INDIAN RAILWAY ESTABLISHMENT CODE VOLUME - I

CHAPTER 6

MEDICAL ATTENDANCE AND TREATMENT

Sub-section (4) : Reimbursement

616. Reimbursement allowed if medical attendance is at the instance of the authorized medical officer. - A railway employee obtaining treatment for himself or member of a family or dependent relative should consult his authorized medical officer first and proceed in accordance to his advice. In case of his failure to do so, his claim for reimbursement will not be entertained as provided. All claims for reimbursement should be scrutinized with a view that the authorized medical officer or any other medical officer who is either of equivalent rank of immediately junior in rank to the authorized medical officer and attached to the same hospital/health unit as the authorized medical attendant was consulted in the first instance.

(Rules 905, 919 RI, Para 1443 to 1448, 1452, 1457 (i) of the IREM and Railway Board’s letter No. 67/H/1/11 dated 4-3-1968 and 71/H/1-1/6 dated 9-11-1971).

617. Treatment in an emergency.—In an emergency if a railway employee has to go for treatment including confinement to a government hospital/recognized hospital or a dispensary run by a philantherapic organisation without prior consultation with the authorized medical officer, reimbursement of the expenses incurred to the extent otherwise admissible, will be permitted if after a careful examination of the circumstances of the case, the competent medical authority accords ex-post facto approval. In such case, before reimbursement is admitted, it will be necessary to obtain in addition to other documents prescribed, a certificate in the prescribed form from the medical superintendent of the hospital to the effect that the facilities provided were the minimum and essential for the patients treatment.

Note :

1. In such cases, GMs are delegated powers to allow reimbursement of medical expenses upto a of Rs. 3000/- in each case in private institution and upto Rs. 10000/- in recognized/Government hospitals.

   (Railway Board’s letter No. 91/H/6-4/26 dated 20-11-95.)

2. CMDs are authorized to reimburse claims upto Rs.1000/- of railway employees in the event of special investigations (laboratory tests etc.) got done from non-recognised institutions on the advice of the authorized medical officer in the absence of such facilities in the railway hospital. These cases should be decided in consultation with FA&CAO provided these were done at the instance of the authorized medical officer. These powers will not be re-delegated.

   It has also been decided that claims above those permitted in Note (1) and (2) above, be referred to the Railway Board for consideration along with FA&CAO’s comments and the circumstances which necessitated such investigations being done at non-recognised institutions.

   (Railway Board’s letter No. 91/H/6-4/26 Pt. dated 5-1-94 & 4-5-94)

3. Sterility-per-se. - Cases of treatment of sterility may also be treated at par with other cases for reimbursement under the existing rules.

   (Railway Board’s letter No.86/H/6-4/58 dated 21-12-1988)

4. Recognition of CATSCAN test for reimbursement.
   1. General Managers are fully empowered to sanction charges levied at a Government hospital for catscan.
   2. In case cat scan in a government hospital is not possible in time CMD will arrange for catscan at a reasonably priced private institution. In such case, General Manager is empowered to sanction Catscan facility charges upto Rs.2000/- in each case. MRI, CMDs can within their power sanction Rs.3000/-. For fees beyond this amount, concurrence of associate finance be obtained and proposals submitted to Railway Board for consideration and sanction. Chief Medical Director should ensure that prior permission is accorded to get this Catscan done only in very deserving and definitely needed cases.

      (Railway Board’s letter No.86/H/3/3 dated 22-1-1987)

5. General Managers have been delegated powers for granting post-facto sanction even in cases where prior permission of Chief Medical Director could not be obtained for reimbursement of expenses incurred on Cat scan upto Rs.2000/- only in each case done in Government hospitals.

   (Railway Board’s letter No.88/H/6-4/80 dated 12-5-89)

6. Chief Medical Directors are empowered to sanction Catscan fee charges upto Rs.2000/- in each case. Powers are also delegated for granting post-facto sanction.

   (Railway Board’s letters No.88/H/6-4/57 dated 21-12-88 and 88/H/6-4/80 dated 9-9-89)

7. Chief Medical Directors can sanction reimbursement of the cost of hearing aid for employees and dependent family members upto Rs. 1500/-. The cost shall be paid to the firm directly. Cases where cost of hearing aid exceeds the limit of Rs. 1500/- they should be referred to the Railway Board duly concurred by the FA&CAO.

