Ex-servicemen Contributory Health Scheme- Various kinds of medical treatment undertaken for ex-servicemen
Treatment at Polyclinics
1. The starting point for medical attendance will be the nearest military/non military polyclinic. All available treatment within the capabilities of the polyclinic shall be provided at the first instance. Medical and para medical staff are hired/employed on contract for working at polyclinics. These polyclinics remain open for eight hours during week days and shall remain closed on Sundays and Gazetted holidays. Patients requiring attention outside working hours will be handled by duty MOs of service hospitals (in military stations) and by on-call civilian doctors in non-military stations. One nursing assistant will be available in all clinics in non-military stations after working hours. Depending on the type (A, B, C, D) which has been decided on the number of Veterans residing in that area, each polyclinic will have emergency bed with monitor, physiotherapy equipment, analysis with regents, digital ECG machine, dental chair, Ultra Sound machine, X Ray machine, Oxygen Concentrator, Nebulisor, minor OT and BP machine etc.
2. Manpower at Polyclinics*
*Note- This may undergo change with additional manpower sanctioned by MoD.
Treatment at Military Hospital/Empanelled Hospitals.
3. In case the required treatment is beyond the scope of the polyclinics, the Medical Officer in the first stage will refer the patient to the local MH where required treatment facility is available. Should MH not have the desired treatment/doctor/bed space, the ECHS patient will have the choice of going to any empanelled hospital in the station. In case the treatment is not available in that station, the ECHS member can go to any empanelled hospital in India. However, the cost of conveyance is to be borne by the individual. The list of the hospitals already empanelled along with details regarding the specialities for which the hospitals are empanelled is placed as Appendix ‘B’.
Referral to Hospitals
4. Military Stations. Ex-servicemen and their dependents requiring hospital admission will, in normal course, be referred to service hospitals in the station. In case of non-availability of beds/facilities in service hospital, patients will be referred to empanelled hospitals for admission.
5. Non-Military Stations. In non-military stations, ESM and their dependents will be referred to the nearest service hospital/empanelled hospitals by medical officer of ECHS Polyclinic.
6. In both the above mentioned cases/referrals, hospitals will only treat patients for conditions for which they have been specifically referred to from the ECHS Polyclinic, except in life saving/emergency situations.
Payment to empanelled Hospitals/Nursing Homes/Diagnostic Centres
7. The payments by ECHS to the empanelled Hospitals, nursing Homes and Diagnostic Centres will be governed by the following procedure:-
(a) Referral to Empanelled Hospital/Nursing Home/Diagnostic Centre.. Payment of bills to empanelled Hospitals will only be authorised when patients are referred to them from ECHS Polyclinic for necessary treatment/investigation. Hospitals will only treat patients for conditions for which they have been specifically referred from the ECHS Polyclinic, except in life saving/emergency situations.
(b) Payment of charges to Empanelled Hospitals/Diagnostic centres.
(i) The rates of payment to empanelled hospitals/Diagnostic centres in cities/towns covered under CGHS will be governed by the package deal rates as laid down for CGHS. The rates laid down for CGHS for various towns/cities will be applicable for ECHS Polyclinics located in corresponding/adjoining geographical areas.
(ii) For the Polyclinics located in cities/towns not covered under CGHS, the rates of payment to the Empanelled Hospitals/Diagnostic Centres will be negotiated and fixed by ECHS based on the facilities available and the prevailing market rates. The rates so fixed will, in any circumstances, not exceed the CGHS rates applicable to the nearest cities/towns covered under CGHS.
(iii) For diseases and conditions not in the list of CGHS package deals, the payment to the empanelled hospital/diagnostic centre would be at rates of AIIMS New Delhi or Actuals, which ever is less. Where AIIMS rates are not available, the actual cost of drugs and room rent etc will be reimbursed.
(iv) The package deal rates will include all charges pertaining to a particular treatment/procedure including admission charges, accommodation charges, ICU/ ICCU charges, monitoring charges, operation theatre charges, operation charges, anaesthetic charges, procedural charges/Surgeons fee, cost of disposables, surgical charges and cost of medicines used during hospitalisation, related routine investigations, physiotherapy charges etc.
(v) The package rate does not include diet, telephone charges, TV charges and cost of cosmetics, toiletry and tonics. Cost of these, if offered, on request of patient will be realized from individual patient and are not to be included in package charges.
(vi) The package deal includes
(aa) 12 days for Specialised procedure
(ab) 7-8 days for other procedures
(ac) 3 days for laparoscopic surgery
(ad) 1 day for day care/minor procedures(OPD)
(vii) If the beneficiary has to stay in the hospital for his/her recovery for more than the period covered in the package rate, the additional reimbursement will be limited to room rent as per entitlement, cost of prescribed medicines and investigations, doctors visits (not more than 2 times a day ) for additional stay.
