ANDHRA PRAGATHI GRAMEENA BANK (Sponsored by Syndicate …apgb.in/files/1_2_509364e82afd4.pdf · Kolkata, Ahmedabad, Bangalore & Hyderabad Other Places Rs. per visit Rs. per visit

ANDHRA PRAGATHI GRAMEENA BANK (Sponsored by Syndicate Bank)

HEAD OFFICE : KADAPA

Circular No.28–2007-BC-STF Date:26.2.2007

GUIDELINES FOR REIMBURSEMENT OF HOSPITALISATION EXPENSES TO OFFICERS AND CLERICAL & SUB-STAFF (WORKMEN)

Attention of all Branches/Offices/Officers/Employees is invited to Circular

No.92-2006-BC-STF dated 30.09.2006 wherein it is stated that the detailed guidelines for reimbursement of hospitalization expenses to Officers/workmen employees will be circulated in due course. Accordingly the guidelines for reimbursement of

Hospitalisation expenses are given as below.

REIMBURSEMENT OF HOSPITALISATION EXPENSES TO WORKMEN EMPLOYEES

The reimbursement of hospitalisation expenses will be restricted to the following charges:

Sr.No. Details Extent of reimbursement

1 (a) Hospital Registration Fees 100% for self and 75% for dependent family members of the amount actually

incurred or Rs.200/- whichever is lower.

(b) Surcharge/tax on hospital

bills

Proportionate to the extent of the bill

passed by the bank

2 Charges for bed per day (excluding boarding charges)

100% for self and 75% for dependent family members of the amount actually

incurred or Rs.400/- whichever is lower.

3 ICU/CCU/Neo-natal Nursery 100% for self and 75% for dependent family members of the amount actually incurred or Rs.500/- per day, whichever is

lower. This is in addition to bed charges.

4 Diagnostic material charges, X-rays, Pathological tests,

ECGs, etc.

As per Annexure-I hereto

5 Medicines, drugs, injections

(including disposable syringes), bandage and dressing materials, etc.

(except tonics/vitamins)

100% or 75% as the case may be of actual

expenses (except tonics/vitamins)

Circular No.28-2007-BC-STF dated 26.02.2007

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6. OPERATION CHARGES

Particulars

100% for self and 75% for dependent family

members of the amount actually incurred or the amount as mentioned below against each item, whichever is lower.

Rs. Rs. Rs

Special Operation Major

Operation

Minor

Operation

(a) Operation Theatre Charges 3,000/- 2,000/- 650/-

(b) Anaesthetist‟s Charges 3,000/- 2,000/- 650/-

(c) Surgeon‟s Fees for Operation

(including Fees for Assistants)

10,000/- 6,500/- 2,100/-

(d) Expenses of maximum Rs.5000/- limit for dialysis, blood transfusion, Cataract

operation with IOL implantation, Phaco emulsification with foldable lense, Heart valve replacement, angiography, implanted items during surgery wherever they do not form

part of package charges and pace-maker may be reimbursed at the rate of 75% for family members and 100% for workman himself at rates not exceeding the rates applicable to lowest paying bed of AIIMS, New Delhi.

Indicative list of Special, Major and Minor operations is appended below:

Special Operations: (time taken is more than 3 hours)

1. Cardiac including By-Pass Surgery 2. Brain, Lung and Cancer Operations

3. Kidney/Liver Transplantation Operation

4. Bone Marrow transplant and 5. Multiple Fractures

Major Operations :(Time taken approximately 1 to 3 hours)

1. Kidney Stone (including lithotripsy) 2. Prostate 3. Thyroid

4. Caesarean Delivery 5. Gastrectomy 6. Hysterectomy

7. Fractures 8. Amputations

9. S.P.Nailing 10. Discoidectomy 11. Retina Detachment

12. Liver & Gall Bladder 13. Plastic Surgery (not r beautification) 14. Cataract (with IOL) and

15. Hernia subject to Bank‟s discretion

Minor Operations

(Time taken approximately 60 minutes or less):

1. D & C, Fissure

2. Circumcision 3. Hydrocele 4. Dilatation

5. Vasectomy

6. Abscess

7. Bilateral Hydrocele 8. Appendix 9. Tubectomy

10. Piles

11. Fistula 12. Minor Operations of the Eye, Nose and Ear.

Note:- Operative interference done using state-of-the-art medical techniques

taking less than the time indicated as above will not alter the nature of the operations.


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7. Physician‟s and Consultant‟s fees per visit:

100% for self and 75% for dependent family members of the amount actually

incurred or the amount as mentioned below against each item, whichever is lower

Major „A‟ Class cities viz.

Mumbai, Chennai, Delhi, Kolkata, Ahmedabad, Bangalore & Hyderabad

Other Places

Rs. per visit Rs. per visit

VISIT AT THE CHAMBER

First Consultation 200/- 120/-

Subsequent Consultations 75/- 60/-

VISIT AT RESIDENCE

In case of emergency leading to Hospitalisation

300/- 190/-

Second Consultation 225/- 150/-

Subsequent Consultations 150/- 100/-

VISIT MADE BY SPECIALISTS AT THE HOSPITAL:- SPECIAL VISIT

During the day time 125/- 85/-

During the night time 300/- 150/-

Routine visits 125/- 85/-

Schedule for reimbursement of charges incurred by workmen for pathological etc.

investigations is given in Annexure-I.

