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Medindia » Consumer Health » Health Information » Central Government Health Scheme - CGHS – For Serving Government Employees & Pensioners

Central Government Health Scheme (CGHS)

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CGHS – For Serving Government Employees & Pensioners
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Delegation of Powers under CGHS relating to referral system, Permission cases and Ex Post-Facto Approval

(A) REFERRAL SYSTEM

1. Procedures/investigations for which there is no prescribed CGHS rate for CGHS recognized private hospitals/diagnostic center. Permission for tests/procedures, the estimates of which not exceeding more than Rs. 20,000/- may be granted by HOD (Head of the Department), for Serving employees and by Head of CGHS covered cities for Pensioners, provided that such tests/procedures have been recommended by Government Specialist. Reimbursement may be limited to AIIMS rate, in the case of Delhi and outside Delhi. In case rates have not been fixed by AIIMS for any particular procedure/investigation/test, reimbursement may be made as per the actuals.
2. In case of medical emergency, beneficiary may go directly to a private/Government referral hospital recognized under CGHS and thereafter submit a Medical Reimbursement Claim after discharge from the hospital. Powers are delegated to the Heads of the CGHS organizations in various CGHS covered cities, in respect of both-pensioners and serving employees, for deciding which cases fall under the “emergency” category. This is done after analyzing the merits of each medical case individually.
3. In Pregnancy Cases. Once the pregnancy is diagnosed/confirmed by the Government/CGHS doctors including the Medical Officer working at the dispensary level, the Head of the Department of concerned Department/Ministry may permit admission for confinement purpose in the private hospitals recognized under CGHS.
4. In spite of the medical facility being available in the city, a CGHS beneficiary, still opts or chooses to get treatment in CGHS recognized hospital in another city. The powers for granting such permissions are delegated to the Heads of CGHS organizations in various CGHS covered cities, both in respect of pensioners and serving employees. For availing medical/healthcare facilities in other cities, TA/DA allowances are not given to such CGHS beneficiaries.
5. In case of pensioners, if permission is granted for medical treatment in another city for undergoing such procedures/tests advised by the Government/CGHS medical specialists provided if such medical facilities are not available in the same city of residence. Permission may be granted to pensioner beneficiaries by Head of the CGHS Organization in the various CGSH covered cities on the basis of specific advice from treating Government medical specialist. TA (Travel Allowance) may be limited to the Referral Hospitals available in the nearest city by the shortest route. In case of deviation from the above rule, prior permission of Director, CGHS, needs to be obtained.
6. In case of emergency, in respect of pensioners/serving employees. Since it is not always possible to obtain prior permission in medical emergencies, treatment taken by CGHS beneficiaries in case of an emergency will be considered on merit based on individual study pertaining to such cases. This is applicable even if the treatment is taken from a non-recognized private hospital. For granting eg. Post- facto approval in emergency cases, for both-serving Government officials or pensioner beneficiaries, the power is delegated to the Head of the concerned CGHS covered city.
7. Treatment in a private hospital recognized under CGHS Referrals may be made based on the recommendation regarding the treatment procedure by the concerned Government medical specialist for indoor treatment (IPD) in private hospitals, recognized under CGHS. This is usually done by the Head of CGHS covered city in respect of pensioners and by the Head of the Ministry/Department/Office in respect of serving government employees. The permission for follow-up treatment pertaining to CGHS beneficiary may be given for a period of six months from the date of discharge from the hospital. This permission is granted by the Head of CGHS covered city in respect of pensioners and by the Head of the Ministry/Department/Office in respect of serving employees.











