In exercise of power conferred Under Section 91 181 of the Electricity Act, 2004 and Chapter IV para 18.2 of JERC for the State of Goa UTs

REGD. No. D. L.-33004/99 The Gazette of India CG-HR-E-25112024-258890 EXTRAORDINARY PART III—Section 4 PUBLISHED BY AUTHORITY No. 927] NEW DELHI, WEDNESDAY, NOVEMBER 20, 2024/KARTIKA 29, 1946 JOINT ELECTRICITY REGULATORY COMMISSION (For the State of Goa & UTs) NOTIFICATION Gurugram, the 12th November, 2024 F.No. JERC 34/2024.— In exercise of power conferred Under Section 91 & 181 of the Electricity Act, 2004 and Chapter IV para 18.2 of JERC for the State of Goa & UTs (Recruitment Control and Service Conditions of Officers and Staff) Regulations, 2009, the Joint Electricity Regulatory Commission hereby makes the following Regulations, namely: - 1. Short Title, Extent of Application and Commencement i. These regulations may be called the Joint Electricity Regulatory Commission (Medical Facility) Regulations, 2024. ii. These shall apply to all the employees of the Commission on regular appointment, deputation or short- term contract, retired employees and their families excluding the Chairperson and Members of the Commission. iii. These Regulations shall come into effect from the date of publication in the official Gazette. 2. Definitions In these Regulations, unless the context otherwise requires: - i. "Authorised/Notified Medical Practitioner" means a registered medical practitioner having a degree recognized under the Indian Medical Council Act, 1956 as amended from time to time, or a Registered Medical Practitioner holding Degree or Diploma in Ayurveda/Unani/Siddha/Homeopathy of not less than 4 years duration from a University/Statutory Board/Council/Faculty of Indian Medicine and Homeopathy and equivalent, included in the Schedules of Indian Medicine Central Council Act, 1970/Homeopathy Central Council Act, 1973, as the case may be and registered with the State Medical Council. ii. "Commission” means Joint Electricity Regulatory Commission (For the State of Goa & UTs) iii. "Controlling Officer” means Secretary of the Commission or any other officer to whom such powers may be delegated by the Commission for the purpose of these Regulations. iv. "Employee" means any person appointed by and on the rolls of the Commission, who is allowed to avail the benefit under these regulations by the Joint Electricity Regulatory Commission and also includes the employees who have superannuated (at the age of 60 or as decide by the Central Government) from the Commission, having rendered service of not less than 5 years, after being permanently absorbed in the Commission." Employees in case of his/her retirement on medical incapacitation before superannuation shall also be eligible to avail the benefit under these regulations. Employees in case of his/her voluntary retirement by giving notice of not less than three months in writing to the Commission after he/she rendered more than 20 years of service in PSUs/Government/Autonomous Body /Statutory body etc. as a regular Employee, put together as on date of voluntary retirement and must have also put a minimum of 05 years of service in this Commission. v. "Family" means the employee's spouse, parents, unmarried sisters, minor /unmarried brothers, widowed daughters, widowed sisters, children and step children (including legally adopted children) wholly dependent upon the employee as per provisions of CS (MA) Rules of Govt. of India as amended from time to time. vi. "Patient" means an employee of the Commission or their family members to whom these Regulations apply and who is in need of medical attendance and treatment. vii. The members of the family shall also be entitled to medical attendance and treatment even if they do not stay with the employee. viii. "CGHS beneficiary” may avail CGHS facility as per CGHS Rules and shall not be entitled to these facilities. ix. The medical facilities can be availed only if the retired employee and his/her spouse are not availing any medical facilities from or through the Central/State Government/Public Sector Undertaking/ other authority etc. x. Medical facilities to the employee and his / her dependent family members (as defined in the Central Services (Medical Attendance) Rules, 1944 as amended from time to time) will be admissible for the treatment undergone only in India or otherwise stated specifically. xi. "Empanelled Hospital and Diagnostic Centre" means the Government Hospitals/Diagnostic Centres including all recognised Private Hospital/Diagnostic Centres under CGHS for Specialised and General-Purpose Treatment and Diagnostic Procedures recognised vide Ministry of Health & Family Welfare as amended from time to time or any private Hospital/Diagnostic Centre notified/authorised by the Joint Electricity Regulatory Commission. Any changes subsequently made shall automatically apply to the beneficiaries. xii. "Treatment" means the use of all medical and surgical facilities available at the hospital in which the employee is treated and includes: - a. The services of such pathological, bacteriological, radiological, advance