GUIDELINES FOR AVAILING INDOOR/OUTDOOR FACILITIES

Transcription

1 GUIDELINES FOR AVAILING INDOOR/OUTDOOR FACILITIES INTRODUCTION 1. The following categories are eligible for availing the medical facilities:- (a) Employee serving in the organization. (b) Unemployed and/or unmarried daughters. (c) Unemployed sons below 25 years (d) Spouse of pensioner. (e) Dependent married son is entitled to medical facilities. (f) Medical reimbursement not admissible if the parents do not stay either with the Government servant or with his other family members. (g) Spouse in receipt of fixed medical allowance is not entitled for reimbursement of medical expenses as a member of Government servant. (h) Members of family residing away from the place of posting of the Government servant are entitled to avail medical facilities under CS (MA) Rules. (i) When father is not dependent, mother cannot claim to be wholly dependent on the son. (j) Fixed medical allowance not admissible to those retired with service gratuity. (k) When both husband and wife are Government servants, both can claim reimbursement of medical expenses for their respective parents. (l) An official can opt out of CGHS scheme if his/her spouse employed in private organization providing medical facilities. (m) When the father of the Government servant is not dependent mother cannot be considered as dependent. 2. FACILITIES: Expenditure incurred on services provided by an Empanelled Hospital will be paid directly to them as per the approved rates. As per the existing policy, in the absence of FCI medical officer in the respective District Office/Regional office/zonal Office/ Headquarters (as the case may be) the First Admission Report/ Pre-Authorization duly signed by the Competent Authority of the concerned empanelled hospital is acceptable subject to the fulfillment of the other terms and conditions.

2 3. PROCEDURE OF AVAILING INDOOR FACILITIES: a) The serving/retired employee shall admit in the hospital in possession of the authorization letter and Family Health Identity Card/Photo Identity Card issued by the respective Authority of the FCI. b) In case of emergencies, serving/retired employee or their dependentent can be admitted to the hospital on production of valid Family Health Card and the hospital will give pre-authorization letter in such cases in the prescribed proforma for issue of authorization letter from respective FCI Administrative Office immediately or on the following day. The empanelled hospital shall not demand any advance from the beneficiary and shall provide credit facilities to the concerned patient till authorization letter is received from the Corporation. c) Without Family Health Identity Card/Photo Identity Card, employees are not advised to be admitted except in case of extreme emergency/road accident. In such cases, serving/retired employee or their dependentent will submit the copy of the Family Health Identity Card/Photo Identity Card. In case of non-production of valid Family Health Identity Card/Photo Identity Card, the responsibility of payment will be of the patient/beneficiary or their dependents as the case may be. d) Requisites for issuing Authorization letter:- Copy of Family Health Identity Card/Photo Identity Card legibly depicting medical identity card no, employee number, name of the concerned office where card has been issued and basic pay drawn by the employee. Copy/ in original First Admission Report/ Pre Authorization completely filled and duly signed by the Competent Authority of the concerned empanelled hospital subject to the fulfillment of the other terms and conditions.( refer Circular No.EP dated ) Provision of accommodation for hospital treatment: 1) According to CS (MA) Rules, 1944, where initially accommodation of higher class was allotted by the hospital authorities to the beneficiary as the accommodation of appropriate class was not available at the time of admission of the patient into the hospital, the requirement about the certificate regarding non-availability of accommodation of appropriate class should be met. 2) In such case whenever accommodation of appropriate entitled class provided this does not involve any danger to the health of the patient. If accommodation of the appropriate class does not become available or if the patient cannot be shifted under medical advice, a certificate to that effect should be obtained from the authorities of the hospital of the hospital. Where the accommodation of appropriate class does not become available during the entire period of treatment of the patient, the certificate could be given at the time of discharge of the hospital. 2

3 3) If the accommodation of the appropriate class becomes available and it is considered that the patient cannot be shifted under medical advice, the certificate should be obtained with reference to the point of time at which the accommodation of appropriate class becomes available. 4) It may be clarified that in case even if at a point of time the accommodation of appropriate class was available and it was considered not advisable to shift the patient under medical advice he could still be subsequently shifted if later on the accommodation of appropriate class is available and the patient can also be shifted. FAR (First Admission Report) submitted by the Empanelled Hospitals/ Dental or Diagnostic Centres for issuing of Authorization letter must contain. (a) (b) (c) (f) (h) Particulars of the Patient. FCI medical identity card number. Treatment/Procedure/Investigation to be given. Date & Time of admission. Signature of the representative of the empanelled hospital at the place specified. e) As per the existing Post-Retirement medical schemes of the Corporation, retired employee of the Corporation / spouse thereof, who are members of the schemes, are entitled for IPD and OPD treatment subject to present ceiling of Rs.1,12,000/- (IPD treatment) and Rs.12000/- (OPD Treatment for listed Prolonged Diseases) for a financial year or as revised from time to time by FCI. If no reimbursement is taken by the beneficiary for IPD treatment, an additional amount of Rs.50000/- would be carried forward to the next year. The ceiling will not exceed Rs.1.5 Lakh in any case.(refer CIRCULAR NO. EP dated ) f) SUBMISSION OF BILLS: Empanelled hospitals will submit bills with the following enclosures:- 1) Original FAR (First Admission Report) form completed filled by the Hospital. 2) Photocopy of medical identity Card 3) Summary of the case, including outcome of treatment. 4) All the supporting documents such as investigation report, first admission report/pre authorization letter, copy of authorization letter, original cash memos and discharge summary report be submitted by the hospital to the AGM (Bills) of the concerned FCI office within the stipulated period of time within 3 months from the date of completion of treatment and necessary bill will be authenticated by the patient /escort s signature. 3

