Subject: Relaxation of procedures to be followed in considering requests for medical reimbursement.
No: 4-18/2005-C&P [Vol. I – Pt. (I)] 20th February, 2009
It is directed to state that under the extant instructions, a CGHS card holder, who wishes to apply for reimbursement of the expenditure incurred by him / her on medical treatment of either self or his / her dependent family members, the present reimbursement procedure needs verification of bills and issue of essentiality certificate by the treating doctor, and the Medical Superintendent of the hospital. The process of verification of bills and issue of essentiality certificates are time consuming with the doctor at times being busy or being away from office for whatever reason. This necessitates repeated visits to the hospital for getting the verification done and essentiality certificate obtained. Representations have been received in the Ministry of Health & Family Welfare requesting for doing away with the two requirements and for the Ministries / authorities concerned to verify and check the authenticity of the claims on the basis of the prescription slip and the diagnostic report submitted by the Government servant / pensioner. In the event of any doubt, the concerned Ministry / Authority can always get verification done from the hospital concerned.
2. The undersigned is also directed to state that CGHS guidelines currently provide for relaxation of guidelines to cover full reimbursement in individual cases depending upon merits of each case. In the case of Hon’ble Members of Parliament, the powers to relax the guidelines have been delegated to the Lok Sabha Secretariat and Rajya Sabha Secretariat respectively and in the case of Hon’ble Chief Justice of Supreme Court and Judges of the Supreme Court to the Secretary General of the Supreme Court.
3. In order to reduce the burden on the specialists in individual cases of medical reimbursement claim, it has been decided with the approval of heads of the hospitals to revise the guidelines for reimbursement by the competent authority, as follows:
(1) It has now been decided to do away with the procedure for verification of bills and issue of essentiality certificate by the treating doctor, and the Medical Superintendent of the hospital. Ministries / authorities concerned may verify and check the authenticity of the claims on the basis of the prescription slip and the diagnostic report submitted by the Government servant / pensioner. In the event of any doubt, the concerned Ministry / Authority can always get verification done from the hospital concerned. Modified reimbursement claim form, alongwith checklist is annexed.
(2) All cases involving requests for relaxation of rules for reimbursement of full expenditure will henceforth be referred to a Technical Standing Committee, to be chaired by the DGHS / Addl.DGHS and consist of Director (CGHS) and subject matter specialists. If the Technical Standing Committee recommends the relaxation of rules for permitting full reimbursement of expenditure incurred by the beneficiary, the full reimbursement may be allowed by the Secretary (Health & Family Welfare) in consultation with IFD. A check list for consideration of requests for reimbursements in excess of approved rates may include:
(a) The treatment was obtained in a private non-empanelled hospital under emergency and the patient was admitted by others when the beneficiary was unconscious or severely incapacitated and was hospitalised for a prolonged period;
(b) The treatment was obtained in a private non-empanelled hospital under emergency and was admitted for prolonged period for treatment of Head Injury, Coma, Septicemia, Multi-organ failure, etc.;
(c) The treatment was obtained in a private non-empanelled hospital under emergency for treatment of advanced malignancy;
(d) The treatment was taken under emergency in higher type of accommodation as rooms as per his / her entitlement are not available during that period;
(e) The treatment was taken in higher type of accommodation under specific conditions for isolation of patients to avoid contacting infections;
(f) The treatment was obtained in a private non-empanelled hospital under emergency when there is a strike in Government hospitals;
(g) The treatment was obtained in a private non-empanelled hospital under emergency, while on official tour to non-CGHS covered area;
(h) Approval for air-fare with or without attendant on the advice of treating doctor for treatment in another city even though he is not eligible for air travel / treatment facilities are available in city of residence and
(i) Any other special circumstances.
4. The Office Memorandum is issued with the concurrence of IFD vide Dy. No: 908/AS &FA/2009 dated the 20th February, 2009.
Saturday, February 28, 2009
Revision of income limit for dependency for the purpose of providing Central Government Health Scheme subsequent to sixth Central Pay Commission
Subject: Revision of income limit for dependency for the purpose of providing Central Government Health Scheme (CGHS) coverage to family members of the CGHS covered employees subsequent to implementation of recommendations of the sixth Central Pay Commission – regarding
S.11012/1/98 -CGHS (P) Dated the 10th December, 2008
Subsequent to the implementation of the recommendations of the 5th CPC the income limit for dependency for the purpose of extending CGHS coverage to “family” members of the CGHS covered Central Government employees was enhanced to Rs. 1500/- per month.
