Presentation 1

Master Circular on Bank's Medical Facilities Scheme (BMFS)
By Mala Ramanujam
RESERVE BANK OF INDIA
Introduction: The Bank provides medical facilities to its employees and their eligible family members under the Bank's Medical Facilities Scheme (BMFS). The medical facilities so provided are broadly classified as under: Dispensary Facility Outdoor treatment facility Consultation with BMO /GMP /Specialist Admissibility of medicines Pathological / Radiological Investigations Specialised treatment Indoor treatment (Hospitalisation) Reimbursement of medical expenses on declaration basis Private Treatment Scheme Annual Health Check-up The medical facilities allowed at the Bank's dispensaries and reimbursement of expenses allowed for outdoor /indoor treatment are mainly under the Allopathic system of medicine. Officers may, however, be granted reimbursement of medical expenses incurred for self and eligible family members for Homoeopathic, Ayurvedic and Unani systems of medicines
Medical Assistance Fund (MAF) Scheme : The Bank has set up a Medical Assistance Fund Scheme with effect from January 1, 1987, membership to which is compulsory for those who have joined the Bank after July 1, 1994. However, with effect from April 1, 2009, MAFS has become a purely superannuation scheme available to members only after their retirement. For details, Master Circular on the MAF Scheme may be seen.
Scope of BMFS : Treatments for curative purposes for all ailments are generally admissible under BMFS except certain specific ailments as listed below:
(i) Obesity (ii) Sexually transmitted diseases/Neurasthenia Sexual (iii) Retarded growth (iv) Sterility per se (v) Insanity (vi) Menopausal syndrome (vii) Surgery done for cosmetic purpose (viii) Change of Sex (ix) Claims relating to Allergy tests
Other Recognized treatment : 4.1 Homoeopathic / Ayurvedic treatment for Officers O.P.D (i) The cost of Homoeopathic/Ayurvedic medicines for any one ailment prescribed by Government/Government recognised Trust/Charitable hospitals/dispensaries for curative purposes and purchased from them or from licensed chemist shops against proper prescriptions/receipts may be reimbursed in full. (ii) Cost of treatment taken from a registered private medical practitioner for any one ailment may be reimbursed upto a period not exceeding three months. However, to qualify for reimbursement for such treatment beyond 10 days, it will be necessary to submit doctors prescriptions / receipts mentioning the specific ailment as also the cost of individual items of medicines issued by him. Only one consultation charge will be reimbursed during this period of treatment (i.e. three months). (iii) Cost of medicines prescribed by the doctor as per (ii) above and purchased from licensed chemist shops against proper prescriptions/receipts will also qualify for reimbursement. (iv) Cost of treatment undergone beyond three months at a time for the same ailment, may be reimbursed only if the treatment is taken from Government/ Government recognized Trust/Charitable hospitals/ dispensaries.
Cost of medicines prescribed by the hospitals may be reimbursed even when they are purchased from any pharmacy/druggist subject to the following: (a) A certificate should be produced from the hospital authorities to the effect that the medicines prescribed by them are not available in the pharmacy/dispensary attached to the hospital. (b) The medicines should be purchased from the outside pharmacies/druggists who are approved / recognised by the Central/State Government for the purpose of reimbursement under their rules (Offices may obtain the list of such pharmacies/druggists from the concerned Government authorities). (c) The concerned hospital should certify that the medicines were prescribed by them for curative purposes. Eligibility under BMFS
5.1 Dependents under BMFS An employee and the following members of his family are eligible for facilities under BMFS: Spouse Dependent children Dependent parents Dependent parents-in-law of female employees {Please see 5.2(d)}
Offices may ensure, before settling the medical claims that the declaration of dependency is furnished by the employee and the same has been incorporated in IES/HRMS by the Offices/Departments and retain the original in the service folder of the employee concerned. If both husband and wife are employed in the Banks service, each of them can claim reimbursement separately under Banks Medical Facilities Scheme. However, if they so desire, one of them could seek reimbursement under BMFS for the entire family on the basis of their respective status in the Bank which is more beneficial to them. In case of workmen employees, if the spouse is working as an officer in the Bank and claiming reimbursement for the entire family, then the workmen employee will not be eligible for the reimbursement under Private Treatment Scheme. 5.2 Criteria of dependency: The criteria of dependency may be decided on the basis of the following:
In the case of earning spouse (when employed with some other organization), the medical facilities may be extended to him / her subject to production of a certificate from his / her employers, to the effect that the spouse concerned is not availing of the medical facilities from his / her employer.
In the case of children, the son is treated as dependent till he starts earning income and daughter is treated as dependent till she starts earning or gets married whichever happens earlier. In the case of parents, they are treated as dependent if their total income from all sources other than pension does not exceed Rs.5000.00 (Rupees Five thousand only) per month. (The employee should submit a declaration / certificate of dependency in the prescribed format). RESERVE BANK OF INDIA
A married female employee is eligible to claim medical facilities either for her dependent natural parents or parents-in-law by giving an irrevocable option. However, she can claim reimbursement of medical expenses for her dependent parentsin-law only if her husband is no more or is not earning. The parents/parents-in-law should normally be residing with the employee or in the same city where the employee is posted. The workmen employees and officers may also be allowed to avail of admissible medical facilities in respect of eligible dependent parents even if they are not residing with them or in the same city or its suburbs provided that the treatment is taken at head quarters of the employee or where the parents are ordinarily resident or at a place where Banks Regional Office is located. 5.3 Medical facilities available for workmen employees officiating as Officers on a dayto-day basis : Workmen employees officiating as officers on a day-to-day basis are eligible for reimbursement of medical expenses as Assistant Manager in Gr. A in respect of treatment taken during the period they officiate as officers. They are also eligible for reimbursement of medical expenses on declaration basis as officers as also under Private Treatment Scheme for workmen employees subject to the following:
Under Declaration Scheme for officers : (i)The employee should have officiated as an officer for a minimum period of 30 days on a cumulative basis in a calendar year to be eligible for this facility. (ii) Broken period for less than a month may be reckoned as one month for working out the entitlement. (iii) The employee should indicate in the declaration, the date/s on which the treatment was taken.
Under Private Treatment Scheme for Class III employees

The employee will be entitled for reimbursement of medical expenses incurred to the extent of the full limit for PTS for the entire year and not on pro-rata basis. It should, however, be ensured that the total reimbursement in a calendar year in such cases, i.e. under PTS and Declaration Scheme together does not exceed the amount available/ admissible under declaration scheme for the officers for an year. 5.4 Medical facilities available for part-time employees : 5.4.1 Part-time employees whose working hours exceed 13 hours per week are eligible for reimbursement of cost of indoor hospitalization treatment on proportionate basis according to their number of hours of work. These facilities will not be available to part-time employees who are having working hours of 13 or less in a week or those who are on a contract basis with fixed monthly remuneration.
5.4.2 Part-time employees are eligible to avail medical facilities being provided in the Bank's dispensaries only for themselves and not for the family members.
5.5 Treatment outside headquarters

