Guidelines for settlement of claims

An eligible Govt. employee under the West Bengal Health Scheme, 2008 should make an application to the concerned authority as mentioned in Clause-12 of the Scheme preferring claim for reimbursement of medical expenditure and settlement of advance, if any, within the specified period of three months of the completion of treatment. The respective Department, the Directorate or the office, as the case may be, to which the employee is attached shall examine and settle the medical claim following Clause-13 of the Scheme. The expenditure shall be met from the head “12- Medical Reimbursement under the West Bengal Health Scheme, 2008” subordinate to the concerned head of account under which his/ her salary is drawn. While settling a claim following guidelines may be followed:

(i) For treatment within the State in Govt. hospital/ Govt. aided hospital or recognised Private hospitals vide Annexure-A of the Finance Department notification no. 3473 F dt. 11.05.09 the treatment- cost may be reimbursed on the basis of approved rates given in Annexure- B of the Finance Department notification no. 3473 F dt. 11.05.09 or the actual cost, whichever is less. Class of the Service Provider (Hospitals/ Diagnostic Centres) should be taken into account for reimbursement of the costs.

All the Private hospitals/ diagnostic centres mentioned in Annexure-‘A’ have signed agreement on the basis of Memorandum of Agreement (MOA) (copy of MOA attached at Annexure-C) with the Authority of the West Bengal Health Scheme under the Finance Department, Govt. of West Bengal about recognition and the rates for various medical procedures/ tests/ investigations. The MOA signed with the hospitals also includes the ceiling rates quoted/ offered by the hospital/ diagnostic centre. If the rates quoted by the hospital are lower than the ceiling rates given in Annexure-B, the reimbursement may be allowed on that lower rates.

(ii) No consultation with the Health and Family Welfare Department and the Finance Department will be necessary for reimbursement of the cost of treatment as indoor patient or as outdoor patient in the recognized hospitals.

(iii) No reimbursement may be allowed for treatment taken from unrecognized Private hospitals/ Nursing homes.

(iv) Cost of medicines are reimbursable in full except preparations classified as food, tonics, vitamins, disinfectants, toilet preparations, cosmetic items, telephone calls, etc. Charges for pathological and radiological investigations, cost of devices, implants, etc. as are considered essential and not included in the Package are reimbursable in full.

(v) Special nursing/ Aya/ Attendant charges are reimbursable in full.

(vi) Blood transfusion charges are reimbursable in full but cost of blood is reimbursable as per State Govt. Hospital rate.

(vii) Where an eligible Govt. employee has taken a Medical Insurance Policy would be allowed to claim reimbursement of medical expenses both from insurance company as well as the West Bengal Health Scheme, 2008 subject to the observance of the following procedure:

A medical claim against the original vouchers/ cash-memos would be raised by the employee first from the insurance company who would issue a certificate to the Cadre Controlling Authority/ Head of Office of the amount reimbursed to the employee. He would then prefer his medical claim along with photo copies of vouchers/ cash-memos to the concerned office. The Cadre Controlling Authority/ Head of Office would then reimburse to the employee only the balance admissible amount on the basis of approved rates i.e., admissible amount minus the amount reimbursed by the insurance company.