(viii) If one or more treatment procedures form part of a major treatment procedure, package charges would be made against the major procedures and only half of approved charges quoted for other procedures would be added to the package charges of the first major procedure.
(ix) The rates will be applicable only for allopathic system of medicine. No charges will be reimbursed for Homeopathic, Unani, Ayurveda or traditional systems of medicines.
(x) An empanelled hospital/diagnostic centre whose rates for a procedure/test/ facility are lower than the approved rates shall charge the beneficiaries as per actuals. Expenditure in excess of approved/package deal rates would be borne by the beneficiaries.
(xi) Any legal liability arising out of such services shall be dealt with by the empanelled hospital, nursing homes, and diagnostic centres who shall alone be responsible. ECHS will not have any legal liability in such cases.
(c) Allied Charges
(i) Diet Charges. ECHS beneficiaries, whose Basic Pension + Dearness pension is less than or upto Rs.6,075/- are entitled for free diet during hospitalization empanelled hospitals. In case the beneficiary is suffering from TB or Mental disease, the monetary ceiling for free diet is upto Rs.9,000/-.
(ii) Special Nursing Attendant Charges. Special nursing charges and/or attendant charges will be admissible when such nursing/attendance is essential for recovery/ prevention of serious deterioration of the patient as certified by the Medical Officer-in-charge of the case. The approval of SEMO/SMO/PMO will be obtained through the concerned polyclinic in all such cases. The rate ceiling for special nursing and attendant charges will be as per guidelines of the CGHS. Special nursing/attendant charges will be applicable only for patients admitted in hospitals/nursing homes and will not be applicable for treatment taken at residence.
(iii) Entitlement for Indoor Treatment. Charges as applicable to CGHS will apply. ECHS beneficiaries shall be entitled to a general/semi private/ private ward facility in empanelled hospitals according to their rank structure as under:-
|Basic Monthly Pension(Rs)||Entitlement of Hospital Beds|
|JCOs(Nb Sub to Sub Maj including Hony Ranks of Lt/Capt and Equivalent)||Semi Private Ward|
|NCOs(Sep to Hav including Hony Ranks of Nb Sub and Equivalent)||General Ward|
(iv) A/C Charges. A/C charges will be included for ICU/ICCU patients, private ward patients and specialised treatment patients. In all other conditions where A/C is absolutely essential for treatment of the patient, such charges will be included with a necessary certificate from the treating physician.
(d) The Bills from the empanelled hospital will include the following:-
(i) Medical advance drawn, if any.
(ii) Referral slip from Polyclinic & photocopy of ECHS card.
(iii) Copy of admission and discharge slip
(iv) Summary of the case, including outcome
(v) Consultation charges/Diagnostic/ Package charges as applicable
(vi) Other charges if any not included above(to be specified).
(e) Mode of Payment. Bills and connected documents will be submitted by Hospitals, Nursing homes and diagnostic Centres to the Polyclinic from where the patient was referred. Officer In-Charge (OIC) Polyclinic will authenticate the bills and forward to concerned Senior Executive Medical Officer (SEMO)/Principal medical Officer(PMO)/ Senior Medical Officer (SMO) for scrutiny and onward despatch to station headquarters for payment. Payment will be made by cheque and will be subject to post –audit.
(f) Treatment at Military Hospitals. Hospital stoppage rolls and any other charges expended for treatment in military hospitals will be paid in full by the member and is not reimbursable.
8. The procedure for referral and reimbursement for specialised procedures will be as follows:-
(a) Specialised Tests and Treatment. ESM or dependents will only be referred to the empanelled hospitals/diagnostic centres for Specialised tests and treatment by the specialist at Polyclinic, specialist of service hospital or specialist at empanelled hospitals/ diagnostic centre. Only in case of emergencies and life threatening situations will a non specialist medical officer of the Polyclinic refer a patient directly for Specialised tests and treatment. In such cases, a certificate to this effect will be endorsed by the referring medical officer. Payment to empanelled specialist/super specialist will be made as per procedure laid down.
(b) Specialised Treatment. For treatment in cardiology, nephrology, oncology, joint replacement and other expensive specialised treatment/surgery, payment will be governed by the CGHS rates for various procedures as revised from time to time. When the CGHS rates for treatment are not available, rates of AIIMS or actual, whichever is less, will be applicable. Where the AIIMS rates are not available, the actual cost of drugs and room rent etc will be reimbursed.
