MEDICAL CONDITION CONSIDERED AS EMERGENCY BY RAILWAYS for reimbursement

Reg: MEDICAL CONDITION CONSIDERED AS EMERGENCY BY RAILWAYS

Rly. Bd’s letter No.2006/H-1/13(RTI) dated 17.4.07 (RTI CeIl / 2007/60)

Q (1). Whether following conditions are considered to be an “emergency” by the Railways, for reimbursement of medical expenses for treatment in Private/Government Hospitals;
CONDITIONS OF EMERGENCY – UNDER ECHS
* Acute Cardiac Conditions/Syndromes including Myocardial Infraction, Unstable Angina, Ventricular Arrhythmias, Paroxysmal Supra-ventricular Tachycardia, Cardiac Tamponade, Acute Left Ventricular Failure/Severe congestive Cardiac Failure, Accelerated hypertension, Complete dissection.
* Vascular Catastrophes including Acute limb ischemia, Rupture of aneurysms, medical and surgical shock and peripheral circulatory failure.
* Cerebro-Vascular Accidents including Strokes, Neurological Emergencies including coma, cerebro meningeal infections, convulsions, Acute paralysis, Acute visual loss.
* Acute respiratory Emergencies indulging respiratory failure and decompensated lung disease.
* Acute abdomen including acute obstetrical and gynecologist emergencies
* Life threatening injuries including Road traffic accidents, Head Injuries, Multiple Injuries, Crush Injuries and Thermal Injuries.
* Acute poisoning and Snake bite
* Acute endocrine emergencies including Diabetic Ketoacidosis
* Heat stroke and cold injuries of Life threatening nature
* Acute Renal Failure
* Severe infections, leading to life threatening sequel-including Septicemia, disseminated TB.
* Any other condition, in which delay could result in loss of life or limb.
Ans. All the conditions enlisted in the application as “emergency” (under ECHS) are considered as emergency conditions by Railways also.
While issuing the circular No. 2005/H/6- 4/Policy-I1 dated 31.01.07 by Railway administration, all the conditions (under ECHS) have been included and considered by defining in a separate pattern. The pattern in which they are considered is given in the above mentioned circular.

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The copy of the said Board’s letter dated: 31.01.07 IS attached (Annexure ‘A’) for ready reference.
Copy of RAILWAY BOARD’s letter no No. 2005/H/6-4/Policy-II dated: 31.01.2007
Sub: REIMBURSEMENT OF MEDICAL EXPENSES- PROCEDURE OF DISPOSAL.
The issue of bringing in objectivity, consistency and transparency in disposal of reimbursement cases, where the treatment has been taken in emergency without consultation with the Authorized Medical Officer, has been under consideration of the Board
The Railway Board after thorough review of the whole subject of reimbursement has taken the following decisions which are to be implemented with immediate effect.
Any instructions on this subject as available in IRMM 2000 or any office order issued prior to this office order and will stand modified accordingly.
I The cases to be considered for sanction of reimbursement claim
To provide proper medical treatment, the Indian Railway Health Care Delivery system has 121 number of Railway Hospitals and 586 No. of Railway Health Units established all over India. In addition to this, all Govt. Hospitals and more than 115 private hospitals all over the country have been recognized to provide necessary medical treatment to Railway beneficiaries.