REIMBURSEMENT OF HOSPITALISATION EXPENSES TO OFFICER EMPLOYEES

1. Bed Charges: Self – Rs.600/- per day. Family – Rs.450/- per day.

2. Other Charges: at the Scale of 125% of the limits laid down under the Hospitalisation Scheme applicable to workmen employees in the Bank or actual expenditure incurred whichever is less.


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REIMBURSEMENTOF HOSPITALISATION EXPENSES – GENERAL GUIDELINES

Hospitalisation expenses will be reimbursed to employees in the bank to the extent of

100 per cent in case of self and 75 per cent in case of dependent members of family subject to the procedure for reimbursement of hospitalisation expenses as enumerated hereunder:

1. Hospitalisation charges are reimbursed in case of all ailments and major accidents which require hospitalization only to the extent of what the employee have

incurred had the patient been admitted in the eligible hospital for the treatment and as per the rates and guidelines provided herein for.

2. The eligible hospital means a Govt./Municipal Hospital (or) any „private‟ hospital i.e. Hospital under the management of Trust, Charitable Institution, Religious Mission.

3. Hospitalisation charges incurred will be reimbursed on the strength of original bills, vouchers, certificates, receipts to the extent of 100% in case of self and

75% in case of family members subject to the limits, rates, prescribed as per annexures hereunder.

4. Hospitalisation charges incurred as out patient treatment without hospitalization are not eligible for reimbursement. Further the cases which do not require any

hospitalization in the opinion of the Bank Panel Doctor are liable for rejection.

The staff member or his dependent family member/s, who attend hospitals undergoing elaborate testings and incurring huge expenditure with one day admission being shown will not be considered if all the tests done are within

normal limits/Negative. Such claims will be treated as general out-patient checkup and the claim will be disallowed.

5. The Staff member or his dependent family member(s) will be considered to have been hospitalized only if they are admitted as indoor patient(s) in the hospital in respect of diseases/accidents as mentioned above. However, cases where the patient is

admitted as on out-patient and discharged the same day after surgical procedures involving advanced techniques may also be considered for reimbursement of hospitalization expenses.

6. The expression „family‟ of an employee for the purpose of medical facilities shall

mean the employee‟s spouse, wholly dependent children including dependent step children and legally adopted children and parents wholly dependent on the employee and ordinarily residing with the employee.

7. The term „wholly dependent child/parent‟ shall mean such relative having a monthly income not exceeding Rs.2,550/- p.m. If the income of one of the

parents exceeds Rs. 2,550/- p.m. or the aggregate income of both the parents exceeds Rs.2,550/- p.m., both the parents shall not be considered as wholly dependent on the employee.


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8. A married female employee may include her natural parents or parents-in-law under the definition of family - but not both – provided that the parents/parents-in-law

are ordinarily residing with and wholly dependent on her and satisfy the income criteria as stated above.

9. The employee or members of their families (as the case may be) are expected to secure admission in a Government/Municipal Hospital or any „private‟ hospital

(i.e., hospitals under the management of a Trust, Charitable Institution or a religious mission). The reimbursement will be restricted to the percentage applicable to the employee / dependent family member, i.e. 100% or 75% of the charges applicable

to the lowest paying bed in such hospitals according to hospital rules or the maximum amounts mentioned above, whichever is lower.

10. Normally, the employee and members of family should avail of services of hospital as mentioned as above. However, if he feels, that it is unavoidable to seek

services of a private nursing home/hospital, he can do so in one of the hospitals/nursing homes, approved by the bank. Reimbursement in such cases will, however, be restricted to the extent of the amount which would have been

reimbursable in case of admission to a public or private hospital as mentioned above.

11. Medical expenses incurred within 30 days of „pre‟ and post-hospitalisation period on medical advice, on account of the ailment/disease for which the person was hospitalised, will be considered as hospitalisation expenses for reimbursement purpose.

However, in cases of hospitalisation involving special or major operations, medical expenses incurred for a period not exceeding 45 days of post-hospitalisation will be considered for reimbursement, subject to medical advice. [

12. The tonics/Iron, B.Complex preparations and other vitamins will not be reimbursed.

13. Charges for engaging a nurse/attendant will not be reimbursed. However, nursing charges, if any, charged by hospital authorities in respect of days spent in

ICU / CCU/ neo-natal nursery may be considered for reimbursement on the basis of certificate issued by the hospital authorities and in consultation with bank‟s

Medical Officer. Reimbursement in such cases shall be 100% for employee and 75% for family members of the actual charges.

14. Hospitalisation charges in connection with maternity will not be reimbursable. However, the expenditure incurred by an employee in cases involving operative interference because of complicated labour and caesarean operation and

subsequent hospitalisation thereto will be reimbursed under the hospitalisation scheme to the extent of expenditure incurred in excess of normal maternity charges and consequent hospitalisation thereto subject to the condition that such

reimbursement shall be 70% of the amount actually incurred or the limits prescribed, whichever is less.