(c) Treatment at Institutes of National Repute/Govt Institutions. Certain hospitals/ institutes do not accept post-payment. Such institutes will not ordinarily be empanelled under the ECHS. However, admission/treatment in the institutes of national repute listed below will be permitted. In case ESM or their dependents are referred by ECHS medical officer/specialist to any of the institutes mentioned below, an advance in the form of crossed cheque payable to the concerned hospital will be drawn by the patient from the concerned station headquarter after submitting the referral form by an ECHS Polyclinic and estimate from the concerned hospital. The hospitals where such an arrangement will be permitted are:-
(i) All India Institute of Medical Sciences, New Delhi
(ii) Post Graduate Institute, Chandigarh
(iii) Sanjay Gandhi Post Graduate Institute, Lucknow
(iv) National Institute of Mental Health and Neurosciences,Bangalore
(v) Tata Memorial Hospital, Mumbai(For Oncology)
(vi) JIPMER, Pondicherry
(vii) Christian Medical College, Vellore
(viii) Shankar Nethralaya, Chennai
(ix) Medical Colleges and hospitals under the Central or State Govts
9. Under certain special circumstances, reimbursement of cost of medicines will be permitted only if the patient was referred by the Polyclinic for specialised treatment and the medicines were prescribed to be taken with immediate effect on discharge. The special conditions are:-
(a) Post operative cases of major cardiac surgery/international cardiology
(c) Post operative organ transplant cases
(d) Post operative joint replacement cases
(e) Post operative major neuro surgical/neurology cases
10. The Ex-serviceman should present the suitable prescriptions for medicines for above conditions to the O ic Polyclinic immediately after discharge. A special demand for medicines will be raised by the O ic Polyclinic, through usual channels to the AFMSD. The drugs will be procured from AFMSD under the normal procedures. Drugs will be procured
from concerned SMO if ‘Not Available’ at AFMSD. In the interim, drug purchased by ex-servicemen, is reimbursable. The period of reimbursement in such cases will be limited to one month after date of discharge from Hospital or date of issue of medicines from Polyclinic which ever is earlier.
11. In emergencies and life threatening conditions, when patients may not be able to follow the normal referral procedure, the ECHS member can either report to the nearest service hospital or to the nearest empanelled hospital. The patient can report to any nearest non empanelled hospital either. In such case the ESM or his/her representative will have to pay the charges to the non empanelled hospital initially. In all cases where emergency treatment is availed and where the patient has not gone through the Polyclinic, it will be the patient’s responsibility to inform his Polyclinic/ECHS Central Organisation or Regional Centre within 48 hours, the details of emergency & admission details. The bills will have to be forwarded in original to the ECHS Central Organisation New Delhi. The onus of informing the Polyclinic or ECHS and proving the emergency, shall be that of the ESM patient.
12. Conditions of Emergency covered under the ECHS are envisaged as follows:-
(a) Acute cardiac conditions/syndromes including myocardial infarction, unstable angina, Ventricular Arrhythmias/ Paroxysmal Supraventricular Tachycardia, Cardiac Tamponade, acute left ventricular failure/severe congestive cardiac failure, accelerated hypertension, complete dissection.
(b) Vascular catastrophies including acute limb ischaemia, Rupture of aneurysms, medical & surgical shock and peripheral circulatory failure.
(c) Cerebro vascular accidents including strokes, neurological emergencies including coma, cerebro meningeal infections, convulsions, acute paralysis, acute visual loss.
(d) Acute respiratory emergencies including respiratory failure and de compensated lung disease.
(e) Acute abdomen emergencies including acute obstetrical and gynaecological emergencies.
(f) Life threatening injuries including road traffic accidents, head injuries, multiple injuries, crush injuries and thermal injuries.
(g) Acute poisoning and snake bite.
(h) Acute endocrine emergencies including diabetic ketoacidosis.
(j) Heat stroke and cold injuries of life threatening nature.
(k) Acute renal failure.
(l) Severe infections leading to life threatening sequelae including septicemia, disseminated/ miliary tuberculosis.
(m) Any other condition in which delay could result in loss of life or limb.
13. Procedure to be followed incase of emergency at empanelled and non-empanelled hospitals is as follows:-
(a) Empanelled Hospital- Immediate emergency treatment in any empanelled hospital will be rendered to ESM on confirmation of ECHS membership from the ECHS card. Payment for such treatment will be regulated as under:-
(i) Empanelled hospital will inform ECHS Polyclinic about the emergency admission at the earliest but not later than 48 hrs.
(ii) The onus of informing the OIC Polyclinic is with the Empanelled Hospital and not with the ECHS member/patient. However, the ECHS member may also convey the information on his own to ensure action by the Polyclinic.
