Central Government Health Scheme (CGHS) : Article from Sri. K.V.Sridharan
Central Government Health Scheme (CGHS)
(i) CGHS contributions will be recovered every month from pay bill (ii) If the husband and wife are Government employees, the contribution will normally be paid by one who gets higher pay.
(iii) In case of leave exceeding 4 months, one may opt not to contribute and in such cases, the CGHS facilities will not be admissible.
(iv) Pensioners/Family pensioners have to contribute the amount they were subscribing at the time of retirement/death of Government servant. (v) Pensioners/Family Pensioners should pay their contribution for one year in advance either from January to December or July to June. (vi) Pensioners can avail life time facility by paying 10 years contribution in one lump sum at the time of retirement.
(vii) Medical Allowance is not payable if the pensioners are residing in areas where CGHS facility exists.
(Vii) P&T Pensioners who were not CGHS beneficiaries while in service, but residing in CGHS area where there is no P&T dispensary are entitled to Fixed Medical Allowance.
(ii) Conditions for availing the Scheme:
(i) The employee should reside in the area of operation of the Scheme.
(ii) Pensioners residing anywhere may get registered in any dispensary.
(iii) A family photograph of size 6.5 cm x 5 cm should be affixed to the CGHS token card and got attested by the Department. In case CGHS beneficiaries falling sick outside CGHS area, treatment is allowed under CS (MA) Rules in Government Hospitals/Referral Hospitals/Recognised Hospitals
(iv) If both husband and wife are employees and contribute for CGHS, parents of both can be included for the benefits.
(v) Family of the employee can avail the facility if the employee is transferred to another CGHS area or goes to serve abroad and leaves the family at the old CGHS station.
(vi) Family of the employee who continues to stay back at the old station in a CGHS covered area can avail CGHS facilities even after the transfer of the employee to a non-CGHS area, for a maximum period of six months on payment of CGHS contribution in advance for that period.
(vii) Irrespective of age, the dependent permanently disabled/mentally retorted children residing with Government servant are eligible to avail CGHS.
(viii) From 19.01.2012, minor children of widowed/separated daughters can avail up to the age of 18 hours.
(ix) Dependent condition: Less than Rs. 9000/- PM plus the amount of D.A. (x) May avail medical facilities for in-patient treatment and Post-operative following treatment, while residing in or on visit to a non CGHS area subject to conditions.
(xi) Can undertake medical treatment from any hospital recognised under CGHS subject to the condition that the reimbursement shall be allowed as per CGHS/CS (MA) Rules or the actual expenses incurred whichever is less.(xii) If the treatment of a particular disease is available in the same city, he may be permitted to avail of the treatment in any other city of his choice.
(xiii) If the treatment is not available at the same station, he is eligible for the grant of TA/DA
Medical Attendance Rules : Article
1. C.S (MA) Rules, 1944.
1. Treatment is limited to 10 days (Prolonged treatment is also admissible provided doctor certify it). (40 days for Indian system of Medicine and Homeopathy) with a maximum of four consultations and ten injections. The number of injections may be raised to 15 depending on the condition or ailment of the patient.
2. There should be a reasonable gap between the closing of first spell and recurrence of the second spell of treatment of the same disease.
3. Dependency: - Income should not exceed to the extent of Rs.9000 + DA per month at the time of treatment. But it does not apply in case of spouse.
4. Cost of blood and blood transfusion is reimbursable.
5. Reimbursement of fees paid to specialist of a Govt./recognized hospital for testing eyesight for glasses is admissible once in three years for Govt. Servant alone and not for his family.
6. Dental treatment, including extraction, scaling and gum treatment, root canal treatment and filling of teeth (excluding cost of denture) is admissible. For Denture Maximum of Rs. 2000 /-
7. Expenses incurred for the correction of squint eye is reimbursable. 8. In case of serious illness/accidents where the official is unable to apply, the advance may be sanctioned on an application made by his wife or other legal heir.
9. In case of consultation of a Specialist/other medical officer is required in the opinion of and only on reference of AMA, the limit of 4 consultations within 10 days will count from the date on which the specialist/other medical officer is consulted.
10. If consultation is taken on the 10th day and further medicines are prescribed, the consultation fee for that day shall not be reimbursable. In such cases the patient should go to OPD of Govt. recognized hospital.
11. Cost of medicines, prescribed during these consultations only (i.e. up to 10 days) is reimbursable.
12. Charges for a maximum of 10 injections (it may go up to 15 in special cases) can also be reimbursed.
13. Consultation and injection can be had together and prescribed fee for each can be claimed.
14. A separate claim for each spell of each disease should be preferred.
15. Between two spells of same disease there should be a reasonable gap.
16. If during a spell of treatment of a disease another disease occurs, then consultation made for it will be fresh first consultation and a separate new spell.
17. Medical claim should be preferred within six months of completion of the treatment. However, the Departments may condone delay beyond 6 months. The three months have been raised under OM No.S 14025/19/2015-MSdated 27.05.2015.
18. Family means for availing medical treatment
(i) Husband/wife
(ii) Parents &Step mother
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Note: In case of adoption, only the adoptive and not the real parents. If the adoptive father has more than one wife, his first wife only. A female employee can choose to include either her parents or her parents in law. Option exercised can be changed only once during one's service. Resident condition is not applicable for parents.
(iii) Children
Unmarried Son- Till he starts earning or attaining the age of 25, whichever is earlier.
Daughter - Till she starts earning or gets married, whichever is earlier (irrespective of age limit).
Son suffering from permanent disability or mentally - no age limit.
(iv) Widowed daughter and dependent divorced/separated daughters, irrespective of age limit.
(v) Sisters including widowed, divorced/separated sisters irrespective of age limit.
(vi) Minor brothers and dependent brothers' up to the age of becoming major.
(vii) Minor children of widowed/separated daughters.
(viii) Permanently disabled dependent brother. (No age limit) provided he is unmarried, not having his own family, wholly dependent on and residing with the principal CGHS card holder or beneficiary.
19. Advance may be paid irrespective of pay limit for inpatient hospital treatment. The advance may be paid in one or more instalments for the same illness or injury. There is no limit for the number of advