Section 10: Interpretation

If any question arises as to the interpretation of these rules, the decision of the State Government shall be final.

FORM No. 1 APPLICATION FORM FOR MEDICAL REIMBURSEMENT CLAIMS BY EX­MLA's/ SPOUSES (See Rule 3)

1. Name and Address of the applicant :

2. Name of patient :

3. Period of Treatment :

4. The System under which treatment was received*:

a. Allopathy b. Ayurveda c. Homoeopathy

5. Station where the applicant fell ill and the headquarters of the Authorised Medical Attendant of that Station.

6. The place/Institution with its name and address, where the treatment was received.

a. Consulting room of the Authorised Medical Attendant b. Consulting room of the Government Medical Officer/Specialist c. Medical Institution.

d. Residence of the partients**

7. If Hospitalised Outside the State :

(a) Name of Institution :

(b) Whether prior sanction of the Director of Health Services has been obtained :

(c) If not, whether Ex­post facto sanction of the Government has been obtained :

8. Claims on account of treatment :

(i) Cost of/charges/fee for :

(a) Medicine and other therapeutic substances

(b) Other items/materials used for treatment

(ii) Diagnostic Methods :

(a) Ordinary methods (such as lab tests, X­ray examinations, ECG etc)

(b) Special and costly methods :

(such as scanning, ultrasonography etc.,)

(iii) Treatment methods :

(a) Surgical operations :

(b) Radiation treatment :

(c) Dialysis

(d) Any other method :

(iv) Special Nursing, Intensive care :

(v) Accomodation :

(vi) Consultation :

(viii) Any other items * Attach certificate from the AMA as in the para 5 of the Circular No.8152/MAD1/2008/Leg.

Dated 1­7­2009 ** Treatment at residence means the treatment provided at the residence of the patient, instead of at hospital, under special circumstances such as absence or remoteness of a suitable hospital and severity of the illness: vide rule 7(1) *** Vouchers i.e. Cash bills, receipts, etc. in support of the claims are to be produced together with the application. T.A. Claims are to be preferred in Gazetted Officers T.A. Bill form (TR 47). If T.A. is claimed for the attendant also, separate T.A. Bill Forms (TR 47 Forms) are necessary for the Ex­MLA and the Attendant.

9. If T.A. is claimed state ­

(a) Whether it is for :

(i) the patient only :

(ii) the patient and the attendant :

(b) Starting point and destination and the:

distance between them

(c) Mode/Modes of conveyance and the total distance travelled in each conveyance during the onward and return journeys :

(d) T.A. claimed for ­

(i) the patient :

(ii) the attendant :

(e) Total T.A. claimed :

8. Total amount claimed :

9. Enclosures***

(a) Vouchers :

(b) Certificates :

(c) T.A. Bills :

(d) Affidavit of non­remarriage, attested by a Gazetted Officer/MLA/ (for Spouses) :

(e) Any other enclosures :

Place :

Date : Signature of the applicant * Attach certificate from the AMA as in the para 5 of the Circular No.8152/MAD1/2008/Leg.

Dated 1­7­2009 ** Treatment at residence means the treatment provided at the residence of the patient, instead of at hospital, under special circumstances such as absence or remoteness of a suitable hospital and severity of the illness: vide rule 7(1) *** Vouchers i.e. Cash bills, receipts, etc. in support of the claims are to be produced together with the application. T.A. Claims are to be preferred in Gazetted Officers T.A. Bill form (TR 47). If T.A. is claimed for the attendant also, separate T.A. Bill Forms (TR 47 Forms) are necessary for the Ex­MLA and the Attendant.

Form No.2 ESSENTIALITY CERTIFICATE [See Rule 2(f)(iii) and (iv) and Rule 7 (1)] Certified that the following medicines/vaccines/sera/other therapeutical substances prescribed to Shri/Smt ............................................................................................../Spouse of ….............................................................................................Ex­MLA who was suffering from ..............................................…....the following materials used in his/her treatment, the special nursing provided to him/her, the following diagnostic and treatment methods applied in his/her case during his/her aforementioned treatment, were essential for the recovery/ for the prevention of serious deterioration in his condition and that the medicines do not include therapeutic substances ordinarily available in the Government Hospital, the preparations which are primarily used as food, tonics, toilet or disinfectant and such costly drugs, tonics, laxatives and other elegant and proprietor preparation for which, drugs of equal therapeutic value are available. Certified* also that among the fees claimed below the fees for administering injections and the fees paid to the nurses for having attended to the Ex­MLA Spouse at his/her residence are not included.

Sl.No. Date of Brand Name with Chemical/ Price/Cost/ of Voucher** voucher Pharmacological Name Fee/Charges of Medicine Rs. Ps.

(1) (2) (3) (4) Station : Signature, Name and Designation Date : of the authorised Medical Attendant (Office Seal) * The portion “ Certified also that......................................................... not included” applicable only if the treatment was at the residence of the Ex­M.L.A/Spouse as contemplated in Rule 7(1)­ Vide the Note under Rule 8.