4 4. PROCEDURE OF AVAILING INDOOR FACILITY:(where authorization letter is not issued) The serving/retired employee can take treatment in any hospital without having Authorization Letter issued by the FCI office but in that case at the time of relieving the hospital, the employee/ patient is required to get the hospital bill and receipts, vouchers, Essentiality Certificate etc., duly signed or countersigned by the Authorized Medical Attendant or the medical officer in-charge of the patient in the hospital, as the case may be, for the purpose for claiming refund of expenses incurred. Employee has to prefer his/her claim in the relevant application form, giving full particulars called for therein and also attaching Certificate B along with the medical claim form required to be produced under the rules. 5. OTHER TERMS AND CONDITIONS 1. The Hospital/ Dental/ Diagnostic Centre shall provide the agreed upon services to cases referred on a Referral slip duly authenticated and stamped. The Hospital/ Dental or Diagnostic centre would not refuse admission/treatment or investigations to referred cases on flimsy grounds. 2. The Hospital/ Dental or Diagnostic centre shall raise bills in the prescribed format to the FCI offices on completion of treatment/ discharge of the patient. The rates for tests and treatment would be charged as per mutually agreed rate list and approved by FCI. Under no conditions will rates exceed the rates laid down by the CGHS for the particular zone. FCI will make payments only as per approved/ CGHS rates. Expenditure in excess of approved / package deal rates would be borne by the beneficiaries. 3. During In-patient treatment of the FCI beneficiaries, the Hospital shall not ask the members to purchase separately the medicines from outside but bear the cost on its own, as the package deal rate fixed that includes the cost of drugs, surgical instruments and other medicines etc. 4. All other conditions listed in the MOA will be complied with by both parties, that is, the Empanelled facility and FCI. 6. PROCEDURE OF AVAILING OUTDOOR FACILITY: 1. Medical reimbursement for OPD treatment is not admissible to those who are in receipt of Fixed Medical Allowance. 2. Consultation / injection fee for the treatment taken at the OPD of the Government Hospital not admissible. 3. In case of outdoor treatment an employee or dependent can go for outdoor treatment but for maximum 10 days to empanelled hospitals. After taking treatment he has to submit the completely filled medical claim form along with the Certificate A countersigned by the treating doctor or medical in charge of the hospital. 4

5 4. Where ever an employee wants to claim reimbursement of medical charges for more than 10 days say for one month in that case the employee has to produce a Prolonged Treatment Certificate which is valid for one year. On that basis an employee can claim reimbursement for 30 days instead of 10 days at a time. 5. In case of prolonged disease medicine reimbursement the employees has to enclose medical claim form, Certificate A, prescription indicating the name of medicine prescribed by the treating doctor for the disease and prolonged treatment certificate countersigned by the specialist of Govt. Hospital/specialist of empanelled hospital/ medical officer of FCI. 6. Here, retired employees are eligible only for prolonged specified diseases only for a maximum limit of Rs.12000/- p.a. and they will also have to submit the same documents as submitted by the serving employees only here limit / disease is restricted. (Annexure I) 7. Instructions: a) Cash memos for purchase of medicines must be countersigned by the doctor prescribing the medicines. b) Designation and degree of the doctor is to be indicated. c) Acceptance of money receipts in lieu of cash memo. 8. Time limit for medical claims: Bills to be preferred within 3 months for reimbursement by the central Government servants in respect of a particular spell of illness should ordinarily be preferred within 3 months from the date of completion of treatment. Heads of department is delegated powers to condone delay in submission of claims. 5

6 ANNEXURE I The list of specified prolonged diseases for OPD treatment shall include 13 prolonged diseases is given as under: i. Heartailments and FUC Hypertension ii. Diabetes mellitus iii. Paralysis/ Cerebrovascular attack iv. FUC Thyroid disorder v. Kidney disorders vi. Bronchial Asthma vii. Cancer/ Malignant Tumors viii. Hemolytic Disorder ix. Tuberculosis x. Rheumatoid Arthritis & (OA) Osteo Arthritis xi. Osteoporosis xii. Thalassemia xiii. Chronic Liver Disease 6