West Bengal Health Scheme for the Beneficiaries of Grant-in-aid Colleges and Universities, 2017

Update: Guidelines in respect of modalities of processing of re-imbursement of claims

Update: Flow chart for settlement of reimbursement of claims

Government of West Bengal
Department of Higher Education, Science and Technology & Biotechnology
Bikash Bhavan, Salt Lake, Kolkata – 700 091

No. 1020-Edn(CS)/1M-01/2017 Date: 29/08/2018

NOTIFICATION

In cancellation of this Department’s Notifications No. 848-Edn(CS) dt. 01.08.2017 and No. 493-Edn(U) dt. 25.05.2018, the Governor is now pleased hereby to provide medical benefits to the serving Teachers including Librarians and Graduate Laboratory Instructors of Government-aided Colleges and serving Teachers and Officers of State aided Universities and the family members thereto in the following manner under the scheme detailed below.
Scheme

1. Short title and commencement

(1) This Scheme may be called “West Bengal Health Scheme for the Beneficiaries of Grant-in-aid Colleges and Universities, 2017”.

(2) It shall come into force on such date, its the State Government may, by notification in the Official Gazette, appoint.

2. Application

(1) This scheme shall apply to the serving teacher including Librarian and Graduate Laboratory Instructors of the Government-aided colleges and serving teachers and officers of State aided Universities and their beneficiaries including Librarian and Graduate Laboratory Instructors.

(2) The provision of enrollment under this scheme shall be optional.

(3) A teacher/ officer shall not be entitled to draw the regular medical allowance, if opted for this scheme, with effect from the date of effect of such enrollment under clause 4.

(4) A teacher/ officer shall have the liberty to opt out of this scheme at any time.

Provided that where a teacher/ officer or his/her beneficiary has enjoyed any benefit under this scheme, such employee shall not be allowed to opt out the scheme within five years from the month following the month in which he/she enjoyed the benefit.

A teacher/ officer enrolled under this scheme shall not be eligible to be enrolled again if he/she opts out of the scheme for whatever reason.

3. Definitions

In this Scheme unless there is anything repugnant in the subject or context-

(a) “approved rates” means such rates as may be notified by the Government from time to time for various services, procedures and investigations required in connection with the medical attendance and treatment of a beneficiary;

(b) “beneficiary” means a dependent member of the family of a serving teacher/officer;

(c) “clause” means a clause of the scheme;

(d) i) “teacher” means a full time and regular serving teacher including Librarian and Graduate Laboratory Instructor of the Government-aided Colleges and State-aided Universities of the Government of West Bengal enrolled under clause 4;

ii) “Officer” means serving officers of the state aided universities enjoying the similar scale of pay as of the teachers.

(e) “family”, in relation to a teacher/ officer, means and includes

(i) Husband or Wife, as the case may be,

(ii) Dependent Parents whose monthly income does not exceed rupees three thousand and five hundred;

(iii) Dependent Children including step-children, children related to half-blood and uterine blood, legally adopted children and unmarried daughters;

(iv) Dependent widowed/ divorced daughters;

(v) Dependent Minor brothers, minor sisters;

(vi) Dependent unmarried/ widowed/ divorced sisters.

Note: (1) ‘Son’ is considered to be dependent till he starts earning or attains the age of 25 years, whichever is earlier. Son suffering from permanent disabilities either physically or mentally will be considered dependent without any age limit.

(2) Unmarried daughter is eligible till she starts earning (irrespective of age).

(3) As an exception, parents can live away from employee in another station with other members of family.

(4) A declaration regarding the income of parents should he furnished by the employee concerned once at the beginning of every calendar year.

(f) “Form” means a Form appended to this scheme;

(g) “Government” means Government of West Bengal in the department of Higher Education, Science & Technology & Bio-technology;

(h) “hospital or institution” means such hospital or nursing home or institution as may be recognised from time to time by the Government for the purpose of availing benefits of medical attendance and treatment under this scheme;

(i) “laboratory” means such laboratory or institution as may he recognized by the Government from time to time for availing of benefits of medical attendance and treatment under this scheme;

(j) “medical attendance” means attendance for professional advice and includes pathological, bacteriological, radiological or other methods of investigations for the purpose of diagnosis which are considered necessary by the attending physician and are carried out in a hospital or institution;

(k) “Specified” means specified by order;

(l) “treatment” means the use of medical and surgical facilities and includes-

(i) the employment of such pathological, bacteriological, radiological or other methods or investigations as are considered necessary by the attending physician;

(ii) the use of such medicines, vaccines, serum or other therapeutic substances as may be considered necessary by the attending physician;

(iii) medical and surgical services and procedures;

(iv) dental treatment;

(v) such nursing as is ordinarily provided at the hospital or such special nursing at the hospital as the authorized medical attending physician at the hospital may certify, in writing, to be essential for the recovery or for the prevention of serious deterioration in the condition of the patient, having regard to the nature of the disease.

