Relaxation of Rules for consideration of reimbursement in excess of the approved rates pertaining to medical claims

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 Bhawnn, 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