** Arrange the vouchers in chronological order and assign serial number to each voucher and write the number.

Form No.3 ADVICE CERTIFICATE* [See rule 6(2) and (3)] Certified that I advised Shri/Smt...................................................................................

............................................................................ Ex­MLA Spouse of.................... Ex­MLA to undergo treatment at …....................................................................................................

(Name and address of the institution). ** Since there is no Government/Non­government medical institution in the Station/District/State or *** any other medical institution at that station, in which suitable and necessary treatment can be provided to him/her and that he/she was under treatment herefore the period from ...............................

to ........................................... and the Director **of Health Services/Indian Systems of Medicine/Homeopathy has approved the advice for the treatment at that hospital. Certified also that it was unsafe for him/her to travel unattended and that an attendant was necessary to accompany him/her to travel the place of treatment and back.

Signature, Name and Designation of the Authorised Medical Attendant.

Station :

Date :

(Countersigned) (Office Seal) District Medical Officer ......................................

(Office Seal) * The certificate is intended for the advice to :

(a) Government medical institution at the Station/District

(b) Non­Government medical institution at the Station/District

(c) Any medical Insitution inside/outside the State [vide Rule 6(1)] ** The portion “ since there is no ....................................and back” is to be scored off if the treatment treatment was at the station. The portion “the Director ...................................................at that hospital” is to be scored off, if the treatment was inside the State.

***The words “or any other medical institution at that station” is applicable only if the treatment is at a non­government medical institution in the district but outside the station.

The certificate portion “Certified also that ................................................ and back” is necessary only if T.A is claimed for the attendant accompanied.

Form No.4 CERTIFICATE FOR RESIDENTIAL TREATMENT [See rule 7 (3)] Certified that Shri/Smt. ........................................................................Ex­MLA/ Spouse of....................................................................................................... Ex­MLA has undgergone medical treatment at his/her residence for the period from..............................................

to ................................................................. since it was not possible to provide him/her hospital treatment, owing to the absence/remoteness of a suitable hospital near his/her residence/and owing to the risk involved in the journey to the nearest hospital because of the severity of his/her illness and that is this treatment had been provided to him/her at the nearest hospital instead of at his/her residence, the amount of the cost of similar hospital treatment would have been *₹ ........................................................

Signature , Name and Designation of the Authorised Medical Attendant Station :

Date :

(Office Seal) Countersigned Director of Health Service/ Indian Systems of Medicine/ Homeopathy (Office Seal) * In figures and words “FORM No. 5 DECLARATION [See Rule 3] I, …........................................ do hereby declare that the statements made in the application submitted for claiming reimbursement of medical expenses incurred for me/my spouse are true to the best of my knowledge and belief and that the medical expenditure is incurred for me/my spouse.

I also declare that I have not claimed the medical reimbursment over the bells and vouchers which I have submitted, along with the application, from any other institution/insurance agency.

Station:

Date:

Signature of the applicant” By order of the Governor, Dr.Asha Thomas IAS, Additional Chief Secretary to Government

1. Name and Address of the applicant :

2. Name of patient :

3. Period of Treatment :

4. The System under which treatment was received*:

a. Allopathy b. Ayurveda c. Homoeopathy

5. Station where the applicant fell ill and the headquarters of the Authorised Medical Attendant of that Station.

6. The place/Institution with its name and address, where the treatment was received.

a. Consulting room of the Authorised Medical Attendant b. Consulting room of the Government Medical Officer/Specialist c. Medical Institution.

d. Residence of the partients** of the Government has been obtained :

(viii) Any other items * Attach certificate from the AMA as in the para 5 of the Circular No.8152/MAD1/2008/Leg. Dated 1-7-2009 ** Treatment at residence means the treatment provided at the residence of the patient, instead of at hospital, under special circumstances such as absence or remoteness of a suitable hospital and severity of the illness: vide rule 7(1) *** Vouchers i.e. Cash bills, receipts, etc. in support of the claims are to be produced together with the application. T.A. Claims are to be preferred in Gazetted Officers T.A. Bill form (TR 47). If T.A. is claimed for the attendant also, separate T.A. Bill Forms (TR 47 Forms) are necessary for the Ex-MLA and the Attendant.

9. If T.A. is claimed state -

(e) Total T.A. claimed :

8. Total amount claimed :

9. Enclosures***

(e) Any other enclosures :

* Attach certificate from the AMA as in the para 5 of the Circular No.8152/MAD1/2008/Leg. Dated 1-7-2009 ** Treatment at residence means the treatment provided at the residence of the patient, instead of at hospital, under special circumstances such as absence or remoteness of a suitable hospital and severity of the illness: vide rule 7(1) *** Vouchers i.e. Cash bills, receipts, etc. in support of the claims are to be produced together with the application. T.A. Claims are to be preferred in Gazetted Officers T.A. Bill form (TR 47). If T.A. is claimed for the attendant also, separate T.A. Bill Forms (TR 47 Forms) are necessary for the Ex-MLA and the Attendant.