4. Facilities

A teacher/ officer or his/her beneficiary shall he entitled to the following facilities, namely:-

(a) medical attendance and treatment as an indoor patient in a hospital or an institution; and

(b) medical attendance and treatment at outpatient department of a hospital or an institution, or a clinic attached to such hospital or institution for such diseases, and under such circumstances, as may be specified.

5. Medical attendance and treatment as an indoor patient in a hospital

A teacher/ officer shall be entitled to reimbursement of the cost of his/her or his/her beneficiary’s medical attendance and treatment, as an indoor patient in a hospital or an institution.

Explanation- For the purpose of this clause, the expression “cost of medical attendance and treatment” shall include –

(a) the amount charged by the hospital or institution in accordance with the approved rates;

(b) the cost of medicines purchased from outside on the advice of the attending physician at the hospital or institution.

(c) the charges for such pathological, bacteriological, radiological or other methods of investigations as are considered necessary by the attending physician and carried out, on the advice of the attending physician, in a laboratory or institution, other than the hospital or institution in which the patient is treated.

6. Medical attendance and treatment as an OPD (Out-Patient Department) patient in it hospital

(1) A teacher/ officer shall be entitled to reimbursement of the cost of his or his beneficiary’s medical attendance and treatment as an OPD patient in a hospital or institution in the following cases –

(i) Malignant diseases, (Mainly cancer cases are considered as Malignant diseases)

(ii) Tuberculosis.

iii) Hepatitis B/C and other liver diseases.

(iv) Insulin-dependent diabetes, (Type-2 Diabetic Mellitas is not considered as Insulin-dependent Diabetes),

(v) Heart diseases,

(vi) Neurological disorders/ Cerebrovascular disorders,

(vii) Malignant malaria,

(viii) Renal failure,

(ix) Thallasaemia/ Bleeding orders/ Platelet disorders,

(x) Injuries caused by accidents. (Animal Bite cases will come under the purview of Injuries caused by the accidents).

(xi) Rheumatoid Arthritis

(xii) Systematic Lupus Erythematous (LUPUS)

(xii) Crohn’s Disease.

(2) A teacher/ officer or his/her beneficiary shall also be entitled to reimbursement of the cost of followup medical attendance and treatment relating to Neuro Surgery, Cardiac Surgery (Including Coronary Angioplasty and Implants), Cancer Surgery/ Chemotherapy/ Radiotherapy, Renal Transplant, Hip/Knee replacement Surgery and Accident cases received as an OPD patient in a hospital or institution.

Explanation- For the purpose of this clause, the expression “cost of medical attendance and treatment” shall include-

(a) the amount charged by the hospital or institution in accordance with the approved rates,

(b) the cost of medicines purchased from outside on the advice of the attending physician at the hospital or institution,

(c) the charges for such pathological, bacteriological, radiological or other methods of investigations as are considered necessary by the amending physician and earned out on the advice of the attending physician in a laboratory or institution, other than the hospital or Institution in which the patient is treated.

7. Enrollment

a) Government-aided College Teachers and State-aided University Teachers & Officers will have to apply online for enrollment in West Bengal Health Scheme Portal of Finance Department’s website: . A new URL will he made available under this portal for beneficiaries of Grant-in-aid Colleges and Universities.

(b) Filled up (uploaded with scanned photo and signature of all beneficiaries) application shall be submitted to the concerned DDO. Concerned DDO shall verify the application and approve/ reject accordingly. If approved, the employee can take system generated printout of Certificate of Enrollment (if required) for each beneficiary. If rejected, the application shall be sent back to the applicant with reason of rejection. This application can be again submitted to the concerned authority after modification. Detailed procedure and guidelines for online application will be provided in the website.

(c) On successful enrollment under the health scheme, the drawal of regular medical allowance shall be discontinued with effect from the the day of the month following the month in which the certificate is issued.

(d) i) The Enrollment of existing teachers/ Officers under the scheme shall be completed within l (one) year from the date of notification of the enrollment process.

ii) If one opts under the scheme and spouse name is included, both husband and wife will be covered under the scheme and both will not be entitled to draw regular medical allowance.