technology method or other methods as are considered necessary by the authorised medical attendant; b. The supply of such medicines, vaccines, sera or other therapeutic substances as are ordinarily available in the hospital and as are admissible under CS (MA) Rules; с. The supply of such medicines, vaccines, sera or other therapeutic substances not ordinarily so available as the authorised medical attendant may certify in writing to be essential for recovery or for the prevention of serious deterioration in the condition of an employee except the items mentioned below, namely: - i. preparations which are not medicines but are primarily foods, tonics, toilet preparations or disinfectants and expensive drugs, tonics, laxatives or other elegant and proprietary preparations as specified in Schedule I; and ii. expensive drugs, tonics, laxatives or other elegant and proprietary preparations as specified as Schedule II for which drugs of equal therapeutic value are available. d. A list of Ayurvedic, Unani, Siddha and Homoeopathic medicines for which a refund is admissible is also given in the same Appendix as Schedule III. e. Such accommodation as is ordinarily provided in the hospital as per entitlement as laid down in Regulation 8. f. Physiotherapy and other treatments associated with an integrated system of medicine including, allopathy, Homeopathy, ayurvedic, Unani and Siddha system; g. Such nursing as is ordinarily provided to in-patients by the hospital; and h. The specialist consultation is described in these regulations but does not include diet or provisions at the request of the employee or accommodation superior to that described in Regulation 8. 3. A list of Authorised Medical Practitioners will be prepared and maintained by the Commission, area-wise, on the request of the employees and based on relevant documentary proof including prescription with the registration number of the concerned Registered Medical Practitioner. If an employee is receiving OPD treatment from the empanelled hospital with this Commission /CGHS- recognised hospital (after getting the referral from his AMA), the attending doctor of that empanelled hospital will also be treated as a deemed authorised/Notified Medical Practitioner for the Commission. 4. Procedure for availing outdoor treatment i. The officers and staff/retired/superannuated employees of this Commission, will be entitled for reimbursement of medical expenses for OPD treatment for themselves and their family members including dependents with the annual limits based on the last cell of the corresponding pay matrix in which they are/were working, applicable from April to March every financial year on production of prescription from authorised/notified Medical Practitioners along with bills/cash memos of medicine/test & Investigations. ii. This annual limit is not inclusive of the expenses incurred on major tests such as MRI, CT scan, Angiography etc. which will be reimbursable on an actual basis or the limits laid down by CGHS, whichever is lower. iii. The annual ceiling amounts indicated above can be claimed on production of medical bills/cash memos as per proforma at Annexure-II. 5. Procedure for availing indoor treatment i. Employees/Retired Employees and their dependants may take indoor treatment from the empanelled hospitals mentioned in CGHS list issued from time to time or the hospitals or any private Hospital/Diagnostic Centre notified/authorised by the Joint Electricity Regulatory Commission and the expenses incurred by the employees in this regard will be reimbursed by the Commission to the employee as the case may be, subject to admissibility and rates prescribed in the CGHS as amended from time to time. ii. In case treatment is obtained from any private hospital/nursing home (i.e. other than hospitals mentioned in the CGHS list issued from time to time by the MoHFW or Hospitals authorised by the Commission) in an emergency the reimbursement for such treatment will be limited to the rates prescribed in CGHS or actual expenses incurred, whichever is less. iii. The employees of the Commission shall be entitled for medical treatment including the cost of treatment, pathological, radiological, scanning, hospital accommodation, nursing home facilities etc. as per the package rates prescribed by the Ministry of Health and Family as amended from time to time. iv. The employees of the Commission may get medical treatment in any of the empanelled hospital/diagnostic centre on the advice of Authorised/Notified Medical Practitioner/attending physician. However, in case of emergency they may directly go to any private or recognised private hospital/diagnostic centre nearest to their place of residence. v. The charges paid for clinical tests, etc, to a private non-recognised hospitals/diagnostic centre shall be reimbursable as per rates prescribed for CGHS beneficiaries. Where there are no rates prescribed, the expenses incurred shall be reimbursed on actual basis. vi. If during treatment in an empanelled hospital/diagnostic centre, special nursing becomes necessary, the employee or a member of his family