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File No.
No. 4-18/2005-C&P [Vol. I – Pt. (I)]
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Issued From · Date
Nirman Bhawan, Maulana Azad Road, New Delhi · 20th February, 2009
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| Government of India · Ministry of Health and Family Welfare · Dept. of Health & Family Welfare · CGHS (P) Division | |
The undersigned is directed to state that under the extant instructions, a CGHS card holder, who wishes to apply for reimbursement of the expenditure incurred by him / her on medical treatment of either self or his / her dependent family members, the present reimbursement procedure needs verification of bills and issue of essentiality certificate by the treating doctor, and the Medical Superintendent of the hospital. The process of verification of bills and issue of essentiality certificates are time consuming with the doctor at times being busy or being away from office for whatever reason. This necessitates repeated visits to the hospital for getting the verification done and essentiality certificate obtained. Representations have been received in the Ministry of Health & Family Welfare requesting for doing away with the two requirements and for the Ministries / authorities concerned to verify and check the authenticity of the claims on the basis of the prescription slip and the diagnostic report submitted by the Government servant / pensioner. In the event of any doubt, the concerned Ministry / Authority can always get verification done from the hospital concerned.
2. The undersigned is also directed to state that CGHS guidelines currently provide for relaxation of guidelines to cover full reimbursement in individual cases depending upon merits of each case. In the case of Hon'ble Members of Parliament, the powers to relax the guidelines have been delegated to the Lok Sabha Secretariat and Rajya Sabha Secretariat respectively and in the case of Hon'ble Chief Justice of Supreme Court and Judges of the Supreme Court to the Secretary General of the Supreme Court.
3. In order to reduce the burden on the specialists in individual cases of medical reimbursement claim, it has been decided with the approval of heads of the hospitals to revise the guidelines for reimbursement by the competent authority, as follows:
(1) It has now been decided to do away with the procedure for verification of bills and issue of essentiality certificate by the treating doctor, and the Medical Superintendent of the hospital. Ministries / authorities concerned may verify and check the authenticity of the claims on the basis of the prescription slip and the diagnostic report submitted by the Government servant / pensioner. In the event of any doubt, the concerned Ministry / Authority can always get verification done from the hospital concerned. Modified reimbursement claim form, alongwith checklist is annexed.
(2) All cases involving requests for relaxation of rules for reimbursement of full expenditure will henceforth be referred to a Technical Standing Committee, to be chaired by the DGHS / Addl.DGHS and consist of Director (CGHS) and subject matter specialists. If the Technical Standing Committee recommends the relaxation of rules for permitting full reimbursement of expenditure incurred by the beneficiary, the full reimbursement may be allowed by the Secretary (Health & Family Welfare) in consultation with IFD. A check list for consideration of requests for reimbursements in excess of approved rates may include:
| Sl. | Condition for Excess Reimbursement |
|---|---|
| (a) | The treatment was obtained in a private non-empanelled hospital under emergency and the patient was admitted by others when the beneficiary was unconscious or severely incapacitated and was hospitalised for a prolonged period. |
| (b) | The treatment was obtained in a private non-empanelled hospital under emergency and was admitted for prolonged period for treatment of Head Injury, Coma, Septicemia, Multi-organ failure, etc. |
| (c) | The treatment was obtained in a private non-empanelled hospital under emergency for treatment of advanced malignancy. |
| (d) | The treatment was taken under emergency in higher type of accommodation as rooms as per his / her entitlement are not available during that period. |
| (e) | The treatment was taken in higher type of accommodation under specific conditions for isolation of patients to avoid contacting infections. |
| (f) | The treatment was obtained in a private non-empanelled hospital under emergency when there is a strike in Government hospitals. |
| (g) | The treatment was obtained in a private non-empanelled hospital under emergency, while on official tour to non-CGHS covered area. |
| (h) | Approval for air-fare with or without attendant on the advice of treating doctor for treatment in another city even though he is not eligible for air travel / treatment facilities are available in city of residence. |
| (i) | Any other special circumstances. |
4. The Office Memorandum is issued with the concurrence of IFD vide Dy. No. 908/AS &FA/2009 dated the 20th February, 2009.
