ANDHRA PRADESH POWER GENERATION CORPORATION LIMITED

A B S T R A C T

APGENCO – MEDICAL – Modifications to the existing orders for Medical Reimbursement to APGENCO serving employees / pensioners – Orders – Issued

G.O.O. No.28/CGM(IR)/2009.                                                      Dt.27-04-2009.

Read the following:

 

1)     G.O. Ms. No.74, Health, Medical and Family Welfare (K1) Department,

dt.15.03.2005.                                    

2)     G.O. Ms. No.105, Health, Medical and Family Welfare (K1) Department,

dt.09.04.2007.                         

3)     G.O. Ms. No.397, Health, Medical and Family Welfare (K1) Department,

dt.14.11.2008.

* * *

O R D E R:-

The erstwhile APSEB have made Regulations for Reimbursement of Medical Charges vide B.P. Ms. No.138, dt.17.02.1969.  After restructuring of the APSEB with effect from 01.02.1999, the APGENCO is following the Regulations issued by the APSEB as amended from time to time.  Further, the erstwhile APSEB has prescribed the ceiling limits for reimbursement of medical charges from time to time.  The Government of Andhra Pradesh have constituted a committee and based on the recommendations of the committee, have modified the existing orders of Andhra Pradesh Integrated Medical Rules, 1972 vide G.O. Ms. No.1st cited read with G.O.s under references 2nd & 3rd cited.  The various Associations / Unions in APGENCO have represented to extend the facilities as available to the Government Employees as per the above cited G.O.s to the serving employees / pensioners of APGENCO. 

2) After careful consideration, APGENCO issues the following orders which shall come into force with immediate effect.

i)                               The ceiling limit of Rs.1.00 lakh fixed in B.P. Rt.142, dt.1-7-1995 is enhanced to Rs.2.00 lakhs for life time to serving employees/dependent family members/Retired employees/dependents, and Family pensioners, afresh with immediate effect.   

ii)                             The rates prescribed in the CGHS package rates by Government of India are adopted for the purpose of reimbursement of medical expenditure incurred by the employees both inservice/retired and their dependents/family pensioners as in-patient when the treatment taken in the Private hospitals recognised by APGENCO within the State.  If any rates not covered in the said procedure, the scrutiny authority is empowered to take a decision in the matter basing on the disease/nature of the disease necessity of treatment/medicine. (duly comparing to the Tariff rates of NIMS or to actuals of receipt which ever is less).

 

iii)                           Expenditure incurred in NIMS/SVIMS shall be paid at their package rates.

iv)                            Accommodation facility allowed as per CGHS package rates, as per employees scale of pay i.e., General Ward/Semi Private Ward/Private Ward.

v)                              In respect of treatments/operations obtained for cataract and other eye ailments, and dental diseases/treatments in Private hospitals recognised by APGENCO the scrutinizing authority need not insist on submission of Emergency Certificate.  The reimbursement shall be made as per the package rates prescribed by Government for various eye ailments and Dental procedures/diseases, after duly scrutinizing the bills by the  scrutinizing authorities.  The package rates prescribed for Eye ailments are payable as of G.O.74, dt. 15-3-2005 (and for dental ailment of the maximum ceiling is Rs.10,000/-) for each time is allowed for 3 times in life time including family members.

With regard to cosmetic dental surgery, claims regarding Cosmetic dental surgery are not eligible for any medical reimbursement, except in case of Road Traffic accidents involving upper and low jaws.

vi)                            All types of out-patient including diagnostics, and follow up treatments including Chemotherapy, Radiotherapy, Regular Dialysis for Kidney are allowed for reimbursement when the teatment obtained at Nizam’s Institute of Medical Sciences, Panjagutta, Hyderabad and Sri Venateswara Institute of Medical Sciences, Tirupati and all Government Hospitals.  In respect of the treatment obtained as Out-patients in private hospitals recognised by APGENCO, medical reimbursement is allowed for Chemotherapy and Radiotherapy for Cancer and regular Dialysis for Kidney and also Out-patient treatment for Cardinal diseases like cardiac diseases and severe neurological problems and A.I.D.S are included.  The length of out-patient treatment period should be recommended by the specialist doctor concerned.

a)     No reimbursement of O.P is permitted except as mentioned in clause (vi)

b)     No reimbursement for Alcoholic cases.

c)      No reimbursement for Suicide/attempt to suicide.

d)     No reimbursement for self implicated Injuries.

e)     No reimbursement of Cosmetic surgery/Except in accident cases.

vii)                           In respect of Road Accidents cases if the employee or his dependents (i.e., dependent parents, adoptive parents and in regard to Women employee in-laws when they are wholly dependent on employee) were admitted in near by Private Hospitals which are not recognised as referral hospitals by APGENCO under emergency conditions to save the life of the patient in such case the claim can be considered for reimbursement of medical expenses.