15. The purchase of drugs/medicines will be restricted to approved chemists and arrangements will be made by bank wherever possible to make direct payments to the

chemists.


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16. Bank will have discretion to refuse payment of bills in cases where they are not satisfied about the genuineness of the bills.

17. Ambulance charges for removing the employee or his dependent family member from residence to the hospital/nursing home or from hospital/nursing home to residence on discharge or from one hospital/nursing home to another hospital/nursing

home, within the urban agglomeration or municipal limits may be reimbursed in full subject to the production of proof of receiving/sending the patient by Ambulance with Vehicle No. and amount paid as per the Certificate issued by

the attending/attended Doctor/hospital.

Actual expenses incurred on conveyance by mode other than ambulance shall be reimbursed subject to the maximum as under:

(i) By public taxi - Actuals subject to maximum of Rs.150/- per trip

(ii) By autorickshaw - Actuals subject to maximum of Rs.75/- per trip

In case the patient is to be moved to a hospital/nursing home outside the urban agglomeration/municipal limits, then the expenses incurred on conveyance may be

reimbursed at the rate of Rs.5.00 per kilometer, with a maximum of Rs.1000/- per trip or the amount actually incurred, whichever is the least.

Normally, services of an ambulance should be availed of Where ambulance is not

available or the facility of ambulance is not established, public mode of transport i.e. taxi/autorickshaw could be used. The bank shall consider such claims on merits and facts.

Abuse of the facility will be dealt with treating such claims as acts of gross misconduct.

18. The medical aid and reimbursement of expenses under the hospitalisation scheme

will also be available for medical treatment under the recognised systems of medicines, viz., Ayurvedic, Unani, Homeopathy and Naturopathy if such

treatment is taken in a clinic/hospital recognised by the Central/State Government. Further, reimbursement shall be limited to such expenses within the prescribed ceilings as would have been reimbursable in case the treatment was taken in

a Government/Municipal hospital, subject to the overall limits under the scheme, i.e., 100% of approved expenses for self and 75% in case of family.

19. Package Charges :

Some hospitals are charging on the basis of „package‟ for specialised treatment for

diseases pertaining to heart, kidney, coronary, etc. These package charges generally include all charges pertaining to a particular treatment/procedure including admission charges, accommodation charges, ICU/ICCU charges, monitoring

charges, operation charges, anesthesia charges, operation theater charges, procedural charges/ Surgeon‟s fee, cost of disposables, cost of consumables like catheters, guide wires, etc., surgical charges and cost of medicine used during hospitalisation, related

routine investigations, physiotherapy charges etc.


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-7- In the following cases, package charges will be reimbursed to the extent of 100% in the case of self and 75% in the case of dependent members of family, subject to the limits

specified below:-

(a) Coronary Bypass Surgery Rs.1,40,000/-

(b) Coronary Angiography Rs. 15,000/- (c) Angioplasty/Stentoplasty Rs. 70,000/- (d) Kidney Transplant Rs.1,60,000/-

(e) Liver Transplant Rs.2,00,000/-

1. For the above ailments, employees can claim either as per schedule of expenses

prescribed or package charges whenever the treatment is taken under package charges scheme.

2. In the case of stentoplasty, cost of medicated stents(s), wires/balloon, implanted during surgery may be reimbursed at the rate of 75% for family members and 100% for workman himself at rates not exceeding the rates applicable to

lowest paying bed of AIIMS, New Delhi, in addition to the package charges indicated above.

3. Liver transplant charges are not reimbursable in cases where damage to the

liver has been caused by alcoholism.

20. Domiciliary Treatment

Medical Expenses incurred in respect of the following diseases which need domiciliary treatment as may be certified by the recognised hospital authorities and bank‟s medical officer shall be deemed as hospitalisation expenses and reimbursed to the extent of

100% in case of a workman and 75% in the case of his family.

1.Cancer 2.Leukaemia 3.Thalassemia 4.Ulcerative Colitis

5.Tuberculosis 6.Paralysis 7.Cardiac Ailment 8.Epidermolysis

9.Pleuresy 10.Leprosy 11.Kidney ailment 12.Bullosa

13.Epilepsy 14.Parkinson‟s Disease

15.Psychiatric disorder

16.Venous Thrombosis (not caused by smoking)

17.Diabetes/Hyper Tension (BP)

18.Hepatitis-B 19.Hepatitis-C 20.Aplastic Anaemia

21.Haemophilla 22.Myasthenlagravis 23.Wilson‟s disease 24.Psoriasis &

25.Third Degree Burns

Note:-

1. The cost of medicines “alone will be reimbursed” in respect of domiciliary

treatment for the period stated in the Specialist‟s prescription. If no period is stated, the prescription for the purpose of reimbursement shall be valid for a period not exceeding 90 days.

2. Expenses incurred on radiotherapy and chemotherapy in the treatment of cancer and leukaemia shall be considered for reimbursement under domiciliary treatment to

the extent of 100% in case of a workman and 75% in the case of his family.


