22.05.2018 Reimbursement in excess of CGHS rates.pdf
सत्यमेव जयते
Government of India
Ministry of Health and Family Welfare Department of Health & Family Welfare
EHS Section
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No: Z.15025/38/2018 /DIR/CGHS/EHS
OFFICE MEMORANDUM
Nirman Bhawan, New Delhi
Dated the 22nd May, 2018
Subject:
Relaxation of Rules for consideration of reimbursement in excess of the approved rates pertaining to medical claims
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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.
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:
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
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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.
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:
(i)
(ii)
(iii)
Settlement of medical claims in relaxation of rules
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
Representations from CGHS beneficiaries seeking full reimbursements under
special Circumstances, which are not notified.
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.
тарні
(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), Department of Personnel & Training,
5th Floor, Sardar Patel Bhawan, New Delhi.
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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
20. All Offices / Sections / Desks in the Ministry
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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