शुक्रबार १७ मंसिर, २०७८ (Friday December 03, 2021)

सञ्चयकर्ताको लागी सुरु भयो कर्मचारी सञ्चयकोषको स्वास्थ्य बीमा योजना के के छन् त सुविधा

मंगलवार ४ मंसिर, २०७५ गोर्खाली न्युज सम्वाददाता 4751


सञ्चयकर्ताको लागी सुरु भयो कर्मचारी सञ्चयकोषको स्वास्थ्य बीमा योजना के के छन् त सुविधा

के तपाई कर्मचारी सञ्चयकोषको सञ्चयकर्ता हो ? यदि हो भने  तपाँइको लागि खुसीको खबर छ ।नेपाल कर्मचारी सञ्चयकोषले  तपाइँ लगायत आफना ६ लाख सञ्चायकर्ताको एकै पटक स्वास्थ्य बीमा गरिदिएको छ । उक्त बीमा मंसिर १  देखि लागू भएको छ । कोषले गरेको आम्दानीबाट छुटटाईएका विभिन्न कोषहरुको प्रयोग गरी सञ्चयकोषले बीमा गरिदिएको हो । बीमा बापत सञ्चयकर्ता आफैले भने कुनै रकम भुक्तान गर्नुपर्दैन ।

कोषको उक्त बीमा योजनाले १ लाख बराबरको औषधीउपचार खर्च र १० लाख रुपैयाँ बराबरको घातक रोगको बापतको जोखिम बहन गर्छ । प्रत्येक बर्ष यो बीमा योजना नविकरण गर्नुपर्छ । हालै कोषले राष्ट्रिय बीमा संस्थानसँग बीमा सम्झौता गरेको छ जुन सम्झौता तीन बर्षको छ ।

के कति पाईन्छ त सुविधा ? 

यस स्वास्ठ बीमा योजना अनुसार तपाई दुर्घटनाबाट बिरामी हुनु भयो भने उपचार गर्दा लाग्ने खर्चको अधिकत्तम १ लाख रुपैयाँसम्म कम्पनीमा दाबी गर्न सक्नुहुन्छ । दुर्घटना भएको उपचार गर्दा लागेको खर्च सहित कम्पनीमा दाबी गरेपनि कम्पनीले भुक्तानी गर्छ । त्यसैगरी सरकारले तोकेको नौ घातक रोग लाग्यो भने पनि उपचारको लागी लाग्ने खर्चमध्ये १० लाखसम्म कम्पनीमा दाबी गर्न पाईन्छ ।

तर, उपचार खर्चको लागी पनि बीमा योजनामा विभिन्न सिमा तोकिएको छ । जस्तै, बिरामीले एक बर्षमा एक पटक वा पटक पटक अपरेसन गर्दा लाग्ने खर्चको अधिकतम ३० हजार रुपैयाँसम्म मात्रै दाबी भुक्तानी पाउन सक्नुहुन्छ ।

त्यस्तै चिकित्सकको जाँच शुल्क, एक्सरे वा स्पेस्लिस्ट चार्ज वा प्याथोलोजी तर्फको शुल्कको हकमा एक वर्षमा अधिकतम २० हजार रुपैयाँ र एक पटकमा अधिकतम १० हजार रुपैयाँसम्मको दाबी भुक्तानी पाउने व्यवस्था सो योजनामा रहेको छ । सर्जिकल सामाग्री खरिद गर्नु पर्दा बीमितले ८ हजार रुपैयाँ नबढ्ने गरि दाबी प्राप्त गर्न सक्छन ।

बिमित बिरामीले अस्पताल भर्ना भइ बस्नु परेमा प्रति दिन २ हजार रुपैयाँ नबढ्ने गरी एक वर्षको अवधिमा २५ हजार रुपैयाँसम्मको दाबी भुक्तानी पाउने व्यवस्था गरिएको छ । साथै  औषधि खरिद गर्दा एक पटकमा अधिकतम ५ हजार रुपैयाँसम्मको र वार्षिक रुपमा अधिकतम १५ हजार रुपैयाँसम्मको बीमा रकम पाउन सकिन्छ । प्रसुती सेवाको लागि वर्षमा दुई पटक र एक पटकमा ४ हजार ५०० रुपैयाँसम्मको सिजरियनको सुविधा प्राप्त गर्न सकिन्छ ।

दाबी कसरी र कहिलेसम्म गर्ने त ?

