West Bengal Health Scheme

All the State Governments have been progressively maintaining law and order as well as are striving hard to provide the basic amenities to the citizens at their very best. The basic amenities not only include the facilitation, but also supportive programs and schemes such as health insurance and provisions related.

One of the most important and basic area is healthcare which, if neglected, can lead to a drastic slowdown in human resource growth rate, wherein the main sufferers are women and children. The nation and the states have come a long way since then by regulating various health care schemes and imparting different plans for the benefit of society. According to the Union Budget 2019, the Government aims to spend Rs. 59,039 crore in the financial year 2019-20, whereas it has already allocated Rs. 52,800 crore to the health care sector. As far as the Indian states are concerned, West Bengal Government has worked tremendously in the field of healthcare and development sector. The State Government has been coming up with various Health Schemes since the year 1964. Around the year 2008, in addition to their existing medical services which were regulated in the year 1964, the West Bengal Government further introduced a medical Health Scheme aiming to provide better facilities for the employees to improve their health conditions.

Initially, the West Bengal Health Scheme constituted forgoing of the medical allowance on the salary drawn, later on the Government extended this facility from super-annuation to medical relief from the drawn salary in 2009. Over the last decade, the West Bengal Health Scheme has been extended several times to inculcate medical benefits to the Government employees and pensioners.

Regulation of the West Bengal Health Scheme

The West Bengal Health Scheme is administered by a medical cell formed under the Finance department of Government of West Bengal. This medical cell has been formed to regulate and monitor the West Bengal Health Scheme in collaboration with the health and family welfare department. The medical cell issues the operational guidelines for its implementation.

Thus, being the advisory body of the State Government, the area of medical cell is quite expanded. The policies for implantation, surgeries, treatments, approval for the rates of different processes, empanelment of various hospitals, laboratories and clinics.

Features of the West Bengal Health Scheme

The West Bengal Health Scheme aims to provide best medical and health facilities to the pensioners, employees and officers of the state Government by giving ahead best slabs of rebates and cashless services up to INR 1 lac.

Some of the features are explained as follows:

Cashless indoor treatment facilities upto INR 1,00,000

It gives the benefit of waiver up to Rs. 1,00,000 on indoor treatment, provided it is done in the private empaneled hospitals coming under the West Bengal Health Scheme. If the cost goes beyond Rs. 1,00,000, then the reimbursement is subject to the clauses in DDO/PSA.

OPD Treatment Reimbursement

The cost incurred during the OPD treatment is reimbursable, subject to mention at the time of admission for the period of thirty days along with the period of thirty days after the discharge. The costs are reimbursable, provided the treatment is being done under the hospitals recognized by the scheme.

Non empanelled hospitals

In the case of non-empanelled hospitals, 60% of the actual cost or the approved amount, whichever is less can be claimed for the reimbursement. 80% of the actual cost or approved cost is reimbursable where the number of beds in the hospital is more than 80.

Cost of certain specified investigations

The cost of certain investigations as mentioned in the medical Memo 10 are reimbursed only on the OPD prescriptions by the doctors consulted in the recognized hospitals, or in case the disease investigation is done in the empaneled hospitals.

Reimbursement of treatment in certain Specialty Hospitals situated outside the State:

The cost of treatment is reimbursable, provided the treatment is done within the specified list of hospitals falling outside the state. The actual cost of treatment which includes the cost of journey along with one attendant is reimbursable.

Other features:

  • The beneficiaries are provided with a cashless card to be produced to the hospitals at the time of treatment.
  • The benefits for the existing policy holders remain the same, which is implemented with the help of Government Authorized Agency that carries out the further process.
  • Reimbursement of the indoor treatment should be claimed within three months from the date of discharge.
  • An employee who has registered under the West Bengal Health Scheme can also claim benefits and shall be entitled to the benefits and facilities under West Bengal Services (Medical Attendance) rules, 1964.

Benefits of the West Bengal Health Scheme

The West Bengal Health Scheme works towards a vision of providing a scheme which is:

  • The scheme should be affordable, accessible and providing high quality essential care in the field of health.
  • Focusing mainly on child and women health, elderly people especially living in underdeveloped areas.
  • More and more development of hospitals and healthcare facilities.
  • Children exceeding the age limit of 25 years or earning Rs. 1,500 whichever comes earlier, are not dependent, but if in case they are having disabilities either physically or mentally, they will be considered a beneficiary.

With all these focus areas in mind, West Bengal Health Scheme aims to provide the scheme wherein the package is inclusive of all the charges like anesthesia, operation charges, and admission and registration charges, monitoring and transfusion charges.

  • In case of specialized surgeries, the cover is offered up to 12 days, whereas in major surgeries, it is limited to 8 days.
  • Up to 1014 medical cases are covered which, subject to a maximum coverage, is according to the approved rate.
  • The surgeries involving laparoscopy, endoscopy and normal deliveries are subject to a cover of 4 days, and 1 day for OPD surgeries.

