HRD in CBEC - Directorate General of human resource ...

HRD in CBEC - Directorate General of human resource ... HRD in CBEC - Directorate General of human resource ...

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Details of the Claims Total Amount Amount Non- Amount reimbursed Admissible Spent as per CS(MA) rules Cost of treatment (Doctor’s fees, Medicines, Test, Procedure etc. ICU/CCU charges Room Charges other than ICU/CCU Sundry Charges (Viz Telephone bills, guest room charges, food, conveyance, diet, Ambulance etc.) Total Signature of Commissioner/HOD Name 79

CHECK LIST FOR PROPOSALS FOR GRANT OF FINANCIAL ASSISTANCE OF EXPENSES ON TREATMENT Check that: 1. Copy of request letter of the applicant is enclosed. 2. Claim has been settled under CS(MA)/CGHS Rules. Copy of Sanction Order/ Sanction for reimbursement of medical claim under CS(MA)/CGHS Rules has been enclosed. 3. Copy of bills/vouchers of medical expenses submitted with the medical claim have been enclosed. 4. Proposal has been submitted within prescribed time limit. 5. In case of proposals submitted after the prescribed time limits, justification for condonation of delay have been given. 6. The following certificates as required in Annexure-III have been furnished:- (i) Advisory Committee recommendation. (ii) In case financial assistance is sought for medical expenses incurred on dependent children & spouse, amount of financial assistance received by the applicant earlier from the Welfare Fund for the medical expenses incurred on treatment of dependents. (iii) In case financial assistance is sought for medical expenses incurred on treatment of spouse, a certificate that the spouse of employee/ officer is not working in any State/Central Govt, Banks, PSUs, Private Organizations or is self employed etc. (iv) In case financial assistance is sought for medical expenses incurred on child birth, certificate that the number of surviving children is not more than two. 80

Details <strong>of</strong> the Claims Total Amount Amount Non-<br />

Amount reimbursed Admissible<br />

Spent as per CS(MA)<br />

rules<br />

Cost <strong>of</strong> treatment<br />

(Doctor’s fees,<br />

Medic<strong>in</strong>es, Test,<br />

Procedure etc.<br />

ICU/CCU charges<br />

Room Charges other<br />

than ICU/CCU<br />

Sundry Charges<br />

(Viz Telephone bills,<br />

guest room charges,<br />

food, conveyance,<br />

diet, Ambulance etc.)<br />

Total<br />

Signature <strong>of</strong> Commissioner/HOD<br />

Name<br />

79

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