West Bengal Health Scheme for the Beneficiaries of Grant-in-Aid Colleges and Universities under Department of Health & Family Welfare

Government of West Bengal
Department of Health & Family Welfare
MERT Branch
Swasthya Bhawan, Block – GN – 29,
Salt Lake City, Sector – V, Kolkata -91.

NOTIFICATION

No. HF/O/MERT/594/HFW-24011(13)/2/2020 Dated: Kolkata, the 21st June, 2021

The Governor is hereby pleased now to provide the benefits of “West Bengal Health Scheme for the Beneficiaries of Grant-in-Aid Colleges and Universities under Department of Health & Family Welfare, Government of West Bengal” to the serving Teachers including Librarians and Graduate Laboratory Instructors of the College of Medicine and JNM Hospital, Kalyani and Officers of the West Bengal University of Health Sciences, Salt Lake, Kolkata under Department of Health & Family Welfare, Government of West Bengal and the family members 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 under Department of Health & Family Welfare, Government of West Bengal”.

2.Application

(1) This scheme shall apply to the serving Teachers including Librarians and Graduate Laboratory Instructors of the College of Medicine and JNM Hospital, Kalyani and Officers of the West Bengal University of Health Sciences under Department of Health & Family Welfare and their dependent beneficiaries.

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

(3) This scheme will be implemented in reimbursement mode only.

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

(5) A teacher/officer has the liberty to opt out from the scheme by applying through WBHS portal using his/her individual login. Provided that a teacher/officer shall not be allowed to opt out from scheme within five years from the month following the month in which s/he or his/her beneficiary enjoyed the benefit under the scheme.

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 Finance Department, Government of West Bengal applicable for West Bengal Health Scheme 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 serving teacher/officer with his/her dependent member of the family.

(c) “Clause” means a clause of the scheme.

(d) “Institutions” means the West Bengal University of Health Sciences including College of Medicine and JNM Hospital, Kalyani.

(i) “Head of Institution” means the Vice-Chancellor of the West Bengal University of Health Sciences.

(ii) “Recommending Authority” means any officer having rank in the middle tier of the Institution.

(iii) “Operator” means any clerical staff (LDC/UDC) of the Institution.

(e) “Administrative Department” means Department of Health & Family Welfare, Government of West Bengal.

(i) “Head of the Department” means Addl. Chief Secretary/ Principal Secretary/ Secretary of the Administrative Department.

(ii) “Delegated Approver” means an officer up to the rank of Joint Secretary of the Administrative Department.

(iii) “Verifying Authority” means any DS/ AS/ Registrar/ SO/ Assistant/Clerk (UDA/ UDC/ LDA/ LDC) of the Administrative Department.

(f) (i) ‘Teacher’ means full time and regular serving Teachers including Librarians and Graduate Laboratory Instructors of the College of Medicine and JNM Hospital, Kalyani and the West Bengal University of Health Sciences under Department of Health & Family Welfare, Govt. of West Bengal enrolled under clause 2.

(ii) “Officer” means serving officers of the West Bengal University of Health Sciences under Department of Health & Family Welfare, Government of West Bengal and College of Medicine and JNM Hospital, Kalyani under West Bengal University of Health Sciences.

(g) “Family” in relation to a teacher/officer includes the following;

(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, legally adopted children up to the age of 25 years.

(iv) Dependent widowed/divorced daughters whose age exceeds 25 years but her monthly income does not exceed Rupees one thousand and five hundred.

(v) Dependent Minor brothers and sisters up to the age of 18 years.

(vi) Dependent unmarried/widowed/divorced sisters whose age exceeds 18 years but her monthly income does not exceed Rupees one thousand and five hundred.

(vii) Income (not age) shall not be a consideration when the eligible beneficiaries mentioned with sl. no. (ii) to (vi),stated above are suffering from Critical Illness/Disease as notified by Finance Department, Govt. of West Bengal vide order No. 54-F (MED) WB dt. 22.07.2019.

Note:

1. The conditions of beneficiary are not applicable to the spouse. Spouse can be included irrespective of his/her monthly income. But….

a. If both husband or/and wife is/are working/worked in any organisation under direct control of Govt. of West Bengal and is/are eligible to draw Medical Allowance/Relief, they can enrol themselves individually or jointly to their respective health scheme controlled by their Administrative Department. In case of opting in a health scheme jointly in a particular scheme, only the benefit of that scheme is admissible.

b. Again if the spouse is an employee of Central Govt. or PSU Bank or any Corporation/Undertaking, financed more than 50% total capital by Central/State Govt. or local bodies or aided institution or private organisation which provides medical facility, s/he to choose any one place for getting medical facility. Therefore, if spouse wants to get benefits under this scheme, an official certificate from his/her employer is to be produced first regarding relinquishment of medical allowance and benefit available from his/her employer.