Exclusions of the West Bengal Health Scheme

There are as such no exclusions or terms mentioned in the scheme. The cashless medical treatment scheme covers all the medical expenses specified under the empanelled hospitals. However, the scheme does not cover expenditure incurred in cosmetic treatments or any non-medical procedures. Following features could be considered.

  • An employee is free to opt out of the West Bengal Health Scheme at his discretion, but if his beneficiaries have enjoyed the benefits, he cannot opt out until five years from the execution of the scheme.
  • The female employee cannot make her dependent parents as beneficiary of the scheme. However, she can enroll herself separately and then make her dependent parents as beneficiary, provided they fulfill the income criteria. Children are given the benefit of getting enrolled with either of the parents.

Empanelled Hospitals

The list of empanelled hospitals comprise of Government hospitals, Local body’s hospitals, State-aided hospitals and private aided hospitals. These categories of hospitals have been listed code wise under the West Bengal Health Scheme as well as the diagnostics centers, clinics, laboratories are mentioned, recognized for availing the benefits of this scheme.

Healthcare care organizations (HCO) empanelled under Swastha Sathi scheme shall be eligible for the empanelment under the West Bengal health care scheme with no inspection required. In case of hospitals not enrolled under the Swastha Sathi scheme, the existing benefits will continue.

Implementation of the West Bengal Health Scheme

The West Bengal Health Scheme with the revised rate list and all the benefits, recognized hospitals, medical centers and rebates have been listed in the official website of the Finance department of the State Government. The medical cell has been formed to carry on and regulate the healthcare scheme in collaboration with the health care and family department. The medical facility and the Government authorized agency carry the procedure of implementing the scheme. The authorization request is sent by the healthcare organization to the GAA when the patient gets admitted to the hospital. The GAA verifies the details and sends approval. Once the treatment gets over, all the bills and documents are sent to GAA within a month of the discharge from the hospital.

After complete verification, the approval is sent to the Healthcare care organization and amount is electronically transferred to the HCO.

But in case of the accidental emergencies, the HCO doesn’t have to wait for the Government authorized agency for the approval at the time of admission in the hospital. The beneficiary can check the authorization status on the GAA official website and initiate the process further. All the forms can be downloaded from the official website of the West Bengal Healthcare scheme.

Eligibility criteria of the West Bengal Health Scheme

The eligibility criteria for availing the benefits of this scheme are as follows:

  • The State Government employees, their dependents (fulfilling the criteria), state Government pensioners and their families stand the right to avail the facilities of the scheme.
  • The beneficiaries who have chosen the medical allowance are also deemed to enjoy the benefits of this scheme.
  • Service officers and Pensioners of West Bengal can claim these benefits and facilities.
  • Along with the cashless treatment, this scheme provides coverage for the employee and his family, parents and siblings that are dependent.

The West Bengal healthcare scheme offers cashless treatment and aims to provide best of support to the state Government employees and pensioners in the field of medical and health care. The state Government has made many improvisations since its implementation, only to make it better and completely productive.

FAQ's On West Bengal Health Scheme

Can any employee of the West Bengal State Government opt out of the West Bengal Health Scheme?

Yes, an employee of the West Bengal State Government can choose to opt out of the West Bengal Health Scheme. However, if he or any of his family members has availed any benefit of the scheme, then he will not be able to opt out of the same for a period of five years from the date of availing the benefit.

Who is considered as a beneficiary under the West Bengal Health Scheme?

All family members of the employee of the West Bengal State Government who are financially dependent of the employee and among the ones listed below are considered as beneficiary:

  • Spouse of the employee
  • Dependent parents with an income of less than Rs. 3500 per month
  • Children, either own, step-children or legally adopted, including unmarried, widowed or divorced daughters
  • Siblings less than 18 years of age
  • Dependent sister, either unmarried, divorced or widowed.

Can a dependent son be considered as a beneficiary under the West Bengal Health Scheme?

A son is considered as a beneficiary under the West Bengal Health Scheme till he attains 25 years of age or starts earning a minimum of Rs. 1500 per month.

How to reimburse the treatment cost under the West Bengal Health Scheme if there is no package rate for any particular surgery?

Treatment for any surgical procedure under the West Bengal Health Scheme is done on a particular package rate. So, if there is no specific package rate for that particular surgery, the cost is mapped to any other packages whose cost is similar. However, in such circumstances, a permission needs to be taken from the Finance Department when a specific Package Rate is not available.

If the spouse of the employee is also an employee of any Bank or the Central Government or works in an organization that is wholly or partially owned by the State Government or the Central Government, can she/he still avail the benefits under the West Bengal Health Scheme as a beneficiary?

Yes, the spouse can always avail the benefits and claim reimbursement of the treatment cost under the West Bengal Health Scheme. However, the medical treatment cost can be reimbursed only from one place. So, if she/he claims the same from his company, she/he cannot apply for the reimbursement under the West Bengal Health Scheme. However, she/he doesn’t claim any reimbursement from any other place, she/he can surely claim reimbursement from the West Bengal Health Scheme, provided she/he obtains a certificate from her/his employer with a permission to claim medical benefits from the West Bengal Health Scheme.