Based on the recommendations made by Sixth Central Pay Commission, Ministry of Health & Family Welfare (MOHFW) under the Government of India, has taken the initiative and efforts to introduce an Insurance Scheme specially designed for the Government Employees – Serving officials and Pensioners which has been named as Central Government Employees & Pensioners Health Insurance Scheme (CGEPHIS). In this regard, the Government of India has invited Expressions of Interest from Insurers and Health Insurance consultants for the proposed scheme to be introduced in due course across India.

As per the document known as Expression of Interest published on the CGHS website in this regard, Government of India (GOI) has ambitious plans to provide inpatient health care services to wide-spectrum of Central Government employees.

Proposed Beneficiaries of the proposed CGEPHIS

All personnel of the Central Government including All India Service officers, serving, newly recruited, retired and retiring and others who are covered under the existing CGHS (Central Government Health Services) and under CS (MA) [Central Services (Medical Attendance) Rules] Rules shall be offered the proposed Health Insurance Scheme on voluntary or on compulsorily basis.

Proposed Features of CGEPHIS

The proposed features of CGEPHIS are enlisted below:

CGEPHIS shall be compulsory to all the newly inducted Central Government Employees who would be joining service after the introduction of the proposed health Insurance Scheme.

It shall be compulsory to new Central Government Retirees who would be retiring from the service after the introduction of the proposed Insurance Scheme.

It would be available on voluntary basis for the existing Central Government Employees and pensioners serving in CGHS area/covered under the ambit of CGHS. In such cases however, the serving Central Government Employees and Central Government existing Pensioners shall have to opt out of CGHS scheme. In return, such individuals will have the option of choosing both CGHS and Insurance policy. In such cases, the total premium has to be borne by the beneficiary of the proposed beneficiary scheme.

CGEPHIS would also be available on voluntary basis for the existing serving employees and pensioners in non-CGHS areas not covered by CGHS Act. In this case such serving Central Government Employees and existing Pensioners (who have already opted for CGHS facility) shall have to opt out of CGHS scheme. Such individuals will have the option of choosing both CGHS and Insurance policy. In such a case too, the total premium has to be borne by the beneficiary of the proposed insurance scheme.

The proposals relating to sum assured/policy limits, family size, age limit, Insurance coverage are as follows:

a) Sums Insured / Policy Limits

The scheme shall provide coverage for meeting all expenses relating to hospitalization of beneficiary members up to Rs. 500,000/- per family per year subject to stated limits of the proposed insurance scheme on cashless basis through smart cards. The benefit shall be available to each and every member of the family on floater basis i.e. the total reimbursement of Rs. 5 lakhs can be availed by one individual or all members of the family, who are his/her dependants. In addition, there is a proposal from the Government to restrict the medical/healthcare benefits in respect of Domiciliary hospitalization and Maternity up to Rs.50,000/- for each admission.

b) Family Size / Age Limit

Serving Employees: Self, spouse, two dependent children and dependent parents (New-born shall be considered as insured from day one)

Retired Employees: Self, spouse and one dependent child

Additional dependent family member can be covered under the proposed scheme by paying the fixed percentage of premium per additional dependent family member. This premium has to be borne by the beneficiary.

All beneficiaries shall be insured till their survival.

The definition of dependent will be according to the guidelines issued by Central Government of India, New Delhi.

c) Insurance Coverage

In addition to the coverage proposed under a standard medical insurance policy, the following areas shall also be incorporated under the ambit of CGEPHIS:-

Pre-existing diseases

Maternity benefit

Day-one Coverage for all diseases

New-born babies

Pre-hospitalization and Post-hospitalization cover of 30 days and 60 days respectively

Domiciliary Hospitalization

Based on the recommendations and inputs of Sixth Pay Commission provided for implementing an alternative health insurance scheme in place of the existing CGHS, the existing CGHS needs to be totally revamped, the chief reason for this being that CGHS caters to only a miniscule section of Government employees. Since the Central Government employees community are posted in every nook and corner of the country, including remote areas, the existing CGHS is limited only to 26 cities across India. The rest are covered by Central services (Medical Attendance) Rules, which seldom serve the real purpose.

In such a scenario that is widely prevalent across India, the present contemplation of the Indian Government in bringing a new Health Insurance Scheme in the place of existing CGHS and medical treatment under Central services (Medical Attendance) Rules, is a positive and welcome one. The official documents released by the Government for assessing the willingness of the Central Government employees to join in the proposed health insurance Scheme are known as Demand Survey. Such Central Government Employees have been requested to go through the document in a detailed manner and understand its contents. Such individuals have been invited to apply in the given format, provided that such individuals are willing to join as beneficiary in the proposed health insurance scheme, without any pressure or compulsion or bindings of any sort being exerted on them.

The CGEPHIS scheme has been proposed for non-CGHS centers too. The Central Government employees belonging to non-CGHS centers can send their willingness to join the proposed health insurance scheme to the Deputy Director, Ministry of Health and Family Welfare directly (MOHFW).