Frequently asked questions

The Su-Swastha Yojna is the Employee Health Services Scheme launched by the Govt of Sikkim in 2021. In the current year of launch this scheme is valid for the Regular Employee of the Govt of Sikkim and his/her dependent family members. In this scheme, employees and their dependents shall be able to avail healthcare services for hospitalizations on a cashless basis in empanelled hospital network across India.

1. All employees of the Sikkim government appointed against the regular Post from the date of joining regular post.
2. A central government servant or a government servant of any other state while on deputation to the Government of Sikkim
3. Dependents of the eligible employees- a maximum of 5 eligible dependents can be added for each employee

No, not in this phase. Contractual, MR employees and ad hoc employees are not eligible in the current year of launch; there are plans to include them in subsequent phases- please check our website for notifications on same periodically.

No, retired employees are not eligible in the current year of policy period; there are plans to include them in subsequent phases- please check our website for notifications on same

Dependents as below shall be considered as “dependent family members/ beneficiaries”. A family can have a maximum of five (5) dependent beneficiaries for one (1) government employee.

1. Parents of the primary member or spouse (step-parents are excluded)
2. Legally wedded spouse (husband/ wife) of primary beneficiary member; a legally divorced spouse cannot be added as a dependent. When both spouses are government regular employees, they can choose to enrol separately as primary member of Su-Swastha Yojna OR as dependent on the other spouse.
3. Children, biological or legally adopted, of the primary beneficiary member as below
4. Unemployed unmarried male child upto age of 30 years
5. Unemployed unmarried female child upto any age
6. Unmarried unemployed child suffering from certified mental or certified physical disability preventing gainful employment of either gender upto any age till the tenure of employment of primary beneficiary member
7. Unmarried and unemployed biological brother and/or sister age of 30 years
8. Unmarried and unemployed biological brother and/or sister suffering from certified mental or certified physical disability preventing gainful employment of upto any age till the tenure of employment of primary beneficiary member

Maximum of five (5) dependents can be added for a primary member or employee the list of dependents mentioned above; in no case can more than 5 dependents be added to a primary member. However, any combination of family members from the list of eligible dependents above can be used to constitute and enrol 5 dependents in the scheme.

In no case can the enrolment/membership for a dependent continue if the primary member is not enrolled in the scheme; if the primary member has exited the scheme due to causes including but not limited to death, retirement, termination or resignation, the cover of benefit for dependents automatically stops.

Primary member can add or remove a dependent anytime during the tenure of the membership without requiring a consent of the dependent for such removal

The employee contribution is Rs 200/- per employee per month. The rest of the healthcare fund is created by government contributions.

The amount is Rs 200/- per month per dependent. For example, if you have 5 dependents, you will be contributing (Rs 200 x 5= Rs 1000/-) per month for the 5 dependents. This amount is contributed to a healthcare fund to which the Government of Sikkim contributes funds as well to cover the total healthcare expenses incurred in Su-Swastha Yojna.

You can add any number of dependents between zero (0) and five (5); a maximum of five (5) dependents can be added for a primary member or employee; in no case can more than 5 dependents be added to a primary member.

Total Cover is 10 lacs (ten lacs) for the family- irrespective of number of dependents in the family. This amount is fixed and for the current year it cannot be increased by employee.

1. In-patient Treatment - Covers hospitalization expenses for period more than 24 hrs
2. Day care Dental and Ophthalmic treatment inclusive of implants (However, for cosmetic purpose, dental implants are excluded)
3. Maternity and child healthcare – e.g. hospitalizations related to delivery, caesarean and neonatal care
4. Road Ambulance Expenses-Expenses incurred for transportation of the Beneficiary by ambulance service from home//one hospital to another hospital.
5. Post-Hospitalization- Medical Expenses incurred up to 30 days from the date of discharge from the hospital.
6. Organ Donor Expenses-Expenses incurred for organ transplantation from the Donor to the recipient Su Swastha beneficiary person are payable provided the claim for transplantation is payable
7. Cancer chemotherapy and dialysis
8. Vehicular Accident and Trauma

Cashless benefits scheme can be availed from any of the hospitals in India which have joined on the panel or network of Su-Swastha Yojna. This list is available on our website and continuously updated.

The list will be continuously updated on the website www.suswasthasikkim.com

Cashless benefits cannot be availed if the beneficiary is admitted electively or in a medical emergency in a non-empaneled hospital across India, in or outside the state of Sikkim. In such cases the beneficiary is required to settle the bill directly with hospital and apply for reimbursement through Su-Swastha Facilitation Center

The OPD basis treatment is to be availed using the current system of OPD bills submission and reimbursement. If there is any change in this system the beneficiaries shall be duly notified.

