File No.S.14028 /30/2022 -EHS
S.14028/30/2022 -EHS
Government of India
Ministry of Health & Family Welfare
EHS Section

Nirman Bhawan, New Delhi
Dated 12th September, 2022

OFFICE MEMORANDUM

Subject: Reimbursement of medical claims to pensioners under CS(MA) Rules, 1944 as directed by various CATs/Courts-reg.

The undersigned is directed to say that as per Note-2 below Rule-2 of CS(MA) Rules, 1944, Retired Government officials are not covered thereunder. However, as per extent CGHS guidelines, Central Government Pensioners residing in non-CGHS areas have the following options:

• They can avail Fixed Medal Allowance (FMA) in lieu of OPD facilities under CGHS.
• They can also avail benefits of CGHS (OPO & IPD) by registering themselves in the nearby CGHS covered city after making the required subscription.
• They also have the option to avail FMA, for OPD treatment and CGHS for IPD treatments after making the required subscriptions as per CGHS guidelines.

2. All Ministries/ Departments of Government of India are requested to bring the contents of this OM to the notice of organization(s) under their administrate control for guidance and compliance thereof. Also, retiring Central Government employees may be made aware of the above rule position.

3. Court CATs cases filed by pensioners may be defended by Ministries/ Departments in the light of above rule position. No reference in this regard needs to be made to Ministry of Health & Family Welfare for comments/ clarifications etc, thereon.

4. This issues with the approval of Competent Authority.

Digitally Signed by Guite
Elsy Thang Biak Lun
Date: 12-09-2022 15:52:01
Reason: Approved
(Guite Elsy Thang Blak Lun)
Under Secretary to the Government of India

To

All the Ministries/ Departments, Govt of India.

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Z 15025/12/2020/DIR/CGHS
Government of India
Ministry of Health & Family Welfare
Directorate General of CGHS

Nirman Bhawan, New Delhi
Dated the 13th January, 2022

OFFICE MEMORANDUM

Sub: Reimbursement of cost of OPD Medicines- Special Sanction in view of COVID-19- till 30th April 2022- regarding

In view of the Corona Virus Disease (COVID-19), all out efforts are made by the Government to contain its impact by instituting measures at community as well as at individual level.

2. In this regard the undersigned is directed to draw attention is the OM of even number dated 27.03.2020, 29.04.2020, 29.05.2020 , 24th August 2020, 30th September 2020, 29.12.2020 and 15.04.2021 and 10.08.2021 vide which an option has been provided to CGHS beneficiaries getting medicines for Chronic diseases , to purchase medicines based on the prescription held (prescribed by CGHS Medical Officers / CGHS Specialists /other Govt. Specialists/ Specialist of empanelled hospital) till 31st October 2021, irrespective of Non-Availability certificate from CGHS or otherwise. However, several representations are received in the Ministry seeking extension of the period in view of the COVID-19 Pandemic and resurgence of active cases.

3. The matter has been reviewed by the Ministry and it is now decided, that CGHS beneficiaries getting medicines for Chronic diseases shall be permitted to purchase medicines based on the prescription held (prescribed by CGHS Medical Officers/CGHS Specialists /other Govt. Specialists/ Specialist of empanelled hospital) till 30th April, 2022 on the same conditions as per the earlier OM dated 27.03.2020. It is also clarified that the CGHS Wellness Centres are functional and CGHS beneficiaries also have the option to collect medicines through CGHS Wellness Centres as per normal practice, instead of purchasing from market. This order is valid from the date of issue.

4. Issued with the approval of Integrated Finance Division, MoHFW vide CD No.2576 dated 13.01.2022

(Dr. Alka Ahuja )
Addl.DDG(HQ), CGHS

Reimbursement of Medicines under CGHS Extended till 30.04.2022 – CGHS Orders 2022 PDF Download

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Z 15025/12/2020/DIR/CGHS
Government of India
Ministry of Health & Family Welfare
Directorate General of CGHS

Nirman Bhawan, New Delhi
Dated the 29th May, 2020.

OFFICE MEMORANDUM

Sub: Reimbursement of cost of OPD Medicines: Special Sanction in view of COVID-19- till 31st July 2020- regarding

In view of the Corona Virus Disease (COVID-19) , all out efforts are made by the Government to contain its impact by instituting measures at community as well as at individual level.

2. In this regard the undersigned is directed to draw attention is the OM of even number dated 27.03.2020 and 29.04.2020 vide which an option has been provided to CGHS beneficiaries getting medicines for Chronic diseases, to purchase medicines based on the prescription held (prescribed by CGHS Medical Officers / CGHS Specialists /other Govt. Specialists/ Specialist of empanelled hospital) till 31st May 2020, irrespective of Non-Availability certificate from CGHS or otherwise. However, several representations are received in the Ministry seeking extension of the period in view of the continued ‘Lock Down’.