(iii) Thereafter, the OIC Polyclinic will initiate an emergency referral after verifying the emergency. He will also ensure that the Emergency referral reaches the Empanelled Hospital in time. If, during the course of investigations/treatment a specific diagnosis is established requiring further management, the facts will be verified by concerned O i/c Polyclinic and the patient referred for the same formally.
(iv) The empanelled hospital will not collect payment from ECHS member.
(iv) The actual cost incurred for emergency procedure will be payable by ECHS. Bill for emergency treatment will be forwarded to concerned Polyclinic for payment as per normal procedure. Such bills will be superscribed with ‘EMERGENCY TREATMENT’ written in Block capitals in Red.
(vi) In case of malpractice, unethical practices or medical negligence by an empanelled Hospital or Nursing home particularly in management of emergencies necessary action will be taken by the Station Commander to dis-empanel the
Hospital or Nursing Home.
(vii) Hospital bills, once received at the Polyclinic along with necessary supporting documents, will be processed as per rates. Payment to the Empanelled Hospital will be made within 60 days of submission of claim.
(viii) Treatment of emergency will be provided by the empanelled hospital, irrespective of the fact whether the generalized/ specialized service required for treating the patient is covered under the Memorandum of Agreement (MOA) with ECHS. The bills in such cases will be cleared by ECHS, as per authorised rates, provided necessary emergency information has been given to the OIC Polyclinic in time, by the said Empanelled Hospital.
(ix) In cases where emergency admission information has not been received at the Polyclinic in time from an Empanelled Hospital, the patient would not be held responsible. Instead the hospital authorities will be made answerable and bills cleared /passed accordingly. OIC Polyclinics will ensure that under NO (R) NO circumstances the Empanelled Hospital will compel the ECHS member to pay for Emergency treatment. All cases where an ECHS member has been compelled by an Empanelled Hospital to make payment under duress, for emergency treatment taken therein, should be reported to the Stn HQ under intimation to concerned HQ Command, Regional Centre and this HQ. The matter should be investigated and resolved by the Stn HQ or referred to higher HQ if required. Disempanelment proceedings of the errant Empanelled Hospital may be considered, if warranted.
(b) Non-empanelled Hospital–
(i) Ex-servicemen or his representative should inform nearest Polyclinic within 48 hrs of such admission.
(ii) Thereafter the OIC will initiate an Emergency Information Report (EIR) after ascertaining the emergency.
(iii) The bills will be cleared by the patient.
(iv) He/She will submit the bills along with summary of the case to the concerned Polyclinic with in 30 days of his discharge from the hospital.
(v) Bills will be processed subsequently if the EIR is in order and reimbursement will be as per CGHS rates.
14. In cases where facilities for treatment are not available in Armed Forces hospitals and in certain special conditions, the procedure for referral and treatment will be as follows:-
(a) TB & Leprosy. No OPD charges will be reimbursable. TB and Leprosy will be treated through national programs at district level. However, when the patients require admission in such cases, rates of CGHS as applicable to LRS Institute of TB and Allied Disease will be applicable for hospitalisation.
(b) Hearing Aids. The equipment will be issued to the entitled patients based on the recommendations of ENT specialist after clinical and audiometric justification. The OIC Polyclinic, will procure the hearing aid in consultation with the SEMO, and issue to ESM. Replacement is permitted after minimum of 5 years life, based on a condemnation certificate and approval of ENT specialist. Digital hearing aid will only be given on recommendations of three ENT specialists, including at least one service specialist. Actual cost of hearing aid or CGHS rates, whichever is less, will apply.
(c) Mental Diseases. In all mental illness cases, the patient will be referred to service Psychiatrist/empanelled hospitals for OPD consultation. Drugs prescribed for the patient will be procured by the OIC Polyclinics/SEMO through special demand. Cases requiring hospital admission will be referred to authorised empanelled/Govt hospitals only. Provisions of Mental Health Act, 1987, as amended, will be applicable for all such hospital admissions. Payment will be made in full for admission to Govt hospitals and prescribed rates of CGHS will apply for empanelled hospitals.
(d) HIV AIDS. Ex-service pensioners boarded out of service due to AIDS will be provided treatment as prescribed by Armed Forces Centres for such treatment at the time of discharge. Treatment will be made available to such individuals with effect from two months after the date of discharge. Fresh cases of HIV/AIDS amongst members of ECHS, including dependents will be referred to the nearest Armed Forces Immuno-Deficiency Centres, and treatment as prescribed from these centres only will be made available.
