Wherever clarification or interpretation or relaxation and extension of any of the provisions of this regulation arise, the Appellate Tribunal may refer the matter to the Central Government and the decision of the Central Government shall be final in such matters.
****** Appendix - A APPELLATE TRIBUNAL FOR ELECTRICITY FORM OF APPLICATION FOR MEDICAL CLAIMS Form of application for claiming refund of medical expenses incurred in connection with medical attendance or treatment of the Employees of Appellate Tribunal for Electricity or their families for treatment in a Hospital:
1. Name and designation of the Employee (in Block Letters)
(i) Whether married or unmarried
(ii) If married, the place where wife/husband is employed
2. Pay of the Employee as defined in the Fundamental Rules and any other emoluments which should be shown separately
3. Place of duty
4. Actual residential address
5. Name of the patient and his/her relationship to the employee
6. Place at which the patient fell ill
7. Details of the amounts claimed Name of the Hospital Charges for Hospital treatment, indicating separately the charges for-
(i) Accommodation (State whether it was according to the status or pay of the employees and in cases where the accommodation is higher than the status of the employee, a certificate should be attached to the effect that the accommodation to which he was entitled was not a available)
(ii) Diet
(iii) Surgical operation or medical treatment or confinement
(iv) Pathological, Bacteriological, Radiological or other similar tests, indicating –
(a) The name of the hospital or laboratory at which undertaken; and
(b) Whether undertaken on the advice of the Medical Officer in charge of the case at the hospital. If so, a certificate to the effect should be attached.
(v) Medicines
(vi) Special medicines (Cash memos and the Essentiality Certificate should be attached)
(vii) Ordinary nursing ¹Hkkx IIµ[k.M 3(i)º Hkkjr dk jkti=k % vlk/kj.k 11
(viii) Special nursing, i.e., nurses, specially engaged for the patient. State whether they are employed on the advice of the Medical Officer in charge of the case at the hospital or at the request of the Employee or patient. In the former case a certificate from the Medical Officer in charge of the case and countersigned by the Medical Superintendent of the Hospital should be attached.
(ix) Ambulance charges – (state the journey – to and fro – undertaken)
(x) Any other charges, e.g., charges for electric light, fan, heater, air-conditioning, etc. State also whether the facilities referred to are a part of the facility normally provided to all patients and no choice was left to the patient.
8. Total amount claimed
9. Less advance taken on
10. Net amount claimed
11. List of enclosures DECLARATION TO BE SIGNED BY THE GOVERNMENT SERVANT I hereby declare that the statements in the application are true to the best of my knowledge and belief and that the person for whom medical expenses were incurred is wholly dependent upon me.
Date Signature of the Employees Appendix - B APPELLATE TRIBUNAL FOR ELECTRICITY FORM OF APPLICATION FOR REIMBURSEMENT OF MEDICAL CLAIM
1. Name and Designation ____________________________________
2. Basic Pay + Dearness Allowance __________________________
3. Name of the patient ______________________________________ and relationship
4. Place at which patient _____________________________________ Fell ill
5. Name of the Doctor/_______________________________________ Hospital CLAIM DETAILS AMOUNT CLAIMED Rs. P.
AMOUNT ADMITTED Rs. P.
a) Consultation Charges:
number and dates of consultations b) Special Consultations number and dates of consultations c) Pathological Charges:
d) Cost of Medicines S. No. Cash Memo No. Date Rupees (In words) I hereby declare that the statements in the application are true to the best of my knowledge and belief and that the person for whom medical expenses were incurred is wholly dependent upon me.
12 THE GAZETTE OF INDIA : EXTRAORDINARY [PART II—SEC. 3(i)] List of encl:
Date: Signature of the Employee.”.
[F. No. 46/5/2015-R&R] JYOTI ARORA, Jt. Secy.
Note : The principal rules were published vide number G.S.R.721(E), dated the 28 th October, 2004 and subsequently amended vide numbers G.S.R. 281(E), dated the 6 th May, 2005, G.S.R. 548(E), dated the 22 nd July, 2008 and G.S.R. 558(E), dated the 20 th July, 2011.
Uploaded by Dte. of Printing at Government of India Press, Ring Road, Mayapuri, New Delhi-110064 and Published by the Controller of Publications, Delhi-110054.
2017-01-19T11:45:39+0530 ALOK KUMAR