Government of West Bengal
No. 797-F (MED) dt. 31-01-2011
In partial modification of the memorandum no. 3474-F dt. 11-05-2009 the Governor is pleased to publish the following guidelines for settlement of claims under the West Bengal Health Scheme, 2008:-
2. For surgical cases reimbursable amount should be calculated following Package rates. Where there is no Package rate for a particular procedure, reimbursement may be made following Package rate of identical procedure.
3. For non-surgical cases, reimbursable amount may be calculated adding charges for doctor’s visit, bed, investigations, medicines, consumables etc. as per approved rates.
4. Treatment charges for new-born baby are separately reimbursable in addition to delivery charges of the mother. Baby is entitled to get treatment on the basis of identity card of parents up to six months of age. A separate identity card under the Health Scheme should be obtained within that period.
5. Costs of implants/ prostheses are reimbursable as per the approved rates or as per actuals whichever is less. Where there is no approved ceiling rate, actual cost may be reimbursed.
6. If one or more procedures form part of a major treatment procedure, then full package charge would be permissible for the major procedure only and 60% of charge for minor procedures.
7. If any Government employee/ pensioner or beneficiary is admitted in a recognized hospital on emergency basis, cost of medical attendance and treatment before the ‘Package period’ may be reimbursed adding bed rent , investigation charges, cost of medicines, doctor’s visit, consumables etc.
8. ‘Package’ starts from the previous day of surgery and during ‘Package period’ bed rent, doctor’s fees, investigations, medicine charges, etc., are not reimbursable.
9. Duration of indoor treatment under Package has been mentioned in Annexure-I of the notification no. 796-F (MED) dt. 31.01.2011. No additional charge on account of extended period of stay shall be reimbursable if that extension is due to infection on the consequence of surgical procedure or due to any improper procedure and is not justified. The Sanctioning Authorities should carefully examine such cases on the basis of doctor’s note.
10. Charges for MRI, CT Scan, Endoscopy, Colonoscopy, Ultrasonography, ERCP, Sigmoidoscopy are reimbursable for any disease on the basis of OPD prescription of any recognized hospital. Investigations done in Joint Venture diagnostic centres situated in the Government hospital campuses are reimbursable under the Health Scheme if otherwise admissible.
11. Cost of artificial appliances e.g. dentures, spectacles, contact lens, etc. are not reimbursable.
12. Ambulance charge is not reimbursable.
13. Charges for administering injection/ wound dressing/ Physiotherapy at residence are not reimbursable.
14. Prior permission of the West Bengal Health Scheme Authority will be required for Human Organ Transplantation, Cochlear implant Surgery; implantation of Dual-Chamber Pacemaker, more than two Stents, more than one Drug-Eluting Stents, AICD, CRT with AICD, Neuro implants, viz. Deep Brain Stimulator Implants, Intra-thecal Pumps, Spinal Cord Stimulators; costly devices like digital hearing aid, etc. and for treatment in a Speciality hospital outside the State.
15. Under Clause 2(5) of the Health Scheme an employee has liberty to opt out of the Scheme. As there is no provision for re-enrolment under the Scheme such opt out employee/ pensioner will not get re-entry in the Scheme.
16. Where there is no approved rate of a procedure/ investigation, actual cost may be reimbursed for medical treatment done in a recognized Hospital/ Nursing Home up to 31.01.2011.
17. In the case of death of a Government employee/ pensioner if hospital dues remain unsettled, the hospital authority may send bills to the concerned office. The office shall take necessary steps for payment of the hospital dues.
18. Each and every office shall examine and settle the cases under the West Bengal Health Scheme, 2008 on top priority basis. Any over-billing and unnecessary procedures, if done, should be brought to the notice of the Health Care Organisations within 15 days. For any clarification on a particular case, reference should be made to the Medical Cell, Finance Department within 30 days of discharge from the recognized Hospital/ Nursing Home.
19. Diagnostic centres have entered into agreement under the West Bengal Health Scheme, 2008 for rendering diagnostic facilities only. Reimbursement of the costs of treatment prescribed by any doctor of Polyclinic run by diagnostic centres or any private doctor is not admissible under the Health Scheme.
20. Extra charges for collecting sample for diagnostic investigations are not reimbursable.
21. Beneficiaries under the Health Scheme may avail treatment facilities at any recognized Hospital/ Nursing Home/ Diagnostic Centre at his/ her choice within the State.
22. ‘Medical record’ charge is not reimbursable.
23. No reimbursement shall be allowed for treatment/ services taken from nonrecognized private hospital/ nursing home/ diagnostic centre except in the following cases:-
(a) Accidental injury,
(b) Acute Appendicitis operation on emergency basis,
(c) Delivery on emergency basis,
(d) Haemodialysis [Rs. 900/- (i.e. 60% of Rs. 1,500/-) per dialysis or actual cost whichever is less],
(e) Removal of foreign body on emergency basis
Costs up to 60% of the approved rates may be reimbursed if medical treatment is done in a non-recognized private hospitals/ nursing homes/ diagnostic centres in the above cases subject to fulfilment of the following terms and conditions:-
(i) The treatment shall be availed only from private hospitals or nursing homes having valid Clinical Establishment licence.
(ii) The treatment shall be availed for emergency conditions only and this shall be certified by the treating doctor in a specific form.
(iii) The reimbursement for such treatment availed shall be sanctioned by the Principal Secretary of the Department to which the beneficiary belongs with prior approval of the West Bengal Health Scheme Authority.
(iv) No advance shall be available.
By order of the Governor,
Officer on Special Duty and Ex-officio
Special Secretary to the Government of West Bengal