1. Rajiv Gandhi Jeevandayee Arogya Yojana (RGJAY) would be implemented throughout the
state of Maharashtra in phased manner for a period of 3 years. The insurance policy/coverage
under the RGJAY for the eligible beneficiary families in 8 districts of Phase I will be in force
for an initial period of one year from the date of commencement of the policy (“Phase I”).
The extension of period of the policy will be subject to review and renewal of the policy on a
yearly basis which will be based on the quality of experience and performance as well as
annual IRDA renewal. Notwithstanding, anything to the contrary mentioned elsewhere in this
RFP the memorandum of understanding will be co – terminus with the insurance
policy/coverage which is for a term of 1 year from (From 00.00 hrs. of 02.10.2011 to
Midnight of 01.10.2012 for Phase-I). Based on the quality of experience and performance of
the RGJAY the State Government may at its sole discretion and without any obligation extend
the RGJAY to cover the whole state.
1. NAME OF THE SCHEME:
Name of the scheme is Rajiv Gandhi Jeevandayee Arogya Yojana (RGJAY).
2. OBJECTIVE :
To improve access of Below Poverty Line (BPL) and Above Poverty Line (APL) families
(excluding White Card Holders as defined by Civil Supplies Department) to quality medical
care for identified specialty services requiring hospitalization for surgeries and therapies or
consultations through an identified network of health care providers.
2.a. BENEFIT:
The scheme would provide 972 surgeries/therapies/procedures along with121
follow up
packages in following 30 identified specialized categories:
GENERAL SURGERY
1
ENT SURGERY
2

2. OPHTHALMOLOGY SURGERY
3
GYNAECOLOGY AND OBSTETRICS SURGERY
4
ORTHOPEDIC SURGERY AND PROCEDURES
5
SURGICAL GASTRO ENTEROLOGY
6
CARDIAC AND CARDIOTHORACIC SURGERY
7
PEDIATRIC SURGERY
8
GENITOURINARY SYSTEM
9
10 NEUROSURGERY
11 SURGICAL ONCOLOGY
12 MEDICAL ONCOLOGY
13 RADIATION ONCOLOGY
14 PLASTIC SURGERY
15 BURNS
16 POLY TRAUMA
17 PROSTHESES
18 CRITICAL CARE
19 GENERAL MEDICINE
20 INFECTIOUS DISEASES
21 PEDIATRICS MEDICAL MANAGEMENT
22 CARDIOLOGY

3. 23 NEPHROLOGY
24 NEUROLOGY
25 PULMONOLOGY
26 DERMATOLOGY
Si gnature & stamp of Insurance Agency
27 RHEUMATOLOGY
28 ENDOCRINOLOGY
29 GASTROENTEROLOGY
30 INTERVENTIONAL RADIOLOGY
Detailed list of surgeries and therapies falling under above specified categories and their
package rates are given at Appendix 1 a and that of follow up package are given at Appendix
1 b of Part-IV of the document.
3. BENEFICIARY FAMILIES:
Families holding yellow ration card, Antyodaya Anna Yojana card (AAY), Annapurna card
and orange ration card from eight districts viz. Gadchiroli, Amravati, Nanded, Solapur, Dhule,
Raigad, Mumbai city and Suburban Mumbai. The families with white ration card holding
would not be covered under the scheme. The beneficiary families would be identified through
the “Rajiv Gandhi Jeevandayee Health Card” issued by the Government of Maharashtra or
based on the Yellow and Orange ration card issued by Civil Supplies Department. The total
number of beneficiary families in the state would be around 2,04,30,527; out of which
approximately 49 Lakh families in the 8 districts are to be covered under the scheme in first
phase as on the date of publishing of the Request for Proposal (RFP) document. District wise
profile of the beneficiary families is given below:
Districts
Population

4. *Approximate number of
Phase-I
Beneficiary Families
1
Gadchiroli
970294
182889
2
Amravati
2607160
559473
3
Nanded
2876259
543961
4
Solapur
3849543
830011
Dhule
1707947
397674
5
Raigad
2207929
566231
6