(B) PERMISSION CASES

1. Cases where permission is to be granted for products/services with ceiling rates. When medical treatment is taken with prior permission and where the ceiling rates have been fixed for purchase of implants such as pacemakers, stents, total joint replacement, etc. the procedure of calling 3 quotations is not required. The Head of the CGHS organization of the concerned CGHS covered city may grant permission in such cases.
2. Permission for items for which the Standing Committees exist and the Standing Committee has recommended the case. Permission may be given by the Ministry of Health and Family Welfare (MOHFW) for items that have been notified by the CGHS.
3. Supply of Oxygen Cylinder, Filter, Infusion pump, etc. Permission may be given by the Ministry of Health and Family Welfare (MOHFW) based on the recommendations of the Standing Committee for items that have been notified by the CGHS.
4. Air travel Permission may be given by the Ministry of Health and Family Welfare (MOHFW) based on the recommendations of Director, CGHS.
5. Permission for highly expensive procedures like BMT (Bone Marrow Transplant), Cardiac Defibrillator, Carotid Stents, Total Hip Replacement, etc. as per Government ceiling rates, as the costs involved are very high or where there is no policy decision has been taken so far. For highly expensive procedures like BMT, Cardiac, Defibrillator, Carotid stenting, etc. Ministry of Health and Family Welfare (MOHFW) notifies the list of equipments or instruments or implants for domiciliary use with specific ceiling rates. Hence, permission for any instrument or equipment or implant outside the notified list will be dealt by the Ministry of Health and Family Welfare (MOHFW) on a case-to-case basis in consultation with Finance Division, CGHS.

(C) EX POST FACTO APPROVAL

1. Treatment taken without recommendation of CGHS/Government specialist, but with permission of CMO In-charge of CGHS dispensary in a recognized private hospital within approved ceiling rates. Powers are delegated to the Heads of CGHS organizations in the CGHS covered cities, both-in respect of pensioners and serving government employees to decide such type of cases.
2. Treatment taken in private hospitals recognized under CGHS without prior permission. Powers are delegated to the Heads of CGHS organization in the CGHS covered cities, both-in respect of pensioners and serving employees to decide such type of cases.
3. Emergency cases within the approved ceiling rates in respect of treatment taken in private hospitals recognized under CGHS. Powers are delegated to the Heads of CGHS organization in the CGHS covered cities, both-in respect of pensioners and serving employees to decide such type of cases.
4. Emergency cases within ceiling approved rate in respect of treatment taken in private unrecognized hospital. Powers are delegated to the Heads of CGHS organization in the CGHS covered cities, both-in respect of pensioners and serving employees to decide such type of cases.
5. Cases where prior permission for treatment in CGHS recognized Government referral hospital was granted for a particular surgical procedure, but at the time of actual operation, some device/artificial appliance/additional treatment/procedure/diagnostic procedure has been utilized or undertaken for which no prior permission was taken. Powers are delegated to the Heads of CGHS organization in the CGHS covered cities, both-in respect of pensioners and serving employees to decide such type of cases.
6. Ex Post-Facto permission for treatment in Government Referral Hospitals like AIIMS PGI Chandigarh, etc. For serving employees:Head of the department (HOD) of the concerned Ministry/Department/Office may decide such type of cases. For pensioners:Head of the CGHS organization of the concerned CGHS covered city may take an appropriate decision pertaining to such type of cases.
7. Emergency Treatment in private hospitals recognized under CGHS and approval to be given as per approved rates for approved procedures/appliances/devises. Powers are delegated to the Heads of CGHS organizations in the CGHS covered cities, both-in respect of pensioners and serving employees to decide such type of cases.
8. Treatment availed or taken under emergency, but approval yet to be granted above the approved rates. Ministry of Health and Family Welfare (MOHFW) may decide such type of cases in special circumstances, depending upon the merits of each case-study.
9. Relaxation of CGHS Rules.
Ministry of Health and Family Welfare (MOHFW) will decide such type of cases.
10. Air travel permission/Ex post-facto approval for air travel undertaken for medical treatment. Ministry of Health and Family Welfare (MOHFW) will decide such type of cases.
11. Reimbursement of treatment or surgical procedure or tests, for which there is no prescribed rates under CGHS. Powers are delegated to the Heads of CGHS organizations in the respective CGHS covered cities, both-in respect of pensioners and serving employees. In such cases, however, reimbursement may be made as per AIIMS rate or as per the Actual, whichever may be less. In case there is no AIIMS rate prescribed for a particular medical procedure, then the reimbursement may be made as per the Actual.
12. Monetary limit to issue sanction for settlement of individual Medical Reimbursement Claims or to accord permission or grant of medical advance. Head of the CGHS organization of the concerned city covered under CGHS Act, in respect of Pensioners and Head of the Ministry/Department/Office in respect of serving Government Employees, where, the monetary limits for issuing sanction will be as under : - (a) Rs. 2 Lakhs: In case of serving employees/Beneficiaries By the Head of Ministry/Department/Office.
(b) Rs. 2 Lakhs: (In case of Pensioner/CGHS Beneficiaries) By the Head of the CGHS covered city.