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The Government/Municipal Hospital, Hospital under the Management of Trust, Charitable Institution or Religious Mission are treated as Recognised Hospitals which

can certify the need for Domiciliary treatment to the above referred diseases/ailments. Staff members concerned can claim reimbursement of Medical expenses towards Domiciliary treatment by submitting a certificate issued by the specialist

treatment doctor of these hospitals in the proforma given in Annexure-IV along with the Hospitalisation claim in the proforma given in Annexure III. In case, the staff member takes treatment in private hospital / nursing home for the above referred

diseases/ailments, the certificate given by said hospital / nursing home (as per proforma given in Annexure-IV) should be counter signed; recommending/certifying the need for domiciliary treatment by specialist doctor from Government/Municipal hospital

other than doctor working in PHC (if he is not specialist).

In addition to the above, the staff members concerned shall also fulfill the following

requirements for settling domiciliary treatment claims:

1. The initial hospitalisation in Govt. Hospital / Nursing home / clinic in which the diagnosis of the ailment / disease eligible for domiciliary treatment first detected

is compulsory. The domiciliary certificate from a doctor/hospital/nursing home is not acceptable, without any reasonable treatment/hospitalization after the diagnosis of the specific disease/ailment. However in the case of diabetes

hospitalization is not compulsory.

2. The certificate in the proforma given in Annexure IV should be given by

specialist doctor related to disease/ailment concerned certifying the need for domiciliary treatment by clearly mentioning the period of treatment on domiciliary basis

and medicines prescribed. If the period stated in the specialist‟s certificate is more than one year, the bank shall consider domicilary claim for maximum period of one year only as bank panel doctor suggested to consider domicilary treatment claims by referring to

treatment doctor i.e. specialist doctor for at least every one year stating that same medicines can not be continued beyond one year without review of treatment doctor i.e. specialist doctor. In other words concerned staff shall submit the specialist

certificate for domicilary treatment for every one year.

3. In case the specialist certificate is given by a specialist not working in

Govt./Municipal hospital, the same shall be countersigned by a specialist doctor working in a Govt./Municipal hospital. The certificate / counter certificate given by a Government doctor working in a PHC will not be considered for domicilary

treatment unless he is specialist doctor of the disease.

4. The claim for medicine expenditure under Domiciliary treatment for the certified

period shall be claimed after consumption only in periodical intervals and not in advance. The claims made in advance will be settled at Pro rata as per dosage of medicine prescribed per day, up to the date of claim.

21. Reimbursement of Hospitalisation Expenses incurred on Treatment Abroad.

The procedure to be followed in respect of reimbursement of expenses incurred by the workmen and their families on treatment abroad shall be as laid down in Annexure-III hereto.


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-9- 22. Submission of Hospitalisation Claims.

It is observed that most of Hospitalisation claims are not received in full shape and there by the sanctions are getting delayed. All papers, bills, certificates, reports shall be submitted in original only. Photo copies/Xerox copies are not

acceptable and will be rejected/returned.

In order to avoid delay and to facilitate speedy disposal, Staff members concerned shall submit their Hospitalisation claims in the proforma given in Annexure-III duly filled in all respects along with the details of Cash Bills/ Certificates/ Reports/

Papers submitted such as the hospitalisation Certificate/discharge summary showing date of admission, date of discharge, number of days hospitalised/period of hospitalisation, type of bed allotted etc. The hospitalization certificate should be given

on letterhead of the Hospital/shall contain seal of the Hospital and should be signed by the specialist doctor pertaining to the disease, showing details of diagnosis, ailment, operation (special/major/minor operation), treatment and period of treatment. The

said certificate should be duly signed and be given on letter head of Doctor/Hospital and should contain i) Name of the Doctor ii) Regd.No., iii) name of the Hospital and seal etc. All Test Reports/Investigation Reports, „X‟ Rays, ECGs etc, shall be submitted

in originals and to be listed in Annexure III i.e. claim by the staff member concerned.

To understand clearly the requirement in case of tests, the requirement to sanction the expenditure for X-Ray test is given as under.

1. Prescription of the Specialist doctor to undergo particular X-Ray test.

2. Carbon or X-Ray photo 3. Analysis/written report of the X-Ray 4. Cash Bill paid.

Like wise for speedy disposal staff concerned shall submit the following requirements in case of medicines and other charges for which reimbursement is claimed.

1. The Prescriptions in original from Doctor is compulsory to accept the medicines/drugs bills. If prescription is not available all medicine and drug bills shall be

signed/attested by the Doctor. 2. Duly signed Medical Bills (originals). The same should be listed in Annexure III i.e.,

Claim by the staff member concerned. 3. Hospitalisation expenses certificate showing registration fee, consultation fee, bed

charges, surgeon charges, medicines, other charges etc,.

All papers are to be sorted out and stitched in the order given in the statement of

hospitalisation expenses (Annexure III) to facilitate the HO to process the claims quickly. The Hospitalisation claims shall be submitted to Head Office within 2 months from the date of discharge or date of rejoining of duties whichever is later. Otherwise

the claims are summarily rejected if the reasons for the late submission are not satisfactory.


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-10- The above guidelines shall come into force with effect from 1.10.2006. Hence those hospitalisation claims where the date of admission of staff member/dependent

into the hospital is on or after 1.10.2006 are only eligible under these guidelines.