Also check: Reimbursement of OPD Medicines Special Sanction in view of COVID-19

3. The matter has been reviewed by the Ministry it is now decided that CGHS beneficiaries getting medicines for Chronic diseases shall be permitted to purchase medicines based on the prescription held (prescribed by CGHS Medical Officers / CGHS Specialists /other Govt. Specialists / Specialist of empanelled hospital) till 31st July 2020 on the same conditions as per the earlier OM dated 27.03.2020. It is also clarified that the CGHS Wellness Centres are functional and CGHS beneficiaries also have the option to collect medicines through CGHS Wellness Centres as per normal practice, instead of purchasing from market.

4 Issued with the approval of Integrated Finance Division, MoHFW vide CD No 430 dated 29.05.2020.

(Dr.Sanjay Jain )
Director, CGHS

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CGHS medical facilities reimbursement to Central Government pensioners

CGDA, Ulan Batar Road, Palam, Delhi Cantt.-110010
(Ph.011-25665714,25665560/ Fax-011-25674806/ Email: admin14.cgda@nic.in)

IMPORTANT CIRCULAR

No.AN/XIV/19015/ Govt. Orders/TA /DA/LTC/ Medical

To,
All PCsDA/ CsDA/ PCA (Fys.)
(Through website)

Dated: 29/11/2019

Subject: Reimbursement of medical claims to Pensioners under CS(MA) Rules 1944 – guidelines issued by Ministry of Health & Family

Ministry of Health and Family Welfare vide its OM No. S.14025/23/2013-MS.EHSS dated 29th September 2016 has clarified that CS (MA) Rules 1944 are not applicable to pensioners till date. The Ministry has issued the following guidelines for medical facilities to Central Government pensioners:-

Also check: CGHS – Central Government Health Scheme

a) Pensioners residing in CGHS covered areas:

1. They can get themselves registered in CGHS dispensary after making requisite contribution and can avail both OPD and IPD facilities.

2. Pensioners residing in CGHS areas cannot opt out of CGHS and avail any other medical facility (i.e. Fixed Medical Allowance). Such pensioners, if they do not choose to avail CGHS facility by depositing the required contributions, cannot be granted Fixed Medical allowance in lieu of CGHS.

b) Pensioners residing in non-CGHS areas:

1. They can avail Fixed Medical Allowance (FMA) © Rs. 500/- per month revised to Rs. 10001- from 01.07.2017.

2.They can also avail benefits of CGHS (OPD and IPD) by registering themselves in the nearest CGHS city after making the required subscription.

3. They also have the option to avail FMA, for OPD treatment and CGHS for IPD treatments after making the required subscriptions as per CGHS guidelines.

All retired/ retiring Officers/ Staff of the Defence Accounts Department may please be advised to adhere to the above provisions and subscribe to CGHS facility by depositing the required contributions for availing medical facilities after retirement.

This issues with the approval of Sr. Jt. CGDA (AN).

(Rajeev Ranjan Kumar)
Dy. CGDA (AN)

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No. 21/26/2013-EC-X
GOVERNMENT OF INDIA
DIRECTORTE GENERAL OF WORKS
CENTRAL PUBLIC WORKS DEPARTMENT

Nirman Bhawan, New Delhi
Dated the 24th January, 2014

To
1. All the CEs/SEs/SEs(Coord.)/EEs/DDG (Hort.)/DDOH.

Subject: Reimbursement of Medical Claims-Regarding

Sir,
After repeated requests and making available of the required formalities for processing of reimbursement of medical claims, it has been observed that the medical reimbursement claims are still being received in this Directorate are forwarded/processed in a very casual manner resulting in delay in final settlement of claims of individuals and settling medical claims of different C.G.H.S. approved Hospitals.

To minimize the delay and to streamline the process of scrutinizing and submission of reimbursement of medical claims the stage wise steps required are appended below for action on the part of field units of this Directorate:-

1. The duly filled up Modified Check list for Reimbursement of Medical Claims and Medical Claims Form as per prescribed Performa.

2. The Copy of new CGHS card.

3. The Copy of Permission Letter from concerned office.

4. The Original Bills along with discharge/ Death summary from the Hospital.

5. Emergency Certificate in original from Hospital.

6. In case of death of CGHS Card Holder following documents as prescribed in modified checklist:
i. Affidavit on stamp paper by claimant.
ii. No objection from other Legal Heirs on stamp paper.
iii. Copy of Death Certificate.

7. Whether any advance was granted in the medical Reimbursement Claim? If so, provide the details of the same and under which rules the facility was allowed to applicant.