shall be entitled to such special nursing as may be deemed essential for the recovery or for the prevention of serious deterioration in the condition of the patient having regard to the nature of the disease. The amount to be reimbursed for such special nursing shall be limited to the amount, which is in excess of 25% of the pay of the employee concerned for the period for which special nursing was necessary. For this purpose, a vii. certificate from the Medical Officer-in-charge countersigned by the Medical Superintendent shall be produced. viii. The beneficiaries (employee/retired employee of JERC) who have subscribed to Medical Insurance Policies in addition to availing CGHS facilities / Central Services (Medical Attendance) Rules, 1944, may be allowed to claim reimbursement from both the sources subject to the condition that the reimbursement from such sources should not exceed the total expenditure incurred by the beneficiary on the treatment. If the medical claim against the original vouchers/bills is raised by the beneficiary first from the insurance company, then the insurance company will issue a certificate indicating the amount reimbursed to the beneficiary. The insurance company concerned will retain the original vouchers/bills in such cases. The beneficiary would then prefer his/her remaining medical claim along with photocopies of vouchers/bills duly certified by him/her, along with a stamp of the insurance company on the reverse of the vouchers / bills to the JERC. Reimbursement to the beneficiary shall be restricted only to the admissible amount as per approved rates subject to the condition that the total amount reimbursed by the two entities (Insurance Company & JERC) does not exceed the total expenditure incurred by the beneficiary viii. Package rates for the duration of indoor treatment are as follows: a. 12 days for specialized procedure. b. 7-8 days for other procedures. с. 3 days for laparoscopic surgery. d. 1 day for day care/minor procedures (OPD). 6. Procedure for application for registration/renewal of medical card for retired employee: - i. An employee who is willing to avail the medical benefits for self/spouse/dependants (as defined in the Central Services (Medical Attendance) Rules, 1944 as amended from time to time) after retirement shall submit an option within a period of three months prior to the date of superannuation/Voluntary retirement/retirement on Medical Incapacitation from the Commission as per format specified in ‘Annexure III'. Provided that in case of death of an employee prior to his/her superannuation, the dependents of such employee can opt for these medical facilities. ii. Such employee/dependent shall be registered by issuing medical card as per format specified in 'Annexure IV' within one month from the date of application. The medical card issued shall be valid for a period of five years from the date of superannuation or death of the employee, as the case may be. iii. Provided that in case of any change in the family (as defined in the Central Services (Medical Attendance) Rules, 1944 as amended from time to time) details, the same shall be intimated immediately to this Commission, in writing, who shall on receipt of such intimation issue a modified medical card within one week. iv. The Medical card shall be renewed every five years. The employee/ dependents (as defined in the Central Services (Medical Attendance) Rules, 1944 as amended from time to time) shall be required to apply for renewal within three months prior to the expiry of the medical card (as per format in Annexure IV) to the Secretary, JERC, who shall within a period of one month of the application convey the approval of renewal by issuance of a new medical card. v. In the event of death of the employee after retirement, the spouse and other eligible dependant member of the family (as defined in the Central Services (Medical Attendance) Rules, 1944 as amended from time to time) may continue to avail the facility. vi. The Medical Card shall be rendered invalid from the date any of the eligibility conditions ceases to be fulfilled by the employee or his/her dependant (as defined in the Central Services (Medical Attendance) Rules, 1944 as amended from time to time). 7. Advance for Medical Treatment i. All expenses on indoor treatment shall initially be met by the employee himself and shall claim for medical reimbursement on completion of the treatment. However, on the request of the employee, the competent Authority, JERC may grant an advance to enable him/her initially to meet expenditure on medical attendance and treatment for himself/herself and members of his/her family in the following cases subject to production of a valid prescription and estimate by AMA/CGHS empanelled Hospital, after obtaining approval from the Commission. a. For indoor treatment at a hospital b. For OPD treatment in the case of TB/Cancer ii. The amount of advance shall not exceed 90% of the amount estimated by the treating AMA or demanded by such hospital. iii. The advance paid to the employee shall be adjusted against the medical claim and