Post-Retirement Medical Attendance Facility

The benefits of post-retirement medical attendance facility under the scheme shall be admissible only to the retired officer, dependent spouse and dependent parents. Any dependent unemployed child(ren) who is/are mentally retarded/spastic/suffering from incurable congenital disease(s) with minimum 60% physical & mental disabilities and certified to be incurable may also be included.  The incurable diseases for the purpose have been identified as Heart/Brain damages from birth, physical/mental disabilities from birth which have impaired hearing/speech/vision faculties, AIDS by birth and ‘a person of profound mental retardation since birth & having a mental age below three / four years & generally being unable to learn connected speech or guard against common dangers’.

   In case of death of an employee in service, if the spouse has opted for Rehabilitation Option R-1 or R-2, medical coverage will also be allowed to the dependent children for whom medical facility was availed by deceased employee before death. The facility will continue till they meet the conditions of dependency under Medical rules or till the notional date of retirement of the deceased employee. After the notional date of retirement, the medical coverage will be restricted to as provided under normal provisions of Post Retirement Medical Attendance Scheme. One time lump-sum contribution, under the Scheme, as laid down needs to be paid in respect of each child.

   If the spouse opts for R-3, the Medical facility under PRMAS will be admissible to the spouse for a maximum period of 7 years from the date of death/total permanent disablement of the employee or till the employment of ward, whichever is earlier. 

   The medical facility will also be extended to dependent children for whom medical facility was availed before death/disablement alongwith the spouse for a maximum period of 7 years or till the employment is given or till such time the conditions of dependency is met or till the notional date of retirement of the deceased/ permanent disabled employee, whichever is earlier.

   The above is subject to the Rule that one-time contribution, as applicable, would need to be paid in respect of each beneficiary. Further, there would be no separate entitlement for the spouse and ward as the facility would be admissible to them within the same domiciliary and hospitalisation limits as prescribed for the grade of the deceased/ disabled employee.

  The reimbursable ceiling limits for consultation fees, room charges, charges for various tests and investigations, etc.  shall be those as applicable from time to time under the Medical Rules to a serving Officer of similar rank.

Note : Reimbursement of expenses towards outstation journeys for medical treatment is not permissible under Post-retirement medical scheme.

1.3.4    Hospitalization:

1.3.4.1   Reimbursement of medical expenses incurred during hospitalisation in hospitals other than Nominated Hospitals, i.e., Hospitals nominated for regular employees except Refinery Hospital will be made to the retired officer depending upon their group for every block of two financial years, subject to the following maximum limits per financial year.

                                    Grade A                        –           Rs.25500/-

                                    Grade B &C                   –           Rs.37500/-

                                    Grade D, E&F                –           Rs.50250/-

                                    Grade G, H&I                 –           Rs.63000/-

                                    Board Level                    –           Rs.75000/-

  Note :(1.)The term `for every block of 2 financial years’ is intended to facilitate carry forward of any unavailed amount within the prescribed maximum limits in the first financial year to the next financial year in the block. Similarly, the amount spent in excess of financial limit during the first year be adjusted against the combined ceilings for the first and second financial years of the 2 year block.  The unavailed amount under hospitalization entitlement of a block may be carried forward to be availed in the next block of two years. The current block of 2 F.Ys. is 2010-11 and 2011-12.

    (2) Unutilized hospitalization entitlement brought forward or carried forward to the next year as per laid down provision, is admissible for hospitalization expenses only

  Reimbursement of medical expenses incurred during hospitalisation in Nominated Hospitals nominated by the Corporation is made as per ceilings laid down under the Medical Rules of the Corporation as amended from time to time and as applicable to a serving officer of similar rank. However, expenses beyond laid down financial ceilings are regulated as under.

a) Admissible expenses on account of specified ailments as per notified list given in Annexure-1 is reimbursed irrespective of the financial ceilings.

b) Admissible expenses on account of diseases other than specified ailments as per list referred to at (a) above shall be reimbursable up to 85% of such expenses (75% in the case of workmen).

   In case the member/other beneficiaries is hospitalized, it would be a pre-requisite to notify Management at the earliest.

    The facility for an officer who has exhausted or partly exhausted the annual  entitlement  towards hospitalisation in hospitals other than Nominated Hospitals and then shifts for treatment to a Nominated Hospitals , will be regulated as under:

Whenever in a financial year the facility of hospitalization has been earlier availed in a hospital other than a Nominated Hospital, the financial limit as laid down applies unless the member refunds the expenditure incurred during that financial year on hospitalisation in non-Nominated hospitals. However, in case where urgent treatment is taken in emergency for a specified ailment, in such case refund of reimbursement claimed by the retired employee may not be insisted upon while shifting him to the Nominated hospital. The beneficiary will have the choice of availing hospitalisation in a financial year in accordance with the provision 1.3.4.2 above if it is exclusively in Nominated Hospital.

   In case of death during hospitalization in a non-nominated hospital, thehospitalization expenses would be admissible for reimbursement as if hospitalization has been taken in a nominated hospital.

                 Domiciliary treatment:

    In case of domiciliary medical attendance, the expenses as per the following ceiling limit are reimbursable on Self-certification basis, without any supporting documents twice in a financial year on completion of 6 months period i.e. first claim is to be made after 30th September and second after 31st March in respect of each financial year in the prescribed  proforma.  The claim in no case is to exceed 50% of the entitled annual ceiling.

Note:  The above limits for reimbursement of medical expenses operate as the combined limit for the officer, dependent spouse, dependent parents and dependent eligible children, if any.

