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.
The eligibility criteria for West Bengal Cashless Medical Treatment Scheme can be given as follows:
Some of the notable features of West Bengal Cashless Medical Treatment Scheme can be listed as follows:
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|
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.
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.