balance, if any, shall be refunded forthwith. iv. Normally the recognised private hospitals/diagnostic centres who entered into agreement with the Commission shall charge the rates approved for the package rate. They shall extend credit facilities in emergency cases and submit the bill for reimbursement as per approved rates to the Commission. However, in case of hospitals/diagnostics centres insisting on immediate payment of the cost of treatment, room rent, medicines, various test, etc., the Commission may sanction advance payment to the extent of 90% of approximate expenses as per package rate prescribed for CGHS beneficiaries and issue an account payee Cheque either in the name of the hospital concerned or beneficiary. The balance payment shall be made on submission of final claim by the beneficiary. 8. Accommodation Entitlement of wards for various categories of officers/officials for indoor treatment in Private Empanelled Hospitals will be as follows: - +-----+-----------------------------------+-----------------------------+-----------------------+ | SI. | Corresponding Level in Pay | Ward Entitlement | Room Rent (in ₹) | | NO. | Matrix as per 7th CPC | | | +=====+===================================+=============================+=======================+ | 1. | Upto L6 | General | 1500/- per day | +-----+-----------------------------------+-----------------------------+-----------------------+ | 2. | L7 to L10 | Semi-Private | 3000/- per day | +-----+-----------------------------------+-----------------------------+-----------------------+ | 3. | L11 and above | Private | 4500/- per day | +-----+-----------------------------------+-----------------------------+-----------------------+ | 4. | Day care | Day Care (6-8 Hrs Admission)| ₹ 500/- per day for all | +-----+-----------------------------------+-----------------------------+-----------------------+ 9. Submission of Medical Claims i. Final claims for reimbursement of medical expenses for a particular spell of illness shall ordinarily be preferred within three (3) months, from the date of completion of the treatments. ii. All claims for reimbursement should be accompanied with the doctor's prescription, chemist's cash memo, doctors/hospital receipt in respect of consultations/medicines etc. (as required under these Regulations), shall be submitted along with the claim form. iii. The application for medical claims for Indoor/IPD treatment shall be submitted in the prescribed form given at Annexure-I. iv. The application for medical claims for OPD treatment shall be submitted in the prescribed form given at Annexure-II. v. Claim for outdoor treatment in respect of retired employee may be preferred once in a month. vi. All expenses on indoor treatment shall initially be met by the employee himself and shall claim for medical reimbursement on completion of the treatment. vii. CGHS beneficiaries will submit their medical claims as per CGHS rules. viii. An intimation in writing (through email, fax, etc.) regarding retired employee or his/her dependant (as defined in the Central Services (Medical Attendance) Rules, 1944 as amended from time to time) for serious illness needing hospitalization to be sent to the Secretary, JERC within 72 hours of the hospitalization. ix. The employee shall submit the medical claim in the prescribed format with all relevant supporting vouchers/documents 'in original', to the JERC within three months from the date of discharge. The Administration division of JERC shall verify and ensure, before accepting the claim papers that all relevant documents are enclosed and issue a dated acknowledgement to the claimant in token of receipt of the medical claim. x. If any deficiencies / gaps are found in the medical claim documents/papers, the JERC, shall retain the papers and communicate the list of deficiencies/observations to the employee for removing the deficiencies/shortcomings within one month from the date of the receipt of medical claim. The medical claim may also be returned in original to the beneficiary, if it is absolutely necessary for doing the needful to remove the deficiencies. xi. The medical claim should be scrutinized and processed as per this Medical Regulations of JERC. The amount found admissible may be passed for payment, subject to conditions as stated above. The payment shall be credited online in the Bank Account of the beneficiary within three months by Accounts Division, JERC (excluding the time taken by the beneficiary in attending the deficiencies / shortcomings, if any, in medical claim) from the date of the receipt of the medical claim. 