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MEDICAL FACILITIES TO CENTRAL GOVT.
EMPLOYEES-2016
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Ch. Srinivasa Rao
Founder-Editor, “HARMONY”
Formerly COA, CSIR-NGRI
Hyderabad
A. PRIMARY ASPECTS
Applicability
The Central Services (Medical Attendance) Rules, 1944 are applicable to all Govt. servants, and their families,
civilians paid from the Defence Services Estimates; industrial and work-charged staff who are not covered by
Employees State Insurance Scheme and employees of the Ordnance and Ordnance Equipment Factories who
are put up beyond a distance of 8 Km. radius from the factory premises through an option.
All those Govt. employees who are on deemed deputation of Autonomous/ Statutory Bodies of the Central
Govt. and retiring while on such deemed deputation will also be eligible for CGHS facility, provided they are
receiving Central Civil Pension and are not availing the medical facility provided by such Bodies after their
retirement. The contributions to be made will be decided by the Grade Pay they would have now drawn in the
Govt. in the post held by them but for their absorption.
The families of a Central Govt. servant are eligible for medical facilities even when the Govt. servants are
under voluntary training/embodiment in the Territorial Army/Military service during emergency, proceeding
Ex-India on deputation or leave including study leave and deputation-cum-special leave under the various
schemes.
Govt. Hospitals
Central Govt. employees and the members of their families are permitted to avail of medical facilities in any of
the Central/State Govt. Hospitals and the Hospitals recognized by the State Govt./CGHS Rules/CS (MA)
Rules, 1944, Hospitals fully funded by Central/State Govts. Maternity & Child Welfare Centres with In-patient
arrangements, Cantonment Hospitals, Railway Hospitals, Pay Clinics recognized by State Govts., Hospitals
maintained by Local Bodies, PSUs, Port Trust, including their Medical Officers are also recognized for
treatment of Govt. employees and their families.
Govt. employees and members of his family may avail medical facilities from any of the Central/State Govt.
Hospitals and the Hospitals recognized by the State Govt./CGHS/CS (MA) Rules, 1944 as well as the
Hospitals fully funded by either Central/ State Govt.
Authorized Medical Attendant
A Medical Officer. appointed by the Department of Health & Family Welfare, Govt. of India or any other
Department of the GoI; a Medical Officer whether or not under the employ of the Central Govt. or the
Chairman of the Central Govt. Employees' Welfare Co-ordination Committee in relation to the Central Govt.
employees at that station is considered to be an Authorized Medical Attendant (AMA) under these rules.
The AMA of a Govt. servant is determined with reference to the place at which he alls ill as Officers of
appropriate rank may or may not be available at all the places. In case of emergency, a Govt. servant is allowed
to take treatment from any other empanelled AMA even if such an AMA is not nominated by his own
Department.
Honorary Medical Officers outside Hospital precincts and any AMA who is on leave cannot be treated as
AMAs.
Appointment of private AMA
In terms of Supplementary Rule 2 (10), even a private Registered Medical Practitioner (RMP) can be
appointed as AMA in respect of a class or classes of Central Govt. employees where adequate number of
Doctors in the employ of the Central/State Govt. is not available, or because of remoteness of the area in which
the patient lives. Such an AMA is required to follow CS (MA) Rules strictly. Treatment at Consulting Room
should be limited to the administration of injections only.
An RMP who is owning a Nursing Home should not be appointed as AMA.
No private Dentist is permitted to be appointed as AMA.
Pathological and other tests for the purpose of diagnosis should be carried out on the advice of the AMA only
at the Govt. Hospital.
Indian Systems of Medicine
The policy of the Govt. was that Allopathic scientific medicine should continue to be the basis for the
development of the National Health Services in the country. This policy has recently been modified to admit
Indian and Homoeopathic Systems of Medicines (ISM). Simultaneous treatment in more than one system of
medicine such as Allopathic, Ayurveda, Homoeopathic, Unani, etc., provided that it is done with the
knowledge of the doctor of the other system.
The beneficiaries under CS (MA) Rules, 1944 may purchase only licensed
Ayurvedic/Unani/Sidha/Homoeopathic medicines/drugs prescribed by their AMAs from the nearest source
available.
The concerned Department/Ministry/Office should ensure the authenticity of the medical claims submitted. In
case of any clarifications, Ministry of AYUSH may be approached by the concerned Office.
B. INSTITUTIONAL ASPECTS
CGHS subscription
Pensioners have an option to get their CGHS Card made by either making CGHS contribution on an annual
basis (12 months) or by making contribution for 10 years (120 months) for getting a pensioner CGHS Card
with life-time validity.
Similarly, pensioners under “National Pension Scheme” (NPS) drawing additional relief on death/disability of
Govt. servant in terms of DOPW O.M.No.3841/06/P&)PW(A) dated 5-5-2009 and staying in areas not covered
by CGHS/corresponding Health Scheme of other Ministries can get a pensioners' Medical Card by paying
appropriate amount in the nearest CGHS/corresponding health scheme of other Ministries covered city to their
residence to enable them to obtain indoor treatment.
It is clarified that contributions to be made by pensioners/family pensioners would be the amount that they
were subscribing at the time of their retirement or at the time of death of the Govt. servant. The rate of
subscription is detailed in the pages that follow.
Pension beneficiaries who have already obtained CGHS Card with Life-time validity will not be required to
pay any additional amount even on revision of pay scales. Entitlement of pensioners/family pensioners who
have already deposited their contribution for Life-time CGHS facility will not be changed.
In case of pensioner/family pensioner who is entitled to avail CGHS facilities has not so far got CGHS Card
made, the rate of contribution in such cases will be w.r.t. the Grade Pay that would have drawn in the post held
by him/her at the time of retirement/ death had he/she continued to be in service now but for his retirement/
death.
Pensioners/family pensioners who are contributing to the CGHS on an annual basis and wish to continue to
avail CGHS benefits will have to contribute at the revised rates up to the time of contribution needed to cover a
period of a total of ten years from the time pensioner CGHS Card was issued for the first time to them. The
revised rate of contribution for the remaining period would be with reference to the Grade Pay, he/she would
have drawn in the post held by him/her at the time of retirement/death and continued to be in service now but
for his retirement/death.
On revision of rates: (i) Life-time CGHS Card holders need not pay any additional amount; (ii) Original
entitlement will not change; (iii) those who are paying on annual basis and wish to continue to avail CGHS
benefits will have to contribute at the revised rates up to the time of contribution needed to cover a period of
total of 10 years from the time CGHS Card was issued with reference to the Grade Pay that he/she would have
drawn in the post held by him/her at the time of retirement/death had he/she continued to be in service.
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CGHS subscription rates
S.No.
1.
2.
3.
4.
5.
Grade pay
Up to Rs.1,650
Rs.1,800, Rs.1,900, Rs.2,000, Rs.2,400 and Rs.2,600
Rs.4,200/Rs.4,600, Rs.4,800, Rs.5,400 and Rs.6,600
Rs.7,600 and above
Contribution p.m.
Rs. 50/Rs.125/Rs.225/Rs.325/Rs.500/-
Life-time CGHS Cards
It is compulsory for all the Pensioners to enroll themselves for availing medical facility by making lump sum
one-time contribution. Pensioners on having deposited the lump sum one-time subscription equivalent to 10
years for availing medical facility have to be issued a permanent Medical Identity Card.
CSIR pensioners who enroll themselves with the Dispensaries at the various Labs./Instts. shall now be eligible
for medical treatment and reimbursement as applicable to the Govt. pensioners covered under CGHS Scheme.
If Pensioners or their dependent family members are referred to Govt./recognised Hospital for consultation/
Specialist treatment from Out-Patient Department, the medicines so prescribed have to be procured by the
Dispensary.
The Reimbursable and Non-Reimbursable Diagnostic and Other Procedures have been listed under AnnexureI.
Supply of medicines
Specialists of the Hospital are normally advised to prescribe formulatary drugs of Medical Store Depot to the
beneficiaries of CGHS as far as applicable so that immediate availability of drugs can be ensured. Further,
medicines prescribed by the Specialist having identical Pharmaceutical formulations and therapeutic values, if
available in the Depot/Dispensary, the same may be issued, except otherwise marked as essential.
No reimbursement shall be admissible to the pensioners for OPD treatment at the Govt./Recognised Hospitals
and the medicines prescribed by the Specialists of such Hospitals are to be procured and supplied by the
Dispensaries. Medical reimbursement with regard to indoor treatment shall be admissible provided the patient
is referred for Specialist treatment by the Medical Officer-in-Charge of the Dispensaries.
In respect of CSIR pensioners and their families who reside at places where CSIR Lab./Instt. Dispensary
facilities are not available shall be eligible for the medical facilities provided by a Govt./recognised Hospital or
in lieu of OPD treatment, they are eligible to draw Rs.500/- p.m.
Analogue Insulin: The following types of Insulin (analogue) penfil/vial/cartridges are permitted to be issued to
the CGHS beneficiaries on valid prescription by a Specialist: (i) Inj. Novomix 30; (ii) Inj. Levemir; (iii) Inj.
Novorapid; and (iv) Inj. Lantus vial/Solostar
Supply of Inj. Human Insulin (30/70) in cartridge form on valid prescription is provided without recovering
any cost from the CGHS beneficiaries, including other brands of Penfil Insulin (analogue). The beneficiaries
will bear the cost of the pen from their own sources for utilizing the Injection after obtaining permission from
the Addl. Director (MSD) on valid prescription of Specialist on case-to-case basis, as an interim arrangement.
Generic drugs
In continuation of orders emphasizing the need of prescribing generic drugs, it is reiterated that all
Specialists/Doctors working in CGHS are to ensure that generic drugs are prescribed to the maximum extent
possible with a view to make medical treatment cost-effective and affordable.
Opting out of CGHS
If the spouse of a Govt. servant is employed in a private organization which provides medical facilities, the
Govt. servant can opt out of CGHS and avail the facilities provided by such an organization
Annual medical examination
It has been decided that Group A Officers of Central Civil Services/Posts above the age of 40 years will be
covered by the Annual Medical Check-up Scheme. The following package rates for the above purpose have
been approved: (i) Annual Medical Examination of Men Officers: Rs.2,000/- (ii) Annual Medical Examination
of Women Officers: Rs.2,200/A list of empanelled Hospitals for undergoing Annual Medical Examination in the various cities/towns under
each State has been provided.
