West Bengal Cashless Medical Treatment Scheme offers cashless healthcare services to pensioners, officers, and employees of the West Bengal government, for up to Rs. 1 Lakh. If covered under the scheme, AIS officers and their families can also avail coverage benefits.

Notified in 2014, the West Bengal Health for All Employees and Pensioners Cashless Medical Treatment Scheme was merged with WBHS 2008 from September 15th, 2014.

West Bengal Health Scheme is a comprehensive health scheme that focuses on providing the best medical support to the insured by giving the best rebates as well as cashless services. In the past one decade, the West Bengal Health Scheme has been extended quite a few times to inculcate medical benefits to pensioners as well as government employees.

Note that to avail of policy benefits, one has to submit an enrolment certificate before the Health Care Organisation (HCO). But to avail cashless indoor medical facilities, there is no requirement of pre-authorization. At the time of discharge, the medical bill will have details about the expenses incurred.

Eligibility For West Bengal Health Scheme

Following are the eligibility criteria for West Bengal Health Scheme:

• State government employees, their dependents, state government pensioners, their families are eligible to avail of policy benefits.
• Those who have chosen medical allowance can also avail of policy benefits.
• All India Services pensioners and service officers of Best Bengal are eligible to avail of policy benefits.

Features of West Bengal Health Scheme

Listed below are the features of the West Bengal Health Scheme:

• The scheme offers coverage to employees and his family including dependent parents and siblings.
• An employee who is registered under the West Bengal Health Scheme can also claim benefits and will be eligible to avail benefits under West Bengal Services (Medical Assistance) rules, 1964.
• The people insured are offered cashless cards that they can use to avail cashless treatment at the hospital.
• Reimbursement of indoor treatment should be claimed within 3 months from the date of discharge.
• Expenses incurred on treatment availed in some speciality hospitals (including expenses incurred on journey and one attendant), which are located outside the state will be reimbursable.

Inclusions Under West Bengal Health Scheme

West Bengal Health Scheme covers the insured for more than 1,000 medical procedures including specialised services for up to 12 days major surgeries for up to 7-8 days, Laparoscopic or endoscopic surgeries, normal deliveries for up to 2-4 days, and OPD and minor surgeries for up to 1 day. Explained below are the coverage benefits under the policy:

• OPD Treatment Reimbursement: If covered under the policy, you will be reimbursed for OPD treatment expenses, subject to mention when hospitalised, for a period of 30 days, along with 30 days after discharge. Some OPD treatments covered under the policy include malignant malaria, tuberculosis, renal failure, and Hepatitis B/C and other liver diseases.
• Cashless Indoor Treatment Facilities For up to Rs. 1 Lakh: The policy offers a waiver benefit of up to Rs. 1 Lakh for indoor treatment, if it is done in the private network hospitals under West Bengal Health Scheme. If the expenses incurred exceed Rs. 1 Lakh, then the reimbursement will be subject to clause DDO/PSA.
• Non-Empanelled Hospitals: If the treatment is availed at a non-network hospital, then 60% of the actual cost or the approved amount, whichever is less, can be claimed for reimbursement. In a hospital where the number of beds is more than 80, then 80% of the actual cost or approved cost is reimbursable.
• Cost of Specified Investigations: Expenses incurred on some investigations enlisted in medical Memo 10 will only be reimbursed on the OPD prescriptions advised by the doctors in recognised hospitals, or if the investigation is done in a network hospital.

Exclusions Under West Bengal Health Scheme

West Bengal Health Scheme does not cover you for the following expenses:

• Cosmetic surgeries
• Non-medical treatments

Enrollment For West Bengal Health Scheme

To enrol and register for West Bengal Health Scheme, you are required to visit the website of West Bengal Health Department. You can enrol as a government employee, beneficiary of grant-in-aid college, the beneficiary of grant-in-aid university, and a government pensioner.

To enrol as a government employee, follow the steps given below:

• Visit the West Bengal Health Scheme Portal
• Click on online enrolment and select government employee
• If you have a PRAN/GPF number, then check the Yes box and enter details. And if you don’t have the details, then check No box and select Non-GPF.
• Mention details like residential district and birth date. Save the information to register in the West Bengal Health Portal. Click on next to proceed with the process.
• Enter personal details like name, mobile number, address, employee number, etc.
• Enter your office details
• Enter your family details
• Upload your photograph and signature. Make sure to upload the same in the specified dimensions
• Mention details related to the beneficiary
• Mention details pertaining to head office
• Save the details. Then print the report as you may need it in the future.

West Bengal Health Scheme Application Form Download

To download West Bengal Health Scheme for different sections, you must follow the steps given below after visiting its official website:

For State Government Employees

• Visit the Download section of the West bengal Health Scheme portal
• Select ‘Employees’ from the drop down menu of ‘select category’
• Download the relevant form

For State Government Pensioners

• Visit the Downloads section of the West Bengal Health Scheme portal
• Select ‘Pensioners’ from the drop-down menu of ‘Select Category’
• Download the relevant form

Claim Under West Bengal Health Scheme

West Bengal Health Scheme works on a cashless basis. So, if the treatment is availed as per the terms and conditions of the policy, then the beneficiary will not be required to pay anything at the hospital. Only in case the treatment expenses exceed the amount covered, then the beneficiary will be required to pay the difference.

The claim process involves the following steps:

• Visit an empanelled hospital and submit the cashless card to the concerned authority
• Health Care Organisation (HCO) will send an authorisation request to the Government Authorised Agency (GAA)
• GAA will approve the request after checking the details
• Once you avail the treatment, the hospital or the HCO will send the bill to the GAA. Apart from the bill, there will be other documents as well including doctor’s certificate, medical report, discharge summary, etc.
• The documents will be verified by the GAA
• The amount will be transferred by the GAA to the HCO.