2. ‘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.

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

4. Son/daughter/sister shall not be considered as beneficiary from the date of their marriage.

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

6. A declaration regarding the income of all dependent beneficiaries except spouse shall be furnished biennially by the concerned enrolled teacher/officer in the month of November.

(h) “Order” means all orders issued by Finance Department, Govt. of West Bengal in connection with implementation of West Bengal Health Scheme in reimbursement mode applicable for employees of Govt. of West Bengal and it will be equally applicable for this scheme also.

(i) “Form” means a Form appended to this scheme.

(j) “Government” means Govt. of West Bengal.

(k) “Health Care Organisation (HCO)” means such Govt. or Private Hospital/Nursing Home that may be recognized/empanelled/enlisted from time to time by Finance Department, Govt. of West Bengal for the purpose of availing benefits of medical attendance and treatment under West Bengal Health Scheme.

(l) “Laboratory” means such laboratory as may be recognized by the Govt. of West Bengal from time to time for availing of benefits of medical attendance and treatment under this scheme.

(m) “Medical attendance” means for professional advice and includes pathological, bacteriological, radiological or other methods of investigation for the purpose of diagnosis which are considered necessary by the attending physician and are carried out in a hospital.

(n) “Specified” means specified by order.

(o) “Treatment” means the use of medical and surgical facilities and includes-

(i) The employment of such pathological bacteriological, radiological or other methods of investigations which 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 and his/her dependent beneficiary shall be entitled to get the following facilities, namely:-

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

(b) Medical attendance and treatment as an Out-Patient Department (OPD) patient in a recognised/ empanelled/ enlisted hospital, or a clinic attached to such hospital for the diseases specified by competent authority from time to time.

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

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

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

(a) The amount charged by the hospital in accordance with the approved rates notified by Finance Department, Govt. of West Bengal.

(b) The cost of medicines supplied by the recognised/ empanelled/ enlisted or purchased from outside on the advice of the attending physician of the hospital provided that the certification of Medical Superintendent on non-availability of such medicine in the store of hospital.

(c) The charges for such pathological, bacteriological, radiological or other methods/investigations as are considered necessary by the attending physician and carried out, on the advice of the attending physician, in a recognised/ empanelled/ enlisted hospital/diagnostic centre other than the treating hospital.

(d) The cost of Implants and/or Special Devices as prescribed by the treating surgeon/consultant of a hospital where the treatment is going on is reimbursable as per approved WBHS rate or actual basis in case where no prescribed rate exists.

(e) The cost incurred on account of related medical attendance and treatment received in recognised/ empanelled/ enlisted hospital during the period up to 30 days prior to hospitalization and 30 days from date of discharge.

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

(1) A teacher/officer shall be entitled to get reimbursement of the cost of medical attendance and treatment of him/her and his/her dependant beneficiary’s as an OPD patient in recognised/ empanelled/ enlisted hospital in the following diseases:

(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 Diabetes Mellitus is not considered as Insulin- dependent Diabetes)

(v) Heart diseases.

(vi) Neurological disorders/ Cerebrovascular disorders.

(vii) Malignant Malaria.

(viii) Renal failure.

(ix) Thalassemia/ Bleeding disorders/ 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 Erythematosus (LUPUS)

(xiii) Crohn’s Disease.

(xiv) Endodontic Treatment (Root Canal Treatment).

(xv) Chronic Obstructive Pulmonary Disease (COPD).

(xvi) Ankylosing Spondylitis.

(xvii) None of the above list [Vide para 10 of 797-F(MED), dated 31.01.2011]

(2) A teacher/officer or his/her beneficiary shall also be entitled to get 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 recognised/ empanelled/ enlisted hospital.

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

(a) The amount charged by the recognised/ empanelled/ enlisted hospital in accordance with the approved rates.

(b) The cost of medicines purchased from outside on the advice of the attending physician of the recognised/ empanelled/ enlisted hospital.

(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 recognised/ empanelled/ enlisted hospital or laboratory other than the hospital in which the patient is treated.

(d) The cost of Implants and/or Special Devices as prescribed by the treating surgeon/consultant of a recognised/ empanelled/ enlisted hospital where the treatment is going on is reimbursable as per approved WBHS rate or actual basis in case where no prescribed rate exists.

7. Enrolment

(a) A teacher/officer will have to apply online for enrolment under “West Bengal Health Scheme for the Beneficiaries of Grant-in-Aid Colleges and Universities under Department of Health & Family Welfare, Govt. of West Bengal” through West Bengal Health Scheme Portal having URL https://wbhealthscheme.gov.in. New URLs will also be available within the portal for West Bengal University of Health sciences.