The Officers outside Delhi/NCR where CGHS/CS(MA) Rules recognized Hospitals are available would
follow. The medical reports may be filed in ACRs of respective staff members while providing a copy to the
individuals.
C. ELIGIBILITY CRITERIA
Income limits for dependency
A member of the family is treated as dependant only if his/her income from all sources such as recurring
monthly income from houses, land-holdings, etc. is less than Rs.3,500/- plus Dearness Relief thereon per
month as discussed hereunder. However, lump sum non-recurring income such as CPF benefits, Govt. of India
Prize Bonds, Gratuity, Commuted Gratuity, Insurance benefits, etc. should not be regarded as income for this
purpose.
Further, the income limit for the purpose of providing CGHS coverage to the family members of the CGHS
covered Central Govt. employees to Rs.3,500/- plus amount of Dearness Relief on the basic pension of
Rs.3,500/- as on the date of consideration. The amount of DR as indicated in the income limit stands for the
amount of DR drawn by a pensioner/family pensioner on the date of consideration and not the amount of DR
due on the date of consideration.
If wife and husband are Central Govt. servants, they may be allowed to avail the medical concessions along
with eligible dependents according to his/her status by furnishing their respective administrative authorities, a
joint declaration (in duplicate) as to who will prefer the claim for reimbursement of medical expenses. A copy
of each shall be recorded in their personal files in their respective Offices. Such declaration shall remain in
force till it is revised by them.
The methods of determining dependency of family members on the Govt./CSIR Employees have been given in
Annexure-II.
Entitlement of Wards duration and charges payable are given in Annexure-III.
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Accommodation
Allotment of accommodation in a Hospital depends upon the pay, i.e., pay in the Pay Band/Pension/Family
Pension, being drawn by the Govt. servant at the time of falling ill by himself or by his family members. If
suitable accommodation as per the status of the Govt. servant is not available, accommodation of a higher class
may be allotted, provided that it is certified by the Medical Superintendent of the Hospital that accommodation
of the appropriate class was not available at the time of admission and that the admission of the patient into the
Hospital could not be delayed.
However, before seeking higher class of accommodation, efforts should be put in to seek admission in any
other similar Hospital, if available, at the same station.
Fixed Medical Allowance
At present, Fixed Medical Allowance (FMA) at a revised rate of Rs.500/- is granted w.e.f. 19-11-2014 to the
Central Govt. pensioners/family pensioners residing in areas not covered under CGHS administered by the
MOH&FW and corresponding Health Schemes administered by other Ministries/Departments for their retired
employees for meeting expenditure on their day-to-day medical expenses that do not require Hospitalization.
With regard to the date of eligibility for grant of FMA to Family Pensioners, it is clarified that in cases where
the existing pensioner/family pensioner was in receipt of FMA, the family pensioner next-in-line may be
allowed FMA from the same date from which he/she becomes eligible for family pension, if he/she otherwise
fulfills the conditions for grant of FMA.
FMA under NPS: Pensioners under “National Pension Scheme” (NPS) drawing additional relief on
death/disability of Govt. servant in terms of DOPW O.M. No.3841/ 06/P&)PW(A) dated 5-5-2009 and staying
in areas not covered by CGHS/corresponding Health Scheme of other Ministries can get a pensioners' Medical
Card by paying appropriate amount in the nearest CGHS/corresponding health scheme of other Ministries
covered city to their residence to enable them to obtain indoor treatment. They are also entitled to draw FMA
as fixed by the Govt. As and when the Health Insurance Scheme is introduced, the NPS Pensioners would be
shifted to such Scheme.
D. TREATMENT PROCEDURES
Medical attendance
Medical attendance is distinct from medical treatment. Medical attendance does not require repeated
consultations/prescriptions. It includes attendance at the Hospital/Dispensary or at the residence of the Govt.
servant or at the consulting room of the AMA whether maintained at the Hospital or at the residence of AMA.
Reimbursement of consultation fees at the prescribed rates should be restricted to the first four
consultations/visits at the rate of one consultation in a calendar day which should be completed within a period
of 10 days from the date of commencement of treatment.
A Govt. servant shall be entitled to medical attendance by the AMA free of charge. Any amount paid on
account of such medical attendance shall be reimbursed to him on production of a Certificate in writing by the
AMA.
Status of a Govt. servant will be determined on the basis of the actual pay being drawn at the time of falling ill.
In the case of re-employed pensioners, the pension should be taken into consideration along with pay for the
purpose of determining the grade.
Cost of admissible medicines prescribed during these consultations is reimbursable on production of original
prescriptions/cash memos.
There should be a reasonable gap between the closing of the first spell of illness from the disease and
recurrence of the same disease for a second time to justify a fresh claim. Prolonged treatment should be
received only at the OPDs of a Govt./recognized Hospital.
The Controlling Officer may reject any claim, if he is not satisfied with its genuineness. He may communicate
the reasons for rejection and afford an opportunity to the claimant of being heard within 45 days of the date of
receipt of the order.
Delegation of Powers
It has been decided to further decentralize the powers for settlement of medical claims to individual
Ministries/Departments/Lok Sabha and Rajya Sabha Secretariat and to the Secretary-General of Supreme
Court (as the case may be) as under:
A. Permission/Ex post facto approval for elective treatment/investigation taken in non-empanelled
Hospitals/Diagnostic Centres subject to the reimbursement being restricted to CGHS package rates or actual
expenditure, whichever is less:
a) Pensioners/Ex-MPs/Freedom Fighters, etc.
- Request to be considered by AS & DG (CGHS) in terms of MOH&FW O.M. No.S.11016/16/2010-CGHS(P)
dated 24-1-2011
b) Serving beneficiaries/sitting MPs/Judges of Supreme Court
- Request to be considered by HOD or HOO of individual Ministries/ Departments/LS & RS
Secretariat/Secretary-General of Supreme Court.
B. Ex-post facto approval of elective treatment/investigation in empanelled Hospitals/Diagnostic Centres
without recommendation of Govt.Specialist or CMO-in-Charge, subject to reimbursement being restricted to
CGHS rate or actual expenditure, whichever less:
a) Pensioners/Ex-MPs/Freedom Fighters, etc.
- Request to be considered by A&DG (CGHS) as before in terms of O.M. No.S.11016/16/2010-CGHS(P)
dated 24-1-2011
b) Serving beneficiaries/sitting MPs/Judges of Supreme Court
- Request to be considered by HOD or HOO of individual Ministries/ Department/LS & RS
Secretariat/Secretary-General of Supreme Court
C. Ex post facto approval of elective treatment at empanelled Hospitals with recommendation of Govt.
Specialist/CMO-in-Charge but without obtaining the permission of competent authority, subject to
reimbursement being restricted to CGHS rates or actual expenditure, whichever is less.
Instructions issued vide MOH&FW O.M. No.S.12020/4/97-CGHS(P) dated 7-4-1999 will be applicable.
D. Permission/Ex post facto approval for Cancer treatment taken in non-empanelled Hospital, subject to
reimbursement being restricted to CGHS rates or actual expenditure, whichever is less:
a) Pensioners/Ex-MPs/Freedom Fighters, etc.
- Additional Director of concerned Zones
b) Serving beneficiaries/sitting MPs/Judges of Supreme Court
- HOD or HOO of individual Ministries or Departments/LS&RS Secretariat/ Secretary-General of Supreme
Court.
E. Condonation of delay in submission of medical claims by pensioners, etc.:
a) Less than one year … AD of concerned city/AD(HQs), Delhi
b) Between one and two years … Director, CGHS
c) More than two years … AS & DG (CGHS)
This is w.e.f. date of discharge/completion of treatment.
F. Permission for treatment/investigations at non-empanelled Hospital/Diagnostic Lab. When facility for the
same are not available in any empanelled Hospital/Lab. Or any Govt. Hospital:
Permission to be granted by AS&DG (CGHS) in consultation with Experts, if required.
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Package rate
In compliance of the directions of Hon'ble High Court of Delhi in the case of Shri Kanhiya Singh Vs. UOI and
others [WP(C) 9044/2011 clarifying admissibility/ inadmissibility of items of expenditure for claiming
reimbursement under CGHS, the requisite clarifications regarding admissible and non-admissible items under
CGHS are provided hereunder:
a) “CGHS Package Rate” shall mean and include lump sum cost of inpatient treatment/day care/Diagnostic
procedure for which a CGHS beneficiary has been permitted by the competent authority or for treatment under
emergency from the time of admission to the time of discharge including (but not limited to) -- (i) Registration
charges, (ii) Admission charges, (iii) Accommodation charges including patient's diet, (iv) Operation charges,
(v) injection charges, (vi) Dressing charges, (vii) Doctor/Consultant visit charges, (viii) ICU/ICCU charges,
(ix) Monitoring charges, (x) Transfusion charges, (xii) Anesthesia charges, (xiv) Cost of surgical disposables
and all sundries used during hospitalization, (xv) Cost of medicines, (xvi) Related routine and essential
investigations, (xvii) Physiotherapy charges, (xviii) Nursing care and charges for its services, etc.
