Clarifications on Health Scheme, 2008

Government of West Bengal
Finance Department
Audit Branch
Medical Cell

No. 11254-F (MED) 

           Dt. 16-12-2011

Memorandum

    The West Bengal Health Scheme, 2008 came into effect from 01-06-2009.  Now, the cost of medical treatment in non-empanelled private Health Care Organisation is also reimbursable under certain conditions. Request for clarifications of some points laid down in the said Scheme after its amendments are being received by this department 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 for information and guidance of all concerned. 

Sl. No.	Issues	Clarifications
1.	Employees/ pensioners enrolled under the West Bengal Health Scheme, 2008 and their  dependent family members availing themselves of the medical treatment in nonempanelled private hospitals/ nursing homes prior to issue of the Notification No. 10539-F (MED), dt. 21-11-2011. Whether the costs of such medical treatment will be reimbursed?	Eligible for the benefits of the Scheme as per the prescribed scale as notified under Order No. 10539-F (MED), dt. 21-11-2011 for indoor treatment only w.e.f. the date of their  enrolment under the Scheme. Such cases are to be settled with approval of the Secretary of the Administrative Department.
2.	For medical treatment in non-empanelled private hospital/ nursing home, cost of packages, bed rent, investigation charges, doctor’s fee, implants, etc. are reimbursable up to 80% or 60%, as the case may be, of approved rates under the Health Scheme on the basis of bed capacity of the hospital/ nursing home under Notification No. 10539-F (MED), dt. 21-11-2011. What will be reimbursable rate for the medicines and consumables?	Cost of admissible medicines and consumables will be reimbursed up to 80% or 60% of the actual costs, as the case may be.
3.	Employees/ pensioners enrolled under the West Bengal Health Scheme, 2008 and their dependent family members availing themselves of the medical treatment in private hospitals/ nursing homes that were empanelled initially but it became nonempanelled for a short period due to expiry of contract and then the contract was renewed and it became empanelled under the Health Scheme again. Whether the costs of medical treatment done during the non-empanelled period will be reimbursed?	Reimbursement of costs of such medical treatment may be allowed under the Scheme as per the class of the private hospital after its renewal.
4.	Employees/ pensioners not taken approval of the West Bengal Health Scheme Authority under Finance Department and received medical treatment in a non-empanelled private hospital/ nursing home outside the State. Whether the costs of such medical treatment will be reimbursed?	Not eligible for the benefits of the Scheme for reimbursement of the costs as they availed themselves of the treatment without approval of the West Bengal Health Scheme Authority and as per their own volition.
5.	Employees/ pensioners not taken approval of the West Bengal Health Scheme Authority under Finance Department and received medical treatment in a speciality hospital outside the State (excluding the cases where procedural delay in according approval is involved). Whether the costs of such medical treatment will be reimbursed?	Not eligible for reimbursement of the costs under the Scheme as they availed themselves of the treatment without approval of the West Bengal Health Scheme Authority.
6.	State Government employees who were enrolled under West Bengal Health Scheme, 2008 while in service, are eligible for the benefits of the Health Scheme as pensioners from the day next to the date of their retirement. (vide Notification No. 8219-F (MED), dt. 19-08-2011) Whether the family pensioners are eligible for getting the benefits of the Health Scheme immediately after death of the Government employee/ Government pensioners enrolled under the Scheme?	Yes.

Sd/-
         Joint Secretary to the
              Government of West Bengal,
          Finance Department

Source: www.wbfin.nic.in