10. When both Husband and Wife are in service In case where both husband and wife are in service and eligible for medical facilities from their respective employer, they, as well as eligible dependants, may be allowed to avail of the medical concessions facility according to his/her status. For this purpose, they should furnish to their respective authorities a joint declaration as to who will prefer the claim for reimbursement of medical expenses incurred on the medical attendance and treatment in respect of wife/husband and the children. The above declaration should be submitted in duplicate and a copy of each shall be recorded in the personal file of each of them in their respective office. This declaration shall remain in force till such time as it is revised on the express request in writing by both the husband and the wife, e.g., in the event of promotion, transfer, resignation, etc., of either of the two. 11. Cases where the family stays outside Headquarters (Station) i. Where the family of the employee does not reside at the same place where the employee is posted, they may avail of medical treatment and the expenditure incurred on such treatment shall be reimbursed by the Commission subject to the ceilings prescribed in the Regulations. ii. Employees or members of their families falling ill at a place other than his/her headquarters, or employees falling ill during official tours, are entitled to reimbursement of medical expenses on the same basis as above. 12. Any test costing Rs.4,000/- and above as per rates prescribed by CGHS shall be treated as a major test and reimbursement of such tests shall be in addition to the annual limit prescribed for each category of employee for availing outdoor treatment provided it has been performed at Govt./recognized hospital/diagnostic centres mentioned in CGHS list of Hospital & Diagnostic Centres/Lab. In case, the test is not prescribed as per CGHS rate list, the rates prescribed by the AIIMS list will be taken into consideration. Where, there is no rate prescribed either in CGHS or AIIMS lists, the expenses incurred shall be reimbursable on actual basis. 13. Officers/officials shall be entitled to have 'major dental treatment' from any dental surgeon. 'Major treatment' shall, inter alia, include treatment of the following nature and reimbursement thereof shall be at maximum charges indicated against each or actual expenditure, whichever is less:- a. Flap Surgery- full mouth Rs. 20,000/- b. Fixation of fracture of Jaw Rs. 5,000/- с. Tumor Excision Rs. 4,000/- d. Resection of Jaw Rs. 12,000/- e. Full denture Rs. 8,000/- 14. Reimbursement of purchase of artificial Appliances Reimbursement of expenses for purchase/ replacement/repair/ adjustment of various artificial appliances will be governed by the office memorandum issued by MoH&FW dated 08.07.2014 and subsequent orders/ guidelines, if any, of the Central Government, in this regard. In the case of diseases like Polio, where an appliance is fitted to a child, which has to be readjusted or replaced periodically as the child grows or the affected part improves, reimbursement of cost of boot (shoe) in the case of such patients is permissible if certified as essential by a specialist in the concerned speciality in the hospitals. 15. Other Conditions i. Inadmissible medicines as specified in Schedules I and II of Rule 2(h) (iii) of the CS (MA) Rules, 1944 are not reimbursable. ii. The competent authority in the Commission shall be empowered to disallow any claims or part of the claim which does not satisfy the required condition for such claim. iii. Expenses incurred on the surgery and post-operative care of the donor of an organ for transplantation to an employee of the Commission or to a member of his family shall be reimbursed as per rate prescribed in CGHS or as per actual whichever is less. iv. The expenditure on account of reimbursement of medical claims shall be monitored quarterly by applying the benchmark of an amount equivalent to one-fourth of the budgetary provision for medical expenses (for indoor as well as outdoor treatment) for that particular year. In the event of such expenditure exceeding the aforesaid benchmark ceiling in any particular month, the Chairperson of the Commission shall be the competent authority to approve such expenditure in excess of the benchmark ceiling. 16. Ambulance Charges Ambulance charges for admission to the hospital in case of maternity or serious illness, emergency cases or injury shall be reimbursed. In case public transport such as Taxi has been used to carry the patient in emergency or non-availability of Ambulance, actual charges paid shall be reimbursed. 17. Medical termination of pregnancy The expenditure incurred on medical termination of pregnancy shall be reimbursed in full provided it has been performed at Govt./other hospitals recognized or approved under the Medical Termination of Pregnancy Act 1971. 18. Annual Medical Health check-up The officers and staff of JERC above 40 years of age, may undergo an annual medical examination in a financial year from a recognised hospital. The expenditure on this will be reimbursed subject to the overall ceiling laid down in Regulation 4. In this scheme, the following package rates will be applicable:- Rate of Annual Medical Examination Female Officer and Staff - Rs. 10,000/- Male Officer and Staff - Rs. 7,500/- 19. Power to review The power to review these Regulations shall vest with the Commission. 20. Interpretation If any question arises as to whether any service is included in medical attendance or treatment under these Regulations as to the interpretation of these Regulations, it shall be referred to the Commission whose decision thereon shall be final. 