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Sml::- Frareimg thc Bolicy guidelines regarding- Calculation of reimbursprnenf-
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.by Raihvey A*er c.areful
The.issue of simpiification of prafor.maf*r claiming Medical benefi.ciarieshas been engaging attsntior of the c*nsideration in the tnatfer, a ne\ry pJofoffia has been
Railv'-aysare requestedta replace:tlre ex,istingproforma Railway Medicai benefi.ciariesas p€t enclosedrevised
Carestion slip to A*rexure IiI ef herervitb.
srryof Rai
This hasthe approva! ' 1
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DA/Tvn
{R.S.Sh*kla) *ir*ei*r ffie*itt':) Board R*i.trn'ay
Cepyto:-. I. Chief &f
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cerssf trndiall&.ei?ways {ineludingFU* ard
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No. I/l2/part v
FA & C*s"Ail Sesi*r Pr*fess*rl
Raiin'ays {i.*eludiagF{Jssriil R.eg*}" Indies Raiiways{F{AIR'i,frar*&*, Gwi*raf' .*Ncadernl' I Na^$ional
@ Nattonat Federation of Indian Railwoymen (N,F.LR) 3' Chelmsford Road, New Delhi' Dated:03/08/2017
Copy together with enclosures is forwarded to the General Secretaries of affitiated lJnions of NFIR. AfJiliates may rccall that tke issue o{ simpliJication procedure for reimbursement of medical expenses ingyyed by the serving and rctired Railway empliyees was iaken up by NFIR ia" pNtut nim No. 4I/201 6. C/: Media Centre/NFIR. C/: File No,41/2016 (PNM). C/: IRIV.
st--'?;( .-^l (Dr. M. Raghavaiah) GeneralSecretary
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ro Froforma for cladunh:g AncexureIII refened to in Para648 of IRMM ?6il* relating is arnendedas per enclosed MedicatrReimburs*mentby Railavayh'iedicalbenpfi*iariee Proibrma.
iAuth*ritystal'd'slettrrHa'?*05&{1s.4lpc1i*;g^tdated01.06'201?}
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REIMBTJRSEMENT CLAIPf FORM
t. ., 4. 5. 6, 7.
Nameof theReitrwayl Retd.eniployee{in BLOCKletters) , . Designation cf theRailwaylReid"onplo5.'cc {in BI,OCKletters} OfficeandStarjonof ranployment Payll-*stPayaf tke&ailway/&et{. -erx1ployee inctudinggradepay Residential ad&ess MICIRELHSno.andissuirrgAu$oity MIC/ REttlS rvgir*tersd sxI{ Uni# }fospita,!
tr {A}Hamr ard4ge ofrha pntiant U {A} Patlesl"s -relefioa'r.ship h the&lil S.etrd..ernplcyee III Details of Indoor Treaiment at Non Railway Institute A. Name ofHospjtal: B, Date of Admission: ' C, he.ofDi*chalge: D. Diagnosis; S. Amount of Total Hospital Bill (Attach detailed bill): F. Whether Treatfient was taken in Emergency: G. Are you a CTSE member{YAJ}: IV. Whether subscribing to any Health Insurafic€Policyl 616ouoed under any ofher health scheme: tf yes, haveyou received ar-ryamount firrm insuranceccmpany-for the treab:rentin qutstion. Cive details:if any on separat"*r"et of pupur, V. Tstal Arnount Claimed: Vl. Details of Bank aocountwherc Reimbursernentamount is ro be paid:. b- fu$9ttntNo. a Narne pfBank d. IFSC Code c. BranchMICR Ccde VIl.
U* of enclosures(Please,:Ii,ckihedoeumentsafiachedand write addltional docum8nts) A. Photocopyof MIC/ RF.LHS card B. E*ser*iality cum EnrergencyCcrtiticate by the Noa Rly Hospital C. DischargeSurunary D. Original-Bitlsof Hospital E, Original Casbvoucbers d.fDrugs/consurmbles/in'rplantsetc. if relevant : R :,Ou&rpo*ir of Stsnq pscemsker,fmplants etc. ...,-........ G. Any otherenclosure (ln-caseof many enclosures"write numbei of additiond enclosuieshere and fltach a $cpafiatesheetwi$r details)
DTiCI*4,R.{IXON TO AE ST€}.{E} SY T TS RA&\EIAY EMPLOYEE f Uerely de*lare that the staterflentsin ttris applicatisn tre ffus !0 the best of my knowlcdge and belief and tbat tht pcoon for 'whom mciical expenses were incurred is rvholly dependent upon me. I am aware drat misuss of medical facilities or misepresentation of *y kind caa attract penal aciion including canccllation of MICY R.ELHSCard. I hereby'declarethat tbis is my final claim and I shall not make any claim in future to R.ly or any otherheakh schemeinrespect to this tteat{nent€pisode.
$ignature of the,Rail\aay;ernplslFe.
1 ln ease the beneficiaryhat rnedicalinsurancepolicryand intend tc makeclaim for the treatrn€fnih qu€stiof}then he,/shemay make claimto lnsurancecompanyfirst and ttlen submit clalmta Rlywith docume$ts"billsets' attested by lnsurancecornn!11,
