No: Z. 15025/38/2018/DIR/CGHS/EHS

Nirman Bhawan, New Delhi
Dated the 22nd May, 2018

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)l, dated the 20th February 2009 and to slate 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&OG (CGHS) for consideration of approval. And 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 ill 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.

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

(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.

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

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“It is clarified that those employees superannuating on or before 31.1.2017 and had submitted their application on or before 31.1.2017 may be allowed the subscription at the prevalent rates applicable as on 31.1.2017 vide OM No.S.No.S.11011/2/2008-CGHS(P) dated 20.5.2009”.

No.S.11011/11/2016-CGHS(P)/EHS
Government of lndia
Ministry of Health and Family Welfare
EHS Section

Nirman Bhawan, New Delhi
Dated the 9 February, 2017

OFFICE MEMORANDUM

Sub: Revision of rates of subscription under Central Government Health Scheme due to revision of pay and allowances of Central Government employees and revision of pension/ family pension on account of implementation of recommendations of the Seventh Central Pay Commission- clarification reg.

Attention is drawn to this Ministry’s OM of even No. dated 9th January, 2017 and a subsequent OM of even no. dated 13/7/2017, on the subject mentioned above.

2. This Ministry has been receiving several representations w.r.t applicability of CGHS rates to pensioners superannuating on 31.1.2017. The matter has been examined in this Ministry and it is clarified that those employees superannuating on or before 31.1.2017 and had submitted their application on or before 31.1.2017 may be allowed the subscription at the prevalent rates applicable as on 31.1.2017 vide OM No.S.No.S.11011/2/2008-CGHS(P) dated 20.5.2009. Pensioners applying for CGHS pensioner card on annual/lifetime basis after 31/1/2O17 will have to pay as per the revised rates effective from 1.2.2017 vide OM of even No. dated 13.1.2017.

3. This issues with the approval of the Competent Authority.

sd/-
(Bindu Tewari)
Director

Authority : http://cghs.gov.in/

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No.S.11011/20/2014-CGHS (P)/EHSS
Government of India
Ministry of Health & Family Welfare
Department of Health & Family Welfare
EHS Section

Nirman Bhawan, New Delhi
Dated: the 23 November, 2016

OFFICE MEMORANDUM

Subject: Delegation of powers to Heads of Departments in various Ministries/Departments for settling permission cases and post facto approval relating to referral system and medical reimbursement under CGHS – Enhancement of ceiling rate from Rs. 2 Lakhs to Rs. 5 Lakhs without consultation of IFD of concerned Ministry – Reg.
The undersigned is directed to refer to this Ministry’s OM No. S.12020/4/97-CGHS (P), dated 27.12.2006 and its clarification issued vide this Ministry’s OM No. S.11011/20/2014-CGHS (P), dated 20.06.2014, wherein financial powers were delegated to the Heads of Departments/Ministries to settle all such cases where there is no relaxation of rules involved and admissibility of claim was worked out with reference to the CGHS approved rate list and guidelines.

2. This Ministry has been receiving requests from different Ministries/Departments for enhancement of delegation of financial powers to Head of Departments to settle medical claims/medical advance cases involving financial implications upto Rs. 5 Lakhs without referring the case to Internal Finance Division (IFD).

3. The matter regarding enhancement of delegation of financial powers to the Heads of Departments/Ministries has been examined in this Ministry and it has been decided with the approval of the competent authority to enhance the existing limit of Rs. 2 Lakhs to Rs. 5 Lakhs to settle all cases where there is no relaxation of rules and the entitlement was worked out with reference to the rate list prescribed.

In respect of cases involving payment exceeding Rs. 5,00,000/- (Rupees 5 Lakhs only) but as per the prescribed rate list, the concerned Departments/Ministries may settle such cases in consultation with their respective Internal Finance Division. Only in those cases where the settled scheme/rules are required to be relaxed, should the case be referred to the Ministry of Health and Family Welfare.

4. This issue with concurrence of Internal Finance Division vide FTS No. 91725, dated 01.11.2016.

(Sunil Kumar Gupta)
Under Secretary to the Govt. of India
(Tel 2306 1986)

Source: www.cghs.gov.in

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