Medical Facilities for inpatient treatment and post-operative follow-up treatment to CGHS Beneficiaries in Non-CGHS areas

Government of India
Ministry of Health and Family Welfare
Department of Health & Family Welfare
Nirman Bhawan, New Delhi 110 108

No: S.11011/7/99-CGHS (P)

Dated, the 27th April, 2011

O F F I C E        M E M O R A N D U M

Subject: Medical Facilities for inpatient treatment and post-operative follow-up treatment to CGHS Beneficiaries in Non-CGHS areas.

The undersigned is directed to invite attention to the Office Memorandum of even number dated 30th September, 1999, issued by the Ministry of Health & Family Welfare on the above subject and to state that keeping in view the difficulties being faced by the pensioner CGHS beneficiaries residing in non-CGHS covered areas, it has now been decided to liberalise the CGHS Rules with regard to pensioner CGHS beneficiaries and serving employees, as below, to
enable them to avail medical facilities for in-patient treatment and post-operative follow-up treatment:

a) (i) CGHS pensioner beneficiaries (and their dependant and eligible family members), who are holding a valid CGHS Card and are residing in a non-CGHS areas shall be eligible to obtain treatment from Government hospitals (Central Government / State Government / Local self Government / hospitals recognised under Central Services (Medical Attendance) Rules, 1944 / hospitals and clinics empanelled under Ex-Servicemen Contributory Health Scheme (ECHS) and submit the medical reimbursement claim to the Additional Director / Joint Director of CGHS of the CMO in charge of CGHS Wellness Centre, where the CGHS is registered.

(ii) In case of non-emergency treatment from hospitals approved under Central Services (Medical Attendance) Rules, 1944 and Ex-Servicemen Contributory Health Scheme (ECHS), it is necessary to obtain prior approval from CMO in charge of concerned Wellness Centre where the CGHS card is registered.

(iii) In case of medical emergency, treatment may be obtained from any hospital and medical claim shall be submitted to Additional Director / Joint Director, CGHS of the
concerned city through CMO in charge of the Wellness Centre, where the CGHS card is registered.

(iv) Reimbursement shall be limited to the CGHS rates of the city where the card is
registered and as per the ceiling rates and ward entitlements or as per actuals, whichever is lower.

(v) CGHS pensioner beneficiaries / serving Central Government employees (and their dependant and eligible family members) and holding a valid CGHS Card and on a visit to non CGHS covered area may obtain treatment under emergency from Government hospitals (Central Government / State Government / Local self Government / hospitals recognised under Central Services (Medical Attendance) Rules, 1944 / hospitals and clinics empanelled under Ex-servicemen Contributory Health Scheme (ECHS) and the medical claim shall be submitted to Additional Director / Joint Director, CGHS of the concerned city through CMO in charge of the Wellness Centre, where the CGHS card is registered, in case of pensioners , etc., and to the concerned Ministry / Department / office in case of serving employees.

(vi) Reimbursement shall be limited to the CGHS rates of the city nearest to the place, where treatment is obtained and as per the ceiling rates and ward entitlements or as per actuals, whichever may be less.

b) (i) CGHS pensioner beneficiaries (and their dependant and eligible family members) , who are holding a valid CGHS Card and residing in a non-CGHS areas shall be eligible to obtain post operative follow-up treatment from Government hospitals (Central Government / State Government / Local self Government / hospitals approved under Central Services (Medical Attendance) Rules, 1944 / hospitals and clinics empanelled under Ex-servicemen Contributory Health Scheme (ECHS) in follow up cases of Renal Transplant surgery, Knee and Hip Joint Replacement, Cancer treatment , Neuro-surgery and cardiac surgery. However, prior permission is to be obtained from the CMO in charge of the concerned Wellness Centre, where the CGHS card is registered.

(ii) Permission shall be issued for 3 to 6 months at a time and may be extended based on medical requirement. Reimbursement for consultation, procedures and investigations shall be limited to CGHS rates of the city, where the card is registered and as per the ceiling rates and ward entitlements or as per actuals, whichever may be lower. OPD medicines shall be obtained from the concerned Wellness centre for a maximum period of 3 months at a time.

c) Wherever treatment is obtained from a hospitals approved under Central Services (Medical Attendance) Rules, 1944 / ECHS approved hospital, the beneficiaries (as in (a), (b) & (c) above) shall submit a certificate from the hospital that they have not charged more than the approved applicable hospitals approved under Central Services (Medical Attendance) Rules, 1944 / ECHS rates.

d) This Office Memorandum supersedes the earlier OM of even number dated 30th September 1999.

e) This arrangement is provisional and would be in place till such time the proposed Health Insurance Scheme for Central Government employees & pensioners is brought into effect.

f) These orders will come into effect from the date of issue.

[R.Ravi]
Director

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