GOVERNMENT OF INDIA
MINISTRY OF HEALTH AND FAMILY WELFARE
DEPARTMENT OF HEALTH AND FAMILY WELFARE

LOK SABHA UNSTARRED QUESTION NO. 590
TO BE ANSWERED ON 9TH DECEMBER, 2022

CASHLESS FACILITIES TO CGHS BENEFICIARIES

590. DR. MANOJ RAJORIA: SHRIMATI RANJEETA KOLI: SHRIMATI SAJDA AHMED: SHRI BALAK NATH:
SHRI RAJENDRA DHEDYA GAVIT:

Will the Minister of HEALTH AND FAMILY WELFARE be pleased to state:

(a) the details of the total number of CGHS beneficiaries in the country, State/UT-wise including Rajasthan;

(b) the details of the beneficiaries in Sikar and Alwar in Rajasthan, district-wise;

(c) whether the Government is aware that several CGHS empanelled hospitals across the country including Rajasthan have stopped providing cashless facilities to CGHS beneficiaries due to pending dues of the Government;

(d) the list of hospitals whose payment has been put on hold/stopped during 2021-2022; and

(e) ) if so, the details thereof along with the measures taken in this regard?

ANSWER

THE MINISTER OF STATE IN THE MINISTRY OF HEALTH AND FAMILY WELFARE (DR. BHARATI PRAVIN PAWAR)

(a) to (e): State/UT-wise details of the total number of CGHS beneficiaries in the country, including Rajasthan are at Annexure. There is no separate database pertaining to the districts of Sikar and Alwar. There has been a time lag on account of established procedures for processing the claims. However, the procedures are streamlined now.

Annexure

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Reimbursement cannot be denied to a central government employee either during service or after retirement if he/she does not seek treatment from a hospital that is not on the list of CGHS empanelled hospitals, the SC said.

In its judgement, a two-judge bench of the apex court clearly says that an employee of the central government cannot be denied reimbursement of medical bills on the grounds that the employee opted for treatment from a private hospital during an emergency.

Reimbursement cannot be denied either during service or after retirement if the employee does not seek treatment from a hospital that is not in the government panel or in the list of the Central Government Health Scheme (CGHS) empanelled hospitals, the SC said.

“The right to medical claim cannot be denied merely because the name of the hospital is not included in the government order,” the bench of Justice RK Agrawal and Justice Ashok Bhushan said.

Speaking for the bench, Justice RK Agrawal stated, “Can it be said that taking treatment in speciality hospital by itself would deprive a person to claim reimbursement solely on the ground that the said hospital is not included in the Government Order?”

“The real test must be the factum of treatment. Before any medical claim is honoured, the authorities are bound to ensure as to whether the claimant had actually taken treatment and the factum of treatment is supported by records duly certified by Doctors/Hospitals concerned.”

“Once, it is established, the claim cannot be denied on technical grounds,” the Supreme Court said.

‘No fetters can be placed on rights of Central govt employee’

The apex court went on to add that it is a settled legal position that the employee during his lifetime in service or after his retirement is “entitled to get the benefit of the medical facilities and no fetters can be placed on his rights”.

It further said that speciality hospitals are established for treatment of specified ailments and services of doctors specialized in a discipline are availed by patients only to ensure proper, required and safe treatment.

The court also took note of “slow and tardy pace of disposal of MRC by the CGHS in case of pensioner beneficiaries and the unnecessary harassment meted out to pensioners who are senior citizens, affecting them mentally, physically and financially…”

SC orders formation of high powered committee

Directing that all such claims “shall be attended by a Secretary-level High Powered Committee in the concerned Ministry which shall meet every month for quick disposal of such cases”, the court said: “We are of the opinion that after submitting the relevant papers for claim by a pensioner, the same shall be reimbursed within a period of one month.”

It also directed the setting up of “Committee for grievance redressal of the retired pensioners consisting of Special Directorate General, Directorate General, 2 (two) Additional Directors and a specialist in the field which shall ensure timely and hassle-free disposal of the claims within a period of seven days.”