2. With the implementation of the recommendations of the 6th Central Pay Commission, the issue of revision of income limit for dependency for the purpose of providing CGHS coverage to family members of the CGHS covered Central Government employees and pensioner CGHS beneficiaries was under consideration keeping in view the amount of minimum pension/ family pension fixedPLEOTOR 20 by the 6th Central Pay Commission.
3. On the basis of the recommendations of the 6th CPC, the Department of Pension and Pensioners’ Welfare under para 5.5 of their OM No. 38/37/08-P&PW (A) dated 2.9.2008, has fixed the amount of minimum pension as Rs. 3500/- per month and under para 8.1of this OM the amount of family pension has been fixed as 30% of the basic pay in all cases shall be subject to a minimum of Rs.3500/- per month and maximum of 30% of the highest pay in the Government. The DoP&PW at para 8.5 of the same OM has decided that dependency criteria for the purpose of family pension shall be the minimum family pension along with dearness relief thereon.
4. It has been decided, in consultation with the Department of Expenditure, to revise the income limit for the purpose of providing CGHS coverage to the family members of the CGHS covered Central Government employees to “Rs.3500/- plus the amount of dearness relief on basic pension of Rs.3500/- as on the date of consideration”.
5. As such, all the orders related to the CGHS Rules stands amended to the extent that the income limit for Rs.1500/- per month from all sources including pension/ and family pension stands amended to an income of Rs. 3500/- plus amount of the dearness relief on the basic pension of Rs.3500/- as on the date of consideration. The amount of dearness relief, as indicated in the income limit stands for the amount of dearness relief drawn by a pensioner/ family pensioner on the date of consideration and not the amount of dearness relief due on the date of consideration.
6. The income limit for dependency of “Rs. 3500/- plus amount of the dearness relief on the basic pension of Rs.3500/- as on the date of consideration”, shall also be applicable for the cases covered under CS (MA) Rules, 1944 for the purpose of examining eligibility of family members of the Central Government employee for medical facilities under the Rules.
7. The order shall be effective from 1st January, 2009.
8. This issues with the concurrence of the Department of Expenditure vide their I.D. No. 566/EV/2008 dated 4.11.2008.
S.11012/1/98 -CGHS (P) Dated the 10th December, 2008
Subsequent to the implementation of the recommendations of the 5th CPC the income limit for dependency for the purpose of extending CGHS coverage to “family” members of the CGHS covered Central Government employees was enhanced to Rs. 1500/- per month.
2. With the implementation of the recommendations of the 6th Central Pay Commission, the issue of revision of income limit for dependency for the purpose of providing CGHS coverage to family members of the CGHS covered Central Government employees and pensioner CGHS beneficiaries was under consideration keeping in view the amount of minimum pension/ family pension fixedPLEOTOR 20 by the 6th Central Pay Commission.
3. On the basis of the recommendations of the 6th CPC, the Department of Pension and Pensioners’ Welfare under para 5.5 of their OM No. 38/37/08-P&PW (A) dated 2.9.2008, has fixed the amount of minimum pension as Rs. 3500/- per month and under para 8.1of this OM the amount of family pension has been fixed as 30% of the basic pay in all cases shall be subject to a minimum of Rs.3500/- per month and maximum of 30% of the highest pay in the Government. The DoP&PW at para 8.5 of the same OM has decided that dependency criteria for the purpose of family pension shall be the minimum family pension along with dearness relief thereon.
4. It has been decided, in consultation with the Department of Expenditure, to revise the income limit for the purpose of providing CGHS coverage to the family members of the CGHS covered Central Government employees to “Rs.3500/- plus the amount of dearness relief on basic pension of Rs.3500/- as on the date of consideration”.
5. As such, all the orders related to the CGHS Rules stands amended to the extent that the income limit for Rs.1500/- per month from all sources including pension/ and family pension stands amended to an income of Rs. 3500/- plus amount of the dearness relief on the basic pension of Rs.3500/- as on the date of consideration. The amount of dearness relief, as indicated in the income limit stands for the amount of dearness relief drawn by a pensioner/ family pensioner on the date of consideration and not the amount of dearness relief due on the date of consideration.
6. The income limit for dependency of “Rs. 3500/- plus amount of the dearness relief on the basic pension of Rs.3500/- as on the date of consideration”, shall also be applicable for the cases covered under CS (MA) Rules, 1944 for the purpose of examining eligibility of family members of the Central Government employee for medical facilities under the Rules.