8. Criteria for Reimbursement of Claims

i) Enrolled teachers of Grant-in-aid colleges and teachers/ officers of Grant-in-aid universities will get the facility of medical treatment in Government hospitals, in hospitals managed by local bodies like municipalities, in State-aided hospitals, in selected Specialty hospitals outside the state, in empanelled private hospitals, nursing homes, Institutions, Clinics, Laboratories, Diagnostic centres (commonly called ‘Health Care Organisation’ or HCO) as listed in Finance Department’s Notification No. 3473-F dt. 11.05.09, and as amended from time to time. List of such HCOs will be available in the Heath Scheme portal.

The beneficiaries under this Health Scheme may also avail the indoor medical treatment facilities in any non-empanelled private hospital/nursing home. Reimbursement of the cost of such indoor medical treatment will be made under the Health scheme in the following manner:

a) Cost up to 80% of the West Bengal Health Scheme Approved Rates may be reimbursed for the indoor medical treatment, if availed in a non-empanelled private hospital/nursing home with bed capacity more than 80 (eighty).

b) For indoor medical treatment in a non-empanelled private hospital/ nursing home with bed capacity 80 (eighty) or less, costs up to 60% of the West Bengal Health Scheme Approved Rates may be reimbursed.

ii) Accommodation/ Entitlement

a) In the case of medical attendance and treatment as an indoor patient in a hospital or an institution, a teacher/ officer or his/her beneficiary shall be entitled to such accommodation as tabled below:-

b)

c) Where the type of accommodation in a hospital does not correspond to the nomenclature as referred to above, the Government shall in consultation with the authorities of the hospital concerned, determine the entitlement of the beneficiary.

iii) The admissible cost of medical attendance and treatment shall be worked out on the basis of the approved rates as per Finance Department’s Notification no. 796-F(MED) dated 31.01.2011, as revised from time to time. List of Rate Chart will be available in the Health scheme Portal.

iv) The financial power for sanction of cost of medical attendance and treatment as indoor patient and OPD treatment is given hereunder:

v) Tenure – Notwithstanding anything contained in this scheme and without prejudice to the provisions of sub-clause (2) of clause 6, the cost incurred on account of related medical attendance and treatment received in a hospital or an institution during the period upto 30 days prior to hospitalisation and 30 days from the date of discharge, shall be reimbursable.

9. Settlement of Reimbursement Claims

i) Teachers/ Officers have to apply with details of claim online in the West Bengal Health Scheme Portal. The duly filled in application along with supporting vouchers will have to be submitted to the concerned Head of office (Principal/ Vice-principal/ TIC/ Dean of Faculty or any senior teacher as authorized by VC) as the case maybe for consideration of claim. The head of office will verify the claims and will give necessary approval if the claim amount is within financial power. On approval, Sanction order will be generated. The DDO will then take necessary action for payment in the beneficiary as per Sanction Order.

If the admissible claim amount is more than the presented limit mentioned above, concerned authority will forward the same to the appropriate authority for necessary approval, if required.

ii) The appropriate authority will act accordingly. On approval Sanction order will be generated by the concerned head of office. The DDO will then make necessary arrangement for payment to the beneficiary.

10. Treatment in a hospital or institution outside the State

(i) Notwithstanding anything contained elsewhere in this scheme, the Government may recognize specialized hospitals and institution outside the State for treatment of specific diseases.

(ii) Prior approval of the Secretary/ Pr. Secretary of the department of Higher Education, Science & Technology and Biotechnology shall he obtained before receiving medical attendance and treatment in these hospitals or institutions.

(iii) Claim for reimbursement of the cost of medical attendance and treatment in these hospitals or Institutions shall be allowed on the basis of the rates of various services provided by and investigations and procedures carried out by these hospitals/ institutions in the course of medical attendance and treatment.

11. Operational guidelines, clarifications, etc.

(1) The Department of Higher Education, Science & Technology and Biotechnology, in consultation with the Finance Department (Medical Cell), wherever necessary, shall issue operational guidelines, clarifications, etc for implementation of the scheme.

(2) If any difficulty arises in the course or implementation of the scheme, it shall be referred to the Finance Department (Medical Cell) and the decision of the Finance Department (Medical Cell), thereon shall be final.

(3) Further operational guidelines, in this regard, will be issued later on.

12. The fund for medical reimbursement in this regard will be debitable to the Heads of Account, as detailed in this Department’s Order no. 16-Edn(B) dt. 12.02.18.

13. The Annexure prescribing the Forms of Enrollment and Reimbursement of Claims will be made available in this website.

All concerned are being informed.

By Order of the Governor,

Joint Secretary to the
Government of West Bengal

No. 1020-Edn dated 29.08.2018, Source