MACP ON PROMOTIONAL HIERARCHY – MACP Supreme Court Order – Heard & Reserved

“We further direct the concerned Ministry to take steps to form the Committee as expeditiously as possible,” the court said.

CGHS approach ‘very inhuman’

The court order was issued on a petition by a retired central government official who had sought treatment from two private hospitals and demanded the reimbursement of medical bills. The government had initially refused to reimburse the bill saying that implant of CRT-D device was not required.

The court said: “It is acceptable to common sense, that ultimate decision as to how a patient should be treated vests only with the doctor, who is well versed and expert both on academic qualification and experience gained. Very little scope is left to the patient or his relative to decide as to the manner in which the ailment should be treated.”

Holding that the CGHS approach in the instant case was “very inhuman”, the court said: “This is hardly a satisfactory state of affairs. The relevant authorities are required to be more responsive and cannot in a mechanical manner deprive an employee of his legitimate reimbursement.”

The Central Government Health Scheme (CGHS), the court said was propounded with the purpose of providing a health facility scheme to the central government employees so that they are not left without medical care after retirement.

Source: India Today

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Z 15025/35/2019/DIR/ CGHS/ CGHS(P)
Government of India Ministry of Health & Family Welfare
Department of Health & Family Welfare

Nirman Bhawan, New Delhi
Dated the 29th May, 2019

OFFICE MEMORANDUM

Sub: Consultation from Specialists at CGHS empanelled hospitals in respect of CGHS beneficiaries aged 75 years and above -regarding

With reference to the above mentioned subject the undersigned is directed to state that the matter related to relaxation of consultation norms in respect of elderly CGHS beneficiaries was under consideration of this Ministry and it has now been decided that hereinafter, CGHS beneficiaries aged 75 years and above shall be permitted to seek direct OPD Consultation from Specialists of private hospitals empanelled under CGHS without referral from CGHS Wellness Centre.

2. If any investigations / procedures are advised and are required in emergency, no other authorization is required and the same may be undertaken. However, in non-emergency conditions approval of competent authority is required if any non-listed investigations | procedures are advised. Medicines prescribed are to be procured from CGHS Wellness Centre.

3. Private hospitals empanelled under CGHS shall provide such facilities on cashless basis at CGHS rates to pensioners, ex-MPs , Members of Parliament and such other Categories of CGHS beneficiaries , who are eligible for treatment /investigations on credit basis. More than 75 year old dependents of serving CGHS beneficiaries, who are otherwise not eligible for Cashless treatment shall claim the reimbursement from concerned Ministry /Department. Beneficiaries of Autonomous Bodies /Statutory Bodies covered under CGHS shall claim reimbursement from the respective organization.

4.These orders are in supersession of the earlier guidelines on the subject.

Sd/-
Dr.Manoj Jain
Addl.DDG(HQ)CGHS

Source: CGHS

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GOVERNMENT OF INDIA
MINISTRY OF HEALTH AND FAMILY WELFARE
DEPARTMENT OF HEALTH AND FAMILY WELFARE
RAJYA SABHA

UNSTARRED QUESTION NO. 2566

TO BE ANSWERED ON 9TH AUGUST, 2016

MEDICAL FACILITIES FOR GOVERNMENT EMPLOYEES

2566. SHRI RAM KUMAR KASHYAP:

Will the Minister of HEALTH AND FAMILY WELFARE be pleased to state the details of medical facilities being provided to Central Government employees?

ANSWER

THE MINISTER OF STATE IN THE MINISTRY OF HEALTH AND FAMILY WELFARE (SHRI FAGGAN SINGH KULASTE)

(i) Central Govt. employees drawing their salary from Central Civil Estimates of Government of India are covered under Central Govt. Health Scheme (CGHS) in the cities where CGHS is in operation.

Facilities available to Central Government employees under CGHS are as under :

1. OPD treatment and medicines from CGHS Wellness Centres

2. Specialist Consultation at Govt. Hospitals

3. Hospitalization at Govt. and CGHS empanelled hospitals

4. Investigations at Govt. and empanelled Diagnostic centres.

5. Medical consultation and dispensing of medicines in Ayurveda, Homeopathy, Unani and Siddha systems of medicine (AYUSH).