As per extant rules, a railway beneficiary must report to Railway Medical Officer for his/her and dependents’ medical treatment. The Authorized Medical Officer will make necessary arrangements for medical treatment through Railway Hospital/Govt. Hospital / Pvt. Recognized Hospital. In exceptional situations, CMOs of Zonal Railways can obtain special permission from Railway Board for treatment in any Private Hospital on case to case basis. Hence, there is no scope available for any railway beneficiary to go to any private hospital himself/herself or their dependents on their own volition, except in case of real emergency situation.
“Emergency” shall mean any condition or symptom resulting from any cause, arising suddenly and if not treated at the early convenience, be detrimental to the health of the patient or will jeopardize the life of the patient. Some examples are- Road accidents, other types of accidents, acute heart attack etc.
Under such conditions, when the Railway beneficiary feels that there is no scope of reporting to his/her authorized Railway Medical Officer and avails treatment in the nearest and suitable private Hospital, the reimbursement claims are to be processed for sanction, after the condition of the emergency is confirmed by the authorized Railway Medical officer ex-postfacto.
In order to establish the emergency condition, following parameters are to be examined on record:-
(a) Admission details:-
(i) Date and time of admission.
(ii) Admitted through OPD service/ emergency service.
(iii) Admitted to an ICU bed or general bed or cabin bed.
(b) Clinical findings at the time of admission. Following findings should be made available and critically evaluated:-
(i) Pulse rate.
(ii) B.P.
(iii) Level of consciousness
(iv) Any convulsive feature.
(v) Urine output
(vi) Any other feature of shock.
(vii) Body temperature
(viii) Extant of external wound
(ix) Extant of active bleeding.
(x) Extant of Chest pain or pain in other parts of the body.
I Types of medical treatment given immediately after admission.
(i) List of Emergency medicines used immediately after admission.
(ii) Type of surgical procedure done immediately after admission.
II Calculation of the amount of reimbursement to be sanctioned out of the claimed amount:-
Once the emergency is established beyond doubt, then the case should be further processed for calculating the amount/money to be sanctioned.
For that, following guidelines are given:-
a) Treatment taken in Govt. Hospital – Full admissible amount should be recommended for sanction.
b) Treatment taken in Recognized Private Hospital for an ailment for which it is recognized – Rate as approved by Railway should be processed for sanction.
c) Treatment taken in a Recognized Private Hospital but for an ailment for which it is not recognized or Treatment taken in a non- recognized Private Hospital:-Reimbursement should be made at the CGHS rates of that city or nearest city. CGHS (Central Govt. Health Scheme) approved rates are to be recommended/processed as an upper limit for sanction.
III The approved rates of private hospitals recognized by Railway should be put on the Web sites of the Zonal Railways so that at all levels of processing/sanction these are accessible to all concerned.
IV In Medical Science, no list can be fully exhaustive. Hence, it is likely that there will be few occasions when a claim has been submitted which is not appearing exactly in the CGHS rate list. On these cases, the MD/CMS/MS in charge of Divisions will apply their mind and will come to a logical conclusion. Then, they will pass a speaking order to certify the rate/s being recommended, in consultation with Associate Finance.
V All the reimbursement cases be processed as per check-list issued earlier to avoid back reference.
VI These instructions shall be effective from the date of issue of this letter. Past cases, already decided, shall not be re-opened.