In addition to the above mentioned items, some patients may require additional facilities/procedures which are
admissible with proper justification in deserving cases. Therefore, it is not possible to give a comprehensive
list of items, which are not admissible. However, Telephone charges, Toiletries, Sanitary napkins, Talcum
powder, Mouth fresheners, etc. are not admissible.
b) Cost of Implants/Stents/Grafts is reimbursable in addition to package rates as per CGHS ceiling rates for
Implants/Stents/Grafts or as per actual, whichever is lower in case there is no ceiling rate prescribed under
CGHS.
c) During In-patient treatment of the CGHS beneficiary, the Hospital will not ask the beneficiary or his/her
attendant to purchase separately the medicines/sundries/ equipment or accessories from outside and will
provide the treatment within the package rate, fixed by the CGHS which includes the cost of all the items.
d) In cases of conservative treatment/where there is no CGHS package rate, the above mentioned items are
admissible -- itemwise at CGHS rates or as per AIIMS rates (if there is no CGHS rate) or as per actual (if there
is no CGHS/AIIMS rate) available for any item.
e) Package rates envisage up to a maximum duration of indoor treatment as follows:
Specialized/Super Specialties) treatment … 12 Days
Other Major Surgeries … … 7 Days
Laparoscopic surgeries/normal deliveries; and … 3 Days
Day-care/Minor (OPD) surgeries … … 1 Day
However, if the beneficiary has to stay in the Hospital for his/her recovery for a period more than the period
covered in package rate, in exceptional cases, supported by relevant medical records and certified as such by
Hospital, the additional reimbursement shall be limited to accommodation charges as per entitlement,
investigation charges at approved rates, and doctors' visit charges (not more than 2 visits per day per visit by
Specialists/Consultants) and cost of medicines during additional stay.
No additional charge on account of extended period of stay shall be allowed if that extension is due to infection
on the consequences of surgical procedure or due to any improper proceed.
In the absence of prescribed rates
The claims for reimbursement of charges of treatment/examination, etc. for which no corresponding rates are
not available in the nearest Govt. Hospitals for regulating such claims may be reimbursed by (a) restricting
such claims to the rate of Govt. Hospitals in the concerned State, and (b) where such rates/facilities are not
available in the concerned State, full reimbursement of such charges may be made on the certification of the
Director of Health Services of the concerned State.
Permission for procedures
The recommendation of a specific treatment/investigation procedure by Govt./ CGHS/CMO-in-Charge is in
itself adequate for issuing permission and an endorsement “referred to CGHS recognized/approved Centre” is
neither necessary nor to be insisted upon for grant of permission.
Tests/investigations at empanelled Diagnostic Labs.
In case of CS (MA) Beneficiaries availing tests/investigations at private Hospitals/ Diagnostic Labs./imaging
Centres empanelled, and after obtaining permission from their respective Departments/Ministries, the medical
prescription issued by an AMA (Govt. Specialist) prescribing Diagnostic tests/investigations shall be treated as
valid for a single use within a period of two weeks from the date of prescription. However, the medical
prescription shall remain valid beyond two weeks for undertaking Diagnostic tests/ investigations, if
specifically prescribed by the AMA/Govt. Specialist, about the date or period by which the prescribed tests are
to be conducted for a routine check up or follow up treatment. The medical prescription would require
revalidation or issue of a fresh prescription from the prescribing AMA/Govt. Secialist for getting the
prescribed tests done after expiry of the validity period of two weeks or as prescribed by the AMA/Govt.
Specialist, as the case may be.
Relaxation of procedures
It has been decided to do away with the procedure for verification of bills and issue of Essentiality Certificate
by the treating doctor, and the Medical Superintendent of the Hospital. Authorities concerned may verify and
check the authenticity of the claims on the basis of the prescription slip and Diagnostic report submitted by the
Govt. servant/pensioner. In the event of any doubt, they can always refer for verification.
All cases involving requests for relaxation of rules for reimbursement of full expenditure will henceforth be
referred to a Technical Standing Committee (TSC) to be chaired by the DGHS/Addl. DGHS and consist of
Director (CGHS) and subject matter Specialists. If the TSC recommends the relaxation of rules for permitting
full reimbursement of expenditure incurred by the beneficiary, it may be allowed by the Secretary (H&FW) in
consultation with Internal Finance Division.
A check list for consideration of requests for reimbursements in excess of approved rates may include:
a) the treatment was obtained in a private non-empanelled 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;
b) the treatment was obtained in a private non-empanelled Hospital under emergency and was admitted for
prolonged period for treatment of Head injury, coma, septicemia, multi-organ failure, etc.
c) the treatment was obtained in a private non-empanelled Hospital under emergency for treatment of advanced
malignancy; (i) when there is a strike in Govt. Hospitals (or) (ii) while the individual was on Official tour to
Non-CGHS covered area.
d) the treatment was taken under emergency in higher type of accommodation as rooms as per his/her
entitlement are not available during that period;
e) the treatment was taken in a higher type of accommodation under specific conditions for isolation of patients
to avoid contacting infections.
f) approval for airfare with or without an 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; and
g) any other special circumstances.
Empowerment of HODs
Powers have been delegated to the Heads of Departments of Ministries/ Departments to accord post facto
approval/permission in cases where an employee or his dependent family members go to an empanelled
Institution after due prescription by a Govt. Specialist but without obtaining prior permission from Ministry/
Department, subject to the Head of Department being satisfied with the genuineness of the reason which made
the beneficiary go directly to an empanelled Institution even before obtaining the approval. The reimbursement
to be made in such cases will be the financial ceiling and the procedure to be followed.
Cancer treatment: Powers are also hereby delegated to the above authorities for grant of permission to Cancer
patients for post-operative follow up treatment from the same Centre where permission has been granted
earlier for treatment.
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Consultation with Specialist
If the AMA is of the opinion that the case of a patient is of such a serious or special nature as to require
medical attendance by some person other than himself, he may refer the patient to a Specialist or Officer or if
the patient is too ill to travel, summon such Specialist/Medical Officer to attend upon the patient.
In case of emergency
In case of emergency, the recognized private Hospital cannot refuse admission or even demand advance from
the beneficiary. They shall provide credit facilities to the concerned patient on production of valid CGHS Card.
Reimbursement in respect of serving CGHS beneficiaries will be made by the respective Departments.
On the advice of Specialist of CGHS/Govt. Hospital/CMO-in-Charge of CGHS Dispensary, the beneficiary is
free to avail specialized treatment/Diagnostic tests at any CGHS recognised Hospitals/Centres as per
prescribed rates.
For non-emergency cases, CGHS beneficiaries are entitled to medical reimbursement for treatment in
recognised Hospitals, subject to written permission from the competent authority. On production of
permission, the recognized Hospitals/ Diagnostic Centres shall provide credit facilities to CGHS beneficiaries
including pensioners, family pensioners and their dependents.
CSIR Pensioners who are holding permanent/valid Medical Identity Card or CGHS Card with a photograph of
self with dependent family members can avail OPD treatment in any of the CSIR Lab./Instt. Dispensaries,
subject to the condition that any expenditure incurred on Inpatient treatment during such visit by that
Lab./Instt. will be recouped by the concerned Lab./Instt./CSIR HQs., as the case may be, where the Pensioner
is registered for medical facility.
Expenses incurred in Emergency
Reimbursement of medical expenses incurred in emergency would be allowed as per the prevailing nonNABH CGHS rates as applicable to a CGHS covered city; and non-NABH rates applicable to the nearest
CGHS covered city in case of Non-CGHS city, as the case may be, or the actuals, whichever is less.
When package rates are prescribed under CGHS, the non-NABH rates of the CGHS covered city and nonNABH rates of the nearest CGHS city (in case of Non-CGHS covered city) or the actuals, whichever is less,
will be applicable.
Special diseases
A Central Govt. servant or a member of his family may receive treatment for special diseases such as Cancer,
Diabetes, Mental diseases, Poliomyelitis, Cerebral Palsy and Spastics, Tubercular diseases. Leprosy,
Thalassemia Major, at a Hospital where specialized treatment for a particular disease is available on the
recommendation of Medical Superintendent of the recognized Hospital to whom the patient is referred for
treatment.
In cases where a patient who has undergone treatment in a recognized Hospital for a particular disease is
advised by the Medical Superintendent of the Hospital to continue certain treatment or check-ups after
discharge from the Hospital, such patient may be allowed to consult and receive medical treatment directly
from a Govt./ recognized Hospital without consulting the AMA.
Super-imposition of another disease
Where a patient consults the same Doctor in regard to another disease during the course of treatment of one
disease, such consultation should be regarded as “fresh consultation” and paid at full rate. If one or more minor
treatment procedure form part of a major treatment procedure, package charges would be made against the
major procedures. Only half of actual charges quoted for the minor procedures would be added to the package
charges of the first major procedure.
Liver-related issues
The CGHS/CS (MA) beneficiaries will have to submit their request for permission for Liver Transplantation to
the Standing Committee through their respective Departments in case of serving employees and the Addl.
Director, CGHS of the concerned city in case of pensioner. As Liver Transplant Surgery is a planned surgery,
prior permission has to be obtained before the surgery is undertaken. However, if for some reason it is done in
emergency to save the life of the patient, the Standing Committee shall consider the cases referred to it for
recommending grant of ex post facto permission on case to case basis.
Ceiling rate: Effective from 16-1-2013, an amount of Rs.11,50 lakhs plus pre-transplant evaluation of donor
and recipient Rs.2,50,000/- is payable. The package rate for Liver Transplant Surgery involving a deceased
donor shall be Rs.11,00 lakhs which includes, the cost of consumables during the organ retrieval and the cost
of preservative solution, etc.
The package charges include:
30 days stay of the recipient and 15 days for the donor starting one day prior to the transplant surgery.
Charges for Medical and Surgical consumables, surgical and procedure charges, operation theatre charges,
Anaesthesia charges, pharmacy, investigations and in-house doctor consultation for both donor and recipient
during the above period which includes all post-operative investigations and procedures during the above
mentioned period;
and exclude:
Charges for drugs like Basiliximab/Daclizumab, HBIG and peg Interferon
Cross Matching charges for blood and blood products.
The extra stay, if any, may be reimbursed after justification by the treating Specialists as per CGHS Guidelines
only
The drugs mentioned above would be reimbursed as per CGHS rates or actual whichever is lower.
Cancer-related issues
As the list “CGHS, Delhi” did not have any empanelled Hospitals for treatment of Cancer patients, as an ad
hoc measure, it has been decided to permit treatment at any of the 25 Regional Cancer Centres recognized by
the MOH&FW under National Cancer Control Programmes, subject to the condition that the reimbursement
will be as per the rates fixed in such Centres or actuals, whichever is less.
Coronary diseases
The rates of Coronary Bypass Surgery in respect of all recognized private Hospitals have been regulated on
package deal basis. No limit has been prescribed on number of bypass surgeries.
