MEDICAL REIMBURSEMENT RULES
M.D.’S
ORDER NO. 17/78 DATED 12.11.78
RULES
FOR REIMBURSEMENT OF MEDICAL EXPENSES
4. Authorised Medical Attendant:
5. Approved Medical Institution:
6. Autherised purposes of reimbursement:
7. Medicines cost of which are reimbursable:
9. Availing of medical attention/treatment:
13. Limit for preferring claims:
14. Preferring of claims and method of passing
the claim:
15. Reference to claimant/medical attendant:
In exercise of the powers vested in the Managing
Director as per Bye-Laws 4 and 5
of Part III of Chapter IV of the
Staff Bye-Laws, the following Rules are issued governing the reimbursement of
medical expenses to the employees of this Corporation. All rules and orders issued earlier on the
subject stand modified to the extent provided for in the rules given under.
All employees of this
Corporation to whom the Staff Bye-laws should apply (vide bye-law 2 of Part I)
other than temporary and provisional employees (as defined in the Staff
Bye-laws) and employees who are not covered under E.S.I. Scheme are eligible
for reimbursement of medical expenses.
Employees on deputation to the Corporation may opt to be governed by the
rules applicable to them in their
parent organisation or to be governed by these rules but the option once
exercised shall be final during the entire period of deputation. Option in this case may be given on plain
sheet to the Secretary & Admn. Officer.
The term of family will mean
family as defined in the staff bye-laws. However, if any member of the family is employed in
Govt./quasi Govt./other organisation, public or private, which provides medical
facilities to its employees, the medical expenses incurred for such member will
not be eligible for reimbursement. Any
additions or deletions to the family should be reported in Form ‘B’ appended to
these rules immediately.
Medical attendance means the
professional advice and care during sickness or injury whether at an approved
medical institution or at the residence of the employee or at the consulting
room of the authorized Medical Attendant.
It includes such pathological, bacteriological, radiological or other
methods of examination for the purpose of diagnosis as are available in any of
the approved medical institution and are considered necessary by the authorized
Medical Attendant and also such consultation at any place with a specialist or
other medical officer as the authorized medical attendant certifies to be
necessary to such extent and in such manner as the specialist or medical
officer may in consultation with the authorized medical attendant determine.
For the purpose of the rules, authorised medical
attendant includes:
(i) All medical officers in Govt. Service.
(ii) All medical officers attached to the
approved medical institution.
(iii) All ‘A’ class registered medical
practitioners in Allopathic, Ayurvedic and
Homeopathic medicines.
(1)
All Government Hospitals, Government Ayurvedic and
Homeopathic Institutions, Public Health Laboratories and special
institutions like T.B. Sanitorium, Leprosy Asylum and other hospitals and
medical institutions maintained by
Government for providing medical relief, diagnosis or relief.( list attachd)
and such other medical institutions as may be approved by Managing Director
from time to time.
Under these rules
reimbursement will be made for the following purposes:
1.
Fee for
consultation/medical attendance
2.
Cost of medicines
etc.
3.
50% of the rent paid
for pay ward in an approved medical institution.
4.
Fee for pathological,
bacteriological and other clinical tests paid to laboratories.
5.
X-ray charges
6.
Operation charges
7.
Charges for
extraction/filling/fitting of teeth etc.
Medicines do not include
proprietary preparations for which equally effective alternative preparations
are available, primary foods, tonics, dentures, spectacles, toilet preparations
or disinfectants. Items which are not
considered as medicines by the State Govt. will also not be considered as
medicines for the purpose of these rules.
Consultation fee for authorised medical attendant shall not exceed Rs.15/- per consultation. For continued medical treatment the fee paid to the medical attendant shall not exceed Rs.60/- for one ailment.
Though medical
attention/treatment will be permitted under allopathic, homeopathic and
Ayurvedic system no employee will be entitled to such attention/treatment under
more than one system for one ailment.