This circular shall be circulated among all the staff working at branches/Offices against

their acknowledgement. Clarification, if any, on this circular may be sought from the Personnel Department,

Head Office, Kadapa.

(M.OBULESU) CHAIRMAN

Enclosures:

Annexure – I - Schedule for reimbursement of charges incurred by workmen for pathological etc., investigations.

Annexure – II -Scheme of reimbursement of expenses incurred by the workmen for treatment abroad.

Annexure –III- Claim for reimbursement of medical/ hospitalisation expenses

incurred under hospitalisation scheme Annexure – IV –Certificate for Treatment on domiciliary basis.

Annexure- I to Circular No.28–2007-BC-STF dated 26.02.2007

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SCHEDULE FOR REIMBURSEMENT OF CHARGES INCURRED BY WORKMEN FOR PATHOLOGICAL ETC. INVESTIGATIONS

Sl. No.

NAME OF PROCEDURE

100% for self and 75% for dependent family members of

the amount actually incurred or the amount as mentioned below against each item,

whichever is lower (Rupees) 1. CLINICAL PATHOLOGY

EXAMINATION OF URINE

1 Urine Routine 40

2 Urine for Albumin 20

3 Urine for 17 Ketosteroids 360

4 Urine Culture 115

5 Urine for Column Count Test 115

6 Sensitivity Test 150

7 Urine for Acid Fast Bacilli (T B Culture) 105

8 Urine Bile Pigment and Salt 40

9 Urine Urobilinogen 40

10 Urine Occult Blood 40

11 Urine Total Proteins 80

12 Urine Sodium 80

13 Urine Chloride 80

14 Bence Jones Protein 50

EXAMINATION OF STOOL

15 Stool Routine 40

16 Stool Occult Blood 40

2. HAEMATOLOGY

EXAMINATION OF BLOOD 17 Blood Count with Indices (Hb, TLC, DLC) 70

18 Blood Count without Indices (Hb, TLC, DLC) 65

19 RBC and Hb with Indices 70

20 RBC and Hb without Indices 55

21 Total WBC and Differential Count (TC/DC) 55

22 Blood Smears for parasites (MP, etc.) 40

23 Peripheral smear examination 45

24 Blood for Microfilaria 100

25 Platelet Count 70

26 Bleeding and Coagulation time (BT CT) 65

27 Clot Retraction Time 65

28 Prothrombin Time 75

29 Erythrocytes Sedimentation Rate

(Westergren‟s method) 30

30 Sedimentation Rate (Both Methods) ESR 30


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31 Hb, TLC,DLC, ESR 85

32 Blood Culture 160

33 Clot Culture 160

34 Glucose Phosphate Dehydrogenase (G&PD) 150

35 Reticulocyte Count 45

36 Absolute Eosinophil Count 40

37 Packed Cell Volume (PCV) 40

38 R.B.C. Fragility Test 70

39 L.E. Cell 95

40 Haemogram 85

41 Bone Marrow Smear Examination 205

42 Partial Thromboplastin 135

3. BLOOD BANK

43 Coomb‟s Test direct (for coating antibodies) 150

44 Coomb‟s Test (for complete and incomplete indirect antibodies)

200

45 Blood Grouping and Rh Factor only (not for matching) for Non-maternity Cases

65

46 Blood Transfusion per Bottle and Donor‟s fees (including Pathologist‟s attendance and cross-matching)

360

47 Packed Cell Preparation 255

4. BIOCHEMISTRY

48 Blood Urea/Calcium/Phosphorus/Phosphatase/ Sodium/Potassium/FBS/PPBS/Serum Bilirubin

100

49 Blood Urea Nitrogen 100

50 Urea Clearance Test 170

51 Creatinine Clearance Test 170

52 Serum Proteins or Plasma Proteins 100

53 Serum Proteins Electrophoresis 200

54 Blood for Fibrinogen 110

55 Blood for Creatinine 75

56 Blood Uric Acid 100

57 Blood Sugar Curve (Glucose Tolerance Test) GTC or GTT

280

58 CO2 Combining Power of Plasma 130

59 Blood Cholesterol, HDL/LDL/VLDL/STG/ total cholesterol

475

60 Blood Protein Bound Iodine (PBI) 300

61 Blood Chlorides (S Cl) 100

62 Serum Sodium (S Na) 85

63 Serum Potassium (S K) 85

64 Serum Iron (S Fe) 130

65 Serum Iron Studies 220

66 Serum Calcium (S Ca) 85

67 Serum Phosphorous (S.P.) 85


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68 Serum Alkaline Phosphatase 75

