Goa Mediclaim Scheme

What is the Goa Mediclaim Scheme?

Goa Mediclaim Scheme is a financial assistance scheme of the Health Services Department, Government of Goa, for patients who need super-speciality treatment that the state's own government hospitals cannot provide. According to the scheme document published on goa.gov.in, the scheme applies to every permanent resident who has been residing in Goa for 15 years, and its purpose is to meet the cost of treatments such as dialysis, plastic surgery, intensive care, angiography and angioplasty, open heart surgery, kidney transplantation, neurosurgery, radiotherapy and chemotherapy for cancer, cochlear implants and bone marrow transplants.

The scheme is administered by the Directorate of Health Services from a dedicated Mediclaim Cell at Campal, Panaji, and applications are addressed to the Director of Health Services.

Main features

• A fixed permitted ceiling limit is prescribed for each category of sickness.
• Payment is the lower of the permitted ceiling or the actual expense of treatment.
• Treatment must be taken at a hospital recognised under the scheme, and the hospital list along with the treatment each hospital is recognised for is part of the scheme guidelines.
• Applications are offline only, in a prescribed form with the guidelines PDF.

How much does the Goa Mediclaim Scheme pay for each treatment?

Two conditions govern every one of these figures. First, the amount released is either the permitted ceiling or the actual expense of treatment, whichever is the least. Second, the treatment must be taken at a hospital recognised under the scheme for that particular treatment, since recognition is treatment-wise and not blanket.

Who is eligible for the Goa Mediclaim Scheme?

You can apply if:

• You are a permanent resident of Goa.
• You have been residing in Goa for 15 years, your name figures in the voters' list, and you hold a permanent ration card.
• Your income is less than Rs 1,50,000 per annum. Retired state government employees are eligible irrespective of their income.
• You require a facility that is not available in a government hospital of Goa, including Goa Medical College, Bambolim, and the district hospitals.
• You are suffering from a sickness that needs one of the 12 listed treatments.

You are not eligible if:

• You have lived in Goa for fewer than 15 years, or your name is not in the voters' list, or you do not hold a permanent ration card.
• Your annual income is Rs 1,50,000 or more and you are not a retired state government employee.
• The treatment you need is available at a government hospital in Goa. The only relaxation is for NICU, ventilatory support and kidney dialysis, where a patient may opt for an empanelled hospital even though the government facility exists.
• Your ailment falls outside the 12 listed categories. A treatment that is not named in the scheme document cannot apply for a ceiling of its own.

What documents are required for the Goa Mediclaim Scheme?

The Mediclaim certificate from the Medical Superintendent of Goa Medical College is the pivot of the whole file. It is the document that establishes the central eligibility test, namely that the required facility is not available in a government hospital of Goa. Applications are commonly delayed because this certificate is sought last rather than first.

How to apply for the Goa Mediclaim Scheme

1. Download the prescribed form from the Goa Mediclaim Scheme guidelines PDF on goa.gov.in, or collect it from the Mediclaim Cell at the Directorate of Health Services.
2. Obtain the medical certificate from your treating doctor at Goa Medical College Bambolim, Hospicio Hospital Margao or Asilo Hospital Mapusa.
3. Obtain the Mediclaim certificate from the Medical Superintendent, Goa Medical College, Bambolim, certifying that the facility you need is not available in a government hospital.
4. Apply to the concerned Mamlatdar for the income certificate in prescribed Form B, in original. If you are a retired state government employee, take a certified copy of your Pension Payment Order instead.
5. Assemble the residence certificate, election or ration card photocopy, Aadhaar card, DDSSY card, patient photograph and the signed declaration form.
6. Fill in the prescribed form, addressed to the Director of Health Services, Panaji, Goa, and sign it.
7. Submit the complete file at the Mediclaim Cell, S-37, Second Floor, Directorate of Health Services, Campal, Panaji, Goa.
8. Keep a photocopy of the entire submitted set, since the original income certificate and the original Mediclaim certificate are retained by the department.

How to check the status of a Goa Mediclaim application

Goa Mediclaim Scheme is an offline scheme without an online tracking service. Status is followed up with the Joint Director of Accounts (Health) at the Directorate of Health Services, Campal, Panaji, on 0832-2225646, extension 214, quoting the patient's name and the date of submission at the Mediclaim Cell. Applicants should carry or quote the acknowledgement given at the counter when the file was submitted.

Why Goa Mediclaim applications get rejected

• Facility is available in a government hospital. This is the most common reason. Unless the treatment is NICU, ventilatory support or kidney dialysis, a facility that Goa Medical College or a district hospital can provide is not funded outside the government system.
• Income above Rs 1,50,000 with no PPO to fall back on.
• Income certificate not in Form B, or submitted as a photocopy rather than in original from the Mamlatdar.
• Fifteen years of residence not established, or the applicant's name absent from the voters' list, or no permanent ration card.
• Medical certificate from a hospital other than GMC Bambolim, Hospicio Margao or Asilo Mapusa.
• Treatment taken at a hospital not recognised under the scheme for that specific treatment.
• Claim exceeds the ceiling for that category, in which case only the ceiling amount is admissible.

How the Goa Mediclaim Scheme sits alongside DDSSY

Goa runs the Deen Dayal Swasthya Seva Yojana alongside the Mediclaim Scheme, and the Mediclaim document checklist itself asks for the DDSSY card. The two work on different logics. DDSSY is cashless insurance covering 447 listed procedures at empanelled hospitals, needs five years of residence and has no income ceiling for basic eligibility. Goa Mediclaim Scheme is targeted financial assistance for super-speciality care that the state's government hospitals cannot deliver, needs 15 years of residence and, for most applicants, income below Rs 1,50,000. A patient facing a high-cost super-speciality treatment should check the DDSSY procedure list first and treat Mediclaim as the route where the treatment falls outside what the state's own hospitals and the DDSSY cover can handle.

Help and grievance redressal

• Officer to be contacted: Joint Director of Accounts (Health), Directorate of Health Services, Campal, Panaji, Goa, phone 0832-2225646, extension 214.
• Office where the application is submitted: Mediclaim Cell, S-37, Second Floor, Directorate of Health Services, Campal, Panaji, Goa.

No fee is charged for the Goa Mediclaim application form, which is printed with the scheme guidelines on the state government website.