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.
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,
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
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