(e) Artificial Limbs/Appliances. Artificial limbs/appliances will be reimbursed in full when procured and fitted at Artificial Lim Centre(ALC), Pune, and Artificial Limb Sub Centres in the AFMS hospitals. CGHS rates will apply in other cases treated in empanelled
(f) Rehabilitation/Terminal Care. Rehabilitation/terminal care will be provided in empanelled rehabilitative homes and hospitals. Patients, admitted to service hospitals or empanelled hospitals/nursing homes where the finality of treatment has been
reached and definitive medical treatment has run its course, will be referred to rehabilitative homes/hospitals for nursing care and rehabilitation. The conditions for which rehabilitative care will be admissible are paraplegia, quadriplegia, Alzheimer’s disease, cerebrovascular accidents, other neurological and degenerative disorders, amputations, cancer terminal care and other such medical conditions, when duly referred by treating specialists. Approval of SEMO/SMO/PMO will be obtained for these referrals. The payments for such cases will be regulated as under:
(i) Rates of payment for rehabilitation/terminal care cases will be limited to maximum rates permissible under CGHS for Special Nursing/Aya/Attendant charges PLUS charges for medical treatment as per CGHS rules. Where the rates of CGHS are not laid down, AIIMS charges or actuals which ever is less will be applicable. In case rates have not been defined by AIIMS, the actuals will be reimbursed. Rehabilitative care/terminal care does not include old age homes.
(ii) Reimbursement will be limited to maximum period of 6 months.
Thereafter cost of such care has to be borne by the patient.
(g) Medical Equipment for Residences. Medical equipment including nebulisers, CIPAP /BIPAP machines and glucometers etc., as authorised under the CGHS will be issued to members, on recommendations of the specialist, when use of such equipment is considered absolutely essential on medical grounds, on recommendations of the Specialist and approved by the Senior Advisor and Consultant of the concerned speciality, under whose jurisdiction the Polyclinic is located. The equipment will be procured through a special demand by the O ic Polyclinic. Consumables for the
equipment will be issued under arrangements of O ic Polyclinic. Cost on repair and annual maintenance contracts will be borne by the member themselves and will not be reimbursable.
(h) Medical Examination/Health Check Up/Screening Tests. The ECHS beneficiaries may undergo medical examination/health check up at the Polyclinic once a year. The medical examination/health check up will be limited to facilities available in the Polyclinic. Referrals to empanelled institutes for medical examination/health check up /screening tests are not permissible.
(j) Dental Treatment. Dental treatment including referral will be as per laid down procedures for other medical cases. Dentures will be permitted only if advised by Dental Officer at ECHS Polyclinic or service Dental Officer. A particular type of partial /complete denture will be permitted on one time basis only for each member/ dependent of the Scheme as per CGHS rates.
(k) Intra Ocular Lens. Intra Ocular lens(IOL) implantation will be provided to ECHS members at the nearest service eye center. Incase of IOL implantation undertaken at Civil hospitals, payment will be limited to prevailing CGHS rates. Type/make of IOL implanted will be specified in the bills by empanelled hospital.
(l) Spectacles. Spectacles will not be provided under ECHS, except post operatively in cases of conventional operation of cataract. Cost of spectacles in such cases will be limited to Rs.200/. Replacement of spectacles will be admissible once in three years
provided the same is under taken on the advice of the Medical officers of the Polyclinic or empanelled consultant.
(m) Plastic Surgery. Reimbursements and payments for plastic surgery will not be permissible under ECHS except for therapeutic reasons and in post traumatic cases on recommendations of SEMO/SMO/PMO. Provisions of CGHS and package deal rates/ceilings will apply.
15. Diagnostic Tests & Other Investigation Charges. Investigations/ laboratory diagnoses will be carried out at ECHS clinics in normal course. Referral for the tests, if required, will only be made by the Medical Officer ECHS/Specialist to empanelled Diagnostic Centres/ Hospitals/nursing Homes. The charges as approved by the CGHS for investigations will be valid for ECHS.
16. OPD Charges. Charges for drugs and other consumables for outpatient treatment are not reimbursable except under special conditions as listed in para 6 above. Medicines will be procured by the ECHS clinics and issued to the patients.
17. Travelling allowance. The following procedure will govern the movement of patient to referred clinics:-
(a) Travelling allowance for journeys undertaken for medical treatment (both ways) is admissible to ECHS beneficiaries for treatment in another city, if such treatment is not available in the same city and referral is advised by ECHS Medical Officer/Specialist.
Amount admissible will be limited to rail fare in entitled classes as applicable at the time of retirement, by shortest/main route or actual expenditure, which ever is less.
(b) One attendant or escort who is required to travel along with the patient will be entitled to travelling allowance if the Medical Officer attending the patient certifies in writing that it is unsafe for the patient to travel alone and such attendant escort is necessary to accompany the patient. Amount as admissible to the patient is reimbursable.