5.5.1 For Officers When the family members of an officer are residing at a place other than the place of his posting and the Bank has its office at such a place, the medical expenses incurred on any family member for indoor/outdoor treatment may be reimbursed as admissible under the BMFS provided the treatment is taken in consultation with the BMO. In case there is no Banks office/dispensary at that place, reimbursement of medical expenses may be allowed if treatment is taken as an out-patient/in-patient of a Government/Municipal/Trust/Corporate hospitals for eligible family members excluding dependent parents subject to scrutiny of the bills by BMO in regard to admissibility/reasonableness of the charges. When a child/children of an officer is/are left as boarder in a school/college, cost of treatment availed from the Medical Officer attached to the school/ college and that taken as an out-patient/in-patient may be allowed to the extent certified by the BMO.
5.5.2 For workmen employees The employees themselves on tour, leave, etc, and their eligible family members in respect of whom they have opted for dispensary facilities under the PTS will be entitled to receive usual medical treatment from the Bank's dispensary at the place of visit, if any or OPD treatment in Government /Municipal /Trust/ Corporate Hospital. They will also be entitled for indoor hospitalization facilities there as admissible at head quarters for temporary period, not exceeding three months. 5.5.3 For Dependent parents of officers and workmen employees The officers and workmen employees may be allowed to avail of admissible medical facilities in respect of eligible dependant parents even if they are not residing with them or in the same city or its suburbs provided that the treatment is taken at head quarters of the employee or where the parents are ordinarily resident or at a place where Banks Regional Office is located. Banks Dispensary Facility For the purpose of providing medical facilities, the Bank has set up dispensaries at offices and at most of the staff quarters situated at different centers across the country. Where it is not feasible to have the Banks own dispensary, the Bank has made arrangements with Private Medical Practitioners for consultation / prescription of medicine on a contract basis . Employees and eligible members of their family including dependent parents are entitled for dispensary facilities such as consultation with the BMO, issue of drugs from the dispensary stock or on credit slips from the Bank's office dispensaries and also from the staff quarters dispensaries, where they are staying. However, the families of workmen employees who have not opted for dispensary facilities for the purpose of reimbursement of medical expenses under the Private Treatment Scheme will not be eligible for the above facility.
Officers and workmen employees staying outside the staff quarters are also eligible to avail of the services available at the staff quarters dispensaries for themselves and eligible members of their family. 6.2 The relatives (other than the dependent family members), who have been permitted to reside with the employees in the staff quarters may also avail of the medical facilities from the staff quarters dispensary on payment. The charges to be recovered from the employee on account of the cost of mixtures, powders, etc. dispensed in such cases should be fixed by offices in such a manner as to ensure that no amount of subsidy is involved in extending this facility. No medicines should also be prescribed to the relatives on credit slips. The position regarding the cost thereof should be reviewed annually and rates of recovery refixed, if necessary. 6.3 Offices should obtain the particulars of the family members of the employees staying in the staff quarters - dependents and non-dependents - in the prescribed format (cf. DAPM.No.178/ M.1Oc-94/95 dated September 9, 1995) at the time of allotment of flat and forward the same to the concerned dispensary for record. Similar declaration should be obtained from the employees who are residing outside the staff quarters but are obtaining medical facilities from the dispensary. Names of persons, who are not eligible for free medical attendance may be shown separately in the declaration and the same may be duly authenticated.
6.4 Stocking of Medicines in the Banks Dispensaries: Insulin cartridges of human mixtards may be stocked but not Insulin Pens. Januvia tablets may be stocked for treatment of diabetes. About five combination of drugs each for treatment of Diabetes, High BP, IHD, Parkinsonism and combination of one for Non Steroid Anti- Inflammatory Drugs (NSAID) and a muscle relaxant with/without Paracetamol may be stocked. Eye drops required for treatment of Glaucoma and Lubricant eye drops may be stocked. Multivitamins and anti-oxidants may be stocked. Prescription of medicines by a Specialist may be permitted for issuance of medicines from the Banks dispensary/credit slips beyond six months subject to BMOs approval. Outdoor Treatment 7.1 Consultation
7.1.1 For Officers