69 Serum Acid Phosphatase 135

70 Serum Glutamic Oxalic Transaminase (SG OT) 75

71 Serum Lipase 130

72 Serum Glutamic Pyruvic Transaminase (SG PT) 75

73 Serum Anylase 195

74 C P K 315

75 Glucose 6 Phosphate Dehydrogenase 170

76 Serum Lactic Dehydrogenase(LDH) 145

77 Serum Lactic Dehydrogenase with Isoenzyme 375

78 SMA 12-2 (14 Blood Chemistry) 625

5. HISTOPATHOLOGY

79 Smear Analysis 60

80 Body Fluids-C.S.F. analysis 170

81 Plural/Ascitic fluids, protein/sugar/cell count etc., 170

82 Malignant Cells 135

6. BACTERIOLOGY & SEROLOGY

83 Brucella Agglutination Test* 130

84 Cold Agglutination Test for Virus Pneumonia 130

85 Paul Bunnel Test 150

86 C Reactive Proteins** 135

87 Smear Gram-Strain Examination 50

88 Sputum Smear A.F.B. Stain 50

89 V.D.R.L. 75

90 Widal Test 75

91 R.A.Test 100

92 Culture & Sensitivity (other specimens) 150

93 Vibro Cholera Culture 130

94 Conjunctival Swab for Microscopic and Culture

Examination 140

95 Smear Examination for Micro Organisms 95

96 Fluids or Exudates for Malignant Cells 140 * For hospitalised patients only ** For Rheumatic disease to be reimbursed for hospitalised patient

7. X-RAY

97 Fluroscopy Chest 120

98 Abdomen AP Erect (One Film) 135

99 Abdomen Lateral View (One Film) 135

100 Abdomen for Pregnancy 135

101 Chest PA View (One Film) 135

102 Chest Oblique or Lateral (One Film) 135

103 Mastoids 135

104 Extremities, Bones and Joints (One Film) 135

105 Pelvis (One Film) 135

106 Paranasal Sinuses (One Film) 135


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Page 14 of 21

107 T.M. Joints (One Film) 135

108 Abdomen & Pelvis for K.U.B. 225

109 Skull A.P. & Lateral 225

110 Spine AP & Lateral 225

111 Barium Swallow 525

112 Sinography/Sialography 600

113 Cystography/Urethrography 900

114 Arthrography 675

115 Retrograde Pyelography 750

116 Oral or I.V. Cholecystography 750

117 Barium Enema 975

118 Barium Meal Upper or Lower 975

119 Bronchography 1050

120 I.V. Urography 1050

121 Myelography 1200

122 Pneumo Encephalography 900

123 Barium Meal Complete 1200

124 Cerebral/Femoral Angiography 1425

8. C T SCAN/MRI

125 CT Scan 2500

126 CT Scan (with contrast) 4000

127 MRI 5000

128 MRI (with contrast) 6500

9. ULTRA SONOGRAPHY AND ECHOCARDIOGRAPHY

129 Electro Cardiogram (ECG) 120

130 Thyroid Test: 1.Thyroid scan

2.Thyroid scan & Iodine Uptake 3.Electro Encephalography (EEC)

4.Electro Myography (EMG)

395

131 U C G (Phono-cardiography, Telemetry C, Cardiac Ex Test, Stress Test)

690

132 Echo Cardiography 790

133 Cardio Version 510

134 Ultra Sonography 395

135 US Guided Biopsy 530

10. SKIN

136 Tuberculin Test (Mantaux) TT or MT 105

137 Scraping for Fungus 55

138 Skin Clipping & smear for Leprosy 105

139 Nasal smear for leprosy 85

11. LIVER FUNCTION TESTS

140 Thymol Turbidity Test 90

141 Cephalin Cholesterol Floculation Test 90

142 Vanden Berghn Reaction and Icterus Index (Quantitative Bilirubin)

150


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143 Takata Ara Reaction 100

144 Bromsulphalein Excretion Test (Excluding

injection charges)

220

12. PLEURAL AND PERICARDIAL AND ASCITIC FLUIDS

145 Pleural Fluid for Routine Examination 140

146 Pleural, Pericardial and Ascitic Fluids- Culture & Sensitivity studies

140

EXAMINATION OF SPUTUM

147 Sputum Routine 90

148 Sputum for Acid Fast Bacilli only (Sputum AF B) 90

149 Sputum for Culture (Culture for TB) 140

150 CSF for Diptheria 125

151 Culture for Diptheria 105

13. GASTRIC ANALYSIS

152 Gastric Contents for Routine Analysis (Gastric Analysis or Fractional Test Meal)

215

153 Sternal Marrow Routine Cytology (Bone Marrow) 285

154 Basal Metabolic Rate (BMR) 250

155 Lung Function Test 250

14. PSYCHIATRY TEST

156 ECT 140

157 CO2 80

158 Psychology Testing 140

15. R I A

159 T3 300

160 T4 30

161 TSH, LH, FSH, Prolactin (for each test) 125

162 Testosterone 430

163 Parathyroid 430

164 Estrogen (Total) 430

165 ACTH 430

166 HBsAg by RIA or EIA, HIV I & II 500

16. FOR SURGICAL INVESTIGATION & TREATMENT OF CANCER

167 Scopies and Biopsies 500

Chemotherapy:

