Cashless Medical Treatment – Agreement of Finance Dte & HCO

Government of West Bengal
Finance Department
Nabanna, Howrah

No. 4803-F (MED) Dated: 12.09.2014

MEMORANDUM

In continuation to the recently notified West Bengal Health for All Employees and Pensioners Cashless Medical Treatment Scheme, 2014 vide notification no. 4476-F(MED.) dt. 28.8.2014 read with Notification No 4656-F(MED) dated 05-09-2014 regarding cashless medical treatment facility upto Rupees one lakh only to State Government officers and employees, State Government pensioners including family pensioners, All India Service (AIS) officers, AIS pensioners including family pensioners, and their eligible family members in private empanelled hospitals within the State and the NCR Delhi and in view of immediate implementation, it has been further decided the payment procedure, of the existing Agreements with the Health Care Organisations (HCOs) will be treated to be substituted by the new procedure as given below. This will continue to be in vogue till fresh agreement with HCOs is made.

2. Governor is, therefore, pleased to direct that Clause 14 of the Agreement already in existence between HCOs and the Finance Department for providing medical attendance and treatment to the beneficiaries under the WBHS 2008 be treated as substituted with the following:-

14. PAYMENT

14.1 The following procedures will have to be followed to provide cashless medical treatment facility to the eligible beneficiaries up to a ceiling of Rupees one lakh only.

14.2 The Government Employees/Pensioners and their eligible dependent(s) enrolled under the scheme will be entitled to all the benefits of the WBHS 2008 plus additional benefit of Cashless treatment upto Rupees One Lakh provided the Employee/ Pensioner enrolls himself/herself online as per the procedure mentioned in said notification and will be made available from 15-09-2014 on http://wbfin.nic.in.

14.3 The concerned employees/pensioners including family pensioners would enroll themselves from 15-09-2014 on Health Scheme portal of the aforesaid website of this Department. Respective DDO of the department/office would issue enrolment certificate under his seal and signature through online procedure as mentioned in the aforesaid notification 4656-F(MED)dated 05-09-2014 of this department. This will serve as Health Card till such time formal Health Cards are issued.

14.4 The beneficiary would produce this enrolment certificate before the approved Health Care Organisation (HCO) (website of Finance Department may be consulted for up to date approved list of such HCOs) for undergoing cashless medical treatment as provided in the West Bengal Health for All Employees and Pensioners Cashless Medical Treatment Scheme, 2014.

14.5 For undergoing cashless indoor medical treatment no advance authorization will be required by the HCO. On production of the enrolment certificate by the beneficiary, the HCO will login to the aforementioned website for verification of the enrolment. After being satisfied that the beneficiary is enrolled, the medical treatment will be extended in terms of the provisions of West Bengal Health for All Employees and Pensioners Cashless Medical Treatment Scheme, 2014, as amended.

14.6 On admission of the beneficiary, a written estimate of the expected bill shall be handed over in case the expenditure exceeds Rupees one lakh. Whenever there is a change of setting requiring the escalation of this estimate, a fresh estimate shall be given to the patient/patient party within 24 hours.

14.7 No charges of would be realized from the beneficiary enrolled under the present scheme up to Rupees one lakh. Where charges for treatment as per existing approved rate exceed Rupees one lakh the amount over and above Rupees One lakh would be realized from the beneficiary. At the time of discharge, only a bill showing the charges of treatment as well as the relevant Code No(s) will be handed over to the beneficiary under receipt.

14.8 In case of death of a Government employee/Pensioner, enrolled under the scheme, while receiving indoor treatment in a recognised HCO, if the hospital dues remain unsettled, the hospital authority shall send the bills with necessary treatment papers to the concerned Department for clearance of dues.

14.9 In case of HCOs in Kolkata, the receipted bill along with copies of all prescriptions, reports, bills etc as are ordinarily required to be given by the hospital authority to the patient party for seeking reimbursement in terms of the provisions of WBHS 2008, will now be required to be sent to the respective Government department of the employee/pensioner as per his declaration. The name of the ‘department’ in which the employee is posted immediately prior to his seeking treatment for self or his eligible family member in a HCO will be treated as the ‘department’ for this purpose.

14.10 In case of employees of government offices located in regional offices in the districts, who may seek medical treatment in a HCO located within Kolkata region, the department which administratively controls the office of the employee will be treated as the department for this purpose. The concerned department, after due scrutiny of the bills, will authorize payment to be made to the concerned HCO for the cashless part of the treatment rendered through online procedure to the Medical Cell of the Finance Department. In case of pensioners/family pensioners, the name of the ‘department’ will be the administrative department which controls the PSA.

14.11 In respect of the HCOs of a particular district, the receipted bill along with copies of all prescriptions, reports, bills etc as are ordinarily required to be given by the hospital authority to the patient party for seeking reimbursement in terms of the WBHS 2008, will be required to be sent to the Medical Cell of that District Magistrate for scrutiny and payment. The list of HCOs and the authorities to which the bills are to be sent is given in Annexure to this Notification.

14.12 In respect of bills raised by Kolkata based HCOs, Finance Department (Medical Cell) will release payment and in respect of the HCOs of a district, payment will be released by the District Magistrate to the HCO concerned (maximum of Rupees One Lakh per beneficiary) in a consolidated way. All the payments will be made within one month of receipt of the claims from the HCOs. Payment will be made by bank transfer to the nominated bank account of the HCO after deducting applicable taxes once in a month. An abstract statement of the payment released will be sent by e mail to the HCO by the Finance Department /District Magistrate.

14.13 In respect of HCOs located in the NCR, New Delhi, the procedure relating to districts as mentioned above will be followed mutatis mutandis with the exception that the role of District Magistrate will be substituted by that of the Resident Commissioner, New Delhi.

14.14 If any difficulty arises in the course of implementation of the scheme, it shall be referred to the Finance Department and the decision of the Finance Department thereon shall be final and binding on all the HCOs and the beneficiaries.”

8. Government expects that all HCOs will extend their fullest cooperation in implementation of the new system as detailed above. Unless any objection in writing is received from any HCO it will be presumed that HCOs have agreed to the new modalities as above. If any HCO finds any difficulty in implementing any provision of the new system as enunciated in the notification dt. 28.08.2014 read with notification dt. 5.09.2014, Medical Cell of Finance Department may be consulted immediately for necessary assistance.

Sd/- H.K. Dwivedi
Principal Secretary to the
Government of West Bengal

No. 4803-F dated 12.09.2014, Source