Goa - Apply for Compensation Under Family Planning Indemnity Scheme

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Procedure

Apply In-Person:

1. To apply for compensation under Family Planning Indemnity Scheme, the beneficiary must report to the respective health facility where the Family Planning treatment was conducted.
2. Visit the facility and get the Claim form from the relevant authority.
3. Complete the form with appropriate information under each section.
4. After filling the form, make sure to attach all the documents listed in the “Required documents” section of this page.
5. Then, submit it in person to the relevant authority in-charge.
6. The in-charge of the health facility will report the case to the District Indemnity Scheme Committee which is headed by the Collector.
7. The claim will then be verified and sent to the state office for payment.

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Required Documents

• Failure of Sterilization operation documents with original & one set of Xerox copy for payment.
• Claim form.
• Consent form cum Application form for sterilization operation.
• New Sterilization Certificate (in original).
• New case paper.
• Admit paper.
• Discharge card.
• Old case paper.
• Old Ligation certificate (in original).
• Aadhaar card & Election card of both husband & wife.
• Birth certificate of both the child.
• Bank details with 2 photo copies of beneficiary.

Office Locations & Contacts

Department of (H&FW) Government of Goa,
Secretariat,Pororim, Goa - 403521
Tele off : 0832-2419405
Mobile : 9999533859
E-mail : [email protected]
Website Link
State wise Health Department portals Link Please click on the relevant State name to view the Directorate of Health homepage.
Department of Health &Family Welfare Contacts Link

Eligibility

Under the FPIS, beneficiaries who satisfy any one of the following criteria can apply for corresponding compensation:

• Death following sterilization (inclusive of death during process of sterilization operation) in hospital or within 7 days from the date of discharge from the hospital.
• Death following sterilization within 8 - 30 days from the date of discharge from the hospital.
• Failure of sterilization.
• Cost of treatment in hospital and up to 60 days arising out of complication following sterilization operation inclusive of complication during process of sterilization operation from the date of discharge.

Fees

No fees is required to apply for compensation.

Validity

Explain the time until which the certificate/document is valid.
e.g. Birth Certificate Valid Forever

Documents to Use

Click on the link to view Claim Form Link Please scroll down to page 33.

Sample Documents

Please attach sample completed documents that would help other people.

Processing Time

The stipulated time limit for settlement of claims would be 15 working days in case of death and 21 days in case of others, after completion of processing.

Related Videos

Videos explaining the procedure or to fill the applications.
Attach videos using the following tag <&video type='website'>video ID|width|height<&/video&>
from external websites.
Please remove the '&' inside the tags during implementation.
Website = allocine, blip, dailymotion, facebook, gametrailers, googlevideo, html5, metacafe, myspace, revver,
sevenload, viddler, vimeo, youku, youtube
width = 560, height = 340, Video ID = Can be obtained from the URL of webpage where the video is displayed.
e.g In the following url 'http://www.youtube.com/watch?v=Y0US7oR_t3M' Video ID is 'Y0US7oR_t3M'.

Instructions

• The claims will fall within the “Family Planning Indemnity Scheme” only if the beneficiary files the claim with the DISC within 90 days from the occurrence of the event of death/ failure/complication.

Required Information

• Claim Number
• Details of the Claimant
• Details of the person undergone sterilization operation
• Occupation/Business
• Details of Dependent children
• Date of Sterilization Operation
• Nature of Sterilization operation
• Name and address of the doctor who conducted the operation
• Name and address of the hospital where operation was conducted
• Nature of claim
• Details of any disease suffered by beneficiary prior to undergoing sterilization operation
• Date
• Place
• Name of the Claimant
• Signature/Thumb impression of the Claimant

Need for the Document

The procedure is required to claim compensation for Death/Failure/Complication following sterilization operation.

Information which might help

• The Family Planning Indemnity Scheme has all India coverage.
• All persons undergoing/undergone sterilization operations in public health facility and health facilities of non-government and private sectors empanelled/accredited with District Health Authority are covered under Section- I–A, I-B, I-C and I-D of the scheme.
• Please click on the following link to view the manual for FPIS Link

Other uses of the Document/Certificate

Please explain what are other uses of obtaining this document/certificate.
e.g. Birth Certificate can be used as proof of identity.

External Links

Place some external links which might help.

Others

More information which might help people.