Package rate means a lump sum cost of In-patient treatment or Diagnostic procedure which includes all
charges, admission, accommodation, ICU/ICCU, monitoring, operation theatre, anesthesia, cost of disposables,
surgical charges, surgeon's fee, related routine investigations, physiotherapy charges and medicines used
during Hospitalization, etc.
Package rate for CABG and Coronary Angiography includes room rent from the date of admission to the date
of discharge, service charges, nursing/medical care, surgeon's and anesthetist's fee, operation theatre charge,
etc. The Hospital/Centre cannot charge more than the package rate from the beneficiary.
Package rate does not include diet, cosmetics, TV charges, telephone charges, toiletry, tonics and medicines
advertised in mass media, etc. Expenses over and above the prescribed rates, if any, have to be borne by the
beneficiaries.
If the beneficiary is required to stay in the Hospital for recovery for more than the above period, the additional
reimbursement shall be limited to room rent as per entitlement, cost of the prescribed medicines and
investigations, doctors' visits (2 times a day) during additional stay.
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IVF treatment
The following Guidelines are laid down for considering cases for reimbursement of expenses incurred on In
Vitro Fertilization (IVF) treatment by CGHS beneficiaries and beneficiaries under CS (MA) Rules, 1944,
w.e.f. 22-11-2013:
i) Requests for IVF treatment will be considered only on the basis of advice tendered by the HOD of
Gynaecology & Obstetrics (HOD of G&O) of a Govt. Medical Institution (GMI);
ii) Permission for IVF treatment to be undertaken may be given by the HOD in the Ministries/Departments on
the recommendations of the HOD of G&O of a GMI;
iii) IVF procedure will be allowed in a GMI on the recommendations of the HOD G&O of a GMI;
iv) IVF procedure may be allowed, on case to case basis, in a private medical institution registered with the
State/Central Govt. and has the necessary facilities including equipment and trained manpower for carrying out
the procedure. It is mandatory to obtain the recommendations of the HOD G&O of a GMI for permitting the
procedure to be undertaken in a private institution;
v) There should be clear evidence of failure of conventional treatment before permitting IVF treatment
procedure;
vi) The age of women undergoing IVF treatment procedure should be between 21 and 39 years;
vii) The woman has to be married and living with her husband
viii) The IVF treatment procedure will be allowed only in cases of infertility where the couple has no living
issue;
ix) Reimbursement of expenditure incurred on IVF procedure will be allowed up to a maximum of 3 fresh
cycles;
x) An amount not exceeding Rs.65,000/- only per cycle or the actual cost whichever is lower will be allowed
for reimbursement. This amount will be inclusive of the cost of drugs, disposables and monitoring cost during
IVF procedures;
xi) As IVF treatment is planned procedure, reimbursement cases can be considered only if prior approval was
obtained by the beneficiary;
xii) There will be a one-time permission for availing IVF treatment consisting of three cycles. The concerned
Department shall obtain an Undertaking from the applicant that he/she has not claimed the reimbursement
from the GOI in the past and will not claim in the future.
Hearing-Aids
The revised ceiling rates fixed for various types of Hearing-Aids (for one ear) are as given hereunder:
Body-worn/Pocket type … Rs. 3000/Analogue BTE Digital … Rs. 7000/BTE Digital … Rs. 15000/ITC/CIC … Rs. 20000/Dental treatment
Dental treatment is not covered under these rules. However, if the diagnosis of the physiological or other
disability from which a Govt. servant is suffering indicates that teeth are the actual source of problem, dental
treatment of a major kind such as treatment of jaw bone disease, removal of all the teeth, removal of
odontomes and impacted wisdom tooth, gum boils, etc. is reimbursable.
Expenses incurred by Central Govt. employees in connection with the following types of dental treatment, if
obtained at Govt. recognized Hospitals are reimbursable: (a) extraction (b) scaling and gum treatment
(including Pyorrhea and Gingivitis) (c) filling of teeth (d) root canal treatment. Reimbursement of expenditure
for complete Denture with a ceiling of Rs.2000/- (Denture of one Jaw would be Rs.1000/-) is admissible on
one-time basis.
It was decided that the existing facilities for reimbursement of expenditure incurred on dental treatment in
Govt. Hospitals by Central Govt. employees and their families be extended to similar treatment availed of in
private recognized Hospitals on the advice of AMA, if such treatment is not available in the nearest Govt.
Hospital.
In-patient treatment in Non-CGHS areas
It has been decided to liberalize 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:
(a)(i) CGHS pensioner beneficiaries and their dependent 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 Govt. Hospitals
(Central/State Govt./Local Self-Govt./Hospitals recognized under CS (MA) Rules, 1944/Hospitals and Clinics
empanelled under Ex-Servicemen Contributory Health Scheme (ECHS) and submit the medical reimbursement
claim to the Addl. Director/Jt. Director of CGHS of the CMO in charge of CGHS Wellness Centre where the
CGHS Card is registered.
(ii) In case of non-emergency treatment from Hospitals approved under CS (MA) Rules, 1944 and ECHS, it is
necessary to obtain prior approval from CMO in charge of the 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 Addl. Director/Jt. 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 and others, on a visit to Non-CGHS covered area and obtain treatment under
emergency from the above recognized Hospitals under ECHS and the medical claim shall be submitted to
Addl./Director/Jt. Secretary, CGHS of the concerned city through CMO-in-charge of the Wellness Centre
where the Card is registered 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) Similarly they shall be eligible for follow up cases of renal transplant surgery, knee and hip-joint
replacement, Cancer treatment, neurosurgery 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 actual whichever is
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 Hospital approved under CS (MA) Rules/ ECHS, the beneficiaries
(as in (a) & (b) above) shall submit a Certificate from the Hospital that they have not charged more than the
approved applicable Hospitals approved under CS (MA) Rules/ECHS rates.
(d) This arrangement is provisional and would be in place till such time the proposed Health Insurance Scheme
for Central Govt. employees and pensioners is brought into effect.
(e) This O.M. supersedes the earlier O.M. dated 30-9-1999.
In-patient treatment
A Govt. servant can receive treatment in a Hospital where he is ordinarily entitled to receive treatment under
the rules as an In-patient for himself and members of his family without consulting his AMA. While claiming
reimbursement, a Certificate should be produced from the Medical Superintendent of the Hospital that the
facilities provided were the minimum and were essential for the patient's treatment. If a Central Govt. servant
or family member suffering from an infectious disease receive In-patient treatment in a Govt. Infectious
Diseases Hospital situated at a place where the Govt. servant is entitled to receive medical attendance and
treatment.
Cases of medical treatment requiring Hospitalization will normally be referred to a Govt./recognized Hospital
by the AMA for admission. If Hospitalization is not considered necessary but treatment is expected to be
prolonged, a patient should be referred to the OPD of a Govt./recognized Hospital and the charges levied, if
any, are reimbursable.
Prolonged treatment is defined as “a case of single and continuous spell of illness which requires either more
than 4 consultations/visits within a period of 10 days from the date of commencement of treatment or more
than a course of 15 injections.” The average stay in a Hospital as an In-patient should be reckoned as two
weeks. Any Hospital stay beyond three weeks is treated as prolonged stay.
Even in emergency, Hospitalization in Nursing Home/Clinic of AMA is not admissible. However, treatment at
the Consulting room of AMA is permissible.
A Govt. servant and his/her family members are entitled to treatment in such Govt. Hospital at or near the
place where the patient fell ill. If there is no such Hospital other than Govt. Hospital at or near the place which
provides treatment free of charge. Permission can be granted to such employees to obtain medical services
from any of the private Hospitals recognized under CGHS.
Heads of Department are empowered to use their discretion in reimbursement of medical claims in relaxation
of rules in respect of treatment taken in private Hospitals/medical institutions without any distinction between
private Clinics/Nursing Homes. Reimbursement can be allowed up to the extent admissible without any overall
ceiling; but this is subject only to individual itemwise prescribed ceiling.
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Treatment at residence
If the AMA is of the opinion that owing to the absence or remoteness of a suitable Hospital or to the severity
of the illness, a Govt. servant may receive treatment at his residence. He shall be entitled to receive the cost of
treatment as per rules. Claims for reimbursement have to be preferred within three months. Heads of
Departments are delegated with powers to condone the delay, if any, in submission of claims.
Condonation of delay
Henceforth, only the cases in which the bills are submitted after 6 months from the date of completion of
medical treatment/discharge of the patient from the Hospital are required to be taken up for condonation. The
power of condonation of such delays and other terms and conditions would be same as enumerated in the O.M.
No.S.l4025/8/99/-MS dated 25-5-1999.
Engagement of Ambulance
The doctor treating the patient certifies in writing that conveyance of patient by any other mode would
definitely endanger the patient's life or would grossly aggravate his/her condition; and that the journey is
undertaken within the same city. Ambulance service can be availed.
Constant Attendant Allowance
Payment of Constant Attendant Allowance shall be governed by the following provisions:
i) Constant Attendant Allowance (CAA) will be applicable to cases where the disability for which CAA is
payable is attributable to or aggravated by service.
ii) CAA may be granted to a Govt. servant who is awarded a Disability Pension for 100% disablement, and if
in the opinion of the Medical Board, the services of a Constant Attendant for at least a period of three months
is needed, and the necessity arises solely from the condition of the accepted disability or disabilities.
iii) CAA shall not be payable for any period during which the Pensioner is an inmate or an In-patient of a
Govt. Institution or Hospital
iv) Payment of CAA shall be made along with Disability Pension on the basis of ddeclaration in a prescribed
pro forma which shall be submitted to Pension Disbursing Authority during the months of May and November
each year.
Special nursing
Special Nursing as certified to be essential for the recovery or for the prevention of serious deterioration in the
condition of the patient by the Medical Officer concerned and the Medical Superintendent of the Hospital in
prescribed pro forma, limited to the amount which is in excess of 25% of the pay of the Govt. servant
concerned is reimbursable.
Special Nurse/Ayah/Attendant charges
Reimbursement for Attendant charges are admissible only in cases where it is certified by the Hospital
authorities that it forms part of treatment and that the Attendant was not engaged in lieu of "Special Nursing".