18. The claim for reimbursement of travelling expenses will be submitted to the Officer-in-charge Polyclinic with the following documents: –
(a) Application from ECHS members.
(b) Photocopy of Smart Card/ ECHS registration slip.
(c) Referral No. of the polyclinic.
(d) Name of place and hospital referred to.
(e) Contingent bill.
(f) Tickets of the patient and attendant (if applicable).
19. Ambulance-Ambulance services authorised in Polyclinic may be utilised for patients when being referred to service/empanelled hospitals in the same city.
Reimbursement of Medicine/Treatment
20. Free out-patient treatment will be provided to the members at Augmented Armed Forces Clinics and Armed Forces Polyclinics. Reimbursement will be provided to the patients or paid directly from where services are obtained from empanelled diagnostic centres/nursing homes/hospitals for the following:-
(a) Cost of medicines/drugs/consumables
(b) Diagnostic tests
21. In case of an emergency, the beneficiary may report to the nearest Government hospital or nursing home/private hospital empanelled under the Scheme. The bill for expenditure incurred in such cases or dire life threatening medical emergency would be fully reimbursed by the Government. In case of accidents and cases where time for rendering medical aid is crucial for life saving, an ex-servicemen may go to any nursing home/hospital. Ex-post facto sanction for reimbursement for such cases will be accorded by the Central Organisation, ECHS at Delhi. The term “re-imbursement” ceases to exist with the ECHS being put in place. No entitled ECHS membership card holder is required to pay any money for treatment/medicine at any ECHS/Polyclinic/MH or at an empanelled hospital/diagnostic center to which he/she has been referred to by the polyclinic. All bills for treatment/medicine will be cleared directly by the ECHS organisation. The only exception is where cheque of reimbursement will be made to an ESM for emergency treatment under taken in a non-empanelled hospital. When patients are admitted to non-empanelled hospitals in an emergency, the onus of clearing all bills will rest with the patient. For reimbursement, the ECHS member should submit claims for reimbursement to the Officer– in-charge Polyclinic. The bill will be super scribed with ‘EMERGENCY TREATMENT-NON EMPANELLED FACILITY’ written in block capitals in red and will include the following.
(a) Photocopy of Smart Card/ECHS registration slip.
(b) Emergency certificate from the hospital.
(c) Copy of admission and discharge slip.
(d) Summary of the case, including diagnosis and outcome.
(e) Bills in original including consultation charges/diagnostic/ operation /treatment charges as applicable.
(f) Other charges, if any, not included above(to be specified).
22. When an ECHS member is referred for treatment by the Polyclinic to institutes of national repute/Govt institutions, he/she should submit the claim for reimbursement along with original bills within a period of one month from discharge. All claims for settlement of bills will include the following:-
(a) Application for medical claim.
(b) Medical advance drawn, if any, and amount drawn.
(c) Certificate for drugs and consumables utilized in hospitalisation and paid by the ECHS member.
(d) Original bills verified and stamped by ECHS Polyclinic.
(e) Photocopy of ECHS Smart Card.
(f) Discharge slip of hospital.
(g) Summary of case from treating hospital.
(h) Legal heir certificate in case of death of Smart Card holder, along with Death Certificate.
(j) In case of emergency admissions, the Polyclinic has to be informed within 48 hours by the ECHS member or his representative.
Issue of Medicines From ECHS Polyclinic
23. PVMS & NIV medicines will be issued from the ECHS Polyclinics up to a maximum of 90 days, for chronic ailments of Hypertension, IHD, Diabetes mellitus, Tuberculosis, epileptic disorders or any other chronic disease deemed fit by SEMO, subject to following conditions :-
(a) The medicines should have been prescribed by the concerned specialist for the required duration.
(b) The patient should NOT be required to be reviewed during the period of prescription.
24. Issue of medicines up to 90 days will be permitted from ECHS Polyclinics ONLY and not from Service Hospitals. Issue of medicines from Service Hospitals will be restricted to a max of 30 days only as per current practice in the Armed Forces.
25. In case certain medicines prescribed by the MO/ Specialist are not available in the first instance from the Polyclinic dispensary, the same can be issued to rep of member on a subsequent day. It will not be mandatory for the patient himself to come once again in person, just to collect medicines marked ‘NA’ from the Polyclinic at an earlier date. rep of the ECHS member, can come and collect the medicines marked ‘NA’ in an earlier prescription, provided he is in possession of the original prescription and the member’s Smart card as an authority.
26. However when a fresh prescription is required to be generated, the patient needs to be physically present at the Polyclinic for examination and review by the MO each time.