7. The order shall be effective from 1st January, 2009.
8. This issues with the concurrence of the Department of Expenditure vide their I.D. No. 566/EV/2008 dated 4.11.2008.
Laboratory facilities set up by M/s Hindustan Latex Limited at CGHS Dispensary R k Puram Sector XII, New Delhi
Subject:Laboratory facilities set up by M/s Hindustan Latex Limited at CGHS Dispensary , Ramakrishna Puram (No: 57) located Ramakrishna Puram Sector XII, New Delhi – Referral to the
OM. No. 5-6/2007/CGHS/C&P/ CGHS(P), dated 24th February, 2009, issued by the Ministry of Health & Family Welfare
Reference to this Ministry’s Office Memorandum of even number dated the 7th February, 2008 and 27th March, 2008, on the above subject vide which the setting up of Hind labs, a state of the art diagnostic laboratory by M/s Hindustan Latex Limited was conveyed. The decision of the Ministry of Health & Family Welfare was also conveyed that all CGHS beneficiaries (registered with CGHS dispensaries in Ramakrishna Puram Sectors II, III, IV, VI, VII and XII; Jawaharlal Nehru University; Moti Bagh; Nanak Pura; three dispensaries in Sarojini Nagar; Netaji Nagar; Nauroji Nagar and Laxmibai Nagar) shall have to be referred only to that laboratory. As there were some initial teething problems in the Hind labs, it was decided to keep in abeyance the implementation of the instructions contained in the Office Memorandum of 7th February, 2008, referred to above until further orders.
2. It has been brought to the notice of the Ministry of Health & Family Welfare that Hind labs has now overcome the problems faced by it initially and is in a position provide one window quality diagnostic services to the beneficiaries. The undersigned is, therefore, directed to convey the following decisions of the Ministry of Health & Family Welfare:
(i) As Hind lab has been set up by the CGHS in collaboration with M/s. Hindustan Latex Limited, it will be deemed to be empaneled under CGHS, and beneficiaries from any dispensary in Delhi may also get tests done at Hind labs for diagnostic purposes;
(ii) Hind labs will not charge any money from pensioner CGHS beneficiaries for the diagnostic tests to be carried out by it and raise bills on Additional Director (Hqrs), CGHS, Bikaner House, Shahjahan Road, New Delhi 110 011, in a periodical cycle; and
(iii) A CGHS beneficiary can directly go to Hind lab for diagnostic tests, if he / she has been prescribed the same by a Government specialist. For this, the beneficiary has to submit a copy of the prescription by the specialist and a copy of his / her valid CGHS card.
OM. No. 5-6/2007/CGHS/C&P/ CGHS(P), dated 24th February, 2009, issued by the Ministry of Health & Family Welfare
Reference to this Ministry’s Office Memorandum of even number dated the 7th February, 2008 and 27th March, 2008, on the above subject vide which the setting up of Hind labs, a state of the art diagnostic laboratory by M/s Hindustan Latex Limited was conveyed. The decision of the Ministry of Health & Family Welfare was also conveyed that all CGHS beneficiaries (registered with CGHS dispensaries in Ramakrishna Puram Sectors II, III, IV, VI, VII and XII; Jawaharlal Nehru University; Moti Bagh; Nanak Pura; three dispensaries in Sarojini Nagar; Netaji Nagar; Nauroji Nagar and Laxmibai Nagar) shall have to be referred only to that laboratory. As there were some initial teething problems in the Hind labs, it was decided to keep in abeyance the implementation of the instructions contained in the Office Memorandum of 7th February, 2008, referred to above until further orders.
2. It has been brought to the notice of the Ministry of Health & Family Welfare that Hind labs has now overcome the problems faced by it initially and is in a position provide one window quality diagnostic services to the beneficiaries. The undersigned is, therefore, directed to convey the following decisions of the Ministry of Health & Family Welfare:
(i) As Hind lab has been set up by the CGHS in collaboration with M/s. Hindustan Latex Limited, it will be deemed to be empaneled under CGHS, and beneficiaries from any dispensary in Delhi may also get tests done at Hind labs for diagnostic purposes;
(ii) Hind labs will not charge any money from pensioner CGHS beneficiaries for the diagnostic tests to be carried out by it and raise bills on Additional Director (Hqrs), CGHS, Bikaner House, Shahjahan Road, New Delhi 110 011, in a periodical cycle; and
(iii) A CGHS beneficiary can directly go to Hind lab for diagnostic tests, if he / she has been prescribed the same by a Government specialist. For this, the beneficiary has to submit a copy of the prescription by the specialist and a copy of his / her valid CGHS card.
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