Pct Forms

Proforma – I Application form for claiming reimbursement against OP treatment under the NMDC’s Contributory Scheme for Post Retirement Medical Facilities who are not availing PCT. 1.(a).

Name of the Retired Employee

: ____________________________________________

Designation & Employee No.

: ____________________________________________

2.

Name of the Spouse

: ____________________________________________

3.

Medical Card No./Validity

: ____________________________________________

4.

Category to which the Retired Employee belongs : A

5.

OP Claim for the period

: April_____to Sept.______/ Oct______ to Mar_______

6.

Amount Claimed

: Rs._________________/-

7.

Name of Bank & Account No.

: ____________________________________________

8.

Address for Forwarding the Cheque

(b).

B

C

: ____________________________________________ ____________________________________________ ____________________________________________ Certified that the amount claimed against OP treatment for the period mentioned above has been actually incurred by me in respect of treatment for Self / Spouse. (Name & Signature of Claimant) 9. Place / Date : ……………………………………………………………………………………………………………….. [To be filled in by Finance Department] Checked, verified and claim passed for Rs.______________/(Rupees _________________________________________________ only)

JM(F) / AM(F) / MGR(F) / AGM(F) ……………………………………………………………………………………………………………….. Note : a. Claim for the half year – Apr. to Sept. – should be submitted by 10 th Sept and for the half year – Oct. to Mar by 10th of March of every year to the Asst. General Manager(F)(PC), NMDC Ltd., Masab Tank, Hyderabad – 500 173. b. Annual OP Ceiling Category A – E7 & Above B – JO’s, E0 to E6 C – Workmen

Amount Rs.12,000/Rs.9,200/Rs.6,000/-

c.

Workmen / JO’s should submit their claim to the respective Unit from any where they retired.

d.

Claim in respect of IP treatment continue to be submitted in the existing format. ***

Proforma – II Application form for claiming reimbursement against OP treatment under the NMDC’s Contributory Scheme for Post Retirement Medical Facilities who are availing PCT. 1.(a).

Name of the Retired Employee

: ____________________________________________

Designation & Employee No.

: ____________________________________________

2.

Name of the Spouse

: ____________________________________________

3.

Medical Card No./Validity

: ____________________________________________

4.

Category to which the Retired Employee belongs: A

5.

Details of PCT availed by Self / Spouse / Both i) Period of PCT sanctioned: From___________________ to ____________________ (for Self) ii) Period of PCT sanctioned: From___________________ to __________________ (for Spouse)

6.

a) Half-Yearly OP claim for the Period : Apr______to Sept______ / Oct______ to Mar________. b) Quarterly claim for prolonged Treatment: Oct______to Dec______/ Jan______to Mar_______

7.

Amount Claimed a) Half-Yearly: Rs.______________/-

(b).

8.

Name of Bank & Account No.

9.

Address for forwarding the Cheque

B

C

b) Quarterly: Rs.______________/: ____________________________________________

: ____________________________________________ ____________________________________________ ____________________________________________ Certified that the amount claimed against OP treatment for the period mentioned above has been actually incurred by me for the medical treatment of Self / Spouse. 10. Place / Date : (Name & Signature of Claimant) ……………………………………………………………………………………………………………….. [To be filled in by Finance Department] Checked, verified and claim passed for Rs.___________________/(Rupees _______________________________________________________ only) JM(F) / AM(F) / MGR(F) / AGM(F) ……………………………………………………………………………………………… Note: a) OP entitlement Category Annual OP ceiling if Annual OP ceiling Ceiling for cost of medicines purchased Self or Spouse (one if Self & Spouse for PCT availed by member) avails PCT. (both avail PCT) Self/Spouse / Self & Spouse A – E7 & Above Rs.9,000 Rs.4,285 Rs.1,400 pm Rs.1,150 pm, per member B – JO’s, E0 to E6 Rs.6,900 Rs.2,875 Rs.1,150 Rs.875 pm, per member C – Workmen Rs.4,500 Rs.2,000 Rs.850 Rs.725 pm, per member b) Claim for the half year – Apr to Sept should be submitted by 10 th Sept and for the half year – Oct to Mar – by 10th Mar every year to the Asst. General Manager (F)(PC), NMDC Ltd., Masab Tank, Hyderabad – 28 for release of payment. c)

Similarly, claim for quarterly payment towards cost of medicines for PCT should be sent by 10th Jun, 10th Sept, 10th Dec and 10th Mar for release of payment by July, Oct, Jan and Apr, attaching a copy of the approval for availing PCT, certified prescription and Original Cash Memos.

d)

Workmen / JO’s should submit their claim to the respective Unit from where they retired. ***

Appendix – III N M D C LTD., MASAB TANK, HYDERABAD. NMDC CONTRIBUTORY SCHEME FOR POST RETIREMENT MEDICAL FACILITIES Claim Form for Reimbursement of IN-PATIENT MEDICAL EXPENSES incurred by the Retired Employees:Name & Grade of the Retired Employee

Employee No.

Present Address at which the Cheque is to be sent

Last Pay Drawn

Medical Pass Book No. ______________. Validity___________.

: ________________________________________ ________________________________________

_ ________________________________________ _ ……………………………………………………………………………………………………… 1. Name of the Patient : ________________________________________ 2.

Relationship with the Retired Employee: ______________________________________

3.

Place at which the patient fell ill

4.

Name & Address of the Hospital from where treatment taken :_________________________________________

: ________________________________________

5. Period of Treatment : ________________________________________ …………………………………………………………………………………………………….... (To be certified by the Retired Employee) I hereby declare that: a) The statements made in the claim are true to the best of my knowledge and belief. b) I am a member of the Contributory Scheme to Post Retirement Medical Facilities and my Medical Pass Book is valid for “Life Time”. c) I continue to fulfill the conditions of eligibility for availing the benefits under the Scheme d) The medical expenses were incurred for Self / Spouse. e) I fully understand that the Company may refuse / terminate my membership of the scheme at any time with out any notice and without assigning any reason(s). Date: Signature of the Retired Employee / Survivor ……………………………………………………………………………………...................... (To be certified by the Finance Department) Checked, Verified and Claim passed for Rs.___________/- (Rupees ______________ _____________________________ only). JM(F) / AM (F) / MGR (F) / AGM (F) Cont……

DETAILS OF THE AMOUNT CLAIMED A. 1.

Consultation Fees : Date: Amount: Rs. a.___________ ____________ b.___________ ____________ c.___________ ____________ d.___________ ____________ Total 1 : Rs.___________________/-

2.

Injection administration fees Date: Amount: Rs. a.___________ ____________ b.___________ ____________ c.___________ ____________ d.___________ ____________ Total 2 : Rs.___________________/-

3.

Medicine purchased from market : Cash memo No./Date: Amount: Rs. a.________________________ ____________ b.________________________ ____________ c.________________________ ____________ d.________________________ ____________ Total 3 : Rs._______________/Total A (1+2+3) =Rs.________________________/-

B.

Pathological tests: Name of the test: a.________________________ b.________________________ c.________________________ d.________________________ Total B : Rs.______________/-

Amount: Rs. ____________ ____________ ____________ ____________

C. 1. Accommodation charges : Rs.___________/- for ________days period from__________ to ______________ Rs._________/- per day. 2. Surgical operation charges

: _________________________

3. Cost of Medicines

: __________________________

4. Other Charges

: __________________________

5. Total C

: __________________________

Total amount claimed (A+B+C)

: ___________________________ ***