8. Whether credit facility was granted for the treatment? If so provide the details of the same. Under which rule the credit facility was allowed to serving Govt. official?

9. Medical Reimbursement Claim has to be submitted in duplicate.

10. It has to be mentioned by the forwarding /concern office (Chief Engineer) as to whether the amount claimed for reimbursement is as per the CGHS prescribed rate or not and it has also need to be certified that there is no need of any relaxation of rules in the instant case.

11. Original pouch of Stent packets along with requisite documents prescribed by MOHFW from time to time needs to be enclosed in the MRC file in order.

12. The amount mentioned for stents and other consumables may please be checked as per ceiling rates fixed by MOHFW and the same may be indicated in the forwarding letter.

13. As per the observations of IFD and Works Division in the precedent cases the case requires to be submitted in line with the guidelines of precedent cases providing the details of amount charged by the hospital indicating the S.I. No. of the CGHS items with relevant instructions and thus arriving at the amount admissible.

The case may be submitted with the details of amount charged by the hospital indicating the S.I. No. of the CGHS items with relevant instructions and thus arriving at the amount admissible as per the below format:-

(i) Name of the Hospital ……………………………… Period of treatment from ………..   to …………
(extracts of hospital recognition be placed in the file or instructions relating of treatment from non-empanelled hospital be placed in the file and it may be averred all stipulations have been complied with

(ii) All relevant OMs pertaining to the case (item wise-reimbursement) may be placed in the file alongwith the Mb o Health & Family Welfare OM No. S-11011/23/2009/CGHS D-11 dated 17th August, 2010 and subsequent clarificatory OMs issued thereafter.

(iii) It may be indicated whether 10% discount has been availed and case may be put up as per prescribed format as mentioned above.

14. Clarification regarding admissible and non-admissible items under CGHS provided in Mb o Health & Family Welfare’s O.M. No.F.No.2-1/2012/CGHSNC/CGHS(P) dated 01st August, 2013 has to be complied with.

15. As per Ministry of Health and Family Welfare’s Draft MOA F.No. D.12034/22/09/CGHS-Desk-I following has to be checked.

(i) DISCOUNT : Hospital shall also allow a discount of 10% on every cash payment.

(ii) CREDIT: On production of a valid permission by the CGHS beneficiary- the hospital shall provide credit facilities to the Members of Parliament, Pensioners, Ex-Members of Parliament, Freedom Fighters, Serving CGHS employees, serving employees of Ministry of Health & Family Welfare, serving employees of Directorate General of Health Services and such other categories of CGHS cardholders as notified by the Government. In case of emergency the hospital shall provide credit to all CGHS beneficiaries.

(iii) TREATMENT IN EMERGENCY:
In emergency the hospital shall not refuse admission or demand an advance payment from the beneficiary or his family member and shall provide credit facilities to the patient whether the patient is a serving employee or a pensioner availing CGHS facilities, on production of a valid CGHS card and the hospital shall submit the bill for reimbursement to the concerned Deptt./Ministry/CGHS. The refusal to provide the treatment to bonafide CGHS beneficiaries in emergency cases without valid ground, would attract disqualification for continuation of empanelment.

The list of ailments which may be treated as emergency has been mentioned in the MOA for the Hospitals, which is illustrative only and not exhaustive, depending on the condition of the patient.

(iv) For serving employees (other than CGHS/ DGHS /Ministry of H&FW), the payment shall be made by the patient and he shall claim reimbursement from his office subject to the approved ceiling rates. The Private Hospital shall allow a discount of 10% on all payments made in cash.

(v) The treatment procedure shall be performed on the basis of the authorization letter issued by the Chief Medical Officer of the concerned CGHS dispensary in case of pensioners and by the administrative department / ministry in case of serving employees.

(vi) The Hospital agrees that during the In-patient treatment of the CGHS beneficiary, the Hospital shall not ask the beneficiary or his attendant to purchase separately the medicines / sundries / equipment or accessories from outside and shall provide the treatment within the package deal rate, fixed by the CGHS which includes the cost of all the items. Appropriate action, including removing from CGHS empanelment and / or termination of this Agreement, may be initiated on the basis of a complaint, medical audit or inspections carried out by CGHS teams / appointed TPA.

(vii) The hospital shall not refer the patient to other specialist / other hospital without prior permission of CGHS authorities. Prior intimation shall be given to CGHS whenever patient needs further referral.

(viii) Entitlement for various types of wards to CGHS beneficiaries has also been provided in the aforesaid MOA.

This issues with the approval of DDG (HQ)

sd/-
(Rahul Ranbir Singh)
Deputy Director (Administration)

Source: www.cpwd.gov.in
[http://cpwd.gov.in/WriteReadData/other_cir/9291.pdf]

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