————————————————————

ADVANCE CORRECTION SLIP TO PARA 648 of IRMM 2000
Add (3) Para 648 (PROCEDURE FOR) TRETMENT UNDER EMERGENCY as under
REIMBURSEMENT OF MEDICAL EXPENSES- PROCEDURE OF DISPOSAL

The issue of bringing in objectivity, consistency and transparency in disposal of reimbursement cases, where the treatment has been taken in emergency without consultation with the Authorized Medical Officer, has been under consideration of the Board
The Railway Board after thorough review of the whole subject of reimbursement has taken the following decisions which are to be implemented with immediate effect.
Any instructions on this subject as available in IRMM 2000 or any office order issued prior to this office order and will stand modified accordingly.
I The cases to be considered for sanction of reimbursement claim
To provide proper medical treatment, the Indian Railway Health Care Delivery system has 121 number of Railway Hospitals and 586 No. of Railway Health Units established all over India. In addition to this, all Govt. Hospitals and more than I 15 private hospitals all over the country have been recognized to provide necessary medical treatment to Railway beneficiaries.
As per extant rules, a railway beneficiary must report to Railway Medical Officer for his/her and dependents’ medical treatment. The Authorized Medical Officer will make necessary arrangements for medical treatment through Railway Hospital/Govt. Hospital / Pvt. Recognized Hospital. In exceptional situations, CMOs of Zonal Railways can obtain special permission from Railway Board for treatment in any Private Hospital on case to case basis. Hence, there is no scope available for any railway beneficiary to go to any private hospital himself/herself or their dependents on their own volition, except in case of real emergency situation.
“Emergency” shall mean any condition or symptom resulting from any cause, arising suddenly and if not treated at the early convenience, be detrimental to the health of the patient or will jeopardize the life of the patient. Some examples are- Road accidents, other types of accidents, acute heart attack etc.
Under such conditions, when the Railway beneficiary feels that there is no scope of reporting to his/her authorized Railway Medical Officer and avails treatment in the nearest and suitable private Hospital, the reimbursement claims are to be processed for sanction, after the condition of the emergency is confirmed by the authorized Railway Medical officer ex-postfacto.
In order to establish the emergency condition, following parameters are to be examined on record:-
(a) Admission details:-
(i) Date and time of admission.
(ii) Admitted through OPD service/ emergency service.
(iii) Admitted to an ICU bed or general bed or cabin bed.
(b) Clinical findings at the time of admission. Following findings should be made available and critically evaluated:-
(i) Pulse rate.
(ii) B.P.
(iii) Level of consciousness
(iv) Any convulsive feature.
(v) Urine output
(vi) Any other feature of shock.
(vii) Body temperature
(viii) Extant of external wound
(ix) Extant of active bleeding.
(x) Extant of Chest pain or pain in other parts of the body.
I Types of medical treatment given immediately after admission.
(i) List of Emergency medicines used immediately after admission.
(ii) Type of surgical procedure done immediately after admission.
II Calculation of the amount of reimbursement to be sanctioned out of the claimed amount:-
Once the emergency is established beyond doubt, then the case should be further processed for calculating the amount/money to be sanctioned.
For that, following guidelines are given:-
a) Treatment taken in Govt. Hospital – Full admissible amount should be recommended for sanction.
b) Treatment taken in Recognized Private Hospital for an ailment for which it is recognized – Rate as approved by Railway should be processed for sanction.
c) Treatment taken in a Recognized Private Hospital but for an ailment for which it is not recognized or treatment taken in a non- recognized Private Hospital:-Reimbursement should be made at the CGHS rates of that city or nearest city. CGHS (Central Govt. Health Scheme) approved rates are to be recommended/processed as an upper limit for sanction.
III The approved rates of private hospitals recognized by Railway should be put on the Web sites of the Zonal Railways so that at all levels of processing/sanction these are accessible to all concerned.
IV In Medical Science, no list can be fully exhaustive. Hence, it is likely that there will be few occasions when a claim has been submitted which is not appearing exactly in the CGHS rate list. On these cases, the MD/CMS/MS in charge of Divisions will apply their mind and will come to a logical conclusion. Then, they will pass a speaking order to certify the rate/s being recommended, in consultation with Associate Finance.
V All the reimbursement cases be processed as per check-list issued earlier to avoid back reference.
VI These instructions shall be effective from the date of issue of this letter. Past cases, already decided, shall not be re-opened.

————————————————————-

(Authority Railway Board’s letter no No. 2005/H/6-4/Policy-II dated: 31.01.2007)
MEDICAL CONDITION CONSIDERED AS EMERGENCY BY RAILWAYS
(Rly. Bd’s letter No.2006/H-1/13(RTI) dated 17.4.07 (RTI CeIl / 2007/60)

to Sh Harchandan Singh, under RTI)
Q (1). Whether following conditions are considered to be an “emergency” by the Railways, for reimbursement of medical expenses for treatment in Private/Government Hospitals;
CONDITIONS OF EMERGENCY
* Acute Cardiac Conditions/Syndromes including Myocardial Infraction, Unstable Angina, Ventricular Arrhythmias, Paroxysmal Supra-ventricular Tachycardia, Cardiac Tamponade, Acute Left Ventricular Failure/Severe congestive Cardiac Failure, Accelerated hypertension, Complete dissection.
* Vascular Catastrophes including Acute limb ischemia, Rupture of aneurysms, medical and surgical shock and peripheral circulatory failure.
* Cerebro-Vascular Accidents including Strokes, Neurological Emergencies including coma, cerebro meningeal infections, convulsions, Acute paralysis, Acute visual loss.
* Acute respiratory Emergencies indulging respiratory failure and decompensated lung disease.
* Acute abdomen including acute obstetrical and gynecologist emergencies
* Life threatening injuries including Road traffic accidents, Head Injuries, Multiple Injuries, Crush Injuries and Thermal Injuries.
* Acute poisoning and Snake bite
* Acute endocrine emergencies including Diabetic Ketoacidosis
* Heat stroke and cold injuries of Life threatening nature
* Acute Renal Failure
* Severe infections, leading to life threatening sequel-including Septicemia, disseminated TB.
* Any other condition, in which delay could result in loss of life or limb.
Ans. All the conditions enlisted in the application as “emergency” (under ECHS) are considered as emergency conditions by Railways also.
While issuing the circular No. 2005/H/6- 4/Policy-I1 dated 31.01.07 by Railway administration, all the conditions (under ECHS) have been included and considered by defining in a separate pattern. The pattern in which they are considered is given in the above mentioned circular.

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