   (Railway Board’s Letter No. 85/H/6-4/28 dated 26-9-1988.)

8. Reimbursement of expenses on purchase/replacement repair/adjustment of artificial electronic larynx. – Reimbursement of the cost of the artificial electronic larynx should be made to the railway employees and their family members governed by the Railway medical attendance rules on the recommendations of the Director General Health Services. The payment would, however, be made by the administrative authority direct to the supplying agency and not to the railway employee concerned.

   (Railway Board’s letter No. 82/H/6-1/21 dated 11-10-1984.)

9. Provision of specialized medical services to construction staff. - General Managers on merits in such areas can decide provided provision of such consultants is within the norms laid down by Railway Board for appointment of consultants. Cases not falling within the framework of these norms shall be referred to the Board for approval.

   (Railway Board’s letter No. 89/H/2-3/5 dated 24-7-89.)

10. Utilising the service of an Anaesthetist from outside during emergencies. - When Railway Anaesthetist is not available because the post/posts is/are vacant or the anaesthetist had/have gone on leave/sick or is not on duty elsewhere/out of station, the services of an anaesthetist from outside may be utilized on payment of Rs. 150 per case towards professional charges.

    (Railway Board’s letter no. 88/H/6-1/29 dated 6-1-89.)

618. Families accompanying railway officials proceeding on tour.

1. Medical expenses incurred on treatment of a member of railway employee's family accompanying him on tour can be reimbursed on the same scale and conditions on which they can reimbursed to the railway employees himself, if illness occurs during that period and treatment is taken in a government or railway hospital.
2. The above concession is not admissible if a railway employee takes a member of his family along with him with the intention of obtaining treatment in a place other than his headquarters.

   (Rule 916 RI)

619. Treatment at residence.

1. Where owing to the absence or of a suitable hospital (railway or otherwise) or owing to the severity of the illness or other causes considered adequate by the authorize medical officer, a railway employee receives treatment at his residence, the expenses incurred by the railway employee for such items and services as to what have been admissible to the patient otherwise, would be reimbursable.
2. The above claims must be accompanied by a certificate by the authorized medical officer stating the reasons for his opinion as referred to above, and indicating the cost of treatment admissible to the patient otherwise. Such cost should take into account the charges for medicines and dressings, as also amount of money, if any, paid to the authorized medical officer.

   (Rule 908 RI and note 4 below Rule 916 RI)

620. Payment of charges. - Payment to Government recognized hospital on account of hospital charges should in the first instance be made by the railway employee concerned to the hospital authorities and the reimbursement thereof claim at the railway administration later.

Note. - State Government where agreeable should debit the railway administration concerned by preferring bills for those items for which reimbursement is permissible. Those Government recognized hospitals which press for advance deposit of money for treatment of cases referred to them, the medical officer concerned may be allowed an imprest of Rs. 500/-. The holder of the imprest should submit their report for the amount spent.

(Note : below Rules 909(2) and 917 RI, Para 1431 of the IREM and Railway Boards Letter No. E 56ME1/34/Med. Dated 6-9-61.)

621. Claims to be preferred within six months. - All Claims for reimbursement should be preferred within six months of the date of completion of the treatment as shown in the Essentiality certificate of the authorized medical officer. A claim for reimbursement of medical charges not countersigned and preferred within six months of the date of completion of the treatment, should be subject to investigation by the Accounts Officer, where a special sanction is accorded on an application from the railway employee for reimbursement of any charges in relaxation of the rules, the sanction will be deemed to be operative from the date of its issue, and the period of six months for preferment of claim will count from that date.

(Note 2 below Rule 909(2) RI and para 1412 of the IREM).

622. Forms for preferring claims. - The railway employee claiming reimbursement for expenses occurred on account of medical attendance and treatment in a government recognized hospital should claim in a prescribed form accompanied by the necessary documents indicated in the forms.

(Para 1430, 1453 of IREM)

623. All claims for reimbursement should first be carefully scrutinised by the competent authority, should in consultation with the authorized medical officer where contrary, will disallow any claims or items, which do not satisfy rules and orders on the subject. These should be disposed of without delay.

(Rule 1458 of IREM)

624. Rate and schedule of charges.

1. The rates and schedule of charges of government/recognized hospitals concerned may be obtained from the respective state government.
2. In the case of government/recognized hospitals, the tariff which does not indicate the accommodation and diet charges separately, 20% of the flat rate should be reckoned as diet charges and 20 % as charges for accommodation.