(1) If the authorised medical attendant is not
in a position to diagonise or to treat any ailment, the employee/his family may
consult or take treatment from a specialist on proper certification from the
authorised medical attendant. The
certification should be in the form given under:
It is hereby certified that Dr.
……………………………. Specialist in ………………
was consulted by the patient on my advice and that the
consultation was essential for the speedy recovery of the patient.
Signature of authorised medical
Attendant.
Date:
(ii) The medical expenses made for such consultation/treatment including
cost of medicines purchased for that purpose will be reimbursed to the employee
subject to other rules.
Total medical
reimbursement in a financial year to an employee will be limited to Rs.500/-
provided that Managing Director may at his discretion sanction the claims
towards reimbursement of medical expenses over and above the normal limit
mentioned above in appropriate warranting cases. The unutilized portion of the amount in the financial year will
not be carried over to the next financial year.
(i) In case of hospitalised treatment of the
employees as well as his family in an approved medical institution,
reimbursement of medical expenses be allowed in excess of the normal limit indicated above. The claim preferred in this behalf should be supported by
evidence to prove hospitalisation for the period of claim preferred in respect of the person on whose behalf the
claim is preferred. If deemed
necessary, the competent authority for passing the claims may call for further
proof or certification or make a reference to the hospital concerned.
(ii) But separate limits for non-hospitalised
treatment is not admissible. The financial limit of Rs.500/- can be exceeded
only for hospitalised treatment. In
case a claim preferred initially by an employee is for hospitalised treatment
and he has availed of the amount within the limit, his further claim for
non-hospitalised treatment exceeding the financial limit of Rs.500/- will not
be admitted.
(iii) The limits and restrictions laid down regarding reimbursement of
fee paid for consultation, hospital rent paid, cost of primary foods, tonics,
dentures, spectacles, toilet preparations or disinfectants etc. applicable in
the case of reimbursement of medical expenses for non-hospitalised treatment
would be equally applicable in the case of hospitalised treatment also.
Claims for reimbursement
of medical expenses under these rules should be presented before the expiry of
one month from the last date of treatment.
The last date of treatment for the purpose of preferring claim will be
the last date of purchase of medicines, shown in the cash bills produced in
support of the claim bills. If
treatment spreads over two financial years, the claim shall be preferred
separately for expenses in each financial year and the claim for the period
ending 31st March, shall be presented before 30th April following. No relaxation of this rule will be allowed
in any case, except when the employee is able to prove that it was physically
impossible for him to prefer the claim within the time limit above prescribed.
(i) The claims for medical reimbursement
under these rules shall be preferred in form No. ‘A’ appended to these
rules. This should be supported by cash
receipts/ cash bills for the purchase of medicines and other charges. The medical attendant who prescribed the
medicines must countersign the cash bills/cash receipts and the essentiality
certificate at the foot of the form should also be signed by him. Only cash bills/cash receipts in printed
form will be entertained for medical reimbursement.
(ii)
The claim should invariably contain the
details of medicines administered on the patient for scrutinising the
admissibility as per the stipulations laid down in the medical reimbursement
rules.
(iii) The
claim bills preferred as per the above rules should be presented to the Admn.
Dept. by the concerned employee. The Admn.
Dept. will scrutinise the bills regarding the admissibility of the claims
preferred and will forward the same to the Internal Audit for audit. The internal Audit Dept. will audit the
claim preferred and return the same to the Admn. Dept. The audited claim bills
will be passed by the officer authorised by the delegation of powers ad the
same will be forwarded to the Accounts dept. for effecting payment.
If any doubt arises to the
admissibility of a claim on account of the kind of medical attention/treatment
availed or as regards reimbursement of the cost of any item of medicine, the
same shall be referred by the officer passing the claim to the claimant/medical
attendant regarding the bonafides of the claim, or he may ask the employee to
give such further information or details as he may require for such purposes.
If there is any doubt
regarding the meaning or scope of any of these rules arises, the decision given
by the Managing Director shall be final.
Sd/-
MANAGING DIRECTOR.