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

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

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.

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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:
 
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.
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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
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(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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