21. Power to relax Where the Chairperson of the Commission is of the view that it is necessary or expedient so to do, he may, for reasons to be recorded in writing, relax any of the provisions of these Regulations. 22. General i. The recognised hospitals/diagnostic centres will provide necessary medicines and all disposable sundries of standard quality and will not get them purchased through employees of this Commission. ii. Any legal liability coming out of such service shall be dealt by the hospital/diagnostic centre and it shall be their responsibility alone. iii. For all matters which are not covered in these Regulations, the provisions laid down in the CS (MA) Rules / CGHS will be applicable. iv. Any guidelines/rule position issued by the Central Govt. regarding CS (MA), Rules, 1944/CGHS from time to time, will automatically be applicable on this Commission, from the date of their issuance. v. The facilities shall be liable to be withdrawn at any time for misuse or abuse of the facility. vi. In case of any doubt regarding the genuineness or otherwise of the claims preferred by the employee/spouse/dependant (as defined in the Central Services (Medical Attendance) Rules, 1944 as amended from time to time), the JERC reserves the right to direct the employee to be present before an Authorized Medical Practitioner (AMP) of JERC / empanelled hospital and no reimbursement shall be made till the second opinion is received from the appointed AMP / empanelled hospital. vii. The JERC also reserves the right to inspect the records of the Hospital concerned where the employee/his or her dependant (as defined in the Central Services (Medical Attendance) Rules, 1944 as amended from time to time) was admitted for undertaking treatment, through its authorized representative. viii. If, on the basis of recommendations of the Medical Board or otherwise it is found that there is misuse of the facility by any employee, he/she may be summarily debarred from the medical benefits and action may be taken as per rules or as deemed fit. ix. The JERC reserves the right to amend, modify the guidelines of these Regulations in part or full. ************** S.D.SHARMA, Secy. I/C [ADVT.-III/4/Exty./696/2024-25] Annexure-I FORM OF APPLICATION FOR MEDICAL CLAIMS (IPD TREATMENT) Form of application for claiming refund of medical expenses incurred in connection with medical attendance/treatment/facility of the Employee of JERC or their dependent family members for treatment/test investigations in a Hospital: +----+---------------------------------------------------------------------------------------------------------------------------------------------------+---+ | 1. | Name and designation of the Employee (in block letters) | : | +----+---------------------------------------------------------------------------------------------------------------------------------------------------+---+ | | i. Whether married or single | : | +----+---------------------------------------------------------------------------------------------------------------------------------------------------+---+ | | ii. If married, the place where wife/husband is employed | : | +----+---------------------------------------------------------------------------------------------------------------------------------------------------+---+ | 2. | Pay of the Employee as defined in the Fundamental Rules and any other emoluments which should be shown separately | : | +----+---------------------------------------------------------------------------------------------------------------------------------------------------+---+ | 3. | Actual residential address | : | +----+---------------------------------------------------------------------------------------------------------------------------------------------------+---+ | 4. | Name of the patient and his/her relationship to the employee | : | +----+---------------------------------------------------------------------------------------------------------------------------------------------------+---+ | 5. | Place at which the patient fell ill | : | +----+---------------------------------------------------------------------------------------------------------------------------------------------------+---+ | 6. | Details of the amount claimed | : | +----+---------------------------------------------------------------------------------------------------------------------------------------------------+---+ | | Name of the Hospital | : | +----+---------------------------------------------------------------------------------------------------------------------------------------------------+---+ | | Charges for hospital treatment, indicating separately the charges for:- | | +----+---------------------------------------------------------------------------------------------------------------------------------------------------+---+ | | i. Accommodation (State whether it was according to the status or pay of the employees and in cases where the accommodation is higher