168 Single Drug Therapy per day 1000

169 Multiple Drug Therapy per day 2000

170 Infusional Chemotheraphy 3000

17. OXYGEN CHARGES & PHYSIOTHERAPY

171 Oxygen charges shall be reimbursed at the rate of Rs.30/- per hour subject to a maximum of Rs.300/- per day

172 Physiotherapy charges for post operative/paralysis shall be reimbursed at the rate of Rs.300/- per day.

Annexure- II to Circular No.28–2007-BC-STF dated 26.02.2007

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SCHEME OF REIMBURSEMENT OF EXPENSES INCURRED BY THE WORKMEN

FOR TREATMENT ABROAD 1. As a rule, reimbursement of expenses incurred by workmen and their family

members on treatment abroad will not be allowed. 2. In exceptional cases necessitating treatment of a kind yet to be widely established

in the country, where workmen on medical advice obtained in the manner indicated below, choose to go on their own for treatment abroad, permission for treatment abroad may be granted by the Board of Directors of the bank subject to conditions laid

down hereinafter and limited to the expenditure that would have been incurred had such treatment been received in India in a government hospital or a nursing home specially recognised by the Director General of Health Services of the Government of

India. 3. The reimbursement of expenses incurred on air passage for travel abroad in

connection with such treatment will not be reimbursed.

4. Foreign exchange may be released to the workmen for the purpose of treatment abroad to the same extent as is permissible to private citizens.

5. Hospitals and clinics indicated in paragraph 9 below have facility for specialist treatment for which requests are generally received for treatment abroad and in respect of which treatment facility in ordinary hospitals are still inadequate. The

services provided by these hospitals may be availed of by the eligible workmen. In such cases, reimbursement may be allowed subject to the authority sanctioning reimbursement being satisfied about reasonableness of the claim.

6. The following ailments have been identified as ailments for which treatment in India is not yet widely established:

i) Cadaver Kidney Transplant; ii) Old operated by-pass surgery cases (in which the initial operation was done

abroad) needing revascularization; iii) Bone marrow transplant;

iv) Operative correction for high myopia cases; and v) Complex Cyanote – Heart – Lesion and newly born infants suffering from heart

diseases.

7. Reserve Bank of India (RBI) will constitute Medical Boards at Mumbai, Delhi, Kolkata and Chennai and at such other centres as may be considered necessary for the

purpose of recommending whether an employee would be covered under the Scheme. The annual cost incurred on meeting of the Board by way of sitting fees, etc., shall be shared on an annual basis by such of the banks which avail of the services of the

Medical Boards of examining cases of their workmen needing treatment abroad, in a manner as may be decided by the RBI.

Annexure- II to Circular No.28–2007-BC-STF dated 26.02.2007

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The Medical Board should make a specific recommendation and also give reasons for

recommending treatment abroad. The Medical Board will submit its report to RBI, which in turn, could pass it on to the concerned bank.

8. For the purposes of reimbursement, as envisaged in the scheme, the schedule of charges as applicable for private ward treatment at the All India Institute of Medical Sciences, New Delhi, enforced from time-to-time, should be adopted.

9. The following institutions have been identified as having facilities for specialised treatment:

(a) Bypass Coronary Surgery :

1. Southern Railways Headquarters Hospital, Perambur, Chennai. 2. Christian Medical College and Hospital, Vellore. 3. K.E.M. Hospital, Mumbai.

4. Jaslok Hospital, Mumbai. 5. Bombay Hospital, Mumbai. 6. Kasturba Hospital, Bhopal.

7. Sree Chitra Tirunal Institute of Medical Sciences and Technology, Trivandrum.

(b) Kidney Transplant :

1. Christian Medical College & Hospital, Vellore. 2. All India Institute of Medical Sciences, New Delhi.

3. Post Graduate Institute, Chandigarh. 4. Jaslok Hospital, Mumbai.

(c) Blood Cancer :

1. Tata Memorial Hospital, Mumbai. 2. Cancer Institute, Adyar, Chennai.

(d) Complicated Heart Surgery Cases : 1. Southern Railway Headquarters Hospital, Perambur, Chennai.

2. Christian Medical College & Hospital, Vellore. 3. K.E.M. Hospital, Mumbai. 4. All India Institute of Medical Sciences, New Delhi.

5. Bombay Hospital, Mumbai. 6. G.B.Pant Hospital, Delhi. 7. Sree Chitra Tirunal Institute of Medical Sciences and Technology, Trivandrum.

8. Post Graduate Institute, Chandigarh. 9. S.S.K.M. Hospital, Kolkata. 10.Samaritan Hospital, Alwaye (Kerala).

11.Kasturba Hospital, Bhopal (BHEL). 12.N.M. Wadia Institute of Cardiology, Pune.

O

Annexure III to Circular No.28–2007-BC-STF dated 26.02.2007

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ANDHRA PRGATHI GRAMEENA BANK : HEAD OFFICE : KADAPA

CLAIM FOR REIMBURSEMENT OF MEDICAL/ HOSPITALISATION EXPENSES INCURRED UNDER HOSPITALISATION SCHEME

Note: 1. The form should be filled up in all respects as per Cir.No.28–2007-BC-STF dt.26.02.07 2. Claim should be forwarded to Head Office, Personnel Department, Kadapa duly

recommended and forwarded by the regular Branch/Office Head and not the in-charge Officer.

3. During the period of hospitalization of the patient the Officer/employee should be “on

duty”/sanctioned leave to become eligible for the sanction of the Bill. Not eligible during the period of unauthorised absence/suspension.

