What is the Maximum Limit of WBHS?

WBHS Scheme Limits: Understanding Coverage and Key Features

The West Bengal Health Scheme (WBHS) offers considerable financial coverage to employees, pensioners, and their dependents within the state of West Bengal. However, like any other health insurance plan or welfare scheme, WBHS has some restrictions and conditions.

One of the most important things is to learn about the maximum amount of coverage that can be taken under WBHS. Let’s discuss the maximum monetary limits of WBHS, the various types of limits, and how they benefit beneficiaries.

What is the Highest Limit of WBHS?

Indoor treatment services without cash are provided for amounts up to ₹2,00,000 per hospitalization, subject to the treatment being done in private empanelled hospitals. In the case of indoor treatment expenses beyond ₹2,00,000, reimbursement can be sought by filing a claim with the DDO (drawing and disbursing officer) or PSA (pension sanctioning authority)

Key Features and Benefits of WBHS

The West Bengal Health Scheme (WBHS) has several unique features and benefits. These include:

● Off-State Hospitalization Facility

Medical expenses will be covered if the treatment is received at a reputable hospital within another state. This feature is advantageous for individuals who become sick while travelling or require specialized treatment.

● Cashless Indoor Treatment

Another aspect of the WBHS is that it provides coverage for cashless indoor treatment up to the extent of ₹2 lakhs at the covered hospitals.

Allowing hospital coverage across the state ensures that beneficiaries have access to quality healthcare despite their location, especially when they need hospitalization far from home.

● OPD Treatment

As beneficiaries, you may get reimbursement for outpatient treatment based on the policy's waiting period and conditions. The coverage includes routine health expenses and preventive care to maintain overall health.

At Star Health, we also provide financial coverage for outpatient treatment under our Outpatient Care Insurance Policy. This policy includes coverage ranging from diagnostics to non-allopathic treatment, with hassle-free claim settlement and less turnaround time.

● Treatment Coverage in Non-Empaneled Hospitals

The WBHS has a provision for reimbursement of medical costs availed at non-empaneled hospitals. In such scenarios, beneficiaries can get reimbursement for a percentage of the cost of treatment as per the scheme guidelines.

● Pre-authorization Requirement

Some procedures or treatments might require pre-authorization from the WBHS authorities to ensure that the costs will be paid under the scheme.

● Family Coverage

The scheme usually provides coverage to the immediate family members of the employee, i.e., spouses, children, and sometimes dependent parents.

● Emergency Services

Emergency treatment is typically covered regardless of whether it occurs within the state as long as it is provided at an empanelled hospital and adheres to the scheme's rules.

● Network of Empaneled Hospitals

The scheme also keeps a list of empanelled hospitals and health providers that beneficiaries need to visit for cashless treatment.

Eligibility Criteria for WBHS

The following are the conditions to become eligible for the WBHS scheme:

• This scheme is for the employees of the state government, pensioned government servants, and their dependents.
• All India Services (AIS) officers and pensioners can take advantage of this coverage.
• Those who have opted for this scheme under the medical allowance are also eligible.
• Family coverage includes the spouse, dependent parents, children, and dependent brothers/sisters of the beneficiary.

Exclusions Under WBHS

While the maximum limit of the WBHS scheme determines the financial limits of coverage, it is also crucial to know what lies beyond this safety net. The exclusions under the WBHS scheme are as follows:

• Cosmetic Surgeries: Any surgeries performed for cosmetic reasons are not included.
•  Non-Medical Treatments: Treatment that is not medically necessary is excluded.
• Self-Inflicted Injuries: Medical attention for intentional injuries inflicted by the insured individual is not covered under WBHS.
•  Treatment for Substance Abuse: Treatment for drug or alcohol abuse is not included in the scheme.
• High-Cost Treatments: Depending on the conditions, procedures such as organ transplants and rehabilitation therapy might not be covered.
• Outpatient Treatment of Chronic Conditions: Routine consultations and maintenance therapy for chronic conditions such as diabetes and hypertension might not be covered.
• Pre-existing Medical Conditions: Pre-existing medical conditions could have waiting periods or exclusions in the scheme.

How Do You Contact the WBHS Helpline?

If you have any doubts or queries regarding the West Bengal Health Scheme (WBHS), consider communicating with their helpline team. You can either email support.wbmedicalcell@nic.in or call (033) 2254-4123 or (033) 2254-4034.

Recognizing the maximum limits of WBHS is crucial for the beneficiaries to plan their medical care requirements meticulously. If you have any further questions, contact the WBHS helpline.