than the | : | | | status of the employee, a certificate should be attached to the effect that the accommodation to which he was entitled was not available) | | +----+---------------------------------------------------------------------------------------------------------------------------------------------------+---+ | | ii. Diet | : | +----+---------------------------------------------------------------------------------------------------------------------------------------------------+---+ | | iii. Surgical operation or medical treatment or confinement: | : | +----+---------------------------------------------------------------------------------------------------------------------------------------------------+---+ | | iv. Pathological, Bacteriological, Radiological or other similar tests, indicating | : | +----+---------------------------------------------------------------------------------------------------------------------------------------------------+---+ | | a. The name of the hospital or laboratory at which test & investigations undertaken; and | : | +----+---------------------------------------------------------------------------------------------------------------------------------------------------+---+ | | b. whether undertaken on the advice of the Medical Officer in charge of the case at the hospital/AMA. If so, a certificate/medical prescription | : | | | to the effect should be attached | | +----+---------------------------------------------------------------------------------------------------------------------------------------------------+---+ | | v. Medicines | : | +----+---------------------------------------------------------------------------------------------------------------------------------------------------+---+ | | vi. Special Medicines : | : | | | (Cash memos and the Essentiality Certificate/Doctors advice should be attached) | | +----+---------------------------------------------------------------------------------------------------------------------------------------------------+---+ | | vii. Ordinary nursing | : | +----+---------------------------------------------------------------------------------------------------------------------------------------------------+---+ | | viii. Special nursing, i.e., nurses, specially engaged for the patient. State whether they are deployed on the advice of the Medical Officer in | : | | | charge of the case at the hospital or at the request of the Employee or patient. In the former case a certificate from the Medical Officer | | | | in charge of the case and countersigned by the Medical Superintendent of the Hospital should be attached. | | +----+---------------------------------------------------------------------------------------------------------------------------------------------------+---+ | | ix. Ambulance charges: | : | | | (state the journey-to and fro–undertaken) | | +----+---------------------------------------------------------------------------------------------------------------------------------------------------+---+ | 7 | Total amount claimed | : | +----+---------------------------------------------------------------------------------------------------------------------------------------------------+---+ | 8 | Less advance taken on | : | +----+---------------------------------------------------------------------------------------------------------------------------------------------------+---+ | 9 | Net amount claimed | : | +----+---------------------------------------------------------------------------------------------------------------------------------------------------+---+ | 10 | List of enclosures | : | +----+---------------------------------------------------------------------------------------------------------------------------------------------------+---+ DECLARATION TO BE SIGNED BY THE GOVERNMENT SERVANT I ............................................(Name) hereby declare that the statements in the application are true to the best of my knowledge and belief and that the person for whom medical expenses were incurred is wholly dependent upon me. Date Signature of the Employee Annexure-II JOINT ELECTRICITY REGULATORY COMMISSION REIMBURSEMENT OF MEDICAL CLAIM FOR OPD TREATMENT 1. Name & Designation 2. Basic Pay+ DA (As on April,20.....) 3. Name of the Patient & relationship 4. Place where the patient fell ill 5. Name of the Doctor/ Hospital +---------------------------------------+---------------------+---------------------+ | CLAIM DETAILS | AMOUNT CLAIMED | AMOUNT ADMITTED | | | ₹ | ₹ | +=======================================+=====================+=====================+ | Consultation Charges: | | | | | | | | a. No.& Dates of Consultations | | | | | | | | b. Special Consultations | | | | | | | | с. No.