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 draw attention 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.
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.
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
(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.
Sd/-
(Rajeev Attri)
Under Secretary to Government of India
