Step 2.11 Assistance For Major ailments (Karmika Chikitsa Bhagya)

What is Assistance for Major ailments (Karmika Chikitsa Bhagya) scheme?

The "Assistance for Major Ailments" program, also known as Karmika Chikitsa Bhagya, provides support for the medical expenses related to the treatment of significant illnesses for registered construction workers and their dependents.

Under this program, the Secretary or another authorized officer of the Board is empowered to approve a medical expense assistance amount of up to Rs. 2,00,000/- (Rupees Two Lakh only). This approval is contingent upon the fulfillment of all specified conditions by the applicant. The assistance is granted based on the rates outlined in the Central Government Health Service (C.G.H.S), concerning the treatment or operation mentioned in the application or estimate. Importantly, this provision does not prevent the applicant from claiming medical expenses under any other applicable statutes.

What includes in Major ailments?

Major ailments” means any heart operation, covid-19, Kidney transformation [ eye operation, treatment of paralysis, orthopedics operation, uterus operation, treatment of asthma disease, maternity miscarriage cases, treatment of gall bladder related ailments, removal of kidney stone, treatment of brain hemorrhage, treatment of ulcer, cancer [dialysis, kidney related surgery, ENT treatment and surgery, neurosurgery, vascular surgery, esophagus treatment and surgery, gastrointestinal surgery, breast-related treatment surgery, hernia surgery, appendicitis, surgery, treatment of fracture/dislocation, general surgery] or such other ailments as in the opinion of the Board be considered as major ailments and occupational diseases. 

What are the eligibility criteria for accessing benefits from the scheme?

1. Every registered construction worker or their dependent (in the case of the worker's death during treatment) eligible for medical expense assistance must submit an application in Form XXII to the Board.

Karmika Chikitsa Bhagya Hospital List- Government & Private Hospital

List of approved Government and Private Hospitals under Karmika Chiktsa Bhagya

What is the procedure to apply for the scheme?

The application process for medical expense assistance under the Karmika Chikitsa Bhagya involves the following steps:

1. Application Submission: Registered construction workers or their dependents must submit an application in Form XXII to the Board.
2. Certificate Requirement: The application should be accompanied by a certificate in Form XXII-A. This certificate can be issued by:
   1. An Assistant Surgeon of a Government Hospital,
   2. The treating Surgeon or Doctor, or
   3. The Head of a Private Hospital specified in Schedule I of the Karnataka Government Servants’ (Medical Attendance) Rules, 1963, or a hospital recognized under the RSBY.
3. Evaluation by the Secretary or Authorized Officer: The Secretary or an authorized officer of the Board will assess the claim for medical expenses. This evaluation is based on the provisions outlined in the relevant rule.
4. Decision by the Board: The Board, through the Secretary or the authorized officer, has the authority to either accept or reject the claim. The decision reached by the Board is considered final.
5. Opportunity for Representation: Before rejecting a claim, the Secretary or the authorized officer is obligated to provide the applicant with a reasonable opportunity to make a representation. This ensures that the applicant has a chance to present additional information or arguments in support of their claim.

What type of documents required? 

1. Proof of Identity/Smart card issued by the Board
   
2. Employment Certificate
   
3. Proof of Bank Account
   
4. Bills of hospital showing Admission and Discharge Dates and all treatment given
   
5. Any medical documents on hospitalization of beneficiary/dependent in government/private
   
6. Hospital included in schedule1 of the Karnataka government servants (medical attendance)
   
7. Rules 1963 or a hospital recognized under any insurance scheme of the state government.
   
8. Form XXII-A
9. Application can be submitted within 6 months of hospitalization commencement date."
   

Key aspects related to Major ailments (Karmika Chikitsa Bhagya).

Benefits	Amount (Rs.)	Frequency	Applies to	Contribution by worker (Rs.)	Time specified (days)	Time taken (days)	Fee specified (Rs.)	Money spent (Rs.)	Timeline for submission
Major ailments (Karmika Chikitsa Bhagya)	up to Rs. 2,00,000/		Worker + dependents						Within six months of discharge

Why do construction workers often fail to receive the benefits they are entitled under Major ailments (Karmika Chikitsa Bhagya)?

On-ground implementation-

1. The scheme appears to have a somewhat confusing criterion. On one hand, it stipulates that the worker (patient) must undergo hospitalization for a minimum of 48 hours. However, during the application process, it becomes evident that the scheme rejects applications unless the worker is admitted for a period extending 7 days or more. Consequently, the scheme deems an application ineligible if the patient is discharged before completing 7 days of hospitalization.
2. The program stipulates that its validity is contingent upon the treatment being received in a hospital affiliated with the board. However, there have been instances where workers sought treatment in non-affiliated hospitals, which could pose a challenge or limitation to their eligibility under the scheme.
3. Form 22 requires the signature of the attending doctor. However, in numerous cases, another doctor, typically a backup or substitute, ends up signing the form, resulting in the rejection of the claim.

Lack of awareness and trust among workers-

1. The lack of knowledge or awareness among laborers regarding the renewal process may lead to a failure to renew on time. This failure could subsequently result in the loss of benefits if an unforeseen event occurs.

Annexure:

What includes in Major ailments?

Major ailments” means any heart operation, covid-19, Kidney transformation [ eye operation, treatment of paralysis, orthopedics operation, uterus operation, treatment of asthma disease, maternity miscarriage cases, treatment of gall bladder related ailments, removal of kidney stone, treatment of brain hemorrhage, treatment of ulcer, cancer [dialysis, kidney related surgery, ENT treatment and surgery, neurosurgery, vascular surgery, esophagus treatment and surgery, gastrointestinal surgery, breast-related treatment surgery, hernia surgery, appendicitis, surgery, treatment of fracture/dislocation, general surgery] or such other ailments as in the opinion of the Board be considered as major ailments and occupational diseases. 

List of approved Government and Private Hospitals under Karmika Chiktsa Bhagya

What is the procedure to apply for the scheme?

The application process for medical expense assistance under the Karmika Chikitsa Bhagya involves the following steps:

1. Application Submission: Registered construction workers or their dependents must submit an application in Form XXII to the Board.
2. Certificate Requirement: The application should be accompanied by a certificate in Form XXII-A. This certificate can be issued by:
   1. An Assistant Surgeon of a Government Hospital,
   2. The treating Surgeon or Doctor, or
   3. The Head of a Private Hospital specified in Schedule I of the Karnataka Government Servants’ (Medical Attendance) Rules, 1963, or a hospital recognized under the RSBY.
3. Evaluation by the Secretary or Authorized Officer: The Secretary or an authorized officer of the Board will assess the claim for medical expenses. This evaluation is based on the provisions outlined in the relevant rule.
4. Decision by the Board: The Board, through the Secretary or the authorized officer, has the authority to either accept or reject the claim. The decision reached by the Board is considered final.
5. Opportunity for Representation: Before rejecting a claim, the Secretary or the authorized officer is obligated to provide the applicant with a reasonable opportunity to make a representation. This ensures that the applicant has a chance to present additional information or arguments in support of their claim.