(i) Officers may take treatment for themselves and for the eligible members of their family (excluding dependent parents) from any registered General Medical Practitioner (GMP) of their choice possessing a recognised professional degree/ qualification in allopathic system of medicine with or without the prior approval of the BMO and also from the BMO's private clinic. However, to consult a Specialist prior permission of BMO is necessary except for Senior Officers as indicated below at 7.1.A(v). The charges for such private treatment are reimbursable as per schedule.
(ii) In case of dependent parents of an officer, the cost of treatment taken in the OPD of Govt. / Municipal Hospital may be reimbursed in full. (iii) In case a BMO is required to examine additional patient/s during his visit to an officer's residence, the fees charged by him may be admitted for reimbursement to the extent of 50% of the rate of visit fees payable to the BMO, for every additional patient he examines during the same visit. (iv) In the case of outdoor treatment medicines prescribed for curative purposes only are admitted for reimbursement. Drugs/medicines purchased for general health / cosmetic purpose and over the counter (OTC) drugs are not reimbursable under the rules. (v) Senior Officers in Grades D, E & F may consult specialists for self and eligible family members, excluding dependent parents, on the advice of GMP, three times in a calendar quarter without prior / post facto approval of BMO. Such claims may be settled as per rules / schedules, without reference to the BMO unless deemed necessary.
7.1.2
For Workmen Employees
(i) Workmen employees and their eligible family members (excluding dependent parents) may avail of treatment as outdoor patients from the out patient department (OPD) of Government/Municipal/ Trust/Corporate hospitals. Further, consultation with Specialist, if necessary, should also be taken from the OPD of Government/Municipal/Trust/Corporate hospital. In such cases, only consultation charges, if any, levied, will be eligible for reimbursement. They are also allowed reimbursement of OPD treatment if taken in Trust/Corporate hospitals too, provided it is taken on reference/ prior permission of the BMO.
(ii) In case of dependent parents of a wokmen employees, the cost of treatment taken in the OPD of Govt. / Municipal Hospital may be reimbursed.
(iii) When an employee or an eligible member of his family is referred by the BMO to OPD of a Government / Municipal/Trust/ Corporate hospital for consultation with a Specialist, the drugs prescribed by the Specialist/ hospital or similar drugs having same therapeutic value may be supplied from the Bank's dispensary, if available. In case the drugs are not available in the Bank's dispensary, they may be supplied by issue of credit slips. (iv) Offices may enter into arrangements with certain specified labs/diagnostic centres of repute for the purpose of providing pathological/radiological investigations on OPD basis based on the prescription issued by BMOs/Specialists from Government/Municipal/Trust/Charitable/Corporate hospitals. Based on the above prescriptions, authorization letters may be issued by the concerned Establishment Section as and when the investigations are required to be undergone and the bills may be settled directly and periodically by the office with the specified labs/diagnostic centres.
Further, while entering into arrangements Offices may take care to fix the charges with the labs/ diagnostic centres for various pathological/radiological investigations, at less than the rate prescribed in the schedule for the workmen employees in terms of our circular No.C.O.HRDD.No.G.117/10297/18.03.00/2008-09 dated April 21, 2009.
7.2 Admissibility of medicines for reimbursement : In order to determine the admissibility of medicines for reimbursement in the cases of indoor/outdoor treatment, following guidelines may be followed by the offices: Tonics, vitamins for non-curative purposes, food tonics, advertised/over the counter (OTC) drugs, household remedies will not qualify for reimbursement. Cost of hormones (except for thyroid) of any kind and enzymes (except as adjuvant drugs) will also not be reimbursable. Cost of vitamins, calcium and hormones prescribed for short periods for curative purposes may be reimbursed provided the physician certifies that the use thereof was for curative purposes. Cost of drugs/medicines prescribed for ailments such as obesity, sterility per se, insanity, etc, which are outside the scope of Banks Medical Facilities Scheme will not be reimbursable. The cost of vaccines / inoculations for small pox, chicken pox, typhoid, cholera, polio, MMR etc. may be allowed. The cost of Gypsona plaster, steel plates/nails, etc. used for union of bones during orthopedic operations as well as cost of crepe bandages, dressing materials and cotton wool may be allowed.
The cost of medicines prescribed by General Medical Practitioners/Specialists will generally qualify for reimbursement provided the above guidelines are met and the concerned employees are primarily eligible for consultation and / or treatment from Specialist or General Medical Practitioner, in such cases. In case of any doubt regarding admissibility of a particular medicine from the point of view of its relevance to the ailment, as also regarding the quantity to be purchased, BMOs views may be obtained. The BMO may exercise due caution while prescribing or allowing reimbursement of very costly drugs, if other less costly drugs of same therapeutic value which are commonly used and of established efficacy, are available. The cost of lotions/ointments eye/ear drops, etc may be reimbursed if they are required to be purchased in emergency / acute cases, where the officers are not in a position to avail of these drugs from the Bank's dispensary. This should be on the basis of a prescription of a medical practitioner who shall certify that the use thereof is for curative purpose.
The cost of ordinary medicines may also be allowed in case they are prescribed in an emergency on the advice of the attending physician particularly when treatment is taken in a hospital as an inpatient or on the days when the Bank's dispensary is closed.
Cost of disposable syringes when charged separately by the hospitals during indoor hospitalisation treatment or when purchased from chemists on prescription issued by the attending physicians of such hospitals may be reimbursed to the employees. In case of doubt regarding the type of treatment, cost thereof, genuineness of the claim, the relative case may be referred to CO.
7.2.1 Inhaler Claim towards inhalers may be reimbursed on the following basis (i) In the case of workmen employees and their eligible family members the patient should be first examined by the BMO who may refer the case to the OPD of Govt./Municipal/Trust/Corporate hospital. The claim relating to inhaler prescribed by OPD of Govt./Municipal/Trust/Corporate hospital may be admitted. (ii) In the case of officers and their eligible family members, prior permission of BMO is necessary for consulting specialist. The claim relating to inhaler prescribed by a specialist may be admitted. (iii) Combination inhaler containing inhaled corticosteroids (ICS) with Long Acting Beta-agonist (LABA) can be stocked in the dispensaries such as Salmetrol, Formoterol, Fumarate etc.
(iv) However, inhalers having different delivery systems like Diskhaler, Multihaler, Accuhaler (i.e. Sertide / becoride, accuhaler, serflo multihaler) etc., are not to be stocked / issued on credit slips and also are not eligible for reimbursement. 7.2.2 Anti-rabies injections The cost of `Rabipur' and `Verorab' anti-rabies injections may be reimbursed on production of bills / cash memos from the chemists and prescription from Government /Municipal / Private hospitals or even General Medical Practitioners. The reimbursement may, however, be made in consultation with the BMO regarding reasonability of charges incurred in keeping with the prevailing market rate of the injection. The cases where the treatment consists of any other medicine / injection / vaccination, may be referred to Central Office (HRMD).
7.2.3 Hepatitis B vaccine Claims for reimbursement of charges for vaccination for Hepatitis B may be settled as per following guidelines: The cost of vaccine if administered in Government/Trust hospitals or Child Welfare Centres run by Government and for those who are receiving blood transfusion regularly or undergoing dialysis at regular intervals may be reimbursed in full on the basis of valid prescription / receipt. Cost of vaccine administered to new born and pediatric age group may be reimbursed in full if purchased from a chemist on the basis of prescription issued by the attending doctor. If it is administered by the specialist from his stock then the cost of the same may be reimbursed as per schedule. The cost of vaccine if purchased from a chemist on the basis of prescription issued by the medical practitioner, may be reimbursed in full. If administered by the medical practitioner, the same may be reimbursed as per schedule (all inclusive ).
7.3 Pathological/Radiological investigations Pathological / Radiological investigations may be admitted as per schedule subject to the following: 7.3.1 For Officers (i) Officers and their eligible family members excluding dependent parents can undergo pathological/radiological investigations on the advice of General Medical Practitioner as also Specialist but with the prior permission of BMO/MC except for Senior Officers as indicated below at 7.3.1(iii). (ii) The dependent parents of an officer are eligible for reimbursement of pathological/radiological investigations provided the same is undergone at Government/Municipal hospital with approval of BMO. (iii) Senior officers in Gr. D, E & F may be reimbursed the cost of pathological / diagnostic tests carried out for self and eligible family members (excluding dependent parents) on the advice of registered General Medical Practitioners (GMP) without prior or post facto approval of the BMO as per schedule.
7.3.2 For Workmen Employees (i) A workman employee/his eligible family members may undergo pathological/radiological investigations in any Government/ Municipal/ Trust/ Private hospital or private nursing home/clinic/laboratory for the purpose of diagnosing the ailment subject to approval of the BMO. Reimbursement as to the cost of such investigations will be made as per schedules/recommendation of BMO. However, when the treatment is taken in Government/Municipal hospitals at their out patient department, the charges levied by them will be reimbursed in full even if the same are higher than the Banks schedules.
(ii) Under the Private Treatment Scheme, the workmen employees who opt for private treatment in respect of their family members are not entitled for the Bank's dispensary facilities. Normally, therefore, in such cases the question of BMO referring them for pathological / radiological examination to clinics will not arise. However, if such reference is made by BMO for pathological, radiological, etc. tests with a view to having the patient hospitalised and it actually results in hospitalisation, the cost relating to such investigations may be reimbursed under the rules (other than PTS rules).
7.3.3 Investigations not mentioned in Schedule The claims for reimbursement of expenditure incurred on routine investigations which are not mentioned in the schedules may be settled by offices in consultation with the BMO and after taking into account the minimum charges levied therefor by Government / Municipal / Trust hospitals.
7.4 Special instructions with regard to specific ailments / treatment 7.4.1 Eye treatment With the prior permission of the BMO, consultation charges of eye specialist in the case of officers and their eligible family members, excluding dependent parents, may be reimbursed.
7.4.2 Cataract Operation
The cost of cataract operation including intra ocular lenses, if used, may be reimbursed as per schedule.
7.4.3 Cost of Spectacles All officers / workmen and their spouse, in respect of whom medical facilities are being availed, are eligible for reimbursement of the cost of spectacles (lens with frame) once in two years on the basis of prescription issued by Eye specialist or Optician subject to production of proper bills / receipts payable at the grade-wise rates specified from time to time. The present rates separately applicable for self and spouse are as under :
Grades
Workmen
Grade A
Grade B/C
Grade D/E
Grade F
Amount
1600
2500
4500
7000
8000
Henceforth, this facility will be available every alternate calendar year irrespective of the month in which the last reimbursement was availed of. However, consultation charges for refraction test, if any, will not be eligible for reimbursement in case of workmen employees. The cost of more than one spectacles within the prescribed limit may be reimbursed provided the relative bills are submitted under one single claim each for self and spouse, once in two years. Further, it is clarified that reimbursement towards cost of spectacles for spouse may be allowed only if the spouse is dependent on the employee under BMFS.
7.4.4 Lasik Surgery of eye Regional Offices/Central Office Departments may admit claims relating to reimbursement of the cost of Lasik surgery of the eyes, for correction of vision, undergone by employees and their dependent family members with the prior approval of BMO may be made as per schedule for less major operation, subject to the following conditions: The age of the patient should be above 20 years. The extent of myopia in the eye should be at least -5. 7.4.5 CAT Scan Test Charges for CAT Scan Tests undergone with the prior approval / recommendation of the BMO are reimbursable as per schedule. However, for the second and subsequent CAT Scan Tests of the same organ within a fortnight, the charges may be reimbursed to the extent of 50% of the rates given in the schedule. 7.4.6 Diabetes Cost of Insulin/medicines and pathological tests prescribed by the BMO/OPD of Government/Municipal hospital may be reimbursed as per rules to all categories of staff. In the case of Officers, the cost of treatment taken as above as well as from the GMP or Specialist, with prior approval of BMO, is reimbursed. (iii) Drugs such as Diabenese, Glucotrol, Glynase, Daonil, Rastinen Januvia etc. generally used for the control/treatment of diabetes may be stocked in the Banks dispensaries as considered necessary by the BMO for issue to all employees and their eligible family members. (iv) The following four types of human insulin, namely, R (Regular), N (NPH), 30-70 mixture of R & N and 50-50 mixtures of R & N are admissible. (v) Analogues insulin also called designer insulin such as Glargine (Lantus), Lyspro (Humalog), Aspart (Novolog- Rapid insulin), Novopen/ Novo RESERVE Mix etc. areOF not admissible. BANK INDIA
7.4.7 Psychiatric treatment The cost of treatment taken for curative purposes will be reimbursable on merits of each case. The workmen employees / officers and their eligible family members may be allowed to undergo indoor hospitalisation treatment wherever necessary for a period of one month with the prior approval of the BMO. Treatment beyond one month may be referred to Central Office. The cost of OPD treatment taken by workmen staff and their eligible family members (excluding dependent parents) for psychiatric ailment from Government/ Municipal/Trust/Private hospitals and private nursing homes may be reimbursed in respect of pathological/radiological tests, ECT and cost of medicines prescribed by them provided the treatment is undergone with the prior approval of the BMO. However, in such cases, consultation charges levied by Private/Trust hospitals and private nursing homes will be reimbursable to workmen employees only under the Private Treatment Scheme. The officers and their eligible family members (excluding dependent parents) are eligible for consultation and taking OPD treatment for psychiatric ailment from Private / Trust hospitals and private nursing homes, with the prior approval of BMO and the claims preferred by them may be admitted as per schedules/recommendations of BMO. RESERVE BANK OF INDIA
7.4.8 Hearing Aid Offices/ Departments may admit claims from employees and their eligible family members (excluding dependent parents) towards the cost of hearing aid, (single or bilateral) based on the recommendation of the attending specialist, taking into consideration the extent of hearing loss/ impairment duly supported by audiogram/ audiometric test report, in consultation with the BMO without reference to Central Office. The present rates are as under:
Grade
WMen A
18000 22000
B
26000
C
30000
D
34000
E
38000
F
42000
Amt
Requests for reimbursement of the cost of repairs or replacement of old hearing aids may be considered only after a period of five years on merits of each case. Claims in this regard may be referred to Central Office together with full details of the case duly supported by condemnation certificate from a technical expert and recommendations of attending specialist.
7.4.9 Crutches, collars and corset belts The cost of crutches, cervical collar and corset belt may be allowed to all employees and their eligible family members other than dependent parents provided the use of such artificial aids has been advised by specialists in the field, to a reasonable extent as recommended by the BMO. 7.4.10 Artificial limbs The cost of artificial limbs to the extent charged/levied by the Government recognised centres may be reimbursed to all categories of employees for themselves and their eligible family members but excluding dependent parents provided the use thereof is advised by the concerned orthopedic surgeon and the reimbursement is recommended by the BMO. The cost of replacement/repair/ adjustment of artificial limbs may also be reimbursed to a reasonable extent provided the same is advised by the orthopedic surgeon/physician and the reimbursement is recommended by the local BMO.
7.4.11 Skin diseases Cost of treatment taken by officers and their eligible family members for certain skin diseases like eczema, psoriasis, leucoderma, etc. requiring treatment from skin specialists may be reimbursed to a reasonable extent for a period upto one year provided the treatment is undergone with the approval of the BMO. In the case of workmen employees/ their eligible family members, the cost of such treatment may be allowed upto a period of one year if the treatment is taken in Government/Municipal hospital with the prior approval of the BMO. Claims for treatment beyond one year may be referred to Central Office (HRMD) with details such as nature of ailment, expenditure already incurred, chances of recovery etc. for instructions regarding further reimbursement. 7.4.12 Congenital deformity In cases of congenital deformity of officers / their eligible family members, reimbursement may be allowed for operations which are corrective in nature for restoring the normal functional ability of the patient, and not for cosmetic purpose. Such operations should be undergone with prior approval of BMO in all cases and that a certificate from the concerned specialist should be obtained that there is a reasonable chance of correcting the congenital deformity/defect. The category of such operations for the purpose of reimbursement will be determined by the BMO. Claims pertaining to treatment of congenital deformity of workmen employees/ their eligible family members may be referred to Central Office (HRMD) for instructions.
7. 4.13 Ulcerative Colitis Offices may allow reimbursement of the cost of treatment for ulcerative colitis undergone by the officers and their eligible family members with the prior approval of BMO for a period of one year as per schedules and recommendation of BMO. Claims for treatment beyond one year may be referred to Central Office (HRMD). 7.4.14 Maternity expenses Maternity claims may be considered separately during pregnancy involving threatened abortion, hyperemesis, eclampsia, etc. which require indoor treatment. A maximum of two USG tests during pregnancy may be separately allowed. Full reimbursement of expenses incurred on maternity treatment may be made if the treatment is taken in any one of the following : The General Ward of the Government/Municipal/ Trust/Corporate hospital; Child Welfare and Maternity Centre maintained by Government or Municipality or delivery is conducted at the residence by the staff of the Child Welfare and Maternity Centre; Hospitals where reservation of beds has been made by the Bank for treatment of employees and their families (if treatment is taken in the ward in which reservation has been made). If the treatment is taken in a private hospital or a private nursing home or in a higher ward of the Government/Municipal/Trust/Corporate hospital, actual expenditure may be reimbursed for confinement and treatment including pathological etc. investigations, cost of drugs, surgery, special labour fee, etc. within the ceiling amounts as per schedules subject to the following: No reimbursement should be made of the cost of multi vitamin preparations, tonics, hormones, enzymes, etc. Prior approval of the BMO need not be insisted in OF connection with the pre-natal treatment. RESERVE BANK INDIA
An employee is not eligible to avail of the Banks medical facilities towards maternity expenses in respect of his earning wife, if her employers provide medical facilities even if they are less liberal than those provided by the Bank. Reimbursement of expenses may be allowed separately even if the pre-natal and post-natal treatment and confinement are undergone in a private hospital or a nursing home run by any registered medical practitioner (allopathic or non-allopathic) and also in cases where the deliveries are conducted at residences by any private doctor/mid wife. The Charges towards Caesarean operation, wherever applicable, may be reimbursed as per schedule over and above the maternity expenses.
7.4.15 Treatment of a new born child The claims in respect of the treatment of new born child may be admitted for reimbursement separately (outside the maternity schedule) even when the treatment is taken within the period of confinement and post-natal period of six weeks of delivery provided : (a) a separate bill of charges for the treatment of the child is submitted, and
(b) the BMO is satisfied that considering the nature of ailment there is a need for separate treatment of the child. The claims may be admitted to the extent considered reasonable by the BMO as to the amount and number of days of treatment. Daily stoppage charges are to be reimbursed as per normal stoppage charges applicable even if the treatment is given in incubators etc.
7.4.16 Medical termination of pregnancy In the case of medical termination of pregnancy (MTP) covered by the Medical Termination of Pregnancy Act, 1971, the cost of abortion may be reimbursed subject to the following conditions: The pregnancy should be terminated in a hospital established or maintained by Government ; or at a place approved for the purpose by the Government or in a private Trust hospital. If the length of the pregnancy does not exceed 12 weeks, the medical practitioner should certify and if it exceeds 12 weeks but does not exceed 20 weeks two medical practitioners should certify that: continuance of the pregnancy would have involved a risk to the life of the pregnant woman or of grave injury to her physical or mental health; or there was substantial risk that if the child were born it would have suffered from such physical or mental abnormalities as to be seriously handicapped & pregnancy was terminated with the consent of the pregnant woman or her guardian as the case may be, as provided for under the Act.
The bill of expenses should be submitted by the employee through the BMO, who will have to certify in each case in regard to the authenticity of the treatment and the reasonableness of the charges.