(b) At the time of online application, Teacher/Officer has to upload scanned clear photo and signature having size 12-50 kb of all beneficiaries besides other mandatory information. After online submission, s/he has to take a print out of the submitted form and it has to be submitted physically to the Head of the Institution attaching all necessary documents like Birth Proof, Blood Group, Aadhar Card, Income Certificate and any other documents that are required to substantiate the inclusion of beneficiary.

After receiving both soft and hard copy (attached with other instruments), Operator will check it carefully. If s/he detects any error, s/he will modify it. Then Operator will forward it to Recommending Authority. The Recommending Authority will check it again. S/he can modify mistakes or can return it to Operators. Then the Recommending Authority will forward the application to the Head of the Institution for necessary approval. Finally Head of the Institution will approve the application if s/he finds it correct with his/her registered class 2/3 Digital Signature Certificate (DSC).

After getting message from WBHS portal, incumbent will take print out of approved enrolment certificate from WBHS portal after creating his/her individual login. No one except Head of the Institution can approve his/her own enrolment certificate.

The Administrative Department has no role in enrolment procedure.

(c) On successful enrolment under the health scheme, the drawl of regular medical allowance shall be discontinued from the date of effect mentioned in approved enrolment certificate.

8. Criteria for Reimbursement of Claims

a. Enrolled teachers /officers will get the facility of OPD/IPD medical treatment in Govt. Hospitals, Hospitals managed by local bodies like municipalities, State-Aided Hospitals, Speciality/Enlisted Hospitals outside the state and Empanelled Private Hospitals 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 WBHS Portal.

b. The beneficiaries under this health scheme may also avail the only indoor medical treatment facilities in any non-empanelled private hospital/nursing home. Reimbursement of the cost of such indoor medical treatment is admissible under this scheme as per orders issued by Finance Department, Govt. of West Bengal.

c. For availing treatment in enlisted hospitals outside West Bengal, notification of Finance Department, Govt. of West Bengal shall be adhered strictly in this regard.

9. Accommodation/ Entitlement

(a) In the case of medical attendance and treatments as an indoor patient in a Pay Bed of Govt. Hospital or Tata Medical Center, Rajarhat or Other Private Empanelled Hospital, a teacher/officer or his/her beneficiary shall be entitled to avail the following accommodation as tabled below:

10. Financial Power of sanctioning claim

Financial power for sanctioning the cost of medical attendance and treatment for IPD and OPD treatment is given below:

11. Settlement of Reimbursement Claims

(i) Enrolled Teacher/Officer will submit reimbursement claim using his/her individual login through West Bengal Health Scheme Portal. After online submission, s/he has to take a print out of submitted form and it has to be submitted physically to Head of Institution attaching all necessary documents like money receipts, annexure, all treatment documents and any other instruments that are required to substantiate the claim.

(ii) After receiving both hard and soft copy (attached with other instruments), Operator will check it carefully. If s/he detects any error, s/he will modify it. Then Operator will forward it to Recommending Authority. The Recommending Authority will check it again. S/he can modify mistakes or can return it to Operators. The Recommending Authority will forward the correct application to the Head of Institution. Head of Institution will forward the claim to Administrative Department for necessary approval.

(iii) On receiving both soft and hard copy of reimbursement claim, The Verifying Authority of the Administrative Department will check it again. Once s/he finds the claim in correct way, s/he will forward it to the Delegated Approver of the Administrative Department (in the rank of Joint Secretary and above).

(iv) On checking the claim, if the admissible amount is within the ceiling of Delegated Approver of the Administrative Department, s/he will approve it and generate sanction order with his/her registered Digital Signature Certificate (DSC). Delegated Approver of the Administrative Department will forward the claim to Head of the Department (Addl. Chief Secretary/Principal Secretary/Secretary) for approval if the admissible amount exceeds the ceiling delegated to him/her.

(v) Head of the Department will approve the claims those are forwarded by the Delegated Approver of the Administrative Department. Registration of DSC by Head of the Department is not mandatory. S/he can approve and generate sanction order against a claim with his/her registered DSC. When Head of the Department approves claim without DSC, Delegated Approver needs to generate sanction order with his/her registered DSC mandatorily.

(vi) In all sanctioned claims, Administrative Department shall make necessary arrangement of stamping of “Paid and Cancelled” and signature by competent authority in all vouchers of such claim. The Administrative Department shall allocate necessary allotment to DDO of Head of the Institution for submission of claim to linked Pay and Accounts Officer/Treasury.

(vii) After getting, DSC enabled sanction order and vouchers from competent authority, Operator of University/Department will prepare Treasury Bill in TR-31A in WBHS Portal and forward it to DDO for subsequent submission in WBIFMS (E-Billing module). Again DDO has to submit the said Treasury Bill using his/her registered DSC to linked Pay &Accounts office/ Treasury accessing his/her login in WBIFMS Portal without attaching any vouchers and beneficiary list.

