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నాకు బాబు పుట్టాడు. కానీ Pre-Mature. బాబును దగ్గరలోని ఆసుపత్రిలో నెలరోజుల పాటు ఉంచాము. మొత్తం ఖర్చు 3 లక్షలు అయ్యింది. నాకు మెడికల్ రీయింబర్స్ మెంటు వస్తుందా?



GO.Ms.No : 74, Dated: 15-03-2005 ప్రకారం మీరు ట్రీట్మెంట్ కు ఎంత ఖర్చు పెట్టినా ఒక లక్ష మాత్రమే జారీ చేయబడుతుంది.



GOVERNMENT OF ANDHRA PRADESH
ABSTRACT

Andhra Pradesh Integrated Medical Attendance Rules, 1972 – Recommendations of the Committee for revision of the Rules – Accepted – Orders – Issued.

 HEALTH MEDICAL AND FAMILY WELFARE (K1) DEPARTMENT 
G.O.Ms.No.74                       Dated the 15th March, 2005  





Read the following:
1. G.O.Ms.No.465, HM&FW(K1) Deptt., dt.18-8-2003
2. Govt.Memo.No.18300/K1/2003-1, dt.8-9-2003.
3. From the DME, A.P., Hyd., Lr.Rc.No.20866/MA-A/03, dt.18-12-03
4. Govt.Lr.No.18300/K1/2003-2, dt.31-1-2004.
5. From the President, A.P. Sectt. Association, Hyd. repn.dt.19-7-2004
6. Govt.Lr.No.18300/K1/2003-4, dt.4-8-2004.
7. G.O.Ms.No.250, HM&FW(K1) Deptt., dt.11-8-2004
8. From G.A. (SW-II) Deptt., U.O.Note No.101207/SWII-A1/2004-3, dt.9-9-2004.
9. Govt.Lr.No.18300/K1/2003-2, dt.15-9-2004.
10. G.O.Ms.No.413, GA (Poll-D) Deptt., dt.9-12-2004.
11. From Sri N.Narasimhaiah, MLA, reptn dt.29-11-2004
12. From the DME, A.P., Hyd., Lr.Rc.No.20866/MA-A/03, dt.28-12-04.


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O R D E R:
     Government have issued Andhra Pradesh Integrated Medical Attendance Rules, 1972, applicable to State Government employees and their dependents, employees of local bodies, students of Medical Colleges, members of State Legislature, A.I.S. Officers, A.P. State Higher Judicial officers etc. Many private hospitals both in the State and out side the State have been recognised as referral hospitals, for the treatment to the above category of persons on reimbursement basis. There is no uniform rates being charged from the patients by these private hospitals.€€ In Government hospitals, various medical facilities are provided with latest equipments for the treatment to general public and also to the employees. Since the issue of the rules, Government have issued amendments /orders /Clarifications from time to time to the said rules. Therefore, some of the provisions in the said rules became outdated. Due to the above position, Government felt that there is a need to review all the provisions in Andhra Pradesh Integrated Medical Attendance Rules, 1972 and modification and re-issue the rules.€ Accordingly in the G.O. first read above, Government have appointed a committee under the chairmanship of Director General of Medical and Health Services and Commissioner, A.P. Vaidya Vidhana Parishad for revision of Andhra Pradesh Integrated Medical Attendance Rules, 1972 and to submit report to Government. Various terms of reference was specified thereon. In the G.O. seventh read above, the Director of Medical Education has been appointed as Chairman of the said Committee, due to resignation of the Director General Medical and Health Services and Commissioner, A.P.Vaidya Vidhana Parishad.€ As per the terms of the reference of the committee, Government have referred various issues relating to medical reimbursement.€ In the reference fifth read above, the President, Andhra Pradesh Secretariat Association has also represented for reimbursement fecility for Out Patient treatment at Nizam’s Institute of Medical Sciences, Hyderabad / private recognised hospitals, removal of 20% cut on the claim and extend credit facility for obtaining treatment under emergency conditions in private recognised hospitals. This representation was also referred to the Committee.

2.   In the reference 11th read above, Sri N.Narasimhaiah M.L.A. has represented that Out Patient treatment to M.L.A.s may also be allowed on credit basis, to enable to get tests like M.R.I., C.T. Scan etc. and save the health of V.V.I.Ps.