1. Name of the staff member :

2. Employee No. (New) :

3. Designation/Scale/Cadre :

4. Branch/Office where working :

5. Name of the person Hospitalised & age

:

6. Relationship of the patient to the staff

member

:

7. Monthly Income in case of parents/ children/Dependants

:

8. Name/Nature of Ailment/Disease for which the staff member/dependent is admitted into the hospital

:

9. Name/Nature of operation (specify

Whether special/major/minor operation) (Enclose certificate from the doctor to that effect)

:

10. Name & Address of the hospital where treatment is taken

:

11. Indicate whether the hospital admitted in to is a Govt. hospital or a hospital run

by a Charitable Institution/Trust/ Religious Mission

:

12. Whether said hospital is an eligible

Hospital, if so, a certificate from the hospital is to be enclosed

:

13. If the patient is admitted in a Private

Hospital/Nursing Home/Clinic, reason for Admission therein is to be submitted

:

14. Date of Admission & Date of Discharge Total No. of days hospitalised

: : :


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15. Date of operation (if any) :

16. Whether the staff member availed any

leave for the purpose of Hospitalization

:

:

17. Leave particulars of the staff Member : Nature of Leave __________Period from__________ to_________No.of days_____

Sanction Lr. No. dt. Of Office/Branch

18. Total number of cash bills/vouchers/

Certificates/ Reports/ papers submitted.

:

: :

19. Total amount of Claim: Rs.___________

Statement of hospitaliation expenses claimed:

S.

No

Particulars Bill No. Date Amount

paid

1. Bed charges/Room rent (As per bill enclosed)

2. Hospital Registration fee

3. Doctor Consultation Fee

4. Operation theatre charges

5. Anesthesia Charges

6. Surgeon Asst. Surgeon Fee

7. Surgical Implants if any

8. Doctor‟s Daily visit charges

9.

10.

11. Diagnosis/Test Reports*

S.No. Name of the Test Name of the Lab/place

1.

2.

3.

4.

12. Medicines*:

S.No Place of medical shop

1.

2.

3.

13. Other Charges (As per bills enclosed)

1.Oxygen Charges

2.Ambulance charges

3.Blood Transfusion

4.Dialysis etc.

5.Chemo Therapy

6.

7.

Total Claim

* Enclose separate sheet if required as per columns provided


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20. CERTIFICATE/DECLARATION

I hereby declare that the following are my family members and dependants on me.

S.No Name of the dependant Age Relation-ship

Income of the dependant per month

1.

2.

3.

4.

I hereby also declare that I have truly and honestly incurred a sum of Rs……………… (Rupees ………………………………………………………………………only) towards hospitalisation charges for myself/family member (dependant) as stated

above.

I declare and certify that the above information furnished by me is true and

correct and I enclosed all genuine original bills/Certificates/Reports/papers in connection with the above hospitalization expenditure as listed in enclosure.

I am aware that in case of the information furnished by me is found false/incorrect at any later stage I shall stand exposed to disciplinary action to be

initiated against me by the Management of the Bank in addition to recovering hospitalisation expenses claimed by/ sanctioned to me in this regard.

Branch/Office:

Date: SIGNATURE OF THE OFFICER/EMPLOYEE =================================================

Forwarded to Head Office, Personnel Department:

Date:___________

We certify that the Officer/Employee during the period of hospitalization of the patient :

1. is on duty and attended the office/branch 2. is on ……………………..leave for………days from…………………….to…………………...

and the leave is sanctioned vide Lr. No……………………………….dt…………………

by the sanctioning authority……………………………………………….. 3. is not under suspension/unauthorised absence.

Branch/Office_____________ MANAGER/REGIONAL MANAGER

Annexure IV to Circular No.28–2007-BC-STF dated 26.02.2007

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CERTIFICATE FOR TREATMENT ON DOMICILIARY BASIS

Name of the Specialist Doctor issuing Address of Hospital/Nursing Home/ the Certificate: Clinic

………………………………………………… …………………………………………………………

Registration: ………………………………………………………… ………………………………………………….. …………………………………………………………

Phone No:

This is to certify that Mr/Mrs……………………………………………………………………..

S/o,D/o,W/o,M/o,F/o……………………………………………, aged………………… years

working as __________________ (Cadre) in Andhra Pragathi Grameena Bank

……………. ……………………… Branch/Office is suffering from………………………….

………....(ailment) and is treated by me during the period from……………………..

to……………………… in my Hospital/Nursing Home/Clinic at…………………………..

……………………………………………………………(Place).

He/she is advised to take the following medicines on domiciliary basis for a

period of …………….. months/year/s.

S.No. Name of the Medicine Dosage per Day

PLACE:________________ Signature Of The Certifying

Specialist Doctor With Registration

DATE:_________________ No. and Hospital seal

ANDHRA PRAGATHI GRAMEENA BANK (Sponsored by Syndicate …apgb.in/files/1_2_509364e82afd4.pdf · Kolkata, Ahmedabad, Bangalore & Hyderabad Other Places Rs. per visit Rs. per visit

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