e West Bengal Health Scheme, 2008 came into effect from 01-06-2009. Now, the cost
of medical treatment in non-empanelled private Health Care Organisation is also
reimbursable under certain conditions. Request for clarifications of some points
laid down in the said Scheme after its amendments are being received by this department
from various corners.
After careful consideration of the matter, the undersigned is directed by order
of the Governor to offer the following para-wise clarifications for information
and guidance of all concerned.
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Sl.No.
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ISSUES
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CLARIFICATIONS
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1.
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Employees/ pensioners enrolled under the West Bengal Health Scheme, 2008 and their
dependent family members availing themselves of the medical treatment in non- empanelled
private hospitals/ nursing homes prior to issue of the Notification No. 10539-F
(MED), dt. 21-11-2011.
Whether the costs of such medical treatment will be reimbursed?
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Eligible for the benefits of the Scheme as per the prescribed scale as notified
under Order No. 10539-F (MED), dt. 21- 11-2011 for indoor treatment only w.e.f.
the date of their enrolment under the Scheme. Such cases are to be settled with
approval of the Secretary of the Administrative Department.
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2.
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For medical treatment in non-empanelled private hospital/ nursing home, cost of
packages, bed rent, investigation charges, doctor’s fee, implants, etc. are
reimbursable up to 80% or 60%, as the case may be, of approved rates under the Health
Scheme on the basis of bed capacity of the hospital/ nursing home under Notification
No. 10539-F (MED), dt. 21-11-2011.
What will be reimbursable rate for the medicines and consumables?
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Cost of admissible medicines and consumables will be reimbursed up to 80% or 60%
of the actual costs, as the case may be.
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3.
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Employees/ pensioners enrolled under the West Bengal Health Scheme, 2008 and their
dependent family members availing themselves of the medical treatment in private
hospitals/ nursing homes that were empanelled initially but it became non- empanelled
for a short period due to expiry of contract and then the contract was renewed and
it became empanelled under the Health Scheme again.
Whether the costs of medical treatment done during the non-empanelled period will
be reimbursed?
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Reimbursement of costs of such medical treatment may be allowed under the Scheme
as per the class of the private hospital after its renewal.
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4.
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Employees/ pensioners not taken approval of
the West Bengal Health Scheme Authority
under Finance Department and received
medical treatment in a non-empanelled
private hospital/ nursing home outside the
State.
Whether the costs of such medical treatment
will be reimbursed?
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Not eligible for the benefits of
the Scheme for reimbursement
of the costs as they availed
themselves of the treatment
without approval of the West
Bengal Health Scheme
Authority and as per their own
volition.
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5.
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Employees/ pensioners not taken approval of
the West Bengal Health Scheme Authority
under Finance Department and received
medical treatment in a speciality hospital
outside the State (excluding the cases where
procedural delay in according approval is
involved).
Whether the costs of such medical treatment
will be reimbursed?
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Not eligible for
reimbursement of the costs
under the Scheme as they
availed themselves of the
treatment without approval of
the West Bengal Health
Scheme Authority.
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6. |
State Government employees who were
enrolled under West Bengal Health Scheme,
2008 while in service, are eligible for the
benefits of the Health Scheme as pensioners
from the day next to the date of their
retirement. (vide Notification No. 8219-F
(MED), dt. 19-08-2011)
Whether the family pensioners are eligible for
getting the benefits of the Health Scheme
immediately after death of the Government
employee/ Government pensioners enrolled
under the Scheme?
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YES
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