6. In case of emergency, CGHS beneficiaries can go to any hospital, empanelled or non-empanelled and avail medical treatment.

7. Reimbursement of expenses for treatment in Private unrecognized hospitals in case of emergency.

8. The beneficiary can go to any CGHS Wellness Centre in the country.

9. Reimbursement of expenses incurred for purchase of medical equipments such as hearing aid, hip/knee joint implants, artificial limbs, pace makers, ICD/Combo device, Neuro implants etc., as per the CGHS ceiling rates and guidelines.

(ii) Central Government employees who are not covered under CGHS are provided medical facilities under Central Service (Medical Attendance) Rules, 1944. They can avail treatment from Central Government / State Govt. Hospitals and hospitals recognised by the State Govt./CGHS/CS (MA) as well as the hospitals fully funded by either Central Govt. or the State Govt. with the approval of the Head of the Department on the basis of medical prescription issued by the concerned Authorized Medical Attendant.

http://rajyasabha.nic.in

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No. 2-2/2014/CGl-IS. HQ/PPT/CGHS(P)
Government of India
Ministry of Health & Family Welfare
Department of Health & Family Welfare
Nirman Bhawan, New Delhi

Dated: the 25th August , 2014

OFFICE MEMORANDUM

Sub- Issue of medicines / reimbursement of expenditure on investigations / treatment procedures / implants and other medical devices under CGHS- regarding

With reference to the above mentioned subject the undersigned is directed to state that this Ministry has examined the matter in detail and with a View to streamlines the procedures regarding issue of medicines, reimbursement of expenditure on investigations, treatment procedures, implants and medical devices and with a View to plug the loopholes in the system, it has now been decided that:

a) CGHS shall supply / indent only those medicines, which are included in the CGHS formulary, except for para (b) below. However, for medicines prescribed outside formulary, medicines with identical formulations and /or similar therapeutic effect may be supplied from CGHS formulary against such medicines. CGHS formulary containing 1447 generic and 622 branded medicines is available on CGHS Website at http://msotransparentnic.in/cghsnew/index.asp

b) Anti Cancer and other similar medicines are however supplied on a case to case basis. Only the medicines approved by DCGI for use in India shall be supplied. In case an Indian version is available, which is cheaper than the imported medicine, only the Indian medicine shall be supplied even if, an imported medicine has been prescribed.

c) Medicines shall be supplied for a maximum period of one month.

d)In case of CGHS beneficiaries going abroad, issue of medicines shall be restricted for a maximum period of three months.

e) CGHS shall hereinafter allow only the listed investigations / treatment procedures for which there are prescribed CGHS rates, to be under taken in CGHS empanelled diagnostic centres and hospitals.

f) Similarly, only listed implants / medical devices with a CGHS prescribed ceiling rate shall be permitted for treatment / reimbursement under CGHS.

g) In those cases where any unlisted investigation / treatment procedure is undertaken the reimbursement shall be limited to the rate of nearest similar investigation / treatment procedure under CGHS. Addl. Director of the city /zone shall take a decision based on justification in such cases, in consultation with experts in the field, if necessary.

h) In those cases where any unlisted implant / device is installed reimbursement shall be limited to the CGHS rate of nearest similar implant / device. Addl. Director of the city / zone shall take a decision based on justification in such cases in consultation with experts in the field, if necessary.

i) Registration of Mobile number with CGHS has been made compulsory as a guard against misuse of CGHS Card.

j) In order to provide a mechanism to update the investigations / treatment procedures / implants , etc., as an ongoing process , a Technical Committee is being constituted to consider inclusion / exclusion of investigations /treatment procedures / implants , etc., under CGHS.

sd/-

(RAVI KANT)
Under Secretary to Government of India
011-2306 1441

Source: http://msotransparent.nic.in/writereaddata/cghsdata/mainlinkfile/File738.pdf

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