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  • West Bengal Cashless Medical Treatment Scheme

    Health Insurance
    • Premiums as low as Rs12/day for coverage of Rs.4 Lakhs*
    • 10,000+ hospitals for cashless treatment
    • Claim up to Rs. 55,000 deduction under section 80D**

    The Government of West Bengal came up with a scheme in 2014 to provide health insurance service for its employees and pensioners. This scheme was named West Bengal Health for All Employees and Pensioners Cashless Medical Treatment Scheme. This cover ensures that beneficiaries are protected from various medical threats. This scheme is a modification to the existing scheme named ‘West Bengal Health Scheme, 2008’ which also provides reimbursement facility in addition to cashless treatment.

    Eligibility for West Bengal Cashless Medical Treatment Scheme

    The eligibility criteria for West Bengal Cashless Medical Treatment Scheme can be given as follows:

    • This is a health insurance cover primarily intended for state government employees, pensioners, and their families.
    • In addition to state government employees, this scheme is also available to beneficiaries who have opted for this under medical allowance.
    • All India Service (AIS) officers and AIS pensioners of West Bengal can also take this cover.
    • This policy provides coverage for self, spouse, parents, dependent children, and dependent siblings.

     

    Features of West Bengal Cashless Medical Treatment Scheme

    Some of the notable features of West Bengal Cashless Medical Treatment Scheme can be listed as follows:

    • State government employees and other beneficiaries can obtain coverage as per the package list provided for treatment.
    • The package cost of treatment for any medical procedure must be less than Rs.1 lakh in a network hospital.
    • All beneficiaries enrolled in this scheme will receive a cashless card, which must be produced at the time of treatment.
    • Existing members of West Bengal Health Scheme can receive benefits as per their original policy schedule.
    • This policy will be implemented with the help of a Government Authorised Agency (GAA) that is deemed fit to run the scheme.
    • The appointment of GAA shall be done through a tender process. Those organisations with manpower equipped to handle this task can be considered in the tender process.
    • For members of the existing 2008 scheme, pre and post hospitalisation expenses are covered for up to a period of 30 days.

    Benefits of West Bengal Cashless Medical Treatment Scheme

    The package rate benefit offered under this scheme is inclusive of registration fees, admission charges, operation charges, doctor or consultant charges, monitoring charges, transfusion charges, anaesthesia charges, etc.

    Benefits Extent of cover
    Specialised surgeries Up to 12 days
    Major surgeries 7 to 8 days
    Laproscopic or endoscopic surgeries, normal deliveries 3 to 4 days
    OPD and minor surgeries 1 day
    Medical procedures covered Up to 1,014 types subject to a maximum approved rate for each package

    Exclusions of West Bengal Cashless Medical Treatment Scheme

    There are no specific exclusions listed out under the West Bengal Cashless Medical Treatment Scheme. This scheme will cover all reasonable hospitalisation expenses subject to a maximum sum insured amount of Rs.1 lakh. However, cosmetic treatments and non-emergency medical procedures may not be covered under this scheme.

    Claim Procedure

    This is a complete cashless treatment scheme, and the claim process happens between the medical facility and GAA. The health care organisation (HCO) will send an authorisation request to the GAA once the patient gets admitted in the hospital. The GAA will verify the details of the policyholder before sending the approval. The GAA may take up to 3 days to provide the approval to the HCO.

    For accidental emergencies, the HCO need not have to wait for the GAA approval to start the treatment. During the time of authorisation, the beneficiary can check the status of authorisation request in the GAA website.

    Once the treatment is over, a bill for the approved package rate will be sent to the GAA from the HCO. The HCO will provide various details including medical bills, discharge summary, diagnostic reports, cash memos, prescriptions, physician certificate, etc. while sending the bill to the GAA. All the documents must be sent within one month of the patient’s discharge from the medical facility. After receiving the documents, the GAA will verify the documents and ensure that the claim is valid. Upon verification, the settlement amount will be transferred electronically to the HCO.