The daily rate payable per shift of 12 hours are: Special Nurse: Rs.150/- and Ayah/Attendant: Rs. 75/-.
The Head of Office has been delegated with the power to reimburse Ayah/ Attendant charges of up to the
ceiling limit of Rs.2000/- for the period of stay as Indoor patient in the Hospitals recognized under the State
Govt./CGHS Rules/CS (MA) Rules, 1944 on submission of a Certificate from the Medical Superintendent of
the Hospital.
Domiciliary Rehabilitation Medicine
Domiciliary (home-based) care is medically justified in the practice of rehabilitation medicine which involves
the care of the patient with chronic diseases or temporary or permanent disability or functional limitation due
to lack of health. It is justified as such persons find ambulation practically impossible or are significantly
dependent on care-giver or the cost of visiting the Hospitals become higher than the cost of treatment given.
The following allied health services need to be considered for domiciliary care: (i) Physiotherapy; (ii)
Occupational Therapy; and (iii) Speech Therapy (for patients of stroke/head injury).
The decision for the above care should be based on thorough evaluation and specific prescription including the
exact intervention and frequency by a Physical, Medicine and Rehabilitation (PMR Specialist). In case of nonavailability, the treating Govt. Specialist having allopathic Post-graduate qualification in Ortho/Neurology/
Neurosurgery/ENT may allow such benefits following the specific prescription criteria for the following
conditions:
Orthopaedic disorders: Post-joint replacement surgery in acute phase; Physiotherapy up to two weeks, postdischarge.
Neurological disorders (for up to six weeks):
Post-stroke: Occupational Therapy (OT), Physiotherapy (PT) and Speech Therapy (ST);
Traumatic brain injury: OT and PT
Gullian-Barre Syndrome: OT and PT;
Spinal cord injury with significant disability/deformity: OT and PT;
Motor neuron disease: OT, PT and ST.
Locomotor disabilities, with a disability of over 80% or those who are totally dependent on care-giver based on
the opinion of two Govt. Specialists by certified care-giver. Care-giver means Rehabilitation Council of India
certified personnel + Physiotherapist and Occupational therapist (duly qualified diploma/degree holder.
The prescription for home-based rehabilitation programme should include the following descriptive
specifies:
The therapy to be used -Electrotherapy;
Active Exercise Therapy;
ADL Training;
Speech Therapy;
Gait Training, and
Passive Exercises
The technical person required to institute the therapy;
The frequency of the therapy required by the patient; and
Duration of the therapy programme.
The following rates may be reimbursed:
Physiotherapist .. Max. of Rs.300/Occupational Therapist .. Max. of Rs.300/Speech Therapist .. Max. of Rs.300/Certified Care-Giver .. Max. of Rs.150/- or Rs.3,000/- per month for
long term requirement, whichever is less
No reimbursement to be allowed for the purchase/hiring of therapy equipment/ devices.
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Treatment outside the District/State
Central Govt. servants and members of their families may receive treatment for all diseases (other than TB,
Cancer, Polio and Mental diseases) for which treatment is provided in a Govt./recognized Hospital. Even if
necessary facilities for treatment are available in a Govt./recognized Hospital where the person fell ill,
treatment outside the District/State can be availed. The choice of the recognized Hospital where the Govt.
servant would like to avail of the treatment is left to the beneficiary himself, subject to the condition that no
travel expenses are reimbursable.
The restrictions with regard to availability in a Govt./recognized Hospital in the respective District/State and
also endorsement of CMO of the State have been removed.
Treatment at AIIMS
The CGHS beneficiaries possessing a valid Card can avail medical treatment facilities in the All India Institute
of Medical Sciences, Delhi without any prior permission. Drugs prescribed, if any, during the treatment at
OPD should be obtained from concerned CGHS Dispensary on the basis of prescription. The reimbursement
will be as per the entitlement and the prescribed rates of AIIMS.
Accommodation charges in AIIMS
Pay in the Pay Band/Pension/
S.No.
1.
2.
3.
Ward entitlement
Family Pension p.m.
Up to Rs.19,530/From Rs.19,540/- to Rs.25,110/Rs.25,120/- and above
General Ward
Private Ward
Private Ward/Deluxe Ward
Treatment abroad
A Govt. servant desirous of availing of medical treatment outside India for himself or for a member of his
family for treatment as specified in the rules may make an application in prescribed form through the
Department/Ministry to which the Govt. servant is attached. The Standing Committee may recommend one
Attendant to accompany the Govt. servant or a member of his family and the expenditure shall be
reimbursable. The scale of expenditure and the eligibility for treatment shall be identical to the scale of
expenditure and the eligibility of an Official of the Indian Foreign Service of the corresponding grade in the
Ministry of External Affairs under any Assisted Medical Attendance Scheme.
A Govt. servant shall be eligible to claim reimbursement of the cost of any medical treatment obtained inside
or outside India as follows:
Complex/high risk Cardio Vascular Surgery cases for treatment at Centres with Extensive experience
Bone-marrow transplantation
Complex Medical and Oncological disorders such as Leukemia and Neo-plastic conditions
Complex high risk cases in Micro-vascular and Neurosurgery for treatment at Centres with extensive
Experience
Treatment of extremely complex ailments other than those mentioned above which in the opinion of Standing
Committee can only be treated abroad on falling in the high risk category
Appliances
High-end prosthetics/appliances will be reimbursed only to the following category of Govt. servants and their
dependent family members, subject to fulfilling of other criteria:
a) Participating at the State level sport activities duly certified by the competent Sports Authority.
b) Upper age limit for the sophisticated prosthetic appliances will be 45 years
c) Military or para-military personnel duly certified by their respective Medical Boards that the person has
sustained injury while on field duty or undergone amputation because of injury sustained while performing
such duty.
d) Reimbursement will be made within the ceiling limit fixed for such appliances beyond which the
beneficiary will bear the cost.
Reimbursement of the cost of various appliances including the cost of Heart Pace- Maker and replacement of
the pulse generator, cost of replacement of diseased heart valves, artificial electronic larynx, Hearing-Aid is
admissible. In such cases, the administrative authority shall make payment direct to the supplying agency.
The Cost-ceiling for Coronary Stents and other Appliances has been given in Annexure-IV
Approval for implants
Vide CGHS O.M.No.12011/2005/CGHS(R&H)/CGHS(P) dated 4-12-2008 by which the guidelines for
permission/approval for reimbursement of cost of Neuro-implants, viz., Deep Brain Stimulation implants,
Intra-thecal Bacfofen Pump, Intra-thecal Morphine Pump and Spinal Cord Stimulators for CGHS/CS (MA)
beneficieries were notified and to convey the approval of the competent authority to allow reimbursement of
cost of the above implants as per the ceiling rates were made valid till 8-12-2016.
E. REIMBURSEMENT
Claims for Reimbursement
Tests at private institutions: Reimbursement of the charges paid to private practitioners/institutions for
undertaking skiagrams, electric therapy, bacteriological, pathological examinations, etc. on the advice of the
AMA owing to non-availability of the facility at a Govt. Hospital is permissible with the prior consent of the
Director of Health Services/Chief Administrative Medical Officer.
Blood and transfusion charges: Cost of Blood and transfusion charges paid to a Govt. institution or any other
local organization recognized by the State Govt. are refundable, provided that it is certified by the treating
Doctor (AMA) that the blood was not available in the Hospital, and that the price paid was reasonable.
Testing of eye-sight: Govt. servants may get their eyesight tested for glasses at a Govt./recognized Hospital
once in three years on the recommendation of the AMA. Fee paid to the Specialist for such services will be
reimbursed according to the scheduled rates prescribed in the concerned State. Expenses towards correction of
squint (eye) are reimbursable. There is no provision for reimbursement of cost of spectacles. The members of
families are not entitled to the facility for testing of eye sight for glasses.
Other medical facilities: Charges which were not included in medical attendance/treatment under these rules
shall be determined by the AMA and paid by the patient. Keeping in view the inconvenience faced by the
beneficiaries in submission of prescription in original while claiming reimbursement, it has been decided to
relax the above condition and to allow a self-attested photocopy of the medical prescription to claim
reimbursement without a permission letter issued from the Department concerned.
Reimbursement on certain eventualities
Reimbursement of medical expenses incurred during various situations such as: Dies non, suspension, study
leave, foreign service/deputation abroad (to be sought from the foreign employer), special leave abroad
(depending upon the purpose for which the leave is granted), voluntary/ training/embodiment in the Territorial
Army/Military service during emergency, while abroad leaving behind family in India, etc. is admissible.
Reimbursement by Insurance Companies
The beneficiaries under CGHS and CS (MA) Rules, 1944 who have subscribed to “Mediclaim” or similar
other policies from an Insurance Agency are permitted to claim reimbursement of the medical expenditure
from both the sources, viz., the Insurance Agency and CGHS and Ministries/Departments, subject to the
condition that the reimbursement from the two sources would not to exceed the package rates prescribed under
the CGHS for the particular treatment.
The beneficiary will make the first claim to the Insurance company and the second claim to the CGHS or the
Ministry/Department concerned. The medical claim against original vouchers/bills would be raised by the
beneficiary first on the Insurance company which would issue a Certificate indicating the amount reimbursed
to the Director, CGHS or Head of Department concerned.
The Insurance company concerned will retain the original vouchers in such cases. The beneficiary would then
prefer his/her medical claim along with photocopies of vouchers/bills duly certified, in ink, along with stamp
of the company on the reverse of the vouchers to the concerned organization.
Reimbursement from CGHS, etc. will be restricted only to the admissible amount as per approved package
rates, subject to the condition that the total amount reimbursed by the two organizations does not exceed the
total expenditure incurred by the beneficiary.
Special dispensation under CSIR
In CSIR system, the DG has been empowered to settle the cases of reimbursement of medical expenses in
respect of expensive procedures like BMT, Cardiac defibrillator, Carotid stents, or involving usage of costly
equipment/instrument/ implants, etc. while undergoing treatment at a Govt./private recognized Hospital
outside the notified list under CS (MA) Rules, 1944/CGHS for which no rates are available either under CS
(MA) Rules/CGHS or AIIMS. This is subject to the condition that the treatment is obtained with the prior
permission of the Medical Officer-in-Charge of CSIR Dispensary and/or the Director of the Lab./Instt. except
in the case of emergency, as the case may be.
