What is the Time Limit for WBHS Reimbursement?

West Bengal Health Scheme Claim Period and Submission Guide

Launched in 2008, the West Bengal Health Scheme (WBHS) acts as a financial shield for government employees, pensioners, and their dependents, paying for treatment charges in empaneled hospitals.

However, if the application is not made within the specified time limit, then the claim is rejected. Understanding the time limit, documents to be submitted, and procedural requirements is essential to facilitate smooth reimbursement.

Keep reading!

Is There Any Specified Time Limit for WBHS Reimbursement?

Under the West Bengal Health Scheme (WBHS), you have to submit your reimbursement claim within six months of your discharge date for in-patient care or from the consultation date for out-patient care.

Under normal circumstances, any claim submitted after two years will not be entertained.

What are the Steps to Make a Claim under the West Bengal Health Scheme?

The WBHS scheme is cashless in nature, as beneficiaries do not have to pay out of pocket. However, if the overall bill is above the maximum limit of insurance coverage, then the beneficiary will have to bear the expenses.

Here's how you can file a claim under WBHS:

Step 1: Show your WBHS cashless card at the hospital where you are undergoing treatment.

Step 2: The hospital will make a request for verification to the Government Authorized Agency (GAA).

Step 3: The GAA will analyze the information thoroughly and give its approval.

Step 4: Once your treatment is completed, the Healthcare Organization (HCO) will send the bills to the GAA.

Step 5: When the GAA confirms the information, they will pay the hospital bill.

What are the Key Exclusions for Reimbursement at WBHS?

Although the West Bengal Health Scheme provides comprehensive coverage for healthcare, there are certain exclusions in which reimbursement is not made. Such situations include:

● Non-medical treatment or procedures lacking therapeutic value.

● Self-inflicted injury or treatment for substance abuse-induced conditions.

● Cosmetic or aesthetic surgeries are performed to improve appearance.

● Out-patient services for chronic conditions such as diabetes or hypertension management are usually not reimbursed.

● Experimental or investigational treatments without approved medical recognition.

● Expensive procedures, such as organ transplants, unless individually covered.

● Rehabilitation therapies are not specifically defined as covered.

● Treatments at non-empanelled hospitals unless emergency and pre-approved.

What are the Reimbursement Claim Guidelines Under WBHS?

Here are the complete guidelines for medical treatment and reimbursement under the West Bengal Health Scheme:

● Get treated at an empanelled hospital, which is an approved centre under the Health Scheme.

● Show your Health Scheme Identity Card when seeking medical treatment at an authorized hospital or diagnostic centre and submit a photocopy of the card to them.

● While opting for in-patient treatment, be sure to update the address and phone number of the Head of Office or Pension Sanctioning Authority.

● Give notice to your office within three days of receiving in-patient medical care and treatment.

● Ensure that your identification number is on the hospital bill. Also, make sure that the code numbers for all procedures and investigations are on the bill.

● Make sure that the bill for any surgical procedure shows the package rate along with the corresponding code.

● For in-patient treatment, file your reimbursement claim within three months from the date of discharge.

● For outpatient treatment, submit your reimbursement claim within three months of each consultation or acquisition of medicines.

● Get prior approval from the West Bengal Health Scheme Authority for certain medical procedures like the following:

● Organ transplantation

● Cochlear implant surgery

● Implantation of multiple drug-eluting stents

● Dual chamber pacemaker implantation

● Implantation of multiple stents

● AICD/CRT with AICD implantation

● Neuro implants, including deep brain stimulator implants, intrathecal pumps, and spinal cord stimulators

● Digital hearing aids and more

● Obtain prior permission from the West Bengal Health Scheme Authority before undergoing treatment at a special hospital outside the state.

● If you experience overbilling or unnecessary procedures from a healthcare organization, report the matter to the Hospital Authority within 15 days of discharge.

Who is Eligible for the West Bengal Health Scheme?

WBHS is available to all individuals serving under the state government, its pensioners, and their dependent family members. Besides, the officers and pensioners of All India Services are also covered under this scheme. This scheme is also applicable for IAS, IPS, and IFS officers and their family members if they choose to opt out of the CGHS.

The WBHS reimbursement process has a particular timeline from the date of discharge or completion of treatment. Failure to meet this deadline can result in penalties, such as claim rejection.

To prevent financial loss, always submit claims in a timely manner with complete documentation. Besides, the scheme guidelines should be reviewed prudently to understand the scope and limitations. Being informed can help you avoid unexpected financial surprises during treatment.