नेपाल सरकारबाट सम्बन्धन प्राप्त स्वास्ठ चौकी, अस्पताल तथा नसिङ्ग होमबाट बिरामीको उपचार गराउँदा स्वास्थ्य बीमाको भुक्तानी पाउन सकिन्छ । जसमा सञ्जयकर्ताले अस्पतालबाट डिस्चार्ज भएको ३५ दिन वा बिरामी भएको ६० दिन भित्र कोषलाई सोको जानकारी दिनुपर्छ ।

यो बीमा लेख जारी भएको तीस दिनभित्र दुर्घटना बाहेक साधारण औषधोपचार र घातक रोगको हकमा ९० दिन प्रतिक्षा अवधि तोकिएको छ । यस अवधिमा बीमा सुविधा प्राप्त गर्न सकिँदैन । तर यो बीमा लेख नविकरण गर्दाको वेलामा प्रतिक्षा अवधि लागु हुने छैन । दाबीको लागि प्रमाणित गर्नको लागि बीमीतले तोकिएको ढाँचामा बीमीतको निवेदन, कम्पनीबाट उपल्ध गराएको फाराममा अस्पतालको छाप, सम्बन्धित डाक्टरको दस्तखत र सक्कली डिस्र्चान स्लिप र बीमीतको सक्कल रिपोर्टहरु र बीमीतको परिचय पत्र नम्बर सहितको कोषको प्रमाणित पत्र पेश गनुपर्दछ । यसका साथै बीमीतले २५ हजारसम्मको दाबीको  १५ दिन भित्र, २५ हजार देखी माथि १ लाखसम्म दाबीको ३० दिन भित्र, घातक रोगको लागि ४५ दिन भित्र कम्पनीको केन्द्रिय कार्यालयमा आवश्यक प्रक्रिया पुरा गरेपछि प्राप्त गर्न सक्नेछन् ।

के के उपचारमा दावी गर्न सकिदैन त ?

यदि बीमीतले दुर्घटनाबाट उपचारको बाहेक दाँतको उपचार वा अप्रेसन, आँखाको सामान्य जाँच, चस्मा खरिद, श्रवण उपकरण खरिद, कस्मेटिक सर्जरी, दुई वा दुईभन्दा बढि सिजरियन, मादक पदार्थ तथा लागु पदार्थ सेवन तथा अनधिकृत तवरबाट अन्य औषधिको सेवनका कारण सिर्जित रोगहरु तथा चोटपटकको उपचारमा बीमा दावी गर्न पाइँदैन । दुई मुलुक बीच भएको घोषित वा अघोषित लडाई, आम हड्ताल, हुलदंगामा सहभागी भएको अवस्थामा भएको चोट पटक वा उपचार खर्च, बीमालेख प्रारम्भ हुनु भन्दा अगाडि लागेका रोगको उपचार क्रममा भए गरेका खर्चहरु, आयुर्बैदिक उपचार खर्च, चिकित्सकको अनुमति विना विदेशमा गरिएका उपचार खर्च पनि दावी गर्न पाइँदैन ।

यसका साथै पुनः उपचार गराउँदा भएका खर्च, मानसिक खर्च, तौल बढाउन वा घटाउन प्रयोग हुने ओषधी, सौन्दर्य बढाउन गरिने उपचार, प्लाष्टिक सर्जरी, चिकित्सकको आफ्नो ल्याबमा वा क्लिनिकमा गरेका सर्जरी, साधारण मेडिकल चेकअप र छाला सम्बन्धि एलर्जी, सावुनको प्रयोग, लोसन आदिको प्रयोगलाई यो बीमा योजनाले समेट्ने छैन ।

कोषले कर्मचारीहरुको लागि ल्याएको यो योजना हालसम्मकै महत्वपूर्ण भएको कोषले दावी गरेको छ । यो योजनाबाट आफ्ना ६ लाख सन्चयकर्ता लाभान्वित हुने कोषले बताएको छ ।




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