Reimbursement of cost of OPD medicines: CSIR has approved reimbursement of the cost of OPD medicines
for treatment in post-operative conditions in serious diseases in accordance with MH&FW O.M.
F.No.10001/2000/JD/R&H/ CGHS/CGHS(P) dated 30-4-2001 to the CSIR pensioners who are not getting
OPD facilities from CGHS/CSIR Dispensaries in the following cases:
Post-operative Major Neurosurgical/Neurology cases
Post-operative cases of major Cardiac surgery/Cardiology/Oncology cases
Post-operative Organ transplant cases
Post-operative Joint replacement cases
Cashless medical facility for CSIR pensioners: Cashless medical facilities for indoor treatment to CSIR
pensioners, serving employees and their dependant family members, provided:
The CSIR Lab./Instt. may enter into a Memorandum of Understanding with the CGHS recognized Hospitals to
provide this facility as per terms mentioned at (b) above.
The recognized Hospitals should be willing to provide cashless medical treatment on CGHS approved rates. In
case of any difference in rates, the rates specified by the Hospital over and above the CGHS prescribed rates
should be charged to the pensioners/employees by the Hospital.
Relief from CSIR Welfare Fund: The Scheme for providing financial assistance to the CSIR employees for
meeting medical expenses incurred for undergoing treatment for major illness in the private recognized
Hospitals over and above the amount admissible under CS (MA) Rules, 1944/CGHS Rules from CSIR Welfare
Fund has been extended up to 13-12-2016.
As per rules, the medical expenses in respect of the treatment taken in the private recognised Hospitals for
major illness like kidney transplant, coronary bye-pass surgery, heart transplant, chemotherapy, brain surgery,
etc. are restricted to the ceilings fixed by the GoI. As the cost of treatment actually charged by the Hospitals is
very high in comparison with the ceilings fixed under the rules, the additional expenditure will be met from
Welfare Fund of CSIR, on case to case basis.
The rates of financial assistance from CSIR Welfare Fund for reimbursement of medical expenses incurred by
them for undergoing treatment for major illness in private recognized Hospitals over and above the amount
admissible under CS (MA) Rules, 1944/CGHS to the extent of 75% of expenses incurred over and above the
admissible amount, subject to maximum of Rs.2.00 lakhs in case of treatment of self; and 50%, subject to a
maximum of Rs.1.00 lakh in respect of dependent family members
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F. MISCELLANEOUS ASPECTS
Income tax rebates
Individuals claiming expenditure for Income Tax purposes for certain ailments from a Specialist working in a
Govt. Hospital need not produce a Certificate to that effect. As per amended Rule 11DD, the prescription can
be issued by any Specialist mentioned in the amended Rule henceforth, it will not be mandatory to obtain a
Certificate from a Specialist working in a Govt. Hospital.
Further, in case no payment has been made towards medical insurance, very senior citizens can claim
deduction up to maximum of Rs. 30,000/- per year towards actual medical expenses incurred by them.
Additional deduction has been granted in respect of expenses incurred on medical treatment of specified
ailments and supported by medical prescription from a Specialist. Such deduction can be claimed up to
Rs.60,000/- for expenses incurred for senior citizens. From Financial Year 2015-16, higher deduction of up to
Rs. 80,000/- is allowable for expenses incurred on medical treatment of the specified ailments for very senior
citizens.
As per income tax provisions, electronic filing of return is mandatory for persons with total income of Rs.5.00
lakh and above. However, very senior citizens are exempted from electronic filing of return even if their
income exceeds Rs. 5.00 lakh provided the returns are furnished in ITR 1 or ITR 2.
A deduction to the extent of Rs.40,000/- or the amount actually paid, whichever is less is available for
expenditure actually inurred by resident assessee on himself or dependent relative for medical treatment of
specified disease or ailment. The diseses have been specified in Rule 11 DD. A Certificate in Form 10-I is to
be furnished by the assessee from any Registered Doctor.
In view of the rising cost of medical care and special needs of a differently abled person, Finance Bill, 2015
proposes to amend section 80 DD of the Income-tax Act so as to raise the limit of deduction in respect of a
person with disability from Rs.50,000/- to Rs.75,000/- and in respect of a person with severe disability, from
Rs.1.00 lakh to Rs.1.25 lakh.
Certification of disability
Rule 54 (6) of the CCS (Pension) Rules, 1972 had been amended vide DOP&PW Notification No.1/18/01P&PW(E)(VoI.II) dated 25-4-2008 to change the competent authority to issue a Disability Certificate from "a
Medical Officer not below the rank of a Civil Surgeon" to "a Medical Board comprising of a Medical
Superintendent or a Principal or a Director or Head of the Institution or his nominee as Chairman and two
other members, out of which at least one shall be a Specialist in the particular area of mental or physical
disability including mental retardation".
Grant of advance
If an advance is requested by the Govt. servant or on his/her behalf of spouse/legal heir, it will be paid direct to
the Hospital concerned on receipt of an estimate from the treating Physician/Medical Superintendent of the
Hospital. Settlement of advance will be through subsequent claim for reimbursement as admissible under CS
(MA) Rules, and balance, if any, recovered from the pay/leave salary of the Govt. servant in not more than
four equal monthly installments. In case of prolonged treatment, reimbursement of medical expenses may
continue to be allowed to Govt. servants to the extent admissible, and the advance in such cases need not be
adjusted within one month as in the above case, if it is certified by the Medical Officer-in-charge.
Application for advance should be supported by a Certificate that the patient is being treated indicating the
duration of such treatment and the anticipated cost. An advance limited to Rs.10,000/-, or such other amount as
the Medical Officer-in-Charge of the patient may recommend whichever is less would be admissible when a
Govt. servant or a member of his family is being treated (a) as an In-patient in a Hospital (b) as an out-patient
in the case of TB/Cancer. A second advance can also be granted at the discretion of the Head of Office not
exceed Rs.10,000/- including the first advance.
Advance can also be granted for purchase/replacement of artificial appliances.
The limits prescribed for grant of advance for medical treatment are given hereunder which are yet be
revised:
Limitations
S.No.
1.
2.
3.
Nature of treatment
For indoor treatment in a Hospital and
out-patient treatment for diseases like
Cancer, etc. where the duration of
treatment is 3 months or less
In case of TB where the duration of
treatment is more than 3 months
Major illness of Bypass surgery/
Kidney/Cancer including Acute Myeloid
Leukemia, Chronic Active
Hepatitis, Subset of Hepatitis-B
Rs.10,000/- or the amount recommended
by the Physician whichever is less.
Limited to 80% of the estimated cost or
Rs.36,000/- whichever is less
Limited to 90% of the package deal
wherever exists or according to the
estimate submitted by the Govt./
recognized private Hospital.
Heads of Office are empowered to grant advances to Central Govt. servants to enable them to initially meet the
expenditure on medical attendance and treatment for themselves and their family members. Advances are
admissible to all Govt. servants irrespective of their pay, subject to fulfilment of certain conditions. Temporary
Govt. servants can be granted medical advance on providing necessary surety from a permanent Govt.
employee.
Travelling Allowance
When the place at which a patient falls ill is more than 5 miles (8 Km.) by the shortest route from the
consulting room of the AMA, the patient shall be entitled to TA for the journey to and from such consulting
room. If the patient is too ill to travel, the AMA, Specialist AMA, shall be entitled to TA for the journey to and
from the place the patient. However, Compounders/Lab. Assistants are not eligible for TA. Claims for TA
shall be accompanied by a Certificate by the AMA.
The CGHS beneficiaries are not entitled for grant of conveyance charges when they are referred to
Specialists/Hospitals within the city. Since Dispensaries situated at various CSIR Labs./Instts.are equated with
CGHS, no conveyance charges shall be payable to for treatment as an Out-patient in recognized Hospitals in
the same city, even if the distance involved is more than 8 km.
T.A. for Attendant: The facility of TA for the Attendant would only be admissible to those Govt. servants with
Disabilities wherein it is certified by the competent Medical Authority that such a person compulsorily
requires assistance of another person for travel. Under this clause, necessary Certificate is to be obtained from
the HOD of a Govt. Civil Hospital designated for the type/form of disability of the Govt. servant. Based on the
Certificate, HoDs would have to further satisfy the need for an Attendant during travel of the Govt. servant
before allowing the journey for the Attendant.
Casual Workers (TS)
Medical facilities as available in the CSIR Dispensaries can be availed by the Casual/Dailywage workers who
are conferred with Temporary Status, subject to the condition that no reimbursement of medical expenses
would be admissible to them. However, their family members are not entitled to such facility.