1)     The employees on rolls of APGENCO only when met with an accident while performing duty, the total expenditure incurred towards treatment will be reimbursed in full without linking to the ceiling limits prescribed.

viii)            10% cut is imposed on eligible amount after scrutiny by competent authority in the cases of treatment obtained in emergency condition in private hospitals recognised by the APGENCO as per the package rates.

ix)               In respect of medical reimbursement to the employees under suspension, the following two points to be observed.

a)     When an employee provided dismissed or removed from Government service he/she and their dependents are not entitled for reimbursement of medical expenses.

b)     As far as retired and re-employed pensioners are concerned, for persons who were convicted by the court of law for offence or involved in moral turpitude and punishment was imposed under A.P. Revised Pension Rules, 1980, he and his family members shall not be entitled for any free medical treatment in punishment period. 

x)                 The employees/Retired employees their dependents/Family pensioners are permitted to secure treatment of all disease at NIMS/SVIMS, Hyderabad as in-patient and out-patient.

1)     Credit Cards are issued to referral private hospitals recognised by the APGENCO for treatment and operation to the employees and their dependents for major ailment of CABG, Kidney transplantation, Cancer, Neuro Surgery, Open Heart Surgery, all organ transplants, PTCA+STENT, Pace Maker, Plastic Surgery done secondary to accident, and burns cases, and for other chronic disease based on submission of estimation, and acceptance of the credit from the concerned recognised private hospital, subject to ceiling limit as per the package rates prescribed by the Government.

xi)               Medical reimbursement facility to the following family members family of 1+5.

          Self (Employee)

          Spouse

          Children including adopted childrens.

Parents/adoptive parents who are wholly dependents on employee i.e, having no source of income, and in-laws in respect of Women employee or parents.

A declaration of dependence shall be submitted by employees on or before 7.5.2009 and be recorded by HODs for availing medical facility and there by every year in the first week of January.

xii)             Specific drugs for the specialised treatment should be prescribed by the specialist doctors only in both private hospitals recognised by APGENCO, and Primary Health Centres, Community Health Centres, and other government Hospitals.

xiii)           The medical reimbursement facility be allowed to those who obtained medical treatment under emergency circumstances outside the State on official duty only, i.e. the provision may be given only to the persons who proceeds on official duty and suddenly feel ill health, as per the Central Government Health Scheme package rates/ NIMS/SVIMS.

xiv)            No user charges are payable for the treatment obtained by employee and their dependents including the pensioners and their dependent family pensioners in Government hospitals for their treatment for both In-patient and Out-patient.

xv)              As per A.P. Medical Attendants Rules 1972, for belated claim the existing condition under note-3 of Appendix 3, Rule-5 within (iii) The existing condition that preferring claim for medical reimbursement should be within the period of 3 months from the date of discharge of the patient from the hospital but not from the last date of treatment is continued, except for the Coma, expiry cases and accidental cases.  In such cases the claims may be preferred with in 6 months from the last date of discharge from hospital.

xvi)            For scrutiny of bills, the following original documents should be submitted along with the claim:-

1)     Discharge summary

2)     Emergency Certificate (Except for dental and Eye ailments)

3)     Essentiality Certificate

4)     Appendix-II Form

5)     Declaration of dependence to be attested by Gazetted Officer

6)     Non drawl declaration, which should be attested by Drawing and Disbursing Officer concerned.