(viii) No physical voucher is required to be attached at the time of submission of bill to Treasury as per existing provision. All vouchers shall be preserved in College/ University for the purpose of future audit. Only DSC enabled sanction order shall be attached with Treasury Bill in TR Form 31A at the time of drawal of claim to Pay and Accounts Officer/Treasury.

(ix) Moreover, for settling a claim, notification no. 3474-F dt. 11.05.2009, 796-F(MED) dated 31.01.2011, 797-F(MED) dated 31.01.2011, 11253-F(MED) dated 16.11.2011, 796-F(MED) dated 19.09.2013 and other related order issued by Finance Department, Govt. of West Bengal shall be adhered strictly.

(x) List of inadmissible items, viz. Foods, Tonics, Medicines etc shall be guided as per Finance Department (Medical Cell) Memorandum No. 6586-F(MED) dated 29.06.2011.

The Forms of enrolment & reimbursement of claims along with the prescribed format for approval, recommendation and sanction of claim are annexed hereto.

12. Treatment in a hospital or institution outside the State

(i) Notwithstanding anything contained elsewhere in this scheme, the Government may recognize specialized hospitals and institute outside the State for treatment of specific diseases. All hospitals, situated outside West Bengal and notified by Finance Department, Govt. of West Bengal shall have to consider in this case. Treatment cost in case of availing treatment in a hospital outside West Bengal other than enlisted shall not be eligible for reimbursement.

(ii) Prior approval from Addl. Chief Secretary/Principal Secretary/Secretary of Department of Health & Family Welfare shall be obtained for receiving medical attendance and treatment in these enlisted hospitals outside West Bengal. In case of technical opinion from doctor, Administrative Department may consult with West Bengal Health Scheme Authority (WBHSA) before final approval.

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

(iv) Cost of inadmissible items mentioned in different notifications issued by Finance Department, Govt. of West Bengal is not allowed for reimbursement.

13. Medical Advance

(i) The sanctioning authority for reimbursement of the cost of medical attendance and treatment may grant medical advance on submission of a certified estimate from the hospital in which medical attendance and treatment is received as an indoor patient.

(ii) The advance shall not exceed 80 percent of the estimated cost of medical attendance and treatment.

(iii) The medical advance shall be adjusted against the admissible cost of medical attendance and treatment, excess, if any, shall be refunded by the employee. If medical attendance and treatment is not received within 60 days of receipt of medical advance, the entire advance shall be refunded by the employee on the expiry of this period.

(iv) All other orders issued by Medical Cell, Finance Department, Govt. of West Bengal from time to time regarding drawl of medical advance for medical attendance and treatment is equally applicable for this scheme also.

14. Timeline for reimbursement claim submission

(i) Beneficiary has to submit his/her reimbursement claim under “West Bengal Health Scheme for the Beneficiaries of Grant-in-Aid Colleges and Universities under Department of Health & Family Welfare, Government of West Bengal” within 6 (Six) months from date of discharge (for In-patient Department) or date of consultation (for Out-Patient Department).

(ii) No one will be allowed to get reimbursement under “West Bengal Health Scheme for the Beneficiaries of Grant-in-Aid Colleges and Universities under Department of Health & Family Welfare, Government of West Bengal” against any claim submitted after 2 (Two) years from date of discharge (for In-patient Department) or date of consultation (for Out-Patient Department) under normal circumstances.

(iii) All other orders issued by Medical Cell, Finance Department, Govt. of West Bengal from time to time regarding timeline for reimbursement claim submission is equally applicable for this scheme also.

15. Operational Guidelines clarifications, etc.

(i) The Department of Health & Family Welfare in consultations with the Finance Department (Medical Cell), wherever necessary, shall issue operational guidelines clarifications, etc. for implementation of the scheme.

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

(iii) Further operational guidelines in this regard, if required, will be issued later on.

16. The Head of Account for allotment of fund for medical reimbursement

“24-2210-Medical and Public Health-05-MEDICAL EDUCATION, TRAINING AND RESEARCH-105-AHopathy-074-Mcdical Reimbursement to the Teachers and Officers of State aided Univcrsities-31-Grants-in-aid-GENERAL-02-Other Grants-V”.

17. The Annexure prescribing the Forms of Enrolment and Reimbursement of Claims will be available in the Website.

18. This Order is issued with the concurrence of Finance Department. Govt. of West Bengal vide their U.O. No. E-366-F(Med) dt. 18/05/2021 read with UO NO: Group 0/2021-2022/0032 UO Date: 17/06/2021.

19. All concerned are being informed.

By order of the Governor

Special Secretary to the
Govt. of West Bengal

No. HF-594 dated 21.06.2021, Source