References
1. GOI MOH&FW O.M. No.4-24/96-C&P/CGHS/CGHS(P) on 17-9-1999
2. GOI MH&FW O.M. F.No.10001/2000/JD/R&H/CGHS/CGHS(P) dated 30-4-2001
3. GOI MOH&FW O.M. No.4-24/96-C&P/CGHS(P) dated 31-5-2007
4. GOI MOPPG&P DOP&PW Notification No.1/18/01-P&PW(E)(VoI.II) dated 25-4-2008
5. CGHS O.M.No.12011/2005/CGHS(R&H)/CGHS(P) dated 4-12-2008
6. GOI MOH&FW O.M. No.S.11012/1/98-CGHS(P) dated 10-12-2008; Swamysnews, Feb. 2009, 49-50
7. GOI MOH O.M. No. 4-18/2005-C&P(Vol.I-Pt.(I) dated 20-2-2009; Swamysnews, April 2009, 61-62
8. GOI MOH O.M. No.4-24/96-C&P/CGHS/CGHS(P) dated 25-2-2009; Swamysnews, April 2009, 68-69
9. GOI MOPPG&P DOP&PW O.M.No.45/6/2008-P&PW(F) dated 16-4-2009
10. CSIR Lr. No. 34-1(11)/CSIR/Pen/2008-09 dated 12-5-2009; GOI MOPPG&P
11. GOI MOPPG&P DOPT O.M. No.4/25/2008-P&PW(D) dated 26-5-2010
12. GOI MOH O.M.No.4-24/96-C&P/CGHS(P) dated 4-11-2010; Swamysnews, Dec. 2010, 48-49
13. Swamy's Pension Compilation (Edn. 2011)
14. GOI MOH O.M.No.S.14025/8/2010-MS dated 18-1-2011; Swamysnews, Feb. 2011, 62
15. GOI MOH O.M. No. S.11011/7/99-CGHS(P) dated 27-4-2011; Swamysnews, July 2011, 21-23
16. GOI MOH O.M. No.S.11011/24/2011-CGHS(P) dated 1-6-2011
17. GOI MOH O.M. No. Z.15025/5/2011-CGHS-III/CGHS(P) dated 22-11-2011;
Swamysnews, Jan. 2012, 32-33
18. GOI MOH O.M. No.S.11011/32/2011/CGHS(P) dated 19-1-2012; Swamysnews, March 2012, 28-29
19. GOI DOPT O.M. No.21011/1/2009-Estt.(A)-Part dated 1-2-2012; Swamysnews, March 2012, 33-39
20. GOI MOH O.M. No. F.No.S.14025/3/2010-MS/CGHS(P) dated 16-1-2013; Swamysnews, Mar. 2013, 913
21. Swamysnews, Feb. 2013, 79
22. CSIR Lr. No.5-1(72)/2009-PD dated 7-2-2013
23. GOI MOF DOE O.M. No.19030/3/2013-E.IV dated 17-2-2013
24. GOI MOH O.M. No. F.No. S.11045/13/2013/HEC/CGHS(P) dated 4-3-2013;
25. GOI DOPT O.M.No.21011/1/2009-estt.(A)-Part dated 20-3-2013; Swamysnews, May 2013, 8-13
26. Swamysnews, May 2013, 7-8
27. Swamysnews, June 2013, 84-85
28. GOI MOH O.M.No.F.No.S.14025/14/2012-MS dated 11-6-2013; Swamysnews, July 2013, 22-23
29. GOI MOH&FW DOH&FW O.M. No.F.No.2-1/2012/CGHS/VC/CGHS(O) dated 1-8-2013; Swamysnews,
Sept. 2013, 44-46
30. GOI MOPPG&P DOP&W O.M. No. A/25/2008-P&PW(D) dated 2-5-2014
31. GOI MOR (RB) O.M. No.PC-V/2011/A/Med/1 dated 7-7-2014
32. GOI MOH&FW DOH&FW O.M. No.S-11011/25/2014-CGHS-(P) dated 8-7-2014
33. GOI MOPPG&P DOP&PW O.M. No.1/18/01-P&PW(E)(VoI.II) dated 30-9-2014
34. GOI MOF DOE O.M. No.7(1)E.Coord./2014 dated 29-10-2014
35. GOI MOPPG&P DOPT O.M. No. 4/25/2008-P&PW(D) dated 19-11-2014
36. GOI MOH O.M. No.S.3849/09-CGHS(R&H)-CGHS(P) dated 8-12-2014
37. GOI MOH O.M. No.1967/2013/DEL/CGHS/SZ/D52/CGHS(P) dated 30-12-2014
38. GOI MOH&FW DOH&FW O.M. No.1-1/13/Hospital Cell/R&H/CGHS(Pt.I)/CGHS (P) dated 23-2-2015
39. GOI MOH&FW DOH&FW Circular No. S-11011/16/2012-CGHS(P) dated 8-4-2015
40. GOI MOF PIB Notification dated 24-4-2015; www.gconnect.in
41. GOI MOH&FW DOH&FW O.M. No.S.14025/10/2002/MS dated 26-5-2015
42. GOI MOHFW DOHFW O.M. No. S.14025/19/2015-MS dated 27-5-2015
43. GOI MOH&FW O.M. F.No.S.14025/41/ 2015-MS dated 16-12-2015
44. GOI MOH&FW O.M.No.S.14025/22/2015-MS dated 15-1-2016
45. www.gconnect.in
46. www.govtempdiary.com
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Annexure-I
Reimbursable and Non-Reimbursable Diagnostic and other Procedures
I. Reimbursable:
Remarks
Diagnostic test
Treated as one of the major diseases for treating as
an In-patient/Out-patient For rehabilitation/posttreatment/check-up. Patient can consult directly a
Govt./ recognised Hospital without consulting
AMA/State Medical Officer.
Thalassaemia Major
Skiagrams; Electric therapy;
Reimbursable
Bacteriological/pathological tests
Blood
Transfusion charges
Hearing-Aids:
Body-worn/Pocket type: Rs. 2,500/Analogue BTE:
Rs. 7,000/-
Digital BTE:
Rs.20,000/-
ITC/CIC:
Cochlear-implants:
Rs.25,000/-
Rs.5,35,000/-
Admissible, if non-availability of blood in the
Hospital is certified by the treating Doctor
Reimbursable, if done at other than at Govt.
Hospital
On the recommendation by a Govt. ENT Specialist
on the basis of audiometric and audiological
assessment. Type of Hearing-Aid most suited for
the beneficiary to be specified. Replacement after 5
years on condemnation by a Technical Expert and
on approval of a Govt. ENT Surgeon.
Cost of Analogue BTE/Digital BTE/ITC/ CIC type
Hearing-Aid includes the cost of ear mould. Cost
shall include all taxes including VAT and shall
carry “3 years warranty”
With 12 channels/24 electrodes with behind the ear
speech processor (Unilateral implantation
only). Prior permission is needed.
Treatment at residence
Anti-rabic treatment
Specialized treatments: Heart, coronary
diseases, kidney, Cancer, post-operative
care, etc.
Oxygen Concentrators, CT Scan, postoperative care of kidney donor
If the condition is serious
Reimbursable
Testing of eyesight for glasses
Intra-Ocular Lenses:
Only to GS; once in 3 years
As per package deal.
- On the recommendation of the In-charge of the
Respiratory or ICU of the Govt. Hospitals in
prescribed pro forma
Hydrophobic foldable IOL: Rs.5,000/Silicon foldable IOL:
Rs.3,600/-
Admissible
Hydrophilic Acrylic Lens: Rs.5,800/PMMA IOL:
Rs. 490/Conventional cataract operation
Heart Pace Maker, pulse generator, heart
valves, electronic larynx, Hearing-Aid.
CAPD Fluids, Y-Set, Transfer set, MiniCap and related items
Treatment taken outside the District/State
for TB, Cancer, Poliomyelitis, Mental
diseases
Consultation and medicine charge
Cost of spectacles -- up to Rs.200/Payment will be made direct to the
Hospital/supplier
On the advice of Specialist/Govt./ recognized
Hospital. With prior permission of HOD, the GS
may purchase for one month at a time and claim
reimbursement. Utilization Certificate should be
submitted.
Admissible
For treatment of communicable diseases
for Immunizing and Prophylactic
On the recommendation of a Specialist and on
Vaccination for Hepatitis B, Influenza and
countersigning by HOD of concerned Speciality of
Leprovac for high risk individual
Govt. Hospital
Dental treatment such as jaw bone disease,
removal of all the teeth, removal of
If the physiological or other disability indicates that
odontomes, impacted wisdom tooth, gum the teeth are real source of problem.
boils, etc.
Extraction, scaling & gum, filling of
Reimbursable
teeth, root-canal treatments
Complete denture
One Jaw (denture)
Cost of boot (shoe)
Pathological tests
General debility or secondary anaemia
Venereal diseases
Delirium tremens
Sterility
Sterilization
Medical termination of pregnancy
Diet charges:
- For free diet, the pay of GS should not
exceed Rs.7,450/-
In case of TB/Mental diseases, Cancer,
HIV/AIDS, Renal Dialysis and
Thalassemia, the pay limit is Rs.11,160/-
Treatment at the Consulting room of
AMA.
Supply of vitamins, minerals and antioxidants
Prolonged treatment
Administering Injections
Specialist consultation
Physiotherapeutic/Occupational
therapeutic treatment
Non-entitled accommodation in a Hospital
Electrical lighting, fan charges
Injections at AMA's Consulting room
Up to Rs.2000/- -- one time
Up to Rs.1000/- -- one time
Cost of boot (shoe) in case of patients is
reimbursable only after three years for a maximum
limit of 3 times. Repairs and adjustments where
necessitated under the advice of the Medical
Specialist should be got done at the recognized
Centres. It has to be ensured that the cost of
repairs/adjustment of appliances is less than the cost
of replacement.
If not available at Govt. Hospital
Reimbursable
Reimbursable
Reimbursable
Reimbursable
Reimbursable
Reimbursable
- Where the Hospital charges a flat rate which
includes diet, accommodation, ordinary nursing,
medical and surgical services, and also in respect of
Military or recognized factory Hospitals: 20% of
the flat charges will be reckoned as diet charges;
- Where it includes diet, accommodation and
ordinary nursing only: 50% of the charge will be
reckoned as diet charges.
Permissible
Restricted to prevalent CGHS formulary only
Only at OPD of a Govt./recognized Hospital
Up to 15 at Consulting room; beyond 15 at OPD of
a Hospital
On the recommendation of AMA
If not available at Govt. Hospital
On certification of Medical Superintendent
If they form part of accommodation charges
Injection charges admissible
To AMA/patient, if the place of illness is more than
8 Km (but not within the city) But it is not
admissible to Compounders/ Lab. Assistants
On special medicines
Travelling expenditure
Sales tax
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II. Non-Reimbursable:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
Hospitalization and treatment at AMA's Nursing Home even in emergency
Cottage booking fee, admission fee, Dhobi charges
Air-conditioning/heater charges
Dental treatment as such
Foods, diet charges, tonics,
Toilet preparations, disinfectants, napkins, talcum powder, mouth fresheners
Treatment by private Dentist
Treatment by Oculist
Telephone charges
Product manufactured/marketed as food supplement cosmetics and Ayurvedic preparation
prescribed by Allopathic doctors will be inadmissible.
Vaccines in general
Packing & Postage charges on medicines
Annexure-II
Remarks
S.No. Nature of relationship
Wife/Husband
1.
Condition of dependency is not applicable in case of husband
or the wife.