Issue of Hearing Aids prescribed for ECHS Members
27. Procedure for issue of hearing aids prescribed for ECHS members is as follows:-
(a) Recommendations for Hearing Aids will be acceptable ONLY from a Service ENT Specialist.
(b) In case of ‘Digital Hearing Aid’ recommendations of 02 (two) Service ENT specialists are required prior to endorsement of recommendations of Sr Adviseer/Addl Adviser (ENT).
(c) All cases to be forwarded to Senior Adviser (ENT)/Addl Adviser (ENT) for recommendations. In case of non availability of Senior Adviser / Addl Adviser (ENT) locally in the station, documents will be forwarded to concerned Senior Adviser of the zone for recommendations and return. If the Senior Adviser / Addl Adviser desires to examine the patient, the same will be communicated to the ECHS member for compliance under own arrangements.
(d) Detailed case notes will be forwarded to Senior Adviser (ENT) including audiometry report. Audiometry to be conducted by Service ENT Specialist.
(e) All case documents after endorsement by Sr Adviser (ENT) will be forwarded to Central Organisation ECHS for approval and return to Polyclinic.
(f) ‘Authorisation for Hearing Aid’ will be issued by OIC Polyclinic only after receipt of approval from Central Organisation ECHS. Dental Treatment
28. Procedure to be followed for dental treatment under ECHS as follows:-
(a) Dental treatment available through ECHS will be limited to procedures listed below:-
(b) Prosthodontic clinical work (with the exception of procedures listed at para 3(c) below) will be carried out at ECHS Polyclinics only. However, laboratory work will be outsourced to Empanelled Dental Laboratories by O I/C ECHS clinic. In the event of non-availability of Dental officer at Polyclinic, patients may be referred to Service Dental facilities for Prosthodontic work. Such referral will be ON APPOINTMENT ONLY and subject to availability of facilities in the concerned Dental Centres.
(c) The following prosthodontic procedures including clinical work, may be outsourced to Empanelled facilities if not available at Polyclinic :-
(i) Fixed Partial Denture
(ii) Acrylic Denture One Jaw Rates payable inclusive of Lab
(iii) Acrylic Denture Both Jaw charges are as follows:-
(d) Orthodontic treatment is NOT entitled for ECHS beneficiaries.
(e) DGLP funds will be allotted to Service Dental facilities for procurement of consumables required to treat ECHS beneficiaries. Allotment will be made on recommendations of DGDS.
29. Referral to Service Dental Centres: Referrals to Service Dental Centre will only be made on prior appointment and provided the required facilities are available. Appointment will be arranged by the O I/C ECHS clinic. The appointment for treatment will be the prerogative of the OC, Service Dental Centre as it is his liability also to treat Serving personnel and their families. Decision of OsC Service Dental Centres will be final in this regard.
30. Referral to Empanelled Dental Clinics: Referrals for Specialised Dental Services will only be made after the facilities in the ECHS Polyclinics utilized fully. The conditions for which referral can be made are listed at para 6 above When a referral is made, the Dental officer making the referral will clearly state the diagnosis and the procedures/treatment required on the Referral Form. Referrals for lab work will be made to facilities specifically
empanelled for laboratory work.
31. Rates of Dental Treatment: The approved rates as listed in para 28 above will be applicable for signing of the MOA with Dental Facilities approved for empanelment vides MOD/GOI letters issued from time to time.
32. Procedures NOT included the following dental procedures are NOT included in ECHS and will NOT be made available from Polyclinic/Service Dental Centres/Empanelled facilities
(a) Orthodontic treatment.
(b) All cosmetic rehabilitation including Dental Implants and related/subsequent prosthetic work.
(c) Removable metal (cast) Partial Dentures.
Treatment for Senior Citizens
33. All members of ECHS are retd members and very soon will become senior citizens. However at the same time, some old and sick people need to be given priority at ECHS Polyclinics. The senior citizens will be attended out of turn at reception, examination by doctors and issue of medicines.
34. The following will be treated as Senior Citizens:-
(a) Males -75 Yrs & above
(b) Females -70 Yrs & above
Medical Care for ECHS Beneficiaries in Remote/Hilly Areas
35. To mitigate the difficulties being faced by ECHS beneficiaries residing in remote/hilly areas in getting referrals even for minor ailments from their nearest polyclinics due to distance/terrain, they have been permitted to avail the facilities/services of nearest Govt Health Care Centres /Primary Health Centre/ Govt Hospitals (deemed empanelled) without prior referral from the polyclinic subject to the following conditions :-
(a) Distance from nearest polyclinic should be more than 50 Kms.
(b) Applicable for residents of following states only :-
(i) Jammu & Kashmir.