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(R Ravi)
Deputy Secretary to the Government of India
Tel: 2306 3483
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2. Director, CGHS, Nirman Bhawan, New Delhi
3. All Pay and Accounts Officers under CGHS
4. Additional Directors / Joint Directors of CGHS
5. JD(Gr.) / JD(R&H), CGHS, Delhi
6. CGHS Desk-I/Desk-II/CGHS-I/CGHS-II, Dte. GHS, Nirman Bhawan, New Delhi
7. Estt. I / Estt. II / Estt. III / Estt. IV Sections, Min. of Health & Family Welfare
8. Admn. I / Admn. II Sections of Dte.GHS
9. M.S. Section, Ministry of Health & Family Welfare
10. Rajya Sabha / Lok Sabha Secretariat
11. Registrar, Supreme Court of India / Delhi High Court, Sher Shah Road, New Delhi
12. U.P.S.C.
13. Finance Division, Ministry of Health & Family Welfare
Central Government Health Scheme
Modified Check List for Reimbursement of Medical Claims
| Sl. | Item | Status |
|---|---|---|
| 1. | CGHS Token No. and place of issue | ............ |
| 2. | Validity of CGH Card (For pensioners) & Entitlement — from .......... to .......... | Pvt. / Semi Pvt. / General | ............ |
| 3. | Full name of Card Holder (Block Letters) | ............ |
| 4. | Status (Govt. Servant / Pensioner / Other) | ............ |
| 5. | The following documents are submitted (Please tick (√) the relevant column) | |
| (a) Medical 2004 Form | Yes / No | |
| (b) Photocopy of CGHS card | Yes / No | |
| (c) No. of Original Bills | ............ | |
| (d) Copy of discharge summary | Yes / No | |
| (e) Copy of referral by Specialist / CMO | Yes / No | |
| (f) Whether the hospital has given breakup for lab investigations | Yes / No | |
| (g) | Original papers have been lost — the following documents are submitted: | |
| I. Photocopies of claim papers | Yes / No | |
| II. Affidavit on Stamp Paper | Yes / No | |
| (h) | In case of death of card holder — the following documents are submitted: | |
| I. Affidavit on Stamp paper by Claimant | Yes / No | |
| II. No objection from other legal Heirs on Stamp papers | Yes / No | |
| III. Copy of death certificate | Yes / No | |
Name of the Bank .............. Branch .............. SB A/C No. ............
Branch MICR Code .............. Tel. No. of Bank Branch ..............
Central Government Health Scheme
Medical 2004 Form for Reimbursement of Medical Claims of CGHS Beneficiaries
(To be filled by the claimant)
| 1. | CGHS Token No. and Place of issue | : ............ |
| 2. | Validity of CGHS Token Card & entitlement | : from .......... to .......... | Pvt./Semi Pvt./General |
| 3. | Full name of the card holder (Block Letters) | : ............ |
| 4. | Full address | : ............ |
| 5. | Telephone no. (O) .............. (R) .............. | |
| 6. | E-mail address if any | : ............ |
| 7. | Name of the Bank .......... Branch .......... SB A/C Branch MICR Code .......... Tel. No. of Bank Branch | : ............ |
| 8. | Name of the patient & relationship with the card holder | : ............ |
| 9. | Status tick (√): Govt. Servant / Pensioner / Serving employee or pensioner of autonomous body / Member of Parliament / Ex-M.P. / Ex-Governor / Former Judge of Supreme Court / Former Judge of High Court / Freedom Fighter / Legal Heir / others | |
| 10. | Basic Pay / Basic Pension | : Rs. ............ |
| 11. | Name of the Hospital with Address: (a) OPD treatment and investigations (b) Indoor Treatment | : ............ |
| 12. | Date of admission .......... Date of discharge .......... (In case of Indoor Treatment only) | |
| 13. | Total amount Claimed: (a) OPD Treatment (b) Indoor Treatment | : Rs. ............ |
| 14. | Details of Referral | : ............ |
| 15. | Details of Medical advance if any | : ............ |
Dated: ............ Signature of CGHS card holder
| OM No. 4-18/2005-C&P [Vol. I – Pt. (I)] dated 20.02.2009 This OM — Original guidelines. Para 3(2) modified by 2018 OM. |
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| OM No. Z.15025/38/2018/DIR/CGHS/EHS dated 22.05.2018 Modifies Para 3(2) — 7 criteria + High Powered Committee route. |
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| ► | Dispensed with essentiality certificate by treating doctor and Medical Superintendent. |
| ► | Ministries / authorities to verify claims on basis of prescription slip and diagnostic report. |
| ► | Full reimbursement cases referred to Technical Standing Committee chaired by DGHS / Addl.DGHS. (Modified by 2018 OM.) |
| ► | Full reimbursement allowed by Secretary (H&FW) in consultation with IFD, if TSC recommends. |
| ► | Modified Check List (Annexure-I) and CGHS Medical 2004 Form annexed. |
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