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Thursday, 24 May 2018

CGHS Order : Relaxation of Rules for consideration of reimbursement in excess of the approved rates pertaining to medial claims.

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CGHS Order : Relaxation of Rules for consideration of  reimbursement in excess of the approved rates pertaining to medial claims.

केन्द्रीय स्वास्थ्य एवं परिवार कल्याण मंत्रालय ने अपने कार्यालय ज्ञापन संख्या 4-18/2005- C&P [Vo]. l-Pt (1)]दिनांक 20 फरवरी 2009 के पैरा 3 (2) में संशोधन करते हुए सी.जी.एच.एस लाभार्थियों द्वारा इमरजेन्सी में निजि अस्पताल में किए गए ईलाज के पश्चात् सीजीएचएस दर से अधिक के दावों के प्रतिपूर्ति के सम्बन्ध में कुछ शर्तों के साथ आवश्यक छूट प्रदान किया।


Government of India
Ministry of Health and Family Welfare
Department of Health & Family Welfare
EHS Section 

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 drawattention to the Office Memorandum No. 4-18/2005- C&P [Vo]. l-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:
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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
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) 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. l- Pt(1)] dated the 20 February 2009 shall remain unchanged.

(Rajeev Attri)
Under Secretary to Government of India 

[http://cghs.gov.in/showfile.php?lid=4995]

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