(ii) Himachal Pradesh.
(iv) North Eastern States of Sikkim, Arunachal Pradesh, Mizoram, Manipur, Tripura and Nagaland.
(v) West Bengal : District Darjiling only.
(vi) Karnataka : District – Chikmagalur, Kodagu only.
(vii) Tamilnadu : District – Nilgris only.
(vii) Chhattisgarh : District – Bastar and Dantewara only.
(viii) Orissa : District – Koraput only.
(c) Treatment permitted for maximum period of 07 days.
36. Parent Polyclinic will be notified of such treatment undertaken at the earliest (within two working days). Info can be sent by person/telephone/mail/fax/telegram. Parent polyclinic will generate a referral immediately on receipt of information and attach the same with the claim when received. Claims for reimbursement of expenditure incurred should be
submitted to Parent Polyclinic within one month of completion of treatment. The claim will include the following:-
(a) Application of claim by the member. Summary of case including diagnosis and outcome/ further advise by treating doctor/hospital to be enclosed.
(b) Photocopy of ECHS Smart Card/Regn Slip.
(c) Prescription/Clinical notes of treating doctor.
(d) Bills of medicines/investigation/treatment procedure in original duly authenticated by treating doctor/hospital, along with a photocopy. In cases of treatment in Govt Hospitals, consultation is normally free. Bills, therefore, would pertain to medicines and
treatment /investigation charges only, as applicable.
37. In cases of Emergency, patients can get admitted to any hospital. Emergency bills will continue to be processed as per existing instructions. Similarly in cases where further treatment is advised by local Govt Hosp, and/or major treatment procedure is required, patient will be referred to suitable Service/Empanelled Hospital through Parent Polyclinic as per existing procedure.
Follow-Up Treatment Of ECHS Beneficiaries in Empanelled Hospital
38. ECHS beneficiaries will be eligible for follow up treatment by the same consultant/ specialist or in the same empanelled institution where the treatment was earlier carried out in respect of following cases:-
(a) Cardiac Surgery/Interventional Cardiology (including coronary angioplasty and other invasive cardiac procedures).
(b) Cancer Surgery/ Chemotherapy/ Radiotherapy.
(d) Neurology/ Neuro Surgery.
(e) Joint Replacement Surgeries.
(f) Organ Transplantation.
39. Such follow-up treatment/review will be subject to following conditions: –
(a) The Initial Treatment/Surgery should have been carried out in an Empanelled Hospital /Institute of National Repute/Govt Hospital on a valid referral from ECHS Polyclinic.
(b) The re-imbursement of expenditure for Consultation/Treatment including hospitalisation if required/ Investigations will be limited to rates as per MOA with Empanelled Hospital.
(c) In case there is no approved ECHS/CGHS rates for any procedure, or test, re-imbursement will be made as per AIIMS. In case AIIMS rates are not available, payment will be as per actuals charged.
(d) The review consultation from the same specialist will only be permitted if the specialist continues to be employed in an ECHS Empanelled Hospital.
(e) In case, a super specialist has recommended review after a specific gap at the time of discharge from hospital, the patient can be directly referred for needful consultation to the same empanelled Hospital, and need not be routed through Service Hospital.
(f) The beneficiary will be issued with the medicines as prescribed by the Specialist/ Consultant from the parent Polyclinic.
40. Follow-up treatment will be granted by the OIC Polyclinic for maximum period of 6 Months after discharge. This period from initial hospitalisation, may be extended if required, on the basis of medical record and individual merits of case, on recommendation of SEMO. OIC Polyclinics may initiate a one time referral mentioning the periodicity of review and the validity of the referral form for undertaking the follow-up treatment from the particular Empanelled Hospital. ‘One Month’ validity of referral form is not applicable in such cases.
ECHS Membership For Re-Employed Officers
41. The following fresh guidelines will apply in case of re-employed officers, both pre and post 01 Apr 03 retries:-
(a) Re-employed Officer can become ECHS member.
(b) All members will submit an undertaking as hithertofore.
(c) On re-employment an ECHS member will be treated as any other serving personnel. He will exercise option for availing medical facilities by his dependents only. An individual can choose any one medical facility for self and the other for dependents. Certificate of choice duly countersigned by the Station commander at place of posting will be forwarded to Central Organisation ECHS, concerned Regional Centre and parent polyclinic. It will be the responsibility of ECHS members to inform all concerned about his choice.
(d) An individual can change his choice on posting under intimation to concerned Regional centre, Station HQs and parent polyclinic.
(e) The ECHS membership cards of re-employed personnel will not be kept in suspended animation in case the choice for dependents is for ECHS.