Group Accident Insurance Scheme under PMMSY: Medical Treatment — Gujarat

What is the medical treatment benefit under the Group Accident Insurance Scheme?

The Group Accident Insurance Scheme (GAIS) is the insurance sub-component of the Pradhan Mantri Matsya Sampada Yojana (PMMSY), run by the Department of Fisheries, Ministry of Fisheries, Animal Husbandry and Dairying, with the National Fisheries Development Board (NFDB) as the nodal agency. In Gujarat the scheme is delivered through the Commissioner of Fisheries under the Agriculture, Farmers Welfare and Co-operation Department, Government of Gujarat, and appears in Gujarati records as માછીમાર જૂથ અકસ્માત વિમા યોજના.

This guide covers the smallest and most frequently used slab of the policy: the medical treatment or accidental hospitalisation benefit of Rs 25,000.

According to NFDB, the GAIS policy provides:

The death and disability slabs are the headline numbers, but most accidents in Gujarat's fisheries do not end in death or amputation. They end in a fractured arm from a winch, a deep laceration from a hauling line, burns from an engine room fire, a snake or scorpion bite in an inland pond, or a road accident while carrying catch to market. This slab exists for exactly those cases, and it reimburses the hospital bill up to Rs 25,000.

Key features

• Reimbursement of up to Rs 25,000 of hospitalisation expenses arising from an accident.
• Zero premium to the fisher. Total premium is Rs 72.44 per fisher per year, shared 60:40 between the Centre and Gujarat.
• Eligible age band is 18 to 70 years.
• Insurer is Oriental Insurance Company Limited (OICL), with Providence India Insurance Broking Pvt Ltd as intermediary.
• Cover applies from the date the premium is paid to the insurer for that policy year.

Who is covered by the medical treatment benefit?

You are covered if:

• You are a fisherman, fisherwoman, fish worker, fish farmer or any other person directly involved in fishing or fisheries-related allied activities in Gujarat. NFDB defines fishers in exactly these broad terms, so ice plant workers, net menders, dryers and boat crew are within scope.
• You are aged between 18 and 70 years.
• Your name is on the state fisheries department's GAIS enrolment list for the running policy year and the premium for that year has been paid.
• The hospitalisation was caused by an accident of a type listed in the policy.

You are not eligible, and cannot claim, if:

• You are below 18 or above 70 years of age.
• You were not enrolled for the policy year in which the accident happened. Enrolment does not carry forward on its own.
• The hospitalisation is for illness or natural causes rather than an accident. This is an accident policy, not a health insurance policy.
• The injury arose from suicide or an attempt at suicide, or a self-inflicted injury.
• The cause is a pre-existing physical or mental defect or infection.
• You were under the influence of intoxicating liquor or drugs.
• The injury happened while committing a breach of law with criminal intent.
• The claim falls under the pregnancy exclusion clause.
• You were treated as an outpatient only, with no hospitalisation, and hold no admission and discharge record.

Which accidents are covered?

The NFDB brochure lists covered events for the policy as a whole:

• Accidents at sea, on the road or on the railway
• Drowning or going missing in water bodies
• Fire, and accidents from handling poisonous substances
• Stroke of lightning or electric shock
• Accidents while working with machinery
• Falls from height
• Riots and murder
• Snake bite, scorpion bite, animal bite or rabies, and any injury by an animal
• Any other accident

A useful point for Gujarat's inland fishers: snake and scorpion bites are explicitly named, and treatment for them is one of the more common hospitalisation claims in tank and reservoir fisheries.

How to apply for a medical treatment claim

1. Get treated first, and keep every paper. Ask the hospital for the admission record, the discharge summary and itemised original bills, including pharmacy and diagnostic receipts. The Rs 25,000 is a reimbursement, so the bills fix what is actually paid.
2. Report the accident to the police. An FIR and the spot panchnama are required even for a hospitalisation claim, because they are what establish the accidental cause.
3. Intimate the claim within 90 days of the accident. Send it to the NFDB Insurance Cell by post, by e-mail to support@pmmsygais.com, on the toll-free number 1800-425-1660, or through the GAIS IT platform. The district Superintendent of Fisheries office also accepts intimations and must forward them to the Insurance Cell within 7 working days.
4. Collect the rest of the document set, the signed insurance claim form, certified FIR, certified panchnama, medical report and discharge summary, original bills, fishing licence or cooperative society membership certificate, address proof, the NEFT bank account form signed by your bank official, and the discharge voucher with a Re 1 revenue stamp. Add a valid driving licence if it was a road accident and you were driving.
5. Submit the originals at the district fisheries office within 180 days of the accident. The office verifies your enrolment, uploads the file through the MIS and sends the originals with a covering letter to the NFDB Insurance Cell within 7 working days.
6. Wait for settlement. Oriental Insurance settles within 15 working days of receiving all relevant documents, paid by NEFT into your account.
7. Answer document queries the same week they arrive. Almost all delay past the 15-working-day mark is an open query, not a rejection.

How to check the status of a claim

1. Call 1800-425-1660, the NFDB GAIS toll-free number, with the claim intimation reference.
2. E-mail support@pmmsygais.com, the Insurance Cell's published address for claim queries.
3. Ask the district Superintendent of Fisheries office, quoting the inward number, whether the originals have left the district for the Insurance Cell — this is where files most often sit.
4. Escalate to the Commissioner of Fisheries, Gandhinagar through cof.gujarat.gov.in if the district office cannot trace the file.

Why medical treatment claims are rejected

• No enrolment for the policy year. The single biggest cause, and entirely preventable by checking the list once a year.
• No FIR or panchnama. Families often skip the police station for what looks like a minor injury, then cannot prove the accident months later.
• Bills not in original, or bills without an itemised breakdown.
• No admission and discharge record, where treatment was only outpatient.
• Intimation after 90 days or documents after 180 days.
• Intoxication noted in the hospital record, which triggers a policy exclusion.
• NEFT form not signed by the bank official, or an account not in the injured fisher's own name.
• Name or age mismatch between the fisheries register, Aadhaar and the hospital record.

Key dates to remember

• 90 days from the accident: last date to intimate the claim.
• 180 days from the accident: last date to submit the complete documents.
• 7 working days: the time district and state fisheries officials have to forward intimations and verified documents.
• 3 working days: the time the Insurance Cell has to pass an intimation to the insurer.
• 15 working days: the time Oriental Insurance has to settle after receiving all documents.
• 12 months: the policy period, after which enrolment must be renewed.

Where to raise a grievance

• NFDB GAIS toll-free: 1800-425-1660
• NFDB Insurance Cell e-mail: support@pmmsygais.com
• District Superintendent of Fisheries office, listed under District Office Contact Details on cof.gujarat.gov.in
• Commissioner of Fisheries, Gandhinagar, the state nodal office for PMMSY in Gujarat

Enrolment and claims under GAIS cost the fisher nothing at any stage, and no agent has a role in either.