Dated the 6th June, 2018
Subject:- Guidelines for settlement of Medical claims of pensioners and others-
With reference to the above subject the undersigned is to draw attention to the revised timelines and constitution of High Powered Committee in compliance of the directions of Hon’ble Supreme Court of India in their Judgement in the WP(Civil) No 694 of 2015 between Shiva Kant Jha Vs UOI delivered on 13th April 2018 and to state that it has been decided to issue guidelines to the Additional Directors of CGHS for implementing these decisions. The new guidelines are enclosed for perusal and compliance.
GUIDELINES TO PROCESS THE REQUESTS FOR SETTLEMENT OF THE MEDICAL CLAIMS
1. New Timelines for settlement of the Medical Claims
The new timelines prescribed for settlement of normal medical claims are 30 days from the date of submission to the payment by Pay & Accounts Office. Every effort must be made to avoid delay at any stage. Proper calculation sheet must be prepared in the file, so that the same could be shared with the beneficiaries, if there are requests for reasons for the deductions.
2. Full reimbursement case /Cases for relaxation of Rules
As per the new guidelines they fall into two categories
(a) Full reimbursement – Non-HPC (Non- High Power Committee) cases
(b) Full reimbursement – HPC (High Power Committee) cases
a) Full reimbursement – Non-HPC cases
The following cases fall under this category;
i) 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.
ii) 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.
iii) Treatment was obtained in a private unrecognized hospital under emergency for treatment of advanced malignancy
iv) Treatment was taken under emergency in higher type of accommodation as rooms as per his/her entitlement are not available during that period.
v) Treatment was taken in higher type of accommodation under specific conditions for isolation of patients to avoid contacting infections
vi) Treatment was obtained in a private unrecognized hospital under emergency when there is a strike in Govt. hospitals.
vii) Treatment was obtained in a private unrecognized hospital under emergency while on official tour to non-CGHS covered area.
Although the new OM has not mentioned about STC recommendation, it is advisable to have expert Committee meetings under the Chairperson of Addl. DGHS (as in the case of earlier STC meetings) in respect of item Nos. i), ii),iii) and v) before arriving at a decision. The conditions mentioned at Nos. iv),vi) and vii) are administrative in nature and do not require meetings of expert committees and may be recommended by Addl. Director, if conditions are satisfied.
b) Full reimbursement – HPC cases
1. Special Director General…. Chairperson
2. Directorate General, CGHS or his Nominee…Member
3. Additional Director, CGHS(HQ) / Addl. DDG(HQ),CGHS …Member
4. Addl. Director, CGHS(R&H)…Member Secretary
5. One Government Specialist (of concerned Speciality)…Member
1. 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
2. Representations from CGHS beneficiaries seeking full reimbursements under special Circumstances.
3. Relaxation of Rules
Addl Directors shall submit the files with relevant documents to the AD(HQ) / Addl. DDG(HQ) for placing the representations before High Power Committee.
3. In addition there are expert committees to consider several cases
Expert Committee meetings for other purposes shall continue to be held as in the past in the following cases:
- Expert Committee meetings for Consideration of Liver Transplant cases, Bariatric Surgery,
- Bone-marrow / Stem Cell Transplant, Justification of treatment / Implants in selected cases shall continue as before.
- Standing Committee meetings for Cochlear Implant shall continue as before. Expert Committee meetings for approval of Drugs , etc., shall continue