In case of spouse employed in an organization where medical
facilities are provided or Fixed Medical Allowance is given,
he/she can prefer claim from only a single organization,
according to their status or preference.
- Judicial separation does not dissolve marriage and even a
judicially separated wife continues in Law to be a wife.
Judicially separated
wife
Parents
2.
Irrespective of the fact whether receiving maintenance
allowance or not. In case of judicially separated wife and
dependent children, medical expenses in respect of these
children allowed husband/wife whoever prefers the claim till
the question of Guardianship is decided by the Court of Law.
In case adoptive parents are included, real Parents are not
eligible
(excluding step-parents),
step-mother,
Adoptive parents
3.
Parents-in-Law
4.
Sons
5.
6.
7.
8.
9.
A female Govt. servant can choose between her parents and
Parents-in-Law at the time of marriage and the option
exercised can be changed only once during service.
Till start earning or attains 25 years of age whichever is earlier
Ineligible even if he is below 25 years of age.
[Married sons and daughters who are suffering from any
Married son
disorder or disability of mind including mentally retarded or
physically crippled or disabled are not eligible even for family
pension vide GID (30) under Rule 54 in CCS (Pension) Rules,
1972. Ed.]
Defined disabilities: Blindness; Low-vision; Leprosycured; Hearing impairment; Locomotor disability; Mental
Permanently disabled son retardation; and Mental illness; and also includes 80%
[revised as 40%] or more of one or more disabilities such as
autism, cerebral palsy, mental retardation or a combination of
any two or more of such conditions, provided that he is
financially dependent on the CGHS beneficiary.
Suffering from 40% or more of Schizophrenia, provided they
Son suffering with
are financially dependent and is residing with the CGHS
Schizophrenia
beneficiary. This is subject to his continuing to suffer from
the disabilities. Disability Certificate to be submitted once in 5
years.
Till start earning or get married whichever is earlier
Daughters widowed/
divorced/abandoned or
separated from their
husband
Legally adopted
children/Step-children/
On giving same status as that of a natural-born child through a
special 'Will'
Wards (under "Guardians
& Wards Act, 1890)
10.
Widowed sisters
11.
Minor Brothers
Minor children of
dependent widowed/
separated daughters
12.
Dependency and residential conditions with the CGHS
beneficiary will continue to apply
Up to the age of becoming major (18 years)
Effective from 19-1-2012, up to the age of becoming major
(18 years)
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Annexure-III
Entitlement of Wards duration and Charges Payable
Pay (in the Pay Band)/Pension/
S.No.
Family Pension p.m.
1.
2.
3.
4.
Up to Rs.13,950/From Rs.13,960 to Rs.19,530/Rs.19,540/- and above
Day care (6-8 hours admission)
Duration of stay in a Hospital
1.
Specialized procedure
2.
Other procedures
3.
Laparoscopic surgery
4.
Day care/minor procedure (OPD)
Charges payable
Ward entitlement
per day (max.)
General Ward
Rs. 500/Private Ward
Rs.1000/Private Ward/Deluxe Ward Rs.1500/--Rs. 500/-
12 days
7-8 days
3 days
1 day
Monetary ceiling/Pay slab for various issues
1.
2.
3.
4.
Monetary ceiling for direct consultation with Specialists in
Central/State Govt./Municipal Hospitals
Pay slab for determining the entitlement of Nursing Home
facilities in Govt./State Govt./Municipal Hospitals
The monetary ceiling for free diet for CGHS beneficiaries is
revised to pay/pension/family pension
For beneficiaries suffering from TB, Leprosy, Mental Illness,
Cancer and HIV/AIDS, Renal Dialysis therapy and Thalassemia or
mental disease is revised to pay/pension/ family pension
Rs.33,480/- p.m.
and above
Rs.13,950/- p.m.
and above
Rs.7,450/- p.m.
Rs.11,160/- p.m.
Where the Hospital charges a flat rate which includes diet, accommodation, ordinary nursing,
medical and surgical services, and also in respect of Military or recognized factory Hospitals,
20% of the flat charges will be reckoned as diet charges; where it includes diet, accommodation
and ordinary nursing only, 50% of the charge will be reckoned as diet charges.
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Annexure-IV
Cost-Ceiling for Coronary Stents and other Appliances
Cost-ceiling
Remarks
S.No. Name of appliance
(or actual
whichever is
less)
Coronary/Vascular
Stents -Drug Eluting Coronary
Stents:
i) All DCGI and FDA
approved Drug Eluting
Stents
Rs.65,000/-
ii) All DCGI and CE
approved Drug Eluting
Stents
1.
iii) All DCGI approved
Drug Eluting Stents
Rs.50,000/-
Bare Metal Coronary
Stents:
i) Stainless steel stents
Rs.40,000/-
A maximum of three Coronary Stents (of
which not more than two are drug eluting
stents) shall be permitted on the advice of
Govt. Specialist of which not more than
two shall be of Drug Eluting Stents
(DES). However, DES shall be
permitted only for patients where restenosis will involve high risk to patient's
life, i.e., (a) Osteal/ Proximal LAD
lesions; (b) Stenosis of a Coronary artery
which is given collaterals to another
blocked artery, thus supplying a large
area of myocardium; and (c) Stenting of
re-stenotic lesions after previous
angioplasty.
Quote the Batch number and enclose the
outer pouch of the Stent packet along
with the sticker on it on which details of
the stent are printed for reimbursement.
ii) Cobalt stents:
a) All DCGI and FDA
approved
CGHS package rate includes the cost of
CD and medical record.
b) All DCGI and CE
approved
Rs.12,000/Rs.20,000/-
c) All DCGI approved
Rs.18,000/iii) Coated/other stents
Bare Metal Vascular
(Non-Coronary) stents:
Rs.15,000/-
i) Stainless steel stents
ii) Cobalt stents
Rs.25,000/-
iii) Nitinol/other stents
Rs.20,000/-
Rs.20,000/Rs.22,000/-
2.
Rotablator
Pacemaker – single
3.
chamber (without
Rs.25,000/Rs.50,000/-
Or the actual cost whichever is less
Rs.37,500/-
-do-
Rs.65,000/-
-do-
Rs.1,15,000
-do-
rate response)
Pacemaker – single
4.
chamber (with rate
response)
Pacemaker
5.
(dual chamber)
6.
Knee implant
7.
Hip implant
Rs.60,000/+ Rs.5,000/towards cost of
bone cement
Rs.35,000/-+
Rs.5,000/-
-do-
-do-
8.
9.
Hearing-Aid - One sided
Hearing-Aid - Bilateral
towards cost of
bone cement
Rs.10,000/Rs.20,000/-
Digital Hearing-Aid
10.
11.
12.
Rs.30,000/-
Nebulizer
Rs.3,000/-
Pulse generator
Not provided by
CGHS
-do-do(a) Moderate to severe sensory neural
hearing loss with aided speech
discrimination score which cannot be
improved to 70% by use of analog
Hearing-Aid; and
(b) sharply sloping audiogram seen on
Pure tone Audiometry, inverted V
audiogram or U-shaped audiogram
involving 200 Hz. Factors like age,
educational/work requirement and
bilateral congenital losses to be taken
into consideration.
Condemning authority: Service
Engineer of the authorized Hearing Air
Centre/Dealer to be countersigned by the
ENT Surgeon of a Govt. Hospital.
Or the actual cost whichever is less. The
average life is expected to be 5 years.
Replacement on condemnation by the
treating Physician/Specialist
---
Diseased heart
13.
-do-
---
-do-
---
valves
Artificial electronic
14.
Larynx
15.
Cost of boot (shoe)
Repairs and adjustments which should be
less than cost of replacement should be
got done at recognized Centres to be
undertaken under the advice of the
Medical Specialist.
Request may be considered on the
following conditions:
i) individual request for permission/ ex
post facto approval should be considered
by a Screening Committee consisting of
DDG (M), Directorate of GHS and two
Medical Specialists in the concerned
field;
CPAP machine
Rs.50,000/-
ii) request should be accompanied by
copies of Sleep Lab. Report and all basic
investigation reports;
16.
BIPAP machine
Rs.1,00,000/-
iii) beneficiary concerned will have to
submit an affidavit for return of the
machine to the Department concerned
after its utility is over; and
The machine shall be provided once in a
lifetime to a particular beneficiary. The
responsibility for maintenance shall lie
with the beneficiary.
Neuro-Implants:
Rs.3,46,153 +
VAT Rs.13,847
DBS Implant (including
MER)
17.
(Rs.3,60,000)
Cost of battery:
Life of battery: 3-5 years
Prescribing Authority: Neurologist of a
Govt. Hospital
Rs.2,40,385 +
VAT Rs.9,615
18.
Intra-thecal Beclofen
Pump, Intra-thecal
Morphine Pump
(Rs.2,50,000)
Rs.2,51,923 +
VAT Rs.10,077
Life of battery: up to 7 years
(Rs.2,62,000)
Recurring expenditure on Beclofen and
Morphine as per rules applicable to OPD
medicines
Intra-thecal
Infusion pump:
Prescribing Authority:
Rs.2,16,346 +
VAT Rs.8,654
Any two Govt. Specialist of concerned
Specialty/Head of Department of
(Rs.2,25,000)
Neurology/Neuro-Surgery/
Anaesthesiology
Rs.2,51,923 +
VAT Rs.10,077
Spinal Cord
19.
stimulators
(Rs.2,62,000)
Cost of battery:
Life of battery: 3-5 years
Rs.1,92,308 +
VAT Rs.7,692
(Rs.2,00,000)
Replacement of battery before 4 years may be permitted in exceptional cases on the basis of
justification provided by the treating Specialist on case to case basis by the DH&FW.
Warranty for two years from the date of implantation with free replacement, if battery failure or
malfunction of device is reported.
Approving authority:
CGHS: Addl. Director of the concerned city
Under CS (MA) Rules:
DDG (M) or equivalent level Officer of DGHS
Post date: 2016-05-03 19:15:28
Post date GMT: 2016-05-03 13:45:28
Post modified date: 2017-04-18 09:41:52
Post modified date GMT: 2017-04-18 04:11:52
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