3.   In the letter 12th read above, Chairman of the Committee for revision of Andhra Pradesh Integrated Medical Attendance Rules, 1972 and Director of Medical Education has submitted the recommendations of the committee and its report to Government.€ The Director of Medical Education has stated that the committee has met on 24-10-03, 25-11-03, 23-12-03, 25-2-04, 12-8-04, 19-10-04 and 16-11-04 and examined various issues.€ A sub committee was constituted for finalisation of package rates.

4.   The Director of Medical Education has also stated that the following nine service associations have been requested to give suggestions on Andhra Pradesh Integrated Medical Attendance Rules:

1)  A.P. Secretariat Employees Association, Hyderabad.
2)  A.P. Non-Gazetted Officers Association, Hyderabad
3)  A.P. Teachers Federation, Hyderabad
4)  The Secretary, A.P. Revenue Employees Association.
5)  A.P.T.N.G.O. Association
6)  A.P.U.T.F Association.
7)  A.P.P.R.T. Union, Hyderabad.
8)  A.P. State Government Retired Employees Association.
9)  A.P. Secretariat Women Employees Welfare Association.

5.   The General Secretary, A.P. State Government (Retd.) Employees Association and Organising Secretary of A.P. State Government Employees. Association have attended the meeting of the committee held on 8-12-2003. The Director of Medical Education has also stated that the service associations have been reminded on 11-12-2003 to submit their views regarding revision of Andhra Pradesh Integrated Medical Attendance Rules 1972.€ The following service associations have sent their suggestions in the matter:-

1)  A.P. State Government Retired Employees Association.
2)  A.P. Secretariat Employees Association, Hyderabad.
3)  A.P. Secretariat Women Employees Welfare Association.
4)  P.R.T.U. & UTF (Teacher Associations)

6.   The Director of Medical Education has stated that the sub-committee has recommended that the rates prescribed by Central Government Health Scheme may be adopted by State Government also for sanctioning reimbursement. The recommendations of sub committee have been accepted by the committee. He has furnished the recommendations for incorporation and revision of Andhra Pradesh Integrated Medical Attendance Rules rules, 1972.

7.   The Director of Medical Education has requested the Government to consider and issue necessary orders in the matter at an early date.

8.   The recommendations of the Committee includes adoption of Central Government Health Scheme package rates for the reimbursement of medical expenses incurred by State Government employees, their dependents, retired State Government pensioners and their family members etc., allowing medical reimbursement for the treatment obtained at Nizam’s Institute of Medical Sciences, Hyderabad, Sri Venkateswara Institute of Medical Sciences, Tirupati and all Government Hospitals as Out-Patients and follow-up treatments. As regards recognised private hospitals, medical reimbursement for the treatment obtained as outpatients may be allowed for the treatment of Chemotherapy, radiotherapy for cancer, regular dialysis for Kidney, Cardinal cases like cardiac cases, sever neurological problems and A.I.Ds subject to recommendation by the specialist doctor for the length of the treatment, consideration of medical reimbursement in accident cases under emergency conditions for the treatment obtained in unrecognised private hospitals by relaxing relevant rules by Government, conducting of health camps for master health checkup, delegation of powers for scrutiny and sanction of medical reimbursement upto Rs.25,000/- to various district level officers, referring of patients by District/ Area Hospitals to private recognised hospitals, reducing imposition of cut of 20% on the admissibility amount to 10%, when the treatment obtained in Private Hospitals recognised by Government without referral letter, extending medical reimbursement fecilities for the treatment obtained in Sri Venkateswara Institute of Medical Sciences, Tirupati on par with Nizam’s Institute of Medical Sciences, Hyderabad etc.. The Committee after examination of the merits of the representations received from various associations has also recommended to accept certain demands and to reject certain demands.
9.   Government have examined the matter carefully and decided to accept the recommendations of the Committee for revision of Andhra Pradesh Integrated Medical Attendance Rules, 1972 constituted in the Government Orders first and seventh read above.€ Accordingly, in modification of the existing orders on Andhra Pradesh Integrated Medical Attendance Rules, 1972, Government hereby issue the following orders with immediate effect:-