& Dates of Consultations | | | | | | | | d. Pathological Charges: | | | | | | | | e. Cost of Medicines | | | | | | | | f. S.No. Cash Memo No. Date | | | | | | | +---------------------------------------+---------------------+---------------------+ | (In words) Rupees | | | +---------------------------------------+---------------------+---------------------+ I hereby declare that the statements in the application are true to the best of my knowledge and belief and that the person for whom medical expenses were incurred is wholly dependent upon me. List of Encls: Date: Signature of the Employee Annexure - III Joint Electricity Regulatory Commission (For the State of Goa & UTS) REGISTRATION FORM FOR RETIRED EMPLOYEES FOR AVAILING MEDICAL FACILITY FROM JERC 1. Name of Retd. Employee: 2. Father's Name 3. Designation/Post from which retired: 4. Last salary drawn: i. Basic Pay: ii. Grade Pay: iii. Scale of Pay: Pay and Corresponding Level in the Pay Matrix 5. Date of superannuation: 6. Period of Regular Service from the date of From-Direct Recruitment OR Absorption in JERC: To 7. Residential Address after Retirement: 8. Telephone No: (R) Mob. e-mail 9. Details of Family Members: ("Please see the definition of family as provided in Regulation 2 of Joint Electricity Regulatory Commission (Medical Facilities) Regulations, 2024 before filling up this column) # Please attach proof of age +-----+----------+---------------+-----------------------+-----------------+ | SI. | Name | Date of Birth#| Relationship with the | Blood Group | | No. | | | employee | (if available) | +=====+==========+===============+=======================+=================+ | | | | | | +-----+----------+---------------+-----------------------+-----------------+ | | | | | | +-----+----------+---------------+-----------------------+-----------------+ | | | | | | +-----+----------+---------------+-----------------------+-----------------+ | | | | | | +-----+----------+---------------+-----------------------+-----------------+ 10. Details of Bank Account: Name of Bank and Branch Address: Branch Code: Account Number: Type of Account: Savings/ Current IFSC Code: 11. Detail of the Medical Insurance, if any. Please attach a copy of the policy +-------+---------------------+---------------------------+---------------------+---------------------+----------+ | S. No.| Name of the Insurance| Details of the family | Amount insured | Premium Paid | Remarks | | | Company | members covered | (in Rs.) | (in Rs.) | | +=======+=====================+===========================+=====================+=====================+==========+ | | | | | | | +-------+---------------------+---------------------------+---------------------+---------------------+----------+ | | | | | | | +-------+---------------------+---------------------------+---------------------+---------------------+----------+ Annexure-IV Joint Electricity Regulatory Commission (For the State of Goa & UTS) MEDICAL CARD +-------------------------------------------------+---------------------------------------+ | | Space for affixing Joint | | | Photograph of Beneficiaries | +=================================================+=======================================+ | 1. Registration No. | | +-------------------------------------------------+---------------------------------------+ | 2. Entitlement (Pvt/Semi-Pvt/General) | | | (To be filled in by the registering office) | | +-------------------------------------------------+---------------------------------------+ | 1. Name of the retired employee and employee number | | +-------------------------------------------------+---------------------------------------+ | 2. Date of retirement | | +-------------------------------------------------+---------------------------------------+ | 3. Designation at the time of Retirement | | +-------------------------------------------------+---------------------------------------+ | 4. Scale of pay and basic pay as on the date of | | | retirement | | +-------------------------------------------------+---------------------------------------+ | 5. Pay and Corresponding Level in the Pay Matrix | | +-------------------------------------------------+---------------------------------------+ | 6. Permanent Address / Contact Tel. No. | | +-------------------------------------------------+---------------------------------------+ | 7. Present address/Contact Tel. No. | | +-------------------------------------------------+---------------------------------------+ | 8. Validity period of the card | From.............To ................. | +-------------------------------------------------+---------------------------------------+ DETAIL OF ALL BENEFICIARIES: +---------+-----------------+---------------+-----------------------+---------------------+ | SI. No. | Name | Date of Birth | Relationship with the | Blood Group (optional)| | | | | employee | | +=========+=================+===============+=======================+=====================+ | | | | | | +---------+-----------------+---------------+-----------------------+---------------------+ | | | | | | +---------+-----------------+---------------+-----------------------+---------------------+ Specimen signature of the Retired employee/spouse Date of Issue Signature of the issuing officer Designation Uploaded by Dte. of Printing at Government of India Press, Ring Road, Mayapuri, New Delhi-110064 and Published by the Controller of Publications, Delhi-110054.