Here I will be describing my personal experience with an Empanel hospital, ECHS Polyclinic and ECHS RC-1. This post aims to help the ECHS beneficiaries and to guide them on how to take certain precautions while dealing with empaneled hospitals and non-empaneled hospitals.
Full form of ECHS is the Ex-Servicemen Contributory Health Scheme. The aim of this scheme is to take care of the medical needs of the army veterans and their family(do not cover children who are married and earning). Ex-servicemen pensioners and their dependents are entitled for treatment in service hospitals and in civil/private hospitals which are specifically empaneled with the ECHS.
Eligible Hospitals Under ECHS
For ECHS the hospitals are divided into two categories i.e. empanel and non-empanel hospital.
Empanel hospitals are further divided in two categories which the ECHS officials themselves are not aware of.
- These hospitals do not charge anything from the ECHS beneficiary and they get the money spent on the ECHS beneficiary treatment directly into their account from the government. The patient is just required to do some formalities by visiting the polyclinic and get the documents signed from polyclinic which are provided by the hospital , and
- The other hospitals are also empaneled but they do not provide cashless treatment. These hospitals misguide people and ask the patient to deposit the cash for treatment upfront and then claim the same amount from the ECHS. No doubt you will get the amount back but the process of applying and getting the claim takes around six to twelve months and there is uncertainty on the amount that will be reimbursed by ECHS.
When I enquired about this from officers of ECHS they bluntly said you are not supposed to pay any money to empaneled hospitals and the empaneled hospitals cannot put such frivolous demands. The ground reality is that they are doing this practice and there is no one keep a check on them
Non Empaneled Hospital
ECHS beneficiary can get the treatment from a non-empaneled private hospital as well and can claim the reimbursement of the amount spent in hospital for treatment from ECHS. There is a due process to claim that money. Primary condition for claiming and applying for the reimbursement of the amount is that patient must be taken to the private hospital in an emergency condition. You can claim reimbursement of the amount spent for treatment in a private hospital in an emergency case only.
The reimbursement you will get is at the ECHS rates and the ECHS rates are generally one-third of the expenditure incurred in a private hospital. For example- if the bill in a private hospital is three lakhs then the amount you will get in reimbursement is one lakh only approximately.
Requirements/Procedure to Get The Hospital Expenditure Reimbursed From ECHS
When in an emergency situation you could not access the ECHS empanel hospital and you could not even get to the government hospital and instead you admit the ECHS beneficiary to the private hospital of your choice for a timely treatment then according to the guidelines of the ECHS you can claim the reimbursement of the amount spent on the ECHS beneficiary from the ECHS. To claim the amount you need to be meticulous with the paperwork.
List of the documents required to be submitted with ECHS for reimbursement of the said amount is mentioned below:-
- Application to OIC polyclinic for reimbursement.
- ECHS card photocopy and aadhar card photocopy.
- EIR/Referral/Waiver Certificate.
- Emergency Certificate.
- Discharge Summary.
- Hospital final bill, break up bill and payment receipts.
- All lab reports including X-Rays
- If an implants procedure is done(stent invoice outer cover & implant invoice for cardio and ortho case).
- One cheque leaf(cancelled).
- Contingent bill with revenue stamp and sign.
- Personal data (name, address and mobile no.)
- File cover.
My suggestion is that you should be very apt with the paperwork from the beginning itself and collect all the documents from the hospital as when the documents are ready with the hospital. ( In my experience I have to run to the hospital more than a couple of times to collect these documents as I was not aware about the procedure for reimbursement).
PROBLEMS FACED BY MY FAMILY WHICH YOU SHOULD AVOID
My case personally deals with Bhagat Chandra Hospital which is an empanelled hospital with ECHS. When we reached this hospital my grandmother was already on a ventilator. Bhagat Chandra Hospital bluntly refused to admit my grandmother by saying that “you cannot avail the ECHS facility at this hospital unless and until you get a prior permission from ECHS polyclinic”. We, being unaware of the rules and regulations of ECHS, went to the ECHS polyclinic to obtain the referral. At the polyclinic we were told that the process of referral has to be initiated by the empanel hospital itself.
When we told about the same to the superintendent of the hospital, we were told that polyclinic doctors were misleading us but on the contrary it was the superintendent of the hospital who was misleading us and I realized it when she took the money from us for the treatment and even claimed the said amount from the ECHS.(I am able to get some amount back with the help of the Director of ECHS)
Since we were not able to obtain the referral in spite of running pillar to post. The superintendent of Bhagat Chandra hospital very cleverly asked us to give in writing that “we are willing to bear the expense of the patient in cash and do not want to avail benefits of ECHS empanel hospital”.
The hospital crossed all the limits when they asked us to take the patient to the base hospital and ECHS polyclinic to get the referral in such a critical condition while the patient was on a ventilator. When we confronted them they said that it is a rule under the ECHS scheme. (I read the whole website and rules of the ECHS and nowhere it such rule was mentioned)
It was during this critical time when we took my grandmother to the base hospital on a ventilator for referral, the health of my grandmother deteriorated in such time and then she passed away a couple of days later. The said hospital took the amount from us and further claimed the amount from ECHS as well.
Not every hospital tries to extract the amount from your pocket and exploit the patient but there are a few hospitals like this and you must be aware about this and always try to get every communication in writing from the hospital and the Officials of ECHS.