In case of routine or elective hospitalization of non-emergency nature - follow the below process to avail benefits as per Su-Swastha Yojna

1. Visit Su-Swastha website www.suswasthasikkim.com and explore the list of empaneled hospitals and their services
2. Call on Su-Swastha Facilitation Center Helpline for assistance and enquiries regarding the hospitals in Su-Swastha’ s preferred provider network
3. Make an appointment or directly visit empaneled hospital
4. For elective hospitalizations, the hospital shall make an online pre-authorization request which shall be approved by Su-Swastha Facilitation Center
5. Based on this pre-authorization the member can be admitted on a cashless basis with the hospital and receive further treatment
6. Upon discharge, the member settles all charges directly with hospitals corresponding to charges incurred which are not covered in Su-Swastha Yojna- see list of exclusions
7. The hospital settles all covered charges by raising a claim – these charges are paid directly by Dept of Health and Family Welfare as per agreement with hospital.

In case of emergency hospitalizations- follow the below process to avail benefits as per Su-Swastha Yojna

1. Visit any hospital as an emergency
2. Within 24 hours of admission inform Su-Swastha Facilitation Center
3. Su-Swastha approval letter to be submitted to hospital
4. Hospital can choose to provide cashless services in which case the rest of process is as per cashless process described above.
5. Hospital opts out of cashless services, employee settles bill with hospital directly and raises a claim for reimbursement with Su-Swastha on the online web portal to be accessed via website or app.

No, the scheme is valid only till the time you are in employed with the Government. Also, if the primary member has exited the scheme due to causes including but not limited to death, retirement, termination or resignation, the cover of benefit for dependents automatically stops.

When both spouses are government regular employees they can choose to enrol separately as primary member of Su-Swastha Yojna OR as dependent on the other spouse. However, an employee cannot be enrolled as a primary and dependent at the same time.

In this case you will have to make the payment from your own pocket and apply for reimbursement through Su-Swastha. See Question number 12 above.

No, please see the dependent eligibility section on www.suswasthasikkim.com or in the FAQ section.

Yes, you can add your parents or your parents-in-law as dependent.

The total coverage per family is only rupees ten lakhs (10 lacs0

If you have noted down your id number, the id number should suffice the need. We encourage beneficiaries to save both their e-card as well as their member ID in their phone so that they do not have to carry a physical card at all.

You can use one of the following numbers

1. GPF ID
2. CPF ID
3. EPF ID

If you don’t have any of the above IDs please contact your employer for this. Please do not use your employee ID other than above.

Not from Su-Swastha but you may avail the leave and travel allowance from your respective departments subject to their terms and conditions.

Yes, provided you are within the coverage limit and in the empanelled hospital.

Two numbers are issued against each enrolled employee. The policy ID is 1 per family. But every registered person in the family will be provided with their unique Su Swastha member ID Card.

You can simply download one more from the website and save it to your phone or print it on plain paper to use.

A hospital that has signed a MoU with the Govt for providing patients with healthcare facilities under Su-Swastha Yojana is an empaneled hospital. The list of network hospitals will be continuously updated in suswastha.sikkim.gov.in

For availing treatment under the scheme, a beneficiary can go directly to any empaneled hospital or call the helpline before planning a hospitalization at 9800347944.

Cashless care does not cover non-medical expenses or exclusions that are outlined in the scheme document available on website. These costs shall not be reimbursed. But for charges which are included in cashless care, but are paid by patient directly to hospital for any reason shall be reimbursed to employee by employer.

For non-cashless care similarly all medical expenses included in Su-Swastha Yojna shall be reimburses directly by employer. Even in non-cashless care patients will not be reimbursed for charges they have paid but are excluded from the scheme.

Read inclusions and exclusions of Su-Swastha Yojna carefully on our website or call or WhatsApp at 9800347944.

In case the amount ensured under Su Swastha Yojana gets exhausted, the beneficiary will have to bear the extra cost on their own expense.

In case of any queries or grievance, a beneficiary can use below channels-

1. Whatsapp or call 9800347944
2. Email us at support@suswasthasikkim.com
3. Raise a complain or provide a feedback to us on our website
4. Visit our office at Su-Swastha Yojna Facilitation Center at first floor, Old STNM Hospital, Near MG Marg, Gangtok, Sikkim

Yes, hospitals typically will charge an advance for planned treatment at time of admission, or within 24 hours for emergency care. They will also raise a bill for items which are excluded from Su-Swastha Yojna- read carefully inclusions and exclusions of Su-Swastha Yojna on our website. Call or WhatsApp on 9800347944 for any clarifications.

At the time of Hospitalization within and outside Sikkim, the Beneficiary will need to show his/her Su-Swastha Card along with one ID Proof (Aadhar Card/Voter ID / PAN card / Driver’s License etc.)

