22.05.2018. Relaxation of Rules for Reimbursement in Excess of CGHS Rates

File No. Z.15025/38/2018 /DIR/CGHS/EHS	Issued From · Date Nirman Bhawan, New Delhi · 22nd May, 2018
Government of India  ·  Ministry of Health and Family Welfare  ·  Dept. of Health & Family Welfare  ·  EHS Section

Office Memorandum

Subject

Relaxation of Rules for consideration of reimbursement in excess of the approved rates pertaining to medical claims

✦ ✦ ✦ ✦

     With reference to the above mentioned subject the undersigned is directed to draw attention to the Office Memorandum No. 4-18/2005-C&P [Vol. 1–Pt (1)], dated the 20th February 2009 and to state that it has now been decided to modify the Para 3 (2) of the above referred Office Memorandum as per the details given under the succeeding paragraphs.

Para (a) — Full Reimbursement Criteria

a)  The requests for full reimbursement which fall under the following defined criteria shall be examined by Directorate General of CGHS and submitted to AS&DG (CGHS) for consideration of approval. After the recommendation of AS&DG (CGHS), the concurrence of Internal Finance Division and approval of Secretary, Ministry of Health & Family Welfare are required for reimbursement in excess of CGHS rates:

#	Condition for Full Reimbursement in Excess of CGHS Rates
1	Treatment was obtained in a private unrecognized hospital under emergency and the patient was admitted by others when the beneficiary was unconscious or severely incapacitated and was hospitalized for a prolonged period.
2	Treatment was obtained in a private unrecognized hospital under emergency and was admitted for prolonged period for treatment of Head Injury, Coma, Septicemia, Multi-organ failure, etc.
3	Treatment was obtained in a private unrecognized hospital under emergency for treatment of advanced malignancy.
4	Treatment was taken under emergency in higher type of accommodation as rooms as per his/her entitlement are not available during that period.
5	Treatment was taken in higher type of accommodation under specific conditions for isolation of patients to avoid contacting infections.
6	Treatment was obtained in a private unrecognized hospital under emergency when there is a strike in Govt. hospitals.
7	Treatment was obtained in a private unrecognized hospital under emergency while on official tour to non-CGHS covered area.

Para (b) — High Powered Committee

b)  The requests from CGHS beneficiaries, having a valid CGHS Card at the time of treatment, in respect of the following conditions shall be considered by a High Powered Committee constituted by Ministry of Health & Family Welfare:

Sl.	Matter Referred to High Powered Committee
(i)	Settlement of medical claims in relaxation of rules.
(ii)	Approval for air-fare with or without attendant on the advice of treating doctor for treatment in another city even though he/she is not eligible for air travel / treatment facilities are available in city of residence.
(iii)	Representations from CGHS beneficiaries seeking full reimbursements under special Circumstances, which are not notified.

Para (c) — Continuity of Existing Terms

c)  The other terms and conditions mentioned in the OM No. 4-18/2005-C&P [Vol. 1–Pt(1)] dated the 20th February 2009 shall remain unchanged.

(Rajeev Attri) Under Secretary to Government of India Tel No. 011-2306 1883

To

1. Secretary, Ministry of Health & Family Welfare, Nirman Bhawan, New Delhi
2. Director General of Health Services, Nirman Bhawan, New Delhi
3. Special Director General of Health Services, Nirman Bhawan, New Delhi
4. Addl. Secretary & DG, CGHS, Nirman Bhawan, New Delhi
5. All Ministries / Departments, Government of India
6. Director, CGHS, Nirman Bhawan, New Delhi
7. CGHS Desk-I/Desk-II/CGHS-I/CGHS-II, Dte.GHS, Nirman Bhawan, New Delhi
8. Estt.I/ Estt.II/ Estt.III/ Estt.IV Sections, Ministry of Health & Family Welfare
9. Admn.I / Admn.II Sections of Dte.GHS
10. Rajya Sabha / Lok Sabha Secretariat
11. Registrar, Supreme Court of India / Punjab & Haryana High Court, Chandigarh
12. Under Secretary, U.P.S.C.
13. Under Secretary Finance Division
14. Deputy Secretary (Civil Service News), Dept. of Personnel & Training, 5th Floor, Sardar Patel Bhawan, New Delhi
15. PPS to Secretary (H&FW)/ Secretary (AYUSH)/ Secretary(HR)/ Secretary(AIDS Control), Ministry of Health & Family Welfare
16. PPS to DGHS /AS&MD, NRHM / AS (H)
17. Shri Umraomal Purohit, Secretary, Staff Side, 13-C, Ferozshah Road, New Delhi
18. All Staff Side Members of National Council (JCM) (as per list attached)
19. Office of the Comptroller & Auditor General of India, 10 Bahadur Shah Zafar Marg, New Delhi
21. UTI-ITSC, 153/1, First floor, Old Madras Road, Ulsoor, Bengaluru-560008
22. Nodal Officer, MCTC, CGHS with a request to upload a copy of OM on CGHS Web-site
23. Office Order folder

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📄  Previous References

OM No. 4-18/2005-C&P [Vol. 1–Pt(1)] dated 20.02.2009 MoHFW — Relaxation of procedures for medical reimbursement (original order modified by this OM)	View OM  Download PDF
OM No. Z.15025/38/2018/DIR/CGHS/EHS dated 22.05.2018 MoHFW — This OM (current post) — Relaxation of Rules for reimbursement in excess of CGHS rates	Download PDF

☰  Quick Reference Summary

OM No. Z.15025/38/2018/DIR/CGHS/EHS  ·  Dated 22.05.2018

Modifies Para 3(2) of OM No. 4-18/2005-C&P dated 20.02.2009. Full reimbursement in excess of CGHS rates is permissible under the following conditions, subject to approval of Secretary, MoHFW:

►	Emergency treatment in private unrecognized hospital — patient unconscious/severely incapacitated, admitted by others, prolonged hospitalization.
►	Emergency admission for Head Injury, Coma, Septicemia, Multi-organ failure, etc.
►	Emergency treatment for advanced malignancy.
►	Higher accommodation on emergency basis when entitled rooms unavailable.
►	Higher accommodation for isolation to prevent infection.
►	Emergency during strike in Govt. hospitals.
►	Emergency during official tour to non-CGHS covered area.

⚠  Cases under special circumstances (not notified) to be referred to High Powered Committee constituted by MoHFW.

⇩  Download OM No. Z.15025/38/2018/DIR/CGHS/EHS  ·  22.05.2018