    1)  The rates prescribed in the Central Government Health Scheme package by Government of India, Ministry of Health and Family Welfare Affairs, New Delhi for Central Government Health Scheme, Hyderabad are adopted in the State for the purpose of reimbursement of medical expenditure incurred by the State Government employees both in service/ retired and their dependents; family pensioners, M.L.As and their family members and all other eligible categories who are entitled for free medical treatment as mentioned in Andhra Pradesh Integrated Medical Attendance Rules, 1972, when the treatment was taken in the private hospitals recognised by the State Government within the State.€ If medical treatment is taken outside the State, the rates of Central Government Health Scheme, Delhi shall be applicable. If any rates which are not covered in the said procedure, the scrutinising authority is empowered to take final decision in the matter basing on the disease/ nature of disease, necessity of treatment /medicine. In modification of the orders issued in G.O.Ms.No.161, HM&FW (K1)Deptt., dt.5-5-2000 and G.O.Ms.No.58, HM&FW (K1) Dept., dt.1-3-2002, the ceiling limit shall be Central Government Health Scheme package rates ceiling limit and also the criteria for scrutinising bills by the Director of Medical Education or other authorising scrutiny authorities.

    2)   For the expenditure incurred towards the treatment obtained in Nizam’s Institute of Medical Sciences, Hyderabad / Sri Venkateswara Institute of Medical Sciences, Tirupati, their package rates respectively be followed for sanctioning advance, scrutiny and Medical reimbursement purpose.€ Facilities of paying room as per the entitlement of indoor treatment as prescribed in Central Government Health Scheme package system is extended and the State Government Employees are categorized as three categories based on their scales of pay as mentioned below:-

(i) Scale of pay up to  Rs.5,000/- -- 10,600/-   - General Ward.

(ii) Scale of pay  Rs.5,300/- -- 13,000/- to
                              Rs.8,400/- -- 16,525/-            - Semi Private Ward.

(iii) Scale of pay Rs.9,000/- -- 16,525/- above – Private Ward.

    3)   In respect of treatments/ operations obtained for cataract and other eye ailments, and dental diseases/treatments in Government or private hospitals recognised by State Government, the scrutinising authority need not insist for submission of Emergency Certificate.€ In modification of the orders issued in G.O.Ms.No.276, HM&FW (K1) Department, dt.11-5-1993 and subsequent orders issued thereon and on Eye ailments and Dental diseases /treatments, it is ordered that the reimbursement shall be made as per the package rates prescribed by Government for various eye ailments and Dental procedures/ diseases, after duly scrutinising the bills by the Director of Medical Education, A.P. or other scrutinising authorities. The package rates prescribed for Eye ailments are mentioned in Annexure-I and package rates for Dental treatments/ diseases are mentioned in Annexure-II to this order.

    4)   All types of out patient including diagnostics, and follow up treatments including Chemotherapy, Radiotherapy, Regular Dialysis for Kidney are allowed for reimbursement when the treatment obtained at Nizam’s Institute of Medical Sciences, Panjagutta, Hyderabad and Sri Venkateswara Institute of Medical Sciences, Tirupati and all Government Hospitals. In respect of the treatment obtained as Out-Patients in private hospitals recognised by State Government, 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 and shall be scrutinised by the Director of Medical Education, Nizam’s Institute of Medical Sciences, Hyderabad, Sri Venkateswara Institute of Medical Sciences, Tirupati or other scrutinising authorities as prescribed.

    5)   In respect of life long follow up treatment to certain diseases, for every follow up treatment for post operative cases, who requires life long treatments, the concerned patient has to get revalidation of prescriptions once in six months from the specialist Government doctor and reimbursement be allowed on submission of scrutiny report of the Director of Medical Education or other scrutinising authorities concerned.

    6)   The Superintendents of Teaching hospitals and the Superintendents of District Hospitals, Civil Surgeon Specialist of the Civil Dispensary, A.P. Secretariat, Hyderabad, Medical Officers of the rank of Civil Assistant Surgeons of Unit Medical Hospitals of Grey Hounds, Hyderabad, High Court of Andhra Pradesh, Hyderabad, Commissioner of Police, Hyderabad, and Medical Officer attached to Government Civil Dispensary, A.P. Bhavan, New Delhi are authorised to scrutinise the medical reimbursement claims up to a value of Rs.25,000 (Rupees twenty five thousand only), of State Government Employees, retired employees, their dependent family members and family pensioners and other categories of persons entitled for medical reimbursement as per of Andhra Pradesh Integrated Medical Attendance Rules, 1972 received from District level officers from their respective region/Districts and Offices concerned in partial modification of the orders issued in G.O.Ms.No.471, H.M.&F.W. (K1) Department, dated 19-12-2001, G.O.Ms.No.674, HM&FW(K1) Deptt, dated 15-11-2003 and G.O.Ms.No.37, HM&FW(K1) Deptt., dated 31-1-2004. These scrutnising authorities should scrutinise the bills in terms of Andhra Pradesh Integrated Medical Attendance Rules, 1972 and as amended from time to time.

