76-F(MED)WB: WBHS Adds Six New Diseases, Sets Anti-Fraud Rules

Government of West Bengal

Medical Cell, Finance Department,

2nd Floor, Khadya Bhavan,

11A, Mirza Ghalib Street, Kolkata-700087

No.: - 76-F(MED)WB Date: 07.09.2026

NOTIFICATION

Presently, under Clause 7(1) of the West Bengal Health Scheme, 2008, the cost of Out-Patient Department (OPD) treatment is admissible in respect of eighteen (18) specified diseases/conditions, which, for ease of reference, are reproduced in the TABLE below:

Now, therefore, the Governor is pleased to include the following six (06) additional diseases/conditions as items 19 to 24 after the 18th item in the aforesaid TABLE: -

19. Pancreatitis
20. Osteoarthritis
21. Ulcerative Colitis
22. Glaucoma
23. Idiopathic Pulmonary Fibrosis (IPF)
24. Connective Tissue Diseases (CTD), that is to say:
    • Systemic Sclerosis
    • CTD - Associated Interstitial Lung Disease (ILD)
    • Sjögren's Syndrome
    • Dermatomyositis (DM) or Polymyositis (PM)

The cost of medicines prescribed for the aforesaid six (06) diseases/conditions shall be admissible for reimbursement under the West Bengal Health Scheme, 2008, subject to the existing provisions, guidelines, approved rates, limits and other conditions applicable to OPD reimbursement.

The diagnosis of the aforesaid diseases/conditions shall be established in accordance with standard, clinically accepted diagnostic protocols and such other requirements as may be prescribed under the Scheme from time to time.

Internal Control Mechanism

Further, the Governor is pleased to prescribe the following internal control mechanism to safeguard against fraudulent claims, misuse or wrongful availment of benefits under the West Bengal Health Scheme:

1. Where there are reasonable grounds to believe that a beneficiary has obtained or attempted to obtain benefits under WBHS by way of fraud, misrepresentation, wilful suppression of material facts, or knowingly submitting false statements or documents, the competent authority may, having regard to the circumstances of the case, order temporary suspension of the beneficiary's WBHS Enrolment Certificate pending enquiry.
2. Before taking any final action adversely affecting the beneficiary, the competent authority shall cause an enquiry to be conducted in accordance with the prescribed procedure and shall provide the beneficiary a reasonable opportunity of being heard.
3. Where, upon completion of the enquiry, the beneficiary is found to have committed fraud, misrepresentation, willful suppression of material facts, or knowingly submitted false statements or documents for obtaining or attempting to obtain benefits under WBHS, the competent authority may, by a reasoned order and in accordance with the applicable provisions, cancel the beneficiary's WBHS Enrolment Certificate and take such further action as may be permissible under the Scheme or rules.
4. Where any amount has been reimbursed on the basis of a false claim or by reason of fraud, misrepresentation, willful suppression of material facts, or submission of false statements or documents, such amount shall be liable to be recovered from the beneficiary in accordance with the applicable rules and procedure.
5. Where the conduct of the beneficiary constitutes an offence under any applicable law, action may also be initiated in accordance with law. In the case of a serving Government employee, such conduct may also attract disciplinary action under the applicable service rules, wherever warranted.
6. The exercise of any power under this mechanism shall be subject to the principles of natural justice and the applicable provisions of the West Bengal Health Scheme and other relevant rules.

This will take effect from the date of issuance of this order.

By Order of the Governor,

(Khalid A. Anwar, IAS)

Secretary to the

Government of West Bengal