Introduced in 2008 by the Government of West Bengal, the West Bengal Health Scheme (WBHS) gained immense fame as a noteworthy health program intended to provide quality medical care and financial assistance to state government officials. These include government employees, pensioners, and their families.
WBHS covers various medical treatments at authorized, empanelled hospitals. However, understanding the process of claiming and getting reimbursed quickly can save time, effort, and last-minute rush. Let's explore how to reimburse medical expenses in WBHS, ranging from eligibility to final reimbursement.
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Yes, you can get reimbursement for your medical outlays incurred in an empanelled hospital under the West Bengal Health Scheme. For this, you must apply to the concerned authority as per Clause 12 of the Scheme to seek reimbursement of medical charges and repayment of advances.
Remember that the application shall be made within three months from the date of completion of treatment.
West Bengal Health Scheme is cashless, where the beneficiaries do not need to pay any hospital charges directly. Instead, the insurers will directly settle such bills. However, if the total bill goes beyond the highest coverage limit, the beneficiaries will have to pay the excess out of their own pockets.
Here is the step-by-step procedure for claiming reimbursement of the insured amount under WBHS:
Step 1: First, present the cashless card issued by the Government Authorized Agency (GAA) upon admission to an empanelled hospital.
Step 2: The Health Care Organization (HCO) will send an authorization request to the Government Authorized Agency (GAA).
Step 3: The GAA will then check the information and approve or reject the request.
Step 4: Upon completion of treatment, the HCO or the concerned hospital will send the bills, along with other supporting medical documents, to the GAA.
Step 5: Thereafter, the GAA will check and validate these documents.
Step 6: Upon successful verification, the GAA will pay the approved sum to the HCO.
Before checking the reimbursement claim procedure, make sure that you go through the list of eligible individuals who can benefit from the WBHS scheme:
● State Government Employees: Employees of the West Bengal Government who are in service can avail of the WBHS health scheme. They can be permanent or temporary, provided they are paid a salary by the state government.
● Pensioners: Retired state government employees of West Bengal are also eligible for the scheme. This includes people getting regular pensions as well as those getting family pensions.
Eligible Family Members: The scheme is available to the family members of state employees and pensioners. This includes spouses, dependent children, dependent parents, and other family members as decided by the government.
To facilitate effective processing and on-time reimbursement, beneficiaries should comply with the standard guidelines, filing schedules, and proper forms. The following is a well-structured breakdown of the procedure and requirements:
Process/Requirement | Details |
Timely Submission of Claims | ● Indoor Treatments: Claims must be submitted within 3 months from the date of discharge. ● OPD Treatments: Claims must be filed within 3 months from consultation or medicine purchase. |
Use of Essentiality Certificate Forms | ● OPD treatment: Form D1 ● Indoor Treatment and Related OPD: Form D2 ● Non-empaneled Hospital Treatment: Form D3 ● For Government Pensioners OPD Treatment: Form IV1 ● Indoor Treatment and Related OPD: ● Form IV2 ● Non-empaneled Hospital Treatment: Form IV3 |
Role of the Sanctioning Authority | ● The Sanctioning Authority reviews and approves the claim. ● The reimbursement amount is determined based on approved rates for the treatment or procedure. |
Mandatory Details in Government Order (G.O.) | G.O. must include: ● Name and ID of the employee/pensioner ● Name of the patient (if different) ● Hospital name and code ● Disease treated ● Period of treatment ● Surgical package code (if applicable) |
Billing and Package Norms | ● Surgery costs in private hospitals (empaneled or not) must follow package rates. ● Government and Aided Hospitals: Reimbursement is based on actual expenses (bed rent, doctor’s fees, tests, medicines, implants) up to the approved ceiling. ● Speciality Hospitals Outside the State: Reimbursement is on an actual cost basis. |
Restrictions on Travel Costs | ● Airfare for medical travel is not reimbursable under WBHS. |
Important Disease Classification Clarifications | ● Cancer is classified as a ‘malignant disease’ under Clause 7(1)(i). ● Type 2 diabetes mellitus is not considered insulin-dependent diabetes under Clause 7(1)(iv). |
Adherence to Official Guidelines | Authorities must refer to specific Finance Department memos and notifications: ● Memo 797-F(MED) dated 31.01.2011. ● Memo 3474-F dated 11.05.2009 ● Memo 10539-F(MED) dated 21.11.2011 (for non-empaneled hospital cases). |
Well, it’s not difficult to get reimbursed under WBHS—assuming that you stick to the procedure accurately and produce the correct documents. With proper planning and timely application, you can get your reimbursement for medical bills on time. Also, double-check hospital recognition at all times and raise reimbursement claims within the timelines to avoid hassles.