Below are the list of exclusions which are not covered under the cashless scheme of Su-Swastha Yojna:

1. Advances of any amount are not covered in Su-Swastha Yojna
2. Intentional self-injury
3. Use of intoxicating substances, substance abuse, drugs / alcohol, smoking and tobacco chewing and illnesses resulting due to such abuse
4. Venereal Disease and Sexually Transmitted Diseases
5. Injury/disease directly or indirectly caused by or arising from or attributable to war, invasion, act of foreign enemy, warlike operations (whether war be declared or not)
6. Injury or disease directly or indirectly caused by or contributed to by nuclear weapons/materials
7. Expenses incurred on weight control services including surgical procedures such as Bariatric Surgery and /or medical treatment of obesity
8. Expenses incurred on High Intensity Focused Ultra Sound, Uterine Fibroid Embolisation, Balloon Sinoplasty, Enhanced External Counter Pulsation Therapy and related therapies, Chelation therapy, Deep Brain Stimulation, Hyperbaric Oxygen Therapy, Rotational Field Quantum Magnetic Resonance Therapy, VAX-D, Low level laser therapy, Photodynamic therapy and such other therapies similar to those mentioned under this exclusion due to their experimental nature or lack of proven efficacy or scientific evidence.
9. Charges incurred on diagnostics that are not consistent with the treatment for which the insured is admitted in the hospital / nursing home.
10. Admission primarily for diagnostic purpose with no positive existence of sickness / disease / ailment / injury and no further treatment is indicated.
11. Items for post-operative home based therapies and aides such as crutches ,wheel chairs cushions and walking sticks, braces, oxygen cylinder and accessories for use of residence and other aids of similar nature are excluded.
12. Expenses on vitamins and tonics unless forming part of treatment for injury or disease as certified by the attending Physician of the hospital where the insured underwent treatment.
13. Cosmetics, diapers, oral hygiene products, talcum powder and toiletries.
14. Unconventional, Untested, Unproven, Experimental therapies.
15. Stem cell Therapy, Autologous derived Stromal vascular fraction, Chondrocyte Implantation, Procedures using Platelet Rich plasma and Intra articular injection therapy.
16. Oral Chemotherapy, Immuno-therapy and Biologicals, except when administered as an in-patient, when clinically indicated and hospitalization warranted.
17. All types of Cosmetic, Aesthetic treatment of any description, all treatment for Priapism and erectile dysfunctions, Change of Sex etc.
18. Plastic surgery (other than as necessitated due to an accident or as a part of any illness)
19. Hospital record charges and such other charges
20. Inoculation or Vaccination (except for post–bite treatment and for medical treatment for therapeutic reasons).
21. Dental treatment or surgery (more than what is specifically provided) unless necessitated due to accidental injuries and requiring hospitalization.
22. Hospital registration charges, admission charges, telephone charges and such other charges
23. Any hospitalizations which are not Medically Necessary / does not warrant Hospitalization
24. Other Excluded Expenses as detailed and periodically revised as in the website www.suswasthasikkim.com
25. Any claim arising out of Accidents that the beneficiary has caused intentionally or by committing a crime / involved in it or because of / in a state of drunkenness or addiction (drugs, alcohol).
26. Pre-hospitalization Expenses are NOT admissible by Su-Swastha unless they are included in the package of a procedure defined and agreed upon with the hospital during empanelment contracting. When
pre-hospitalization is included in the package of admission and procedure, no separate bill or invoice can be raised by hospital or beneficiary member against such pre-hospitalization expenses.
27. Beneficiary engaging in Air Travel unless he/she flies as a fare-paying passenger on an aircraft properly licensed to carry passengers. For this exclusion Air Travel means being in or on or boarding an aircraft for the purpose of flying therein or alighting there from.
28. Travelling Allowance for attendant, patient, escort shall not be covered by Su-Swastha Yojna. Such allowances may be covered by other Rules of Government of Sikkim. Please reach your employer for same.
29. Accidents that are results of war and warlike occurrence or invasion, acts of foreign enemies, hostilities, civil war, rebellion, insurrection, civil commotion assuming the proportions of or amounting to an uprising, military or usurped power, seizure capture arrest restraints detainments of all kings princes and people of whatever nation, condition or quality whatsoever.
30. Participation in riots, confiscation or nationalization or requisition of or destruction of or damage to property by or under the order of any government or local authority.
31. Any claim resulting or arising from or any consequential loss directly or indirectly caused by or contributed to or arising from:
32. Ionizing radiation or contamination by radioactivity from any nuclear fuel or from any nuclear waste from the combustion of nuclear fuel or from any nuclear waste from combustion (including any self-sustaining process of nuclear fission) of nuclear fuel.
33. Nuclear weapons material-The radioactive, toxic, explosive, or other hazardous properties of any explosive nuclear assembly or nuclear component thereof.
34. Nuclear, chemical, and biological terrorism
35. Any claim arising out of sporting activities in so far as they involve the training or participation in competitions of professional or semi-professional sports persons.
36. Participation in Hazardous Sport / Hazardous Activities
37. Any loss arising out of the Insured Person's actual or attempted commission of or willful participation in an illegal act or any violation or attempted violation of the law.
38. Any payment in case of more than one claim under the policy during the period of enrolment by which the maximum liability of the Govt of Sikkim in that period would exceed the amount specified in the Su-Swastha limit
39. Any claim for Death or Permanent Total Disablement of the beneficiary shall be excluded from Su-Swastha benefits- Su-Swastha is a scheme to pay for healthcare expenses incurred in hospitalization and not for damages paid for disability or death

Su-Swastha Facilitation Center
1st Floor
Old STNM Hospital
Gangtok, Sikkim 737101