wbhealthscheme.gov.in : Guidelines For Medical Treatment & Claims Settlement Under West Bengal Health Scheme

Name of the Organization : Government of West Bengal
Type of Facility : Guidelines For Medical Treatment & Claims Settlement Under West Bengal Health Scheme
Location: West Bengal

Website : http://wbhealthscheme.gov.in/First_page.aspx

West Bengal Health Scheme:
Guidelines For Medical Treatment :
1. Receive treatment in an empanelled hospital/ Government hospital, i.e. recognized hospitals under the Health Scheme.
2. Show Health Scheme Identity Card while receiving medical treatment in recognized hospital/ diagnostic centre. Give a photo-copy of the Identity Card to the hospital/ diagnostic centre.
3. Register address of the Head of Office/ Pension Sanctioning Authority including telephone number at the time of admission for indoor treatment.
4. Inform your office within three days of commencement of indoor medical attendance and treatment.
5. Check whether your identification number has been mentioned in the hospital bill.
6. Check whether code no.s of all the procedures/ investigations have been mentioned in the bill.
7. Check whether bill for surgical procedure has been furnished following package rate with code.
8. In case of indoor treatment prefer claim for reimbursement within three months from the date of discharge.
9. In case of O.P.D. treatment prefer claim for reimbursement within three months of every consultation or purchase of medicines, etc.

10. Take permission of the West Bengal Health Scheme Authority before:-
(a) Human Organ Transplantation;
(b) Cochlear Implant Surgery;
(c) Implantation of Dual Chamber Pacemaker;
(d) Implantation of more than one Drug Eluting Stents;
(e) Implantation of more than two Stents;
(f) Implantation of AICD/ CRT with AICD;
(g) Implantation of Neuro implants, viz., Deep Brain Stimulator Implants, Intra- Thecal Pumps, Spinal Chord Stimulators;
(h) Digital Hearing Aid, etc.

11. Take permission of the West Bengal Health Scheme Authority before treatment in a Speciality hospital outside the State.
12. In case of over-billing and/or unnecessary procedures if done by a Health Care Organisation, bring the same to the notice of the Hospital Authority within 15 days of discharge.

13. For medical treatment of Government employee and their family members use the following Forms of Essentiality Certificates:-
(a) O.P.D. treatment under Clause-7 of the Health Scheme- Form D 1
(b) Indoor treatment and related O.P.D. treatment under Clause-6 & 9 of the Health Scheme- Form D 2
(c) Medical treatment done in non-empanelled hospital/ nursing home – Form D 3.

14. For medical treatment of Government pensioners and their family members, use the following Forms of Essentiality Certificates:-
(a) O.P.D. treatment under Clause-7 of the Health Scheme- Form IV 1
(b) Indoor treatment and related O.P.D. treatment under Clause-6 & 9 of the Health Scheme- Form IV 2
(c) Medical treatment done in non-empanelled hospital/ nursing home – Form IV 3

After examining a claim under the Health Scheme the Sanctioning Authority should issue order sanctioning the maximum admissible amount as per approved rates.

The G.O. should contain the following informations:
(1) Name of the Government employee/ pensioner with identification number,
(2) Name of the patient,
(3) Name of recognized Hospital under the Health Scheme with code no.
(4) Name of disease,
(5) Period of treatment,

(6) Package Code for surgical procedure. While issuing an order of reimbursement the Sanctioning Authority should consider the following matters:-
(a) “Package” is applicable for surgery in empanelled private hospitals/nursing homes/ non-empanelled private hospitals/nursing homes.
(b) Cost of medical treatment in Govt. Hospital, Local Bodies managed hospitals and aided institutions may be reimbursed adding bed rent, doctor’s visit, investigation charges, medicines and implants. Approved rate is the maximum ceiling.
(c) Cost of medical treatment done in speciality hospital outside the State may be reimbursed on actual basis.
(d) Air fare is not admissible under the Health Scheme.
(e) Mainly Cancer cases are considered as ‘Malignant diseases’ under Clause- 7 (1)(i) of the Health Scheme.
(f) Type-2 Diabetic Melitas is not considered as ‘Insulin-dependent Diabetes’ under Clause-7 (1)(iv) of the Health Scheme.
(g) Guidelines of F.D.memo nos. 797-F(MED) dt. 31-1-11, 3474-F dt. 11-5- 2009 and provisions of the Health Scheme have been consulted.
(h) Guidelines of F.D. Notification No. 10539-F (MED), dt. 21-11-2011 have been consulted for medical treatment in non-empanelled pvt. Hospital/ nursing home.

Settlement Of Claims:
The application made under Para-11 for reimbursement of the costs shall be processed by the concerned department, the Directorate or the office, as the case may be, under which the pensioner last worked. Provisions of the Clause-13 of the West Bengal Health Scheme, 2008 shall be applicable for the pensioners. The expenditure shall be met from the head “2071- Pension and other Retirement Benefits- 01- 800- NP-002- 12- Medical Reimbursement under the West Bengal Health Scheme, 2008” under the Demand No-18.

While settling a claim following guidelines may be followed:-
(i) For treatment within the State in Government hospital/ Govt. aided hospital or recognized Private hospitals/ Institutions, etc as (as mentioned at Annexure-A of the Notification No. 3473 F dt. 11.05.09.) cost of treatment may be reimbursed on the basis of approved rates given in Annexure-B of the Notification No. 3473 F dt. 11.05.09. or the actual cost whichever is less. Class of the Service Provider (Hospitals/ diagnostic centres, etc.) shall be taken into account for reimbursement of the costs. If the rates quoted by the hospitals/diagnostic centres are lower than the ceiling rates given in Annexure- B the reimbursement may be allowed on that lower rates
(ii) No reimbursement shall be allowed for treatment taken from unrecognized Private hospitals/ diagnostic centres.
(iii) Costs of medicines are reimbursable in full except preparations classified as food, tonic, vitamin, disinfectant, toiletry, cosmetic items and telephone charges. Charges for pathological and radiological investigations are also reimbursible if not included in package rate. Cost of devices, implants, etc. are also reimbursible.
(iv) Special Nursing/ Aya/ Attendant charges are reimbursible in full.
(v) Blood transfusion charges are reimbursible in full but cost of blood is to be reimbursed as per State Govt. Hospital rates.

Helpline :
For any queries or problems mail us at support.wbmedicalcell@nic.in

Our helpline number is (033)2254-4123/(033)2254-4034.help line line number is available from monday to friday between 11:00a.m – 4:00p:m

Applicants are requested to register themselves online during office hours only(from monday to friday between 11:00a.m – 4:00p:m) so that they can avail help from our end.