   (Para 1436(2) and 1456(B) of the IREM)

625. Expenses incurred as outdoor patient. - Reimbursement of medical expenses incurred as an out-door patient in a railway hospital/health unit or in a government/recognized hospital is permitted.

(Note 3 below Rule 906 RI)

626. Items and services not covered by the definition of the term ‘Treatment’. - Expenditure incurred by a railway employee or a member of his family or dependent relatives on items and services not covered by the definition treatment will not be reimbursable.

627. Reimbursement of costs of medicines which are neither ordinarily stocked nor available in railway medical institutions but are purchased from the market.

1. To minimize claims for reimbursement of cost of items inadmissible, the medical officers concerned with the treatment of the patients, should determine that essentiality certificates should not be issued in respect of items which are not medicines but which are primarily food tonics etc. A decision should depend whether the drug element is small in comparison with the food contents of the proportion prescribed. A propriety item should not be prescribed if a non-propriety prescription of a similar therapeutic value is available. Necessary guidelines should be taken from the Indian Railway Pharmacopoea.
2. The charges for the cost of medicines which are reimbursable will be allowed only if the claim for reimbursement thereof is accompanied by the cash memo and a essentiality certificate duly countersigned by the authorized medical officer in the prescribed Proforma as given in the annexure. Every cash memo must be countersigned by the doctor prescribing the medicines and the essentiality certificate must contain the name of the medicines prescribed and the amount incurred on the purchase of each medicine, whether or not the original prescription have been submitted.

   Note.—The underlined idea is to ensure that the medicines actually considered essential by the authorized medical officer and they may be purchased and consumed by the patient as directed.

3. Sales tax paid on these medicines will be reimbursable.
4. The charges for packing and postage if incurred will not be reimbursable.
5. Ordinarily expenses on account of the cost of medicines intended for injections prescribed at the consulting room of the authorized medical officer but administered at the residence of a patient who is a member of the family or dependent relative of a railway employee will not be reimbursable. In serious cases however the reimbursement is regular vide sub–para (2) above.
6. The State Government where agreeable should debit the railway administration concerned by preferring bills or by raising debits in respect of cost of medicines, vaccination etc. not ordinarily available at hospitals which are certified in writing to be essential for the recovery or prevention of serious deterioration in the condition of a railway beneficiary who is admitted to a non-railway government hospital for treatment at the instance of the authorized medical officer. If the State Government concerned are not agreeable to such an arrangement, reimbursement to the railway employee concerned would be permissible as per rules.

   ( Ministry of Railway’s decision No. 1,2,3 below Rule 903 RI and paragraph 1434 and 1435 (a) of the IREM).

629. The cost of heat valves, pace-makers and pulse generators, as well as the replacement of pulse generators in the case of railway beneficiaries will be made only on the recommendations of the CMD by the administrative authority would make the payment involved direct to the supplying agencies and not to the railway employees concerned.

(Railway Board’s letter No. 78/H/6-4/16 dated 12-12-78 and 81-H/6-4/37 dated 4-6-1982).

630. Items and services rendered in connection with medical attendance and treatment. - Charges for items and services rendered in connection with (but not included in) medical attendance and treatment of a patient entitled to railway medical attendance and treatment facilities shall be determined by the authorized medical officer and paid by the patient.

(Rule 909 RI)

631. Reimbursement of medical expenses incurred abroad. - The matter has been reconsidered by the Government and it has been decided that, in supersession of all previous orders on the subjects, the following guidelines should be adopted in dealing with the cases relating to requests for medical treatment abroad and matters relating thereto:

1. As a rule, reimbursement of cost of medical treatment incurred abroad should not be allowed.
2. In exceptional cases, necessitating treatment of a kind yet to be widely established in the country, where railway employees, on medical advice, choose to go on their own, reimbursement could be authorized by the Ministry of Railways, but should be limited to the expenditure that would have been incurred had such treatment been received in India in a Govt. Hospital or a recognized hospital. However, the question of reimbursement of air passage in such cases shall not arise at all.
3. Foreign Exchange may be released to railway employee for purpose of treatment abroad to the same extent as is permissible to private citizen.
4. The facilities for specialist treatment, as available in Railway Hospitals or other Government/ recognized hospitals should be availed by the railway employees.