    7)   Powers are delegated to all the district level officers of all the Departments in the State to sanction the medical reimbursement claims up to a value of Rs.25,000/- (Rupees twenty five thousand only), subject to scrutiny done by the District Medical Board/ District Hospital Superintendent/ Superintendent of Teaching Hospitals.€ If the claim is over and above of Rs.25,000/-, the claim should be referred by the concerned Department in the districts to Director of Medical Education, A.P., Hyderabad for scrutiny, and the sanctioning authorities for sanction of claims of medical reimbursement over and above Rs.25,000/- are Heads of Departments /District Collectors, after€ getting€ scrutiny report of Director of Medical Education, or Nizam’s Institute of Medical Sciences, Hyderabad or Sri Venkateswara Institute of Medical Sciences, Tirupati, as the case may be€ and where relaxation of rules are not involved.

    8)   Powers are also delegated to the Director of Health, A.P., Hyderabad to scrutinise the Medical Reimbursement claims in respect of the employees working under his administrative control on par with the Commissioner of A.P.Vaidya Vidhana Parishad, duly following the procedure adopted by the Director of Medical Education in scrutinising the bills, as per the existing orders on Andhra Pradesh Integrated Medical Attendance Rules, 1972 as modified from time to time.

    9)   In respect of road accidental cases, if the employee or his dependents and other categories of persons mentioned in rule 6 of Andhra Pradesh Integrated Medical Attendance Rules are admitted in nearby private hospitals which are not recognised as referral hospitals under emergency conditions to save the life of the patient, in such cases the claim can be considered for reimbursement of medical expenses up to a limit of Rs.25,000 (Rupees twenty five thousand only) and the Heads of Departments/ District Collectors are authorised to sanction the claim after getting the scrutiny of bills from the Director of Medical Education or other scrutinising authorities as the case may be. Such claims over and above Rs.25,000 shall be referred by the€ Heads of Departments/ District Collectors concerned after duly getting scrutiny of the bills etc., to the concerned administrative Department in Secretariat for obtaining relaxation of rules and duly consulting Finance Department.

     10)   In G.O.Ms.No.175, H.M.&F.W. (K1) Department, dt.29-5-1997, 20% cut is prescribed on the eligible amount in cases of treatment obtained under emergency condition in private hospitals recognised by Government without referral letter from Government Hospitals or Nizam’s Institute of Medical Sciences, Hyderabad, or Sri Venkateswara Institute of Medical Sciences, Tirupati.€ In partial modification of the orders issued in G.O.Ms.No.175, H.M.&F.W. (K1) Department, dt.29-5-1997, the 20% cut prescribed therein is reduced to 10%, on the eligible amount after scrutiny of bills by the Director of Medical Education or other scrutinising authority as per the package rates, when the treatment was obtained under emergency conditions in private hospitals recognised by Government without referral letter from any Government hospital or Nizam’s Institute of Medical Sciences, Hyderabad, or Sri Venkateswara Institute of Medical Sciences, Tirupati.

    11   In respect of medical reimbursement to the employees under suspension, the following two points be added to rule 6 (i) of Andhra Pradesh Integrated Medical Attendance Rules, 1972:-

“a) Provided dismissed or removed Government servants 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 should not be entitled for any free medical treatment in Government hospital or medical reimbursement. Provided that the retired persons who were punished for any administrative lapses for which the punishment was given, which is not a 100% cut in his pension, can be allowed for free medical treatment/ medical reimbursement as the case may be”.

    12)   As per G.O.Ms.No.445, HM&FW(E2) Department, dt.19-07-1991, the medical advance facility is extended to four earmarked diseases i.e. 1)Acute Mycardial Infracture 2) Acute Coronary Disease, Acute Renal Failure 3) Severe Cases of Head and Spinal injury, Road accident and 4) In cases of Coma only, if the treatment is to be obtained in Nizam’s Institute of Medical Sciences, Hyderabad. The following more major diseases are added for sanction of advance to be included in the said G.O.:-

“(1) PTCA+STENT (2) Open Heart Surgery (3) Pace Maker (4) All organ transplants (5) Plastic Surgery done for accident cases and burns, (6) Mitral Valve replacement, based on package rates of Nizam’s Institute of Medical Sciences and Sri Venkateswara Institute of Medical Sciences based on estimation given by them”.

