dependent family members. Please keep documents ready while filling out the form.



Step 04: Once submitted successfully the application is evaluated and processed by the employer. Once an employer has approved your application you will receive a link to download your member e-card on SMS and email.



Step 05: This e-card is required for availing any benefits of Su-Swastha later.



Documents Required

1. Passport Size Photo

2. Employee ID Proof (Voter’s Card, Aadhar Card, Driver’s license, Passport, or any other government ID)

3. Proof of relationship (Must show the relationship between employee and dependent):

• Aadhar Card

• Voter’s ID

• PAN Card

• Passport

• Driver’s License

• Hospital Discharge Card attested by a gazette government official for newborn babies

• Birth Certificate

• Immunization Certificate

• School Certificate attested by the school authority and gazette government official

• Marriage Certificate

• Affidavit attested by a gazette government official in lieu of no government issue proof