Vidal Health Insurance TPA is one of the leading Third-Party Administrators (TPAs) in India, specializing in managing Government Sponsored health insurance Scheme’s claims and services. We are the largest TPA handling more than 180 million lives across India. We play a significant role in the implementation and functioning of Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB-PMJAY), which is one of the largest government-funded healthcare schemes globally along with various State schemes . Here's an overview of the work done by us in AB-PMJAY/ State run Schemes.
Enrolment and Beneficiary Identification: We assist in the identification and enrolment of eligible beneficiaries into the scheme. This involves verifying beneficiaries based on the Socio-Economic Caste Census (SECC) database and issuing AB-PMJAY cards.
Claims Processing: We handle the processing of claims submitted by Empanelled Network Provider . This includes verifying the authenticity of claims, coordinating with hospitals and healthcare providers, and facilitating the settlement of claims within the stipulated guidelines of the scheme.
Network Management: We establish and manage a network of empaneled hospitals and healthcare providers. Ensuring quality standards, and facilitate cashless treatments for beneficiaries within this network.
Customer Support Services: We assistance and support to beneficiaries in understanding the scheme's coverage, guiding them through the enrolment process, clarifying queries related to treatments, hospitals in the network, and assisting with claim-related issues & grievances.
Fraud Control and Monitoring: We play a role in implementing measures to prevent fraud and misuse of the scheme. They conduct audits, monitor transactions, and ensure compliance with the guidelines to maintain the integrity of AB-PMJAY.
Reporting and Compliance: We are responsible for generating reports on various aspects of the scheme's performance as required by the National Health Authority (NHA) or other governing bodies (SHA). They ensure compliance with the regulations and guidelines set forth by the scheme.
We act as facilitators in the successful implementation of AB-PMJAY by managing various administrative aspects, facilitating smooth interactions between stakeholders, and ensuring that eligible beneficiaries receive quality healthcare services as outlined under the scheme.
Our Presence extend across various State in Government Sponsored scheme:
Ayushman Bharat - Pradhan Mantri Jan Arogya Yojana was launched on 23.09.2018 to provide health cover up to Rs. 5 lakh per family per annum for secondary and tertiary care hospitalisation to around 10.74 crore poor and vulnerable families (approx. 50 crore individuals) based on the deprivation and occupational criteria as per the Socio-Economic Caste Census.
Salient Features of Ayushman Bharat - Pradhan Mantri Jan Arogya Yojana
- Health Coverage: AB-PMJAY provides health coverage of up to 5 lakhs INR per family per year for secondary and tertiary hospitalization.
- Beneficiary Selection: The scheme focuses on providing coverage to deprived rural and urban families identified by the Socio-Economic Caste Census (SECC) database.
- Hospital Network: Beneficiaries can access services in any of the empaneled hospitals across India. This network includes public and private hospitals.
- Coverage of Medical Expenses: The scheme covers a wide range of medical expenses including hospitalization, surgeries, medicines, diagnostics, and pre- and post-hospitalization expenses.
- Portability: The scheme is portable across the country, allowing beneficiaries to access services anywhere in India.
- Paperless and Cashless: The scheme operates on a cashless and paperless mode, reducing administrative hassles and ensuring smooth access to healthcare.
- No Cap on Family Size: The coverage extends to the entire family, irrespective of the family size and the number of members.
- Pre-existing Conditions: The scheme covers pre-existing conditions from day one, providing necessary medical care without exclusion.
- Information Technology: AB-PMJAY relies on robust IT systems for the identification of beneficiaries, verification, and monitoring of healthcare services.
- Fraud Control: Measures are in place to prevent fraud and misuse, ensuring that the benefits reach the intended beneficiaries.
The AB-PMJAY scheme is a significant step towards ensuring that the underprivileged sections of society have access to quality healthcare without facing financial distress. It's designed to alleviate the burden of medical expenses and provide comprehensive healthcare coverage.
Skoch Award & Accolades for Government Business
From 2012 till date – recognition for our passion & commitment in implementing schemes.
- SKOCH Award – Gold in 2022 & Silver in 2020 ( Highest civilian honor in the country conferred by an independent organization. For best of efforts in digital, financial and social inclusion).
- Award for best practices – Government of Tamil Nadu.
- Award for best implementation – Government of Chhattisgarh, Tamil Nadu.
- E Governance award for best technology – Government of Tamil India.