   Patients who suffer from ailments like, Asthma, Diabetes, Parkinson’s Syndrome/ Paralysis of limbs, which are chronic in nature, are generally on medicines for long spells, involving substantial expenditure, which in some cases may go beyond their domiciliary entitlements.

  In order to give relief where the retired employee and/or eligible dependent beneficiaries enrolled under the scheme, is/are suffering from one of these ailments, which are certified to be chronic in nature requiring long spells of continuous medical attendance, the retired employee at his option, may claim reimbursement of actual domiciliary medical expenses duly supported by receipts/cash memos in lieu of claiming on self-certification basis. Such claims will be limited to the annual ceiling prescribed for domiciliary treatment as per sub-clause 1.3.5.1. Reimbursement of expenses on Spectacles/Contact Lens/Hearing Aid or other such appliances, if any, shall not, however, be admissible for reimbursement. The claims under this provision shall be submitted once at the end of each quarter provided the claim amount is not less than Rs.500.

After this limit (as per clause 1.3.5.1) has been exhausted, the medical expenses incurred on certified chronic ailment(s) and other normal ailments will be settled from the available balance under hospitalisation entitlement of the retired employee. This would be subject to the condition that reimbursement of expenses on normal ailments shall not exceed the annual ceiling laid down for Domiciliary Entitlement for the retired employee. This implies that reimbursements earlier made for chronic ailments out of the Domiciliary Entitlement shall stand adjusted against available balance under Hospitalization Entitlement in the books to the extent the claim for normal ailments is settled.

The procedure in this regard is as under:  

a) A retired employee will submit his option to claim reimbursement of domiciliary treatment expenses under this provision. He will also submit a Medical Certificate in original from an Authorized Medical Attendant (AMA) as per Medical Rules in the prescribed proforma.  

b) Once the retired employee has opted to avail relief under ‘Chronic Ailments’ for self and/or eligible dependent beneficiaries, the said option will remain valid for the following financial years also till the retired employee repeals the option and revert to the reimbursement on self-certification basis.  However, the retired employee has to repeal the option by 30th April of subsequent financial year in order to claim reimbursement on self-certification basis.

c) The medical claims for expenses on certified chronic ailment(s) will be submitted through a separate claim form, indicating “Chronic Ailment” on the top and shall not be combined with claims for other ailments.

d) The claims for chronic ailment and/or other ailments shall be settled from the prescribed domiciliary entitlements.  

e) The prescribed limits on consultation fee, diagnostic/ investigation charges etc. in respect of a serving employee of the same status shall be applicable in the case of retired employees. Where the retired employees have opted under the category “chronic-ailments”, and have produced a requisite Certificate from the Medical Attendant at the time of exercising their option, the prescription of the authorised Medical Attendant prescribing medicines up-to a period of 3 months would be considered valid.

f) In case attending physician subsequently changes / adds to the earlier prescribed medicines for ‘chronic ailment(s)’ in the course of treatment, the claims of retired employees as per the revised prescription should be processed for reimbursement provided the revised prescription for medicines is with reference to the existing ‘chronic ailment(s)’.

In cases where the retired employee has exercised the option for reimbursement of domiciliary expenses duly supported by receipt/cash memos, the dental treatment /procedures & Physio-therapy treatment shall be admissible for reimbursement from out of the prescribed annual domiciliary ceiling if it is as per list of items applicable for the serving employees upto the prescribed ceiling for each of these items.

 Domiciliary expenses treated as Hospitalization expenses

 Reimbursement of the following expenses is to be deemed as part of hospitalisation entitlement / expenses.  

a) Reimbursement of expenses on account of Costly investigations/tests/ procedures:

The following investigations/tests/procedures, if obtained as outdoor patient, in a Nominated or Government Hospital, will be excluded from the domiciliary entitlement but reimbursed under hospitalisation entitlement within respective prescribed ceiling for each of them as per existing rules.

–           Endoscopy

–           ERCP

–           Lithotripsy

–           Laser treatment (Non-Cosmetic)

–           Cataract

–           MRI

–           Thallium scan

–           Colour Doppler

–           Dialysis

–        Oxygen Therapy (not exceeding Rs.1500/- p.m.) only in acute  cases of Bronchial Asthma

–          Diabetic Retinopathy, if performed under day-care

b) In addition to above, a single test/investigation/procedure obtained as outdoor patient and costing Rs.1000/- & above will be excluded from the domiciliary entitlement but reimbursed against hospitalisation entitlement within the prescribed ceiling for such test/investigation/ procedure provided the same is undertaken in a Nominated or Government Hospital.  Any grouping of the tests/investigations/procedures would not be admissible for this purpose.

c) The cost of artificial limbs/prosthesis in case of amputation will also be reimbursed as a part of hospitalisation expenses within the prescribed hospitalisation entitlement.

d) Health check-up once in a block of 2 years from out of the hospitalization entitlement of the retired employees is permissible to the members and beneficiaries in a Nominated Hospital as per investigations in Annexure-2. The reimbursement would be made on production of cash memo/receipt including list of tests done. Any test(s)/investigation outside the list including treatment obtained on the basis of health check up will be governed under normal provisions of the Scheme, if admissible.

The medical claims under above clauses will be submitted duly supported by Doctor’s prescription, cash memos/receipts etc., for the medical expenses, from a concerned Nominated Hospital/Government Hospital, as per the existing provisions of the Medical Rules.

e) The post-hospitalization Follow-up domiciliary treatment taken after Heart Surgery in a Nominated Hospital will be considered as part of hospitalization expenses upto 7 years from the date of discharge from hospital after first admission, and reimbursement would be admissible as under: