Policy on reimbursement of medical expenses by Railways where part payment has been. received by the beneficiary through medical insurance claim: Railway Board Order

GOVERNMENT OF INDIA

MINISTRY OF RAILWAYS

(RAILWAY BOARD)

No. 2009/H /6-4/Policy 

Dated: 09 04.2015

General Manager,
All Indian Railways,
New Delhi,
GM/CAO/DG
All Production Unit including RDSO

Sub: Policy on reimbursement of medical expenses by Railways where part payment has been. received by the beneficiary through medical insurance claim.

Ref: Railway Board’s letter no. 2009 /H /6-4/Policy, dated 28.02.2013.

Railway Board has been receiving representations from various quarters for modifying the extant policy on reimbursement of medical expenses where part payment has been made thrOugh insurance claims. After due consideration, in supercession of the above referred letter, the following instructions are issued: 

Railway beneficiaries, both serving employees and retired employees (members of RELHS scheme) who have subscribed to Medical Insurance Policies, may be allowed to claim reimbursement both from the insurance company as well as Railways subject to the condition that the total amount of reimbursement from both the sources should not exceed the total expenditure incurred by the beneficiary for the treatment. The beneficiary will make the first claim to the insurance company and thereafter to the Railway concerned, wherever necessary, as per the procedure explained below.

1. The medical claim against the original vouchers/bills would be raised by the beneficiary first to the insurance company, which would issue a certificate, addressed to the concerned CMS/MD indicating the amount reimbursed. The insurance company will retain the original vouchers/bills in such cases and issue photocopies of bills/vouchers duly certified in ink along with stamp of the insurance company.

2. The beneficiary would thereafter prefer his/her medical claim along with photocopies of vouchers/bills duly' certified, in ink, along with stamp of the insurance company to the concerned MD/CMS through the Health Unit/Hospital where the Medical I card is registered.

3. Medical Department shall scrutinize the Claim as per the extant rules of Railway, ignoring the amount already reimbursed by insurance company, and the amount found admissible, as per Railway approved rates, will be processed fee reimbursement.

4. Reimbursement from Railway will however be limited to the difference between actual amount spent by beneficiary and the amount already reimbursed by insurance company “or” the amount found admissible as per Railway Rules, whichever is lower. (Illustrative examples are enclosed as annexure 1)

5. The fact that the claim has been accepted and processed by an Insurance Company does not confer any validity/legality to the claim as far as reimbursement from Railways is concerned. Reimbursement from Railways shall be done only if the Claim is admissible as per the extant rules of Railways. Just like any other reimbursement claim, it can be rejected at any stage.

These instructions take effect from the date of issue of letter. Past cases shall not be reopened.

DA: One

sd/-

Dir (H&FW)

Railway Board

Annexure to Board’s letter No.2009/H/6-4/Policy dated 09.04.2015 

Illustration No. I

A. Total Medical Expenditure incurred by the Rly beneficiary : Rs.1,00,000/-

B. Amount reimbursed by Insurance Company out of (A) : Rs.40,000/-

C. Amount out of (A) which is reimbursable as per Rly approved rates/rules. : Rs.70,000/-

D. Maximum amount that can be reimbursed by Railways will be either (A-B) OR (C) whichever is lesser.: Rs.60,000/-

Illustration No. II

A. Total Medical Expenditure incurred by the Rly beneficiary : Rs.1,00,000/-

B. Amount reimbursed by insurance Company out of (A) : Rs.20,000/-

C. Amount out of (A) which is reimbursable as per Rly approved rates/rules.: Rs.70,000/-

D. Maximum amount that can be reimbursed by Railways will be either (A-B) OR (C) whichever is lesser: Rs.70,000/-