The Xerox copies of documents shall not be accepted.

xvii)                    No restriction is imposed for treatment obtained in private recognised hospitals by APGENCO for different ailments / operation / treatments.  Medical reimbursement facility for major ailments i.e. CABGS, Kidney transplantation, Cancer neurosurgery, PTCA STENT be restricted to three spells for each of these diseases.  Three spells means, three surgeries for the same ailments, except for Orthopedic and Plastic Surgeries, where more number of operations are warranted for the treatment of the same cause.  A justification certificate issued by the concerned specialist treating doctor of the private hospital recognized by APGENCO hospital should be submitted for the second and third spell claims.

 

The maximum ceiling limit of Rs.2.00 lakhs (Rupees two lakhs only) is fixed for the major ailments of Bypass Heart Surgery, CABGS, Double valve replacement, Open Heart procedure, aortic valve replacement, Kidney Transplantation, Cancer and Neuro-Surgery to Brain irrespective of package rates of CGHS for the treatment obtained in private hospitals, and also for the treatment obtained in NIMS, Hyderabad and SVIMS, Tirupati or actual cost which ever is less. This ceiling limit of Rs.2.00 lakhs is applicable to the serving employees and their dependents and Retired employees/dependents/ family pensioners. 

                   Where package rates in CGHS, NIMS/SVIMS are not available for certain treatments other than Dental ailments, the ceiling limit as prescribed will be Rs.1.00 lakh for serving employees and their dependents and in respect of retired employees and their dependents and family pensioners, it shall be Rs.75,000/-

                            In the conditions, procedures, surgeries where CGHS package rates are available, the CGHS tariff is the ceiling limit and shall be followed for the treatment obtained in Private Hospitals except for the major ailments mentioned above.  The private hospitals recognised by APGENCO as referral hospitals should abide and follow CGHS package rates and Government orders while giving treatment to the employee and their dependents as per APIMA Rules.  They shall not charge excess amount over the package rates mentioned in CGHS package rates.

xviii)         Reimbursement of medical charges for treatment taken by employees in foreign countries under emergency conditions be allowed, only if they are on official visit to that foreign country.  The treating doctor of the concerned hospital has to issue certificate about the nature of the Emergency, Essentiality Certificate and detailed bills provided that they are not paid any amount towards the said treatment by any other authority including company.

1)     Master Health Checkup be allowed to all the employees who crossed the age of 40 years and before retirement from service.  Master Health checkup will be allowed only three times with an interval of one year, between each checkup, and by duly fixing the package rates and can be obtained in all the Government hospitals, Nizam’s Institute of Medical Sciences, Hyderabad, Sri Venkateswara Institute of Medical Sciences, Tirupati and recognised private hospitals, at fixed ceiling limit of Rs.3,000/- (Rupees Three thousand only) for each time.

                                                                                               

xix)           Medical reimbursement for deliveries and tubectomy to the Women Employees be allowed reimbursement up to two deliveries and with two living children as per the package rates.  Hysterectomy operations shall be reimbursable as per package rates.

xx)             If the claimant has claimed his medical reimbursement from the Insurance company, under Health Insurance Scheme by paying premium on his own reimbursement also be allowed from (Government)/APGENCO as per Central Government Health Scheme package rates for balance portion of the bills unclaimed against the Insurance if any (on production of original payment receipts along with bills)

xxi)           The ceiling limit for reimbursement to Master Health Check up is fixed at Rs.3000/- (Rupees Three thousand only) and Master Health Checkup shall include (1) Haemogram (CBP, ESR, Plate count) (2) complete Urine examination, (3) Biochemistry: Serum Uric Acid, Lipid Profile, LFT, Blood Sugar, Fasting and Post Prandial Blood Urea and Serum Creatinine (4) Cardiology ECG, 2D, ECHO Tread mill test whenever necessary (5) Radiology chest X-Ray, Ultra sound Exam abd. (6) PAP Smear (HP) for ladies (7) Micro Biology: HIV, HBs Ag. (8) Blood Grouping Rh. Typing (9) Eye checkup and consultation with physician (10) Thyroid Test and T3, T4, TSH.

xxii)         With regard to Delegation of Powers for issue of credit cards/payment of bills with scrutiny, existing procedure may be followed.

3) The above medical reimbursement scheme formulated shall be In force upto an alternative package scheme evolved by APGENCO in consultation with the Unions/Associations.

           

(BY ORDER AND IN THE NAME OF ANDHRA PRADESH POWER GENERATION CORPORATION LIMITED)

    AJAY JAIN,

                                                                                     Managing Director