The above orders were issued with the approval of Secretary (Health) and concurrences of JS & FA vide Dy. No. 1766/99-JS & FA, dated 23/3/1999.
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Posted by:  GHOSHKALYAN  Posted on: 04/17/2013
Till now MOHFW/CGHS authorities has not clarified regarding loss of 'dependent'status of my wholly dependent daughter in receipt of scholarship for studying in France. Further set back is submission of feedback with option for 'Yes' in reply expected, it fails submission with Message: Submission Failed Following Supply of Invalid Data. For 'No' option in reply expected it is submitted with acknowledgement as "Thank you for providing Feedback...." I trust NIC will correct this snag.

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Posted by:  GHOSHKALYAN  Posted on: 04/17/2013
Complaints and grievances seems to be of no concern to CGHS authorities.My grievance against Dr R K Asthana for not allowing medicines for six months as eligible for CGHS beneficiary visiting foreign country and deleting name as CGHS beneficiary from my card No.6408 at Dispensary no.2, Lucknow. My daughter's name is deleted as she gets scholarship for studying at France. Scholarship is not an income explicitly defined in Income Tax Rule. The CGHS authorities; Honorable Secy and D.G.,Director,Addl Dy Director General, HQ,Joint Director Grievance and Additional Director are tight lipped in spite of my repeated requests. I suppose I have to lodge online registered complaint through DARPG for this trivial issue.My query requires a line to suffice that my daughter is eligible for dependency or not.

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Posted by:  GHOSHKALYAN  Posted on: 04/17/2013
I am a retired central government servant, in CGHS card beneficiaries are 1- self,2-wife and 3-Dependent daughter. My daughter is studying in France under exchange program. She gets scholarship. As per CGHS norm she is entitled to get medicines for six months in one go. Additional Director Dr R K Asthana has not allowed the due prescribed medicines and has also deleted her name as beneficiary. Scholarship is not an income still loss of her dependency status best known to CGHS authorities. They are tight lipped about this in spite of many requests.

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Posted by:  nashpgr  Posted on: 04/09/2013
I am working as a scientist [grade pay Rs6000] in Indian Council of Agricultural research (ICAR).I got my first posting in Meghalaya. My parents are living in Patna and they dependent on me. My father get treatment from a CGHS emplamented Hospital in Patna. Can I get the reimburshment for this. Avinash pandey

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Posted by:  AJITJUNA(Guest)  Posted on: 04/05/2013
The charges towards treatment will be as per new CGHS-2011 Pune and AIMS,. New Delhi and further amendment from time to time if any. In this regard I want to know what are the Fees to be charged for the pathology investigations done in a private Pathology laboratory?

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Posted by:  bhan49  Posted on: 02/17/2013
When is the scheme being implemented as the present scheme of reimbursement does not serve the purpose

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Posted by:  gujral(Guest)  Posted on: 02/05/2013
it has taken a time in long time in implementation of cgephis.pensioners living out of cghs area are badly affected by this. govt may kindly consider it on priority and also intimate expected date of implementation jaspal singh

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Posted by:  KVKMurthy(Guest)  Posted on: 02/02/2013
I'm Retd employee of AAIW and is having CGHS facility at Jabalpur[M.P], now I am staying with my son in Chennai, kindly let me know can I avail CGHS facility in chennai

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Posted by:  prabhat35bn  Posted on: 02/01/2013
I m a serving employee in bsf under ministry of home, presently posted in siliguri, [WB]. Am I eligible for cghs facility?

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Posted by:  nvphad  Posted on: 12/17/2012
If the father is not dependent then mother can be treated as dependent? Pl clarify

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