5. Mumbai City
3338031
482073
7
8
Mumbai Suburban
8640419
1340828
26197582
4903140
Total
* Based on data furnished by Civil Supplies department as on 31.05.2010.
The total number of beneficiary families for each District is an indicative estimate and may
vary. The number of the final beneficiary families for each district will be given within one
month of signing MOU. The total premium payable would be based on this final figure of
eligible beneficiary families.
4. HEALTH CARDS
All eligible families in these districts shall be provided with Rajiv Gandhi Jeevandayee
Arogya Yojana Health Cards in due course of time. These Health Cards will be used for
identification of Beneficiary families in the family under the Scheme. Family Health Cards
will be prepared by using data from valid yellow or orange ration cards coupled with Aadhaar
numbers issued by UID authorities. As an interim measure till the issuance of health cards, the
valid Orange/Yellow Ration Card with Aadhaar number or in case Aadhaar number not
available, any Photo ID card of beneficiary issued by Govt. agencies (Driving license,
Election ID,) to correlate the patient name and photograph would be accepted in lieu of health
card.
5. FAMILY:

6. Family means members as listed and photographed on the Rajiv Gandhi Jeevandayee Arogya
Yojana Health Cards or holding valid Orange/Yellow Ration Card.
6. IDENTIFICATION:
Health card issued by Govt. of Maharashtra/Rajiv Gandhi Jeevandayee Arogya Yojana
Society or valid Orange/Yellow Ration Card with Aadhaar number if Health card is not issued
would act as a tool for beneficiary identification for availing the health insurance facility. The
Si gnature & stamp of Insurance Agency
following actions would be undertaken by Network hospitals in case of the possible
exceptional situations:
Requirement for benefit
Aadhaar number and in case Aadhaar number not
taken any Photo ID card issued by Govt. ( Driving
license, election identity card with photograph) to
No Health Card with beneficiary, but
correlate the patient name & photograph
Valid Yellow or Orange Ration Card
(In instance of emergency admission, provisional
with name of beneficiary is available
preauthorization may be given subject to confirmation
of it against submission of valid photo identity card
issued by Govt. before discharge.)
Children born after issue of card i.e.
Photograph of child with either parent along with
name and photo not available on health

7. Health card/ valid Yellow or Orange ration card of
card or on valid yellow/Orange ration
parent and Birth certificate issued by authorized office.
card
Name is there in Yellow or Orange Not eligible for benefit package
Ration Card and matches with name in (The yellow /Orange ration card is cancelled after
photo identity. But the card is invalid as verification by department but still the family is
it does not match with the digitized list.
holding it)
Exceptional Situation
7. PRE EXISTING DISEASES:
All Diseases under the proposed scheme shall be covered from day one. A person suffering
from disease prior to the inception of the policy shall also be covered under approved
procedures for that disease.
8. SUM INSURED ON FLOATER BASIS:
The Scheme shall provide coverage for meeting all expenses relating to hospitalization of
beneficiary up to Rs. 1,50,000/- per family per year in any of the Empanelled Hospital subject
to Package Rates on cashless basis through Health cards or valid Orange/Yellow Ration Card.
The benefit shall be available to each and every member of the family o n floater basis i.e. the
total annual reimbursement of Rs. 1.5 lakh can be availed by one individual or collectively by
all members of the family.
In case of renal transplant surgery, the immunosuppressive therapy is required for a period of
1 year. So the upper ceiling for Renal Transplant would be Rs. 2,50,000 per operation as an
exceptional package exclusively for this procedure. The cases are likely to be very few and

8. well controlled by Human Organ Transplant Act 1994. The claims related to this have to be
settled by Insurer.
9. PAYM ENT OF PREMIUM:
Rajiv Gandhi Jeevandayee Arogya Yojana Society / Government of Maharashtra will pay in
advance the insurance premium in installments on behalf of insured beneficiary families to the
Insurance Company as mentioned in clause 10 of Memorandum of Understanding (MOU) or
as decided by the Society or GoM.
10. PERIOD OF INSURANCE & PERIOD OF AGREEMENT:
The insurance coverage under the scheme for the beneficiary families in 8 districts of Phase I
shall be in force for an initial period of one year from the date of commencement of the policy
(From 00.00 hrs. of 02.10.2011 to Midnight of 01.10.2012 for Phase-I).
The period of MOU/agreement shall be for three years with effect from 02.10.2011; subject to
review and renewal of policy on yearly basis based on the quality of experience and
performance as well as annual IRDA renewal. Based on the quality of experience and
performance of the scheme, the State Government/ Society may extend the scheme to cover
the whole state.