    13)   In G.O.Ms.No.134, HM&FW (K1) Department, dt.9-4-2001, Government employees both in service and retired and their dependents are permitted to secure treatment for all diseases at Nizam’s Institute of Medical Sciences, Hyderabad directly without referral letter under emergency circumstances. Since Out Patient treatment is allowed for medical reimbursement at Nizam’s Institute of Medical Sciences, Hyderabad and Sri Venkateswara Institute of Medical Sciences, Tirupati, the condition of “emergency circumstances” prescribed in G.O.Ms.No.134, HM&FW (K1) Department, dated 9-4-2004 is hereby deleted. All the reimbursement facilities available in Nizam’s Institute of Medical Sciences, Hyderabad as per the orders issued in G.O.Ms.No.134, HM&FW (K1) Department, dt.9-4-2001, as modified now, be extended to Sri Venkateswara Institute of Medical Sciences, Tirupati on par with Nizam’s Institute of Medical Sciences, Hyderabad.

    14)   All the Heads of Departments and Regional and District Level officers can issue letter of credit (L.O.C.) to private hospitals recognised by State Government for treatment/ operations to their employees and their dependents for major ailments 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, 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. Expeditious steps may be taken by all the departments to issue I.D. cards to all the eligible State Government employees and their dependents for availing of Letter of Credit facility. The referral private hospitals shall also provide treatment immediately after admission of the patient, on production of identity card in emergency situation.

    15)   Medical Reimbursement facility be allowed only to adopted son or daughter, and it is restricted to the family as defined under rule 3 (7) of Andhra Pradesh Integrated Medical Attendance Rules, 1972.

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

    17)   The medical reimbursement facility be given 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 fell ill health, as per the Central Government Health Scheme package rates.
    18)   The powers are delegated to Superintendents of Area Hospitals and the Superintendent of District Headquarters Hospitals under the control of A.P. Vaidya Vidhana Parishad to refer the patients to Private recognised hospitals for specialised treatment.

    19)   Since user charges are abolished for the treatment in Government hospitals, vide G.O.Ms.No.163, HM&FW(M1) Department, dated 14-6-2004, no user charges should be collected from the State Government employees and their dependents including from the pensioners and their dependents and family pensioners in Government hospitals for their treatment both for outpatient and inpatient.

    20)   As per note (3) of Appendix-III, under rule 5 (3) (iii) of Andhra Pradesh Integrated Medical Attendance Rules, 1972 for belated claim, the existing condition that preferring the claim for medical reimbursement should be within a period of six 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 claim may be preferred within eight months from the last date of discharge from the hospital /expiry of concerned patient.

    21)   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.

    22)   In G.O.Ms.No.601, HM&FW(K1) Department, dt.15-10-2003, orders have been issued allowing medical reimbursement for three spells during the life time for€ the same ailments for claiming reimbursement for three spells when treatment obtained in recognised private hospitals.€ In modification of the said orders, it is ordered that no restriction is imposed for the treatments obtained in private recognised hospitals for different ailments operations/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, expect 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 recognised by Government / Government hospital should be submitted for the second and third spell claims.

    23)   Reimbursement of medical 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 bill, provided that they are not paid any amount towards the said treatment by any other authority including insurance company.

    24)   Master Health Checkup be conducted to all the Government employees who crossed the age of 40 years and before retirement form 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.

    25)   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.

    26)   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 Govt. as per Central Govt. Health Scheme package rates.

10.    The above orders will be applicable to all State Government employees, their dependents, retired State Government pensioners and their dependents, family pensioners, M.L.A’s and other categories of persons who are entitled for free medical treatment as specified in Andhra Pradesh Integrated Medical Attendance Rules, 1972. Suitable amendments to Andhra Pradesh Integrated Medical Attendance Rules, 1972 will be issued separately on the above orders.

11.    The Director of Medical Education shall take necessary action in the matter accordingly.

12.    This order issues with the concurrence of Finance Department vide their U.O.No.419/28/A2/Exp-HM&FW-I/2005 dt.3-2-2005.


(BY ORDER AND IN THE NAME OF THE GOVERNOR OF ANDHRA PRADESH)

 DR. I.V.SUBBA RAO
PRINCIPAL SECRETARY TO GOVERNMENT





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