New Health Insurance for Tamil Nadu Government Employees

Imagine this. You are a government employee or a pensioner in Tamil Nadu. You know you have “government health insurance”, so you assume hospital bills are taken care of. Then a family member needs treatment, and the hospital says it is not covered or that your coverage is insufficient. This is a common situation we encounter while helping more than 8,00,000 people find their cover.

In this article, we clearly explain what the New Health Insurance Scheme for Tamil Nadu government employees and pensioners actually is, how it works, its benefits and limitations, and whether you need additional cover on top.

What Is the New Health Insurance Scheme?

The New Health Insurance Scheme (NHIS) is a state-sponsored group health insurance policy introduced by the Government of Tamil Nadu for serving state government employees, pensioners, and their eligible family members and dependents.

The scheme is implemented through a government tender and administered by United India Insurance Company Limited, a public sector general insurance company. Claims are processed through third-party administrators, namely Medi Assist Healthcare Services and MD India.

Under NHIS, hospitalisation expenses are covered up to ₹5 lakh for treatments and procedures listed in Annexure-I of the official notification, within a fixed block of four years for the whole family unit. For employees, this block runs from 01-07-2021 to 30-06-2025, while for pensioners, it runs from 01-07-2022 to 30-06-2026. For certain specified conditions and procedures listed in Annexure-IA, the coverage can be extended up to ₹10 lakh. Hence, if you exhaust it early, there may be no balance left until the next block reset.

Inclusions and Exclusions of the New Health Insurance Scheme

01

No Pre-existing disease (PED) Waiting Period

PEDs are covered from Day 1, subject to the scheme’s terms and conditions.

02

Room Rent Restriction

The room rent is restricted to a standard A/C room, and transport charges are excluded.

03

Disease-wise Sub-limits

Cataract and hysterectomy (uterus removal surgery) have sub-limits of ₹ 30,000 and ₹ 50,000, respectively.

04

Fixed Package Rates

Treatments in network hospitals are covered on a cashless basis up to the package rates set by the government.

05

Emergency/Accident Treatment at Non-network Hospitals

It is covered on a reimbursement basis, subject to package rates determined by the Accreditation Committee.

06

Non-emergency Treatment at a Non-network Hospital

This shall be covered on a reimbursement basis, with the payout restricted to 75% of the package rate for a similar procedure in a similar network hospital.

07

Consumables

There is also a list of non-payable items, such as baby food and tissue paper, which shall not be covered.

Key Features of the New Health Insurance Scheme

• Fixed Premium: The premium for Employees is ₹ 3,240 + GST per annum, while for pensioners it is ₹ 5,472 + GST per annum, for the 4-year block. It is deducted directly from salaries (or pensions). 
• Extension of Tenure: For employees, the scheme has been extended by one additional year after the end of the four-year block, up to 30 June 2026. That said, the government is still clarifying some finer operational details of this extension.
• Mandatory Rnrolment: Enrolment under NHIS is compulsory, even if you are already covered by other government schemes such as CGHS.
• Corpus Fund for Rare and Exceptional Cases: ₹5 per month is deducted from each employee and contributed to a Corpus Fund (non-lapsable) to meet higher expenses in respect of infrequent illnesses and exceptional circumstances, extending the total benefit up to ₹20 lakh. This is separate from the regular NHIS coverage.

Why Choose Ditto for Health Insurance?

At Ditto, we’ve assisted over 8,00,000 customers with choosing the right insurance policy. Why customers like Pallavi below love us:

• No-Spam & No Salesmen
• Rated 4.9/5 on Google Reviews by 15,000+ happy customers
• Backed by Zerodha
• Dedicated Claim Support Team
• 100% Free Consultation

Confused about the right insurance? Speak to Ditto’s certified advisors for free, unbiased guidance. Book your call now, slots fill up fast!

Ditto’s Take on the New Health Insurance Scheme

• Affordable Coverage: The scheme offers extremely affordable health insurance during and even after retirement. Because of this, we recommend continuing with it even if you already have other health insurance coverage.
• Not Fully Comprehensive: The coverage is not comprehensive. Some conditions are excluded, and even covered treatments come with defined limits. These limits can feel restrictive, especially regarding the overall coverage amount and the hospitals where treatment is allowed.
• Additional Personal Health Insurance is Advisable: With medical costs in India rising by roughly 14% every year, a ₹5 to ₹10 lakh cover may not be enough in the years ahead. Keeping an adequate personal health insurance policy alongside NHIS can help bridge this gap.
• Read the Fine Print: It is important to go through the scheme’s policy document carefully. This helps avoid surprises later, especially when you actually need to make a claim.

Conclusion

The New Health Insurance Scheme for Tamil Nadu government employees aims to strike a balance between modest coverage and highly affordable premiums through its tiered structure. That said, the scheme does come with limitations, including strict rules, limited benefits, and a restricted hospital network.

While it’s great that it continues even after retirement, it also provides pensioners with ongoing health coverage. For more well-rounded protection, it makes sense to add a comprehensive personal health insurance plan alongside this scheme, so you are better prepared for rising medical costs and a wider range of treatment options.