7.4.17 Accidental / forced abortion / miscarriage Claims relating to accidental / forced abortion / miscarriage may be settled by offices as per undernoted guidelines : Certificate of the attending Gynaecologist giving specific reasons for undergoing abortion should be obtained. It should be ensured that the case is not covered under the Medical Termination of Pregnancy Act 1971. Reimbursement of charges for operation may be as per schedule for less major surgery. Other items of the treatment may be reimbursed as per rules/ schedules / recommendations of BMO. 7.4.18 Family Planning operations At present employees of the Bank are eligible for reimbursement of cost of sterilisation operation (for family planning) undergone by them/their spouses prescribed by the Bank from time to time. The employees (including part-time employees with weekly hours of work of not less than six hours) in all classes are also entitled for grant of a lump-sum reward of Rs.500/- by way of incentive for undergoing sterilisation operation of self/their spouses subject to the following conditions: The employee and his/her spouse must be within the reproductive age group (i.e. in the case of males upto 50 years and females not above 45 years of age). The employee should have at least one living child. The sterilisation operation must be conducted and the sterilisation certificate must be issued by a competent person of the concerned hospital or clinic. In addition to the above, employees are also entitled for special casual leave for undergoing family planning operation by themselves or by their spouses as indicated in detail in the Master Circular on Leave.
7.4.19 Gynaecological treatment/disorders Cost of indoor treatment for gynaecological problems like leucorrhea, menorrhagia, irregular bleeding cycle, etc is reimbursable to officers and workmen employees subject to specific diagnosis by the attending Gynaecologist and on recommendations of BMO. The cost of OPD treatment taken by workmen employees and their eligible family members may be reimbursed provided the treatment is taken from Government/Municipal/Trust/Corporate hospital. The OPD treatment taken by officers and their eligible family members also qualify for reimbursement. Further, Gynaecological disorders like (i) Poly Cystic Ovarian Disease (PCOD) may be considered for reimbursement (only admissible drugs but not hormone therapy) depending upon the age of the female employees; (ii) the cost of treatment incurred on endometriosis and fibroids maybe allowed for reimbursement. In case of hormonal treatment the case may be referred to Central Office, HRMD.
7.4.20 Physiotherapy Officers and workmen employees and their eligible family members may undergo physiotherapy treatment with the prior approval of BMO with any physiotherapist and the charges levied for such treatment may be reimbursed as per schedules. However, when the treatment is taken in Government/Municipal hospitals at their outpatient department, the charges levied by them will be reimbursed in full even if the same are higher than the Banks schedules.
7.4.21 Dental treatment Officers and workmen employees and their eligible family members (excluding their dependent parents) may undergo dental treatment with the prior approval of BMO with any dentist and the charges levied for such treatment may be reimbursed as per schedules. Officers and Workmen employees and their family members are eligible for one consultation charges as per schedule. However, consultation charges for follow-up, if any, will not be eligible for re-imbursement. Cost of dental bridge(s) / partial dentures may be reimbursed for a maximum of four missing / extracted teeth during the entire service period of an employee. The reimbursement of cost of a dental bridge / partial dentures should be linked to the number of missing / extracted teeth involved in the bridge / partial denture and paid as per schedule of bridge / partial dentures for each missing/extracted tooth. For example, in the case of a bridge unit involving two missing /extracted teeth, reimbursement can be made for double the applicable rate prescribed therein for a bridge. Cost of caps / crowns may be reimbursed, for a maximum of three teeth at a time, as per schedule even if root canal treatment has not been carried out for the same tooth / teeth. The claim towards partial or full dentures to officers and workmen employees and their eligible dependents excluding dependent parents with prior approval of BMO may be allowed subject to the following: Reimbursement of partial dentures may be linked to the number of missing/extracted teeth involved in the denture and reimbursement allowed as per schedule for partial dentures for the number of missing/extracted teeth involved; Cost of partial dentures may be reimbursed for a maximum of four missing/extracted teeth during the entire service of an employee; and The claim towards full dentures may be allowed as per schedule, once during the entire service of an employee.
Offices should record employee-wise particulars of medical reimbursements for dental treatments involving bridges/caps/crowns, in medical account sheets prescribed in Central Office letter DAPM.No.850/18.01.00/ 96/97 dated March 01, 1997. No reimbursement of charges will be allowed for gold fillings.
W. Men 10000
A 15000
B&C 20000
D&E 30000
F 35000
The cost of expenditure incurred by serving employees for undergoing dental Implant with prior permission of BMO may be admitted as under:
The claims to reimburse the cost of expenditure incurred on dental implant may be settled in the light of guidelines contained in Central Office Circular C.O.HRDD.G.123/7085/ 18.03.00/2010-11 dated February 4, 2011.
7.4.22 Chronic ailments Ailments which require continuous treatment for a period of one year or more are usually classified as chronic ailments. Offices may allow treatment for such ailments including Parkinsons disease, keeping in view the nature of ailment, chances of recovery, expenditure already incurred, etc as per recommendations of the BMO.
7.4.23 Lipid Lowering Drugs Lipid lowering medicines may be issued from the dispensary to employees and their eligible dependants, provided it is very much essential, for a period not exceeding 3 months. However, in cases where employees and their eligible dependants who have undergone angioplasty/by-pass surgery or have cardio vascular/genetic disorder or have been suffering from chronic atherosclerosis, the drugs may be issued beyond 3 months on the recommendation of the attending cardiologist as to the period of treatment and his prescription indicating the generic name of the medicine and not the brand name alone.
7.4.24 Osteoporosis: Medicines for treatment for osteopenia/osteoporosis given to officers and workmen employees and their dependant family members from the Banks dispensary on the basis of recommendation of the BMO may be considered for reimbursement/issuance from Banks dispensary beyond three months excluding hormone therapy, nasal spray, long acting drugs and injections. Indoor Treatment (Hospitalisation) Officers and workmen as also their eligible family members including dependent parents are eligible for indoor hospitalisation in Government Municipal /Trust / Corporate / Charitable/ Private hospitals and nursing homes subject to reimbursement of expenses as per rules / schedules / recommendation of BMO. The admissible amount under BMFS may be restricted to prescribed monetary ceilings which at present are as under: i) Workmen employees Rs.1,40,000/Rs.1,80,000/Rs.2,40,000/-
ii) Officers in Grade A B & C iii) Officers in Grade D E & F
The hospitalisation bills towards ordinary ailments for amounts exceeding the above ceiling limits should be referred to Central Office for instructions. Before referring such cases to Central Office, the bills should be thoroughly scrutinised by the office on the basis of available instructions/ guidelines/schedules and the BMOs recommendations and a statement giving the details of item-wise amount claimed, amount admissible under BMFS and the amount reimbursed so far for the ailment should be prepared and forwarded to Central Office along with the bill. The office should also mention specific issue where Central Office instructions are required as also furnish their specific recommendations thereon for consideration of Central Office.
However, for serious ailments such as cancer, heart and chronic renal failure the above ceilings are not applicable and instructions contained in Para 8.1.H below may be followed.
8.1 Expenses incurred during hospitalization 8.1.1 Stoppage Charges Stoppage / ICU / ICCU / IPCU charges may be paid as per schedule. (i) Stoppage charges include Room Rent, Service Charges, Electricity charges, Water charges, Charges for Nursing Care, Injection administration charges, Maintenance charges, Room service charges, Duty Doctor's fees, Infusion Charges, diet charges of the patient, even if levied separately by the hospital, etc. (ii) ICU / ICCU / IPCU charges include charges for monitor, oxygen, Special Nursing in addition to above.
(iii) ECG charges and Doctor's visit levied by hospitals during the period the patient is in ICU/ ICCU / IPCU may be admitted separately as per schedule, if it is more beneficial to the employee. (iv) In respect of Senior Officers (Grade D and above) and their eligible dependents, where a single room with attached bath is not available in the hospital within the schedule rate of stoppage/ICCU, they may be allowed to avail of a single room with AC and attached bath in that hospital with minimum stoppage charges, supported by documents along with other components of stoppage charges. (v) Cases involving unduly long stay in ICU/ICCU/IPCU ward may be referred to Central Office for instructions, with specific recommendations of the office.
8.1.2 Registration fees for indoor / OPD treatment The registration fees/charges levied by hospitals/nursing homes for indoor/OPD treatment may be reimbursed as follows: Workmen Employees/ Officers staff The charges levied by the Government/Municipal hospitals may be reimbursed in full. The charges levied by the Trust/ Charitable / Private hospitals / nursing homes for indoor treatment may be reimbursed as per schedule provided the treatment is taken with prior permission of BMO. The charges levied by the Tata Memorial Hospital, Mumbai for OPD/indoor hospitalisation treatment may be reimbursed in full. 8.1.3 Surcharge on indoor hospitalisation Surcharge levied by Government/Municipal/Trust/Charitable hospitals on various items of indoor treatment such as stoppage charges, operation charges, etc. in respect of all employees (workmen as well as officers) may be reimbursed as per rates levied by these hospitals or at the rate of 20% whichever is lower, on the amount admitted for reimbursement. However, surcharge levied by private hospitals/nursing homes is not reimbursable.
8.1.4 Ambulance charges The claims towards ambulance charges received from staff members (officers as well as workmen employees) may be admitted subject to the following conditions: (i) Ambulance should have been engaged for shifting of the patient within the Municipal limits / urban agglomeration. (ii) The concerned hospital/nursing home/att ending physician should have recommended hiring of the ambulance. (iii) Ambulance should have been engaged for removing the patient from residence to hospital/nursing home and back on discharge and also for shifting of the patient from one hospital/nursing home to another on the advice of the attending physician. 8.1.5 Special Nursing charges In the case of indoor hospitalisation, special nursing charges levied by hospitals/nursing homes are reimbursed by the Bank subject to the following conditions: (i) Special nurses should be engaged for the minimum period necessary, only when their services are considered essential by the Medical Superintendent of the hospital / nursing home, where the treatment is taken. (ii) Prior approval of the BMO should be taken in all such cases before a special nurse is engaged. For this purpose a certificate from the hospital/nursing home authorities should be produced before the BMO, who will record thereon the number of days for which engagement of a special nurse has been authorised by him. If, for any reason, it is not possible for the employee to obtain the prior permission of the BMO, his approval should be obtained immediately after the special nurse has been engaged. (iii) Special nursing charges are not reimbursable when Ayah/Ward Boy charges are reimbursed and vice versa. Charges are reimbursable as per the schedules.
8.1.6 Operation charges Operation charges are to be reimbursed to officers and workmen employees as per respective schedules/rates applicable to their grade, depending on the nature of operation. The operation charges given in the schedules are inclusive of the charges for operation theatre, anaesthesia, surgeon, assistant surgeons, anaesthetist and cost of materials/medicines used in the operation theatre and dressing charges. Classification of operations With a view to having uniformity in classification, offices should observe the following guidelines : Operations may be classified as major plus, major, less major or minor, as per classification of operation mentioned in the schedule in consultation with the BMO. A reference may be made to Central Office regarding classification of operations not covered by the list. In case more than one operation has been performed at the same time, operation charges should not be reimbursed separately for each operation. Such cases may be referred to Central Office(HRMD) for necessary instructions regarding the extent to which the operation charges are reimbursable.
8.1.7 Pre/post hospitalization treatment The admissible pre/post hospitalisation treatment identifiable and related to the ailment(s), for which indoor treatment has been undergone would be treated as an integral part of hospitalisation treatment. This procedure would apply uniformly to workmen employees and officers and their eligible dependants including dependent parents. Pre/post hospitalisation treatment would include the following: (i) Pathological/radiological investigations undergone within 30 days on either side (ii)Admissible medicines (as recommended by the BMO) purchased during 30 days prior to admission & 45 days after discharge. (iii) Consultation charges paid within 30 days on either side of hospitalisation. [Workmen employees may be paid consultation/follow-up consultation charges at rate applicable to Officers in grade A for a maximum of three consultations during pre and post hospitalisation period put together]. (iv) Physiotherapy treatment undergone for a maximum period of 45 days after discharge from the hospital / removal of plaster (As recommended by the BMO). 8.1.8 Major plus ailments / surgeries Coronary angioplasty (PTCA), Bypass surgery (CABG), implantation of pacemaker, Chronic renal failure, cancer treatment, etc. are considered as major-plus ailments / surgeries and claims relating to the same may be settled as per the following guidelines :
8.1.8.1 Coronary angioplasty, Bypass surgery, implantation of pacemaker, Peripheral angioplasty Claims involving Coronary angioplasty, Bypass surgery, implantation of pacemaker, peripheral angioplasty may be settled as per the guidelines / modalities laid down in Circular CO.HRDD.No.3137/18.01.00/2005-06 dated November 29, 2005 read with Para 2 of circular CO.HRDD.No.G.27 /176 /18.01.00/2009-2010 July 6, 2009 and as per rates indicated in the medical schedule. The admissible cost of single chamber/dual chamber Pace Maker is enhanced to Rs.1.30 lakh and Rs.2.60 lakhs respectively. 8.1.8.2 Chronic Renal Failure / Kidney Transplantation (i) Claims involving both OPD and indoor treatment for Chronic Renal Failure / Kidney Transplantation may be settled as per the guidelines / modalities laid down in Circular CO.HRDD.No.1282/18.01.00/2005-06 dated September 16, 2005 and as per rates indicated in the medical schedule. (ii) Claims for reimbursement of the cost of Continuous Ambulatory Peritoneal Dialysis (CAPD) bags may be settled to the extent of Rs.150/- per bag for a maximum of 3 bags per day inclusive of the cost of Minicaps and amount of taxes, if any, or as per actuals whichever is less and allow reimbursement on a monthly basis as per rules/ recommendations of BMO. No credit slips for these items should be issued under any circumstances.
8.1.8.3 Cancer Treatment (i) Claims involving both OPD and indoor treatment of cancer may be settled as per the guidelines / modalities laid down in Circular CO.HRDD.No.1189/18.01.00/2004-05 dated June 1, 2005 and as per rates indicated in the medical schedule. (ii) Intensity Modulated Radiation Therapy (IMRT) and Cyber Knife The cost of Intensity Modulated Radiation Therapy (IMRT) and Cyber Knife treatment may be reimbursed upto a maximum of Rs.1.20 lakhs and Rs.2.00 lakhs respectively or 80% of cost of each whichever is lower.
8.1.8.4 Total Knee / Hip Replacement / Spinal Surgery /Cost of Implants Claims involving indoor treatment of knee / hip replacement may be settled as per instructions contained in Circular CO. HRDD.No.G 89 / 11158/18.01.00 /2006-07 dated April 12, 2007. The cost of implants may be allowed separately over and above the ceiling subject to a maximum of Rs.1.50 lakhs or as per actuals whichever is less. Claims involving Spinal Surgery may also be settled similarly.
8.1.8.5 Unilateral / Bilateral Inguinal Hernia Operation Unilateral Inguinal Hernia operation has been classified as major operation as indicated in Annex VI of Medical Schedule of Rates. Claims involving Bilateral hernia operation (inclusive of the cost of mesh) may be reimbursed to the extent of major surgery schedule plus 40% thereof. The rest of the items of the bill may be admitted as per rules/schedules/recommendation of the BMO. The overall reimbursement will be subject to the prescribed monetary ceiling applicable to the cadre/ grade of the employee.
8.1.8.6 Brain surgery The under-noted guidelines may be kept in view while settling claims relating to brain surgery. Stoppage, operation charges, pathological/radiological tests and cost of medicines may be reimbursed as per rules/schedules/recommendations of BMO. The total reimbursement should be within the grade wise applicable ceiling. Cases exceeding the ceiling may be referred to the Central Office for instructions. The BMO should certify that the surgery relates to brain. 8.1.8.7 Cochlear Implantation: Cochlear Implantation for the hearing impaired may be referred to Central Office (HRMD). 8.1.8.8 Other Major Plus surgeries Claims involving super major surgeries such as kidney / liver transplant, shunt surgery (Brain) and any other costly treatment may be referred to Central Office (HRMD).
8.2 Settlement of claims involving death of an employee / employees family member Claims involving death of an employee/employees eligible family member (including dependant parents) during / immediately after hospitalization may be allowed as under :
In the case of an employee Such claims (where the employee/officer dies during / immediately after hospitalization) may be allowed in full, except expenditure incurred on non-medical items like diet charges for attendant, telephone charges, etc. Reference may, however, be made to Central Office (HRMD) in case the amount involved is disproportionate to the status of the employee. (ii) In the case of a family member Claims for reimbursement of medical expenses incurred by a staff member in connection with the treatment of any of his / her family member (including dependant parents) who dies during / immediately after indoor hospitalisation may also be settled in full excluding non-medical items. Reference may however be made to Central Office (HRMD) in case the claim involved is disproportionate to the status of the employee. 8.3 Submission of claims with proper bills/ receipts from hospitals The offices should ensure that the employees submit bills/ receipts in original and in proper form, i.e. on the letter head of the hospitals / nursing homes and the bills / receipts bearing metallic serial number with dates. In cases of non-submission of bills / receipts in proper printed form, the office may consider such claims if the explanation provided is considered satisfactory by the office and the BMO.
8.4 Claims of employees involving partial reimbursement under Mediclaim Some of the employees might have taken individual mediclaim policy from Insurance Companies. Such cases of partial reimbursement from the Bank may be referred to Central Office. 8.5 Reimbursement of claims from Nursing Homes 8.5.1 Employees are entitled for reimbursement of stoppage charges for treatment taken in nursing homes provided the following requirements are satisfied: The nursing home in which the treatment is taken is duly registered. It has a schedule of rates/charges for different items of treatments/facilities. It issues an acceptable computerized receipt / printed receipt bearing metallic serial numbers with date. The Bank is satisfied about the genuineness of the claim. The Bank has not already taken a decision to reject receipts issued by that nursing home for reimbursement of medical claims from its employees. 8.5.2 As and when offices come across a medical claim where a nursing home is referred to for the first time, they may settle the said claim in accordance with the instructions contained in the preceding paragraph and thereafter make discreet enquiry in consultation with BMO about the credentials of the nursing home. If the office is satisfied about the standards maintained by the nursing home, medical claims relating to it may continue to be settled by the office in accordance with paragraph 8.5.1 above. In case, however, it is found that the nursing home does not maintain the standards expected by the Bank, its name may be included in a negative list maintained for the purpose and Bank employees may be quickly informed that medical claims relating to that nursing home will not be considered by the office. It may be ensured that decision to reject claims pertaining to a nursing home is taken after careful consideration and that the decision is not taken arbitrarily. Grounds for such decision should invariably be recorded. Final decision on the status of each nursing home should be taken with the approval of the Regional Director/Officer-in-Charge. RESERVE BANK OF INDIA
8.5.3 Medical claims in respect of large amount of hospitalization charges particularly not falling under the scheme of direct settlement need to be scrutinized more closely. Clarifications may be obtained from the employees concerned for not availing the direct settlement facility to see if the same are satisfactory. In case of medical claims on reimbursement basis, a system to cross check the leave / attendance position of employees at the time of scrutiny of medical bills should be in place. If patients are referred to a particular hospital / nursing home frequently, necessary information on the expertise available in respect of any one or more ailments / quality of service provided in the hospital may be gathered with a view to justifying such references. ROs / CODs should desist from the practice of referring all claims to BMOs as a matter of routine and should ensure that references to BMOs are made only when absolutely warranted. 8.6 Schedules for reimbursement of hospitalisation treatment, operation charges, expenditure on pathological/radiological investigations, etc. The rates for reimbursement of various items of medical expenses incurred for indoor / outdoor treatment such as pathological / special investigations, clinical and diagnostic procedures , classification of operations etc are given in detail in the medical schedules effective from April 1, 2009 vide circular CO.HRDD. No.G117/ 10297 / 18.03.00 / 2008-09 dated April 21, 2009 read with circular HRDD No. G141/ 12507/18.03.00/ 2008-09 dated June 19, 2009 in case of Non-Metro Centres. The rates applicable to only six metro centres (Viz Mumbai, Kolkata, New Delhi, Chennai, Hyderabad & Bangalore) are given in Circular CO.HRDD.No. G.100 /4241/18.03.00/2010-2011, dated November 01, 2010. The rates given in the schedules are the maximum up to which claims may be allowed. Offices should however, take a view on reasonableness or otherwise of claims taking into account the rates prevalent at their respective centres. Claims for reimbursement of expenditure which are not mentioned in the schedules may be settled in consultation with the local BMO, after taking into account the minimum charges levied thereof by Government / Municipal / Trust hospitals. As far as possible, references to Central Office in such cases may be avoided. However, the cases, where the charges levied for the tests are on high side and local BMO is not in a position to ascertain reasonableness of the rates charged by the hospital, may be referred to Central Office (HRMD).
8.7 Direct settlement of hospitalisation bills The Bank extends the facility of Direct Settlement of Hospitalisation bills for indoor treatment undergone by serving employees and their eligible dependents in approved hospitals. For the purpose of preparing a list of approved hospitals, a Committee, under the Chairmanship of Regional Director /Chief General Manager/Officer-in-Charge comprising at least two senior officers and one Banks Medical Officer as members, may be constituted at Regional Office level. The committee based on its assessment on the availability and adequacy of medical facilities like emergency/casualty, pathology, radiology, well equipped operation theatre for major/minor surgeries, maternity facility etc., as also inputs received through market intelligence, direct visits to the hospitals and other documentary evidences/sources should satisfy about the availability / adequacy of quality medical facilities / infrastructure, professional competence and business integrity of the hospitals to be selected for the purpose. The selection should be restricted to Government hospitals, Trust hospitals and hospitals / nursing homes incorporated as companies under the Companies Act / registered as societies under the Societies Act in force in the states concerned.
8.7.1 The offices may, on merit of each case and with prior recommendation of the local BMO, agree for direct settlement of hospitalisation bills for indoor treatment of an employee or eligible member of his family in the approved hospital subject to the following conditions: (i) The facility will be limited for treatment for a period of one month in each case subject to review. ( ii) The employee should give an undertaking cum declaration prescribed vide circular DAPM.No.818/18.07.00/2002-03 dated January 6, 2003 stating that the difference between the admissible charges and the charges levied by the hospital/nursing home as also the cost of inadmissible items may be recovered from him and that the family member in respect of whom direct settlement is being sought is fully dependent on him. (iii) This facility will not be available for maternity treatment.
(iv) Temporary employees who have put in a minimum service of one year in the Bank will also be entitled for this facility. (v) The Regional Director/Officer-in-Charge may in consultation with the local BMO allow direct settlement of hospitalisation bills facility beyond the period of one month, at his discretion taking into account the nature of illness, the amount already paid to the hospital/nursing home, further period of hospitalisation required, etc.
(vi) If, on account of the facility provided by the Bank any tax or penalty/interest is demanded from the Bank by the Income Tax authorities, the same shall be payable by the employee and that if the Bank is required to pay such amount, it shall be recovered from the employees salary in one or more installments as may be decided by the Bank. (vii) An employee who desires to avail of the direct settlement of hospitalisation bills facility should make a specific application for the purpose, together with the prescribed undertaking cum declaration. On receipt of such a request, the Administration/ Establishment Section attending to settlement of medical bills of the office concerned should, in consultation with the local BMO, issue a letter to the hospital/nursing home concerned requesting them to forward the hospitalisaion bills to the Bank for settlement. Such letters should be signed by an authorised official whose specimen signature should be circulated to the approved hospitals/nursing homes (It may be noted that the BMOs should not issue such letters), only after ensuring that the treatment is approved by the Regional Director/Officer-in-Charge and the employee concerned has given necessary declaration undertaking for refund of inadmissible amount to the Bank 8.7.2 In case of emergency involving serious ailment, Regional Director/Officer-in-Charge may allow, desirably before hospitalisation or immediately thereafter if the situation so justifies, the facility of direct settlement to the employees/officers and their eligible dependents for treatment in hospitals not included in the approved list, provided the proposal is certified as to the genuineness and need thereof by a Senior Official not below the rank of General Manager and Banks Medical Officer.
8.7.3 On receipt of a bill from the hospital/nursing home, the office concerned should pay the amount of bill expeditiously. It may be noted that delay in payment of hospital bills not only causes inconvenience to the concerned hospitals but also puts the Bank in an embarrassing situation, particularly when commitments for payments have been made. Offices should, therefore, ensure that the hospitalization bills where direct settlements have been agreed are settled and paid promptly, without waiting for complete scrutiny with regard to the amount reimbursable, thereof. (i) Once the bill amount is paid to the hospital /nursing home, it should be taken up for detailed scrutiny as per rules/schedules/recommendations of the BMO for reimbursement under the Banks Medical Facilities Scheme. (ii) Recovery of inadmissible amount of directly settled hospitalisation bills may be decided upon by offices taking into consideration the amount of recovery, take home pay of the employee, etc. and the amount may be recovered in suitable installments if considered necessary.
8.7.4 Requests for issue of direct settlement letter to TATA Memorial Centre / Hospital, Mumbai may be forwarded to Central Office (HRMD) after obtaining necessary declaration/ undertaking from the employee, recommendation of BMO, estimate from the hospital if available and approval of RD/OIC.
8.8 Grant of interest free advance for medical treatment of serious ailments / super major surgeries
An interest free advance is granted by the Bank to its employees, on request in the cases of indoor hospitalisation treatment for serious ailments/super major surgeries to meet incidental expenses.
Powers have been delegated to Regional Directors/Officers-in-Charge to sanction such advances subject to the following:
The interest free advances may be granted to staff members, only in indoor hospitalisation cases involving heart operation, kidney transplantation, brain surgery and serious ailments like cancer.
The maximum entitlement of advance for officer staff is Rs.25,000/- (Rupees twenty five thousand only) and for workmen employees Rs.15,000/- (Rupees fifteen thousand only).
The amount will be recovered in maximum 50 equal monthly installments The employee should execute an agreement on non-judicial stamp paper of appropriate value. In case of doubt, as to whether the surgery involved is a super major or not, the recommendation of the BMO may be obtained.
Reimbursement of medical expenses incurred on Outdoor treatment on declaration basis Officers Since July 1991, officers of the Bank are entitled to claim reimbursement of medical expenses incurred on outdoor treatment availed by themselves and eligible members of their families (i.e spouse and dependent children) from private medical practitioners under any system of medicine (Allopathic, Homoeopathic, Ayurvedic, Unani or Nature Cure System) on a declaration basis (without production of bills/receipts) up to a certain limit per annum. The present annual limit for such treatment is as under: Officers in Grades A , B & CRs 4000/-p.a
Officers in Grades D, E & F-
Rs 5500/-p.a
Claims should be submitted in the prescribed proforma of application-cum-declaration enclosed to Central Office circular PPD.No.G.59/566/M.10(2)-94/95 dated January 11, 1995. Claim/s may be preferred within the annual limit in a calendar year on a quarterly basis or in one lump-sum.
Such claims need not be subjected to scrutiny by the BMO or by the office and may be settled for the amount claimed up to the admissible limit, without insisting on receipted bills, cash memos, prescriptions, etc. The facility of obtaining reimbursement of medical expenses on a declaration basis is supplementary to and does not in any way curtail the existing scheme of reimbursement of medical expenses for outdoor treatment, wherein the claims are required to be supported by cash memos, bills, vouchers, etc. and certified to be true / genuine by the BMO. Officers recruited during any month of the calendar year may be reimbursed proportionately under declaration scheme and a form of dependency of eligible dependent parents may be furnished separately as enclosed in the format to Annex.I.
Since the scheme is on reimbursement basis, the claims of officers retiring/seeking voluntary retirement from the Bank during the calendar year may be settled as per their entitlement, irrespective of their date of leaving the Bank.
(vii) Offices should keep a separate account of claims paid on declaration basis in the individual account sheets and ensure that total reimbursement on declaration basis during a calendar year does not exceed the limit.
Private Treatment Scheme (PTS) for workmen employees Workmen employees are eligible for reimbursement of medical expenses incurred for themselves and their family members on declaration basis under the Scheme for reimbursement of cost on account of private treatment. Salient features/guidelines for implementation of the Scheme are given in Annex I. Current entitlements of the employees in Class III and Class IV including part-time employees whose working hours exceed 13 hours per week, effective from November 1, 2007 are as under:
PER ANNUM
Full Time
Class III
2000/-
Class IV
2000/2000/1500/-
Part time with family 2000/Part time without family 1500/-
Scheme of Annual Health Check-up 11.1 The Bank has a comprehensive health check-up scheme for officers, workmen employees and their spouse who are 40 years of age and above for timely detection of health problems, if any. In case of officers the facility of Annual Health Check up is extended to all confirmed officers irrespective of their age. However, in case of spouses the facility will continue to be extended to only those spouses who are 40 years and above. Under the Scheme all eligible employees are required to undergo certain pathological/radiological tests at one of the approved hospitals/clinics once in a year and present the reports for perusal of the BMO. The salient features/guidelines for implementation of the scheme are given in Annex II. It has been observed that this facility is not availed of by a sizeable section of eligible employees. They are either not undergoing AHC or not showing the reports to the BMOs thereby defeating the very purpose of taking the preventive / corrective line of treatment. Concerns have been expressed by the Top Management at this disturbing trend. It may be appreciated that AHC is not a matter of choice. Offices are advised to ensure that all the eligible employees undergo the Health Check-up annually and also consult the BMO with the reports so that incipient health problems, if any, get diagnosed in good time. RDs / Heads of CODs should personally monitor tests being undertaken by Officers in Grade D and above working withBANK them. RESERVE OF INDIA
11.2 The Regional Offices (other than Mumbai office) may review/renew the arrangements for annual health checkup of officers with the approved clinics at their centers every year. In case any enhancement in charges is asked for by the clinics, the offices may allow it up to 10% (ten percent) of the existing charges provided they are satisfied about the services rendered by the clinic. In case any addition to the approved list is considered necessary, offices may do it provided the rates are more or less the same as charged by the clinics, which are already on the approved list. In Mumbai the arrangements will be reviewed / renewed by Central office (HRMD).
Annual Review of Medical Expenditure 12.1 Submission of annual medical report to Central Office by each Regional Office has been discontinued since February 1997. However, a note may be submitted to the Regional Director/General Manager (O-I-C) / Head of the Department as at the end of June giving the analysis of increase in medical expenditure, including cost of drugs stocked in the dispensaries and expenses incurred on medicines issued through credit slips. If there is a significant increase in the cost of drugs stocked in the dispensary and those issued on credit-slips as compared to previous year, taking into account the number of patients treated during the year, comments of the BMOs may be obtained. In such cases, offices may keep Central Office informed of the large variations, if any.
The offices have been submitting a certificate along with annual medical report, indicating the number of eligible employees who have undergone the prescribed health check-up and a statement about the expenditure incurred on settlement of death claims of employees/eligible family members. Since submission of annual medical report has been dispensed with, no such certificate/statement need be submitted to Central Office. The relevant information may, however, be submitted to the RD/GM(OIC)/ HOD for information.
Submission of medical claims by employees 13.1 The employees should make application for reimbursement of medical expenses incurred by them other than those under the Private Treatment Scheme/ Declaration Scheme in form No. Gen 163 of GAM subject to the following : Individual claim exceeding Rs 1000/- for any ailment should be made within three months from the date of completion of the treatment. Small claims for amount of Rs.1000/- and less incurred in respect of medical treatment taken during a period of three months may be submitted by clubbing them together, once, on a quarterly basis within three months from the close of the relative quarter. Offices may please note to incorporate at appropriate place the following information in the medical bill application form (No.Gen.163 of GAM) (a) Age of the patient;
(b) In case of self hospitalization -nature and period of leave availed by the employee
(c) A declaration stating that " the bill has been submitted in accordance with Reserve Bank of India (Staff) Regulations, 1948 and in case declaration given by me regarding dependency is found to be false, I am liable for disciplinary action for mis-conduct within the meaning of Regulation 47 of the Reserve Bank of India (Staff) Regulations, 1948".
Deduction of tax at source in respect of medical facilities/ reimbursement of medical expenses to the employees Section 17 (2) of Income Tax Act, 1961 defines the Perquisites which are included for tax purpose. Exemption to certain medical benefits from perquisite value has also been provided under sub-clause (b) of (ii) of the Proviso to clause (2) of Section 17. They are furnished below: The value of any medical treatment provided to employee in any hospital, clinic, dispensary or a nursing home maintained by the employer. Reimbursement by the employer, of expenditure incurred by the employee on his medical treatment or treatment of any member of his family in any hospital (clinic, dispensary or a nursing home) maintained by the Government, Local Authority or in a hospital approved by the Government for its employees Payment made by the employer directly (reimbursement of the expenditure to the employee, to a hospital, clinic, dispensary or a nursing home) which is approved by the Chief Commissioner of Income Tax for treatment of prescribed disease or ailment.
The prescribed ailments are a) Cancer, b) Tuberculosis, c) AIDS, d) disease of Heart, Blood, Lymph Glands, Bone Marrow, Respiratory System, Central Nervous System, Urinary System, Liver, Gall Bladder, Digestive System, Endocrine Glands of the skin requiring surgical Operation, e) Ailment or disease of the Eye, Ear, Nose or Throat requiring surgical operation, f) Fracture in any part of the Skeletal system or Dislocation of Vertebrae requiring surgical operation or Orthopaedic Treatment, g) Gynaecological or Obstetric ailment or disease requiring surgical operation or caesarean operation or baroscopic intervention. Ailment or disease of the organs mentioned at (iv)(d) above requiring medical treatment in Hospital for at least 3 continuous days. Burn injuries, mental disorder, drug addiction anaphylactic shocks, drug reaction and other allergic manifestations requiring medical treatment in hospital for at least 3 continuous days. Group medical insurance (mediclaim) obtained by the employer or his employees or reimbursement of insurance premium to the employee who takes such medical insurance on his life or his family members. Reimbursement by employer of amount spent by the employee in obtaining medical treatment for himself or any member of his family from any doctor not exceeding in aggregate Rs.15000/- in an year. Any expenditure incurred by the employer (reimbursement of expenditure incurred by the employee) on medical treatment of the employee or any member of the family of the employee outside India subject to certain conditions.
It has been decided that subject to the exemptions mentioned above, the amount reimbursed is to be treated as perquisite and the valuation of the same may be done as under: Reimbursement of medical expenses on declaration basis and reimbursement on the basis of medical bill submitted by the employee for out door/indoor treatment are to be treated as Monetary Perquisites. Direct settlement of medical bills made by the Bank (amount to be restricted to the extent admissible under BMFS) with Hospitals for indoor treatment are to be treated as Non-Monetary Perquisite. 14.1 Implementation (i) On the basis of the guidelines provided above and the hospitals classified under Sr. No 14 (i), (ii) & (iii) above, all Regional Offices/Central Office Departments are advised to workout the Perquisite Value after segregating the medical bills settled during the year, subject to the changes, if any, in the Finance Act in future.
(ii) As regards the recovery of tax on reimbursement of medical expenses preferred by legal heir in case of death of serving employee, the cases may be referred to Central Office for consideration along with following particulars: (a) Statement showing amount claimed/ admissible, item-wise.
(b) Amount paid, if any, to the hospital by way of deposit by the Bank at the time of admission of the employee. (c) Amount reimbursed to the employee and the legal heir (separately) against bills submitted by the employee till the time of his demise. (d) The date of demise of the employee and the date of hospital bill.
(e) Whether a letter was issued by the Bank to the hospital agreeing for direct settlement of the hospitalisation bill at the time of admission of the employee to the hospital. (f) Part payment, if any, made to the hospital against its bill during the period of treatment.
Scrutiny of individual accounts relating to reimbursement of medical expenses to officers Offices may scrutinise annually the individual accounts relating to reimbursement of medical expenses made to officers and prepare a statement showing details of cases where reimbursement of medical expenses in respect of outdoor treatment to officers / their family members exceeded a sum of Rs.5000/- for any one ailment during the financial year (April - March) and put up the statement to the RD/GM (O-I-C)/HOD for information and appropriate action in case any unusual features are observed.
Transfer of Medical Sheet It has been decided that whenever employees are transferred from one centre to the other, their medical account sheets maintained by offices in terms of instructions contained in circular DAPM.No.850/18.01.00/96-97 dated March 1, 1997 may also be transferred to the new centre of posting along with their service file.
Annex. I Private Treatment Scheme (PTS) for workmen employees The scheme known as Private Treatment Scheme (PTS) for reimbursement of medical expenses on account of treatment taken from private medical practitioners by workmen employees in Class III and IV and their family members up to a prescribed limit was introduced from October 1, 1970. The scheme, which was originally subject to production of medical bills from Registered Medical Practitioners, has been converted on a declaration basis from November 1, 1994. Accordingly the employees are now required to apply for reimbursement of medical expenses under PTS in a prescribed application-cum-declaration form. Under PTS, expenditure incurred on treatment taken by employees themselves and their dependent family members viz. spouse, children and parents is eligible for reimbursement up to certain limits. Part-time employees whose working hours exceed 13 hours per week are eligible for reimbursement of medical expenses under PTS on par with full-time employees. In the case of female employees whose husbands are also in the service of the Bank, they may opt for PTS for themselves as also for their parents independently. Their husbands may avail of the facility for themselves and their children separately up to their entitlement.
The scheme is supplementary to and does not in any way curtail or adversely affect the regular Banks Medical Facilities Scheme for dispensary facility, hospitalisation and other facilities including those for maternity expenses. Any treatment taken from a Registered Medical Practitioner under the Allopathic, Homeopathic, Ayurvedic or Unani systems of medicine will qualify for reimbursement under PTS. The limits for reimbursement under PTS are to be availed calendar year wise (January to December) and un-availed portion of limit can be carried forward upto three years. Retiring employees, including those retiring voluntarily, will be eligible for reimbursement of expenses upto the full limit for the entire year irrespective of the date of retirement. In the cases of resignation, retrenchment, dismissal from the Banks service, reimbursement will be admissible on proportionate basis upto the date of cessation of service. In other words, amount received in excess, if any, shall be recovered from them. The criteria to fill up the Form MPT-I and MPT-II for workmen employees are done away with and may only be insisted from the workmen employees the eligible dependent parents as given in the format enclosed, a copy of such declaration may be filed in the service record of an employee.

Presentation 1

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Master Circular on Bank's Medical Facilities Scheme (BMFS)

Under Private Treatment Scheme for Class III employees

5.5 Treatment outside headquarters

RESERVE BANK OF INDIA

7.1.1 For Officers

For Workmen Employees

RESERVE BANK OF INDIA

RESERVE BANK OF INDIA

RESERVE BANK OF INDIA

RESERVE BANK OF INDIA

RESERVE BANK OF INDIA

ii) Officers in Grade A B & C iii) Officers in Grade D E & F

RESERVE BANK OF INDIA

RESERVE BANK OF INDIA

Officers in Grades D, E & F-

Part time with family 2000/Part time without family 1500/-

RESERVE BANK OF INDIA

RESERVE BANK OF INDIA

RESERVE BANK OF INDIA

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