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Clarifications of Cashless Medical Treatment Scheme, 2014

Whether Government Employee/ Pensioner and their eligible dependent members of the family can avail reimbursement facility with the ‘Certificate of Enrolment’ generated from Health Scheme Portal?

For any query, ask here: Clarifications of Cashless Medical Treatment Scheme, 2014

Government of West Bengal
Finance Department
Medical Cell

No. 884-F(Med)WB Date: 31.07.2015

Memorandum

Consequent upon implementation of West Bengal Health For All Employees and Pensioner Cashless Medical Treatment Scheme, 2014 (hereinafter called the said scheme) w.e.f 15.09.2014; requests for clarifications of some of the points laid down in the scheme are being received 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 on the points for information and guidance of all concerned:

SL NO. Points of Doubt Clarifications
1. Whether Government Employee/ Pensioner and their eligible dependent members of the family can avail reimbursement facility with the ‘Certificate of Enrolment’ generated from Health Scheme Portal of West Bengal Health For All Employees and Pensioners Cashless Medical Treatment Scheme, 2014 ? The Government Employees/ Pensioners and their eligible dependent member of the family enrolled under the said scheme will be entitled to all the benefits of the WBHS 2008 plus additional benefit of cashless treatment upto Rupees One Lakh Only. So, the ‘Certificate of Enrolment’ generated for the said scheme will be valid for both Cashless Treatment and Reimbursement treatmenti) Cashless Treatment:- Approved indoor package/ non- package treatment cost of which upto Rs One lac only will be covered under cashless mode of treatment in private empanelled HCO.ii) Reimbursement Treatment:- (a) OPD treatment as stipulated in clause 7(1) of WBHS, 2008, (b) Indoor treatment (Not covered by Cashless treatment), (c) Indoor treatment at Government Hospitals, Municipal Hospitals, and State aided Hospitals (d) Indoor/ Day Care treatment in Non-empanelled HCO within this state (e) Treatments at Specialty Hospitals outside the state subject to observance of cl 14 of WBHS 2008.

 

System generated “Certificate of Enrolment” under the said scheme duly authenticated by the seal and signature of the concerned DDO will serve as Health Card till formal Health Cards are issued. Government Employee/ Pensioner may avail both Cashless treatment and Reimbursement Treatment on producing this “Certificate of Enrolment” to the HCO.

2. Whether patient discharge on Risk Bond can avail cashless treatment in empanelled H.C.O? No Cashless Treatment will be available from the HCO in case of discharge on Risk Bond, only reimbursement treatment will be available and Transaction ID generated at the time of admission will be cancelled by the concerned HCO after putting the value zero in place of Total Treatment cost in Form-H.However, Govt Employee/ Pensioner will prefer reimbursement claim as usual for that treatment.
3. Who will sign over different forms in case of death of Government Employee /Pensioner during Cashless treatment at empanelled HCO ? Empanelled HCO will submit Death Certificate of Government Employee/ Pensioner and the relevant forms will be signed by the near relative of the Govt. Employee/ Pensioner preferably dependent member of the family of Govt Employee/ Pensioner.
4. What will happen if empanelled HCO fails to provide cashless treatment due to reason as mentioned in sl 2 and various other unavoidable reason? Under any unavoidable circumstances if empanelled HCO fails to provide cashless treatment then the concerned HCO will provide declaration mentioning clearly the reason behind not providing cashless treatment and not submitting that particular claim as cashless case in online in Health Scheme Portal.The concerned Govt Employee/ Pensioner will also submit a declaration to the Head of Office/ DDO during submission of Claim that he/ she has not availed any cashless facility for that particular period of treatment received in the empanelled HCO.
5. What are the responsibility of the Government Employee/ Pensioner under the said Scheme ? If any claim is found false/ not true/ not necessary at any point of time, the concerned beneficiary will be proceeded against under existing provision of law including W. B. S. (C.C.A) Rules, 1971 for the time being in force as well as the benefit availed of by him/ her or the benefit accrued to him/ her shall be summarily cancelled and excess drawal amount will be recovered in one lump from the concerned beneficiaries.
6. What will happen if the following situation happens i.e. there is no internet connectivity, Server Error in Health Scheme Portal, late night admission, patient reached HCO in emergency without Certificate of Enrolment ? In all those situations, treatment may start on the basis of advice of treating doctors of the concerned HCO but the Patient Admission Information (Cashless Treatment) may be uploaded within 24 hrs from the actual time of admission with proper justification to be uploaded in the Health Scheme Portal from the concerned HCO and the copy of the said justification to be attached with the final bill when submitted for settlement of the cashless claim.
7. Whether any kind of Health Check up, Routine Investigations are allowed in reimbursement, Cashless scheme? No, Health Check up, Routine Investigations are not allowed in the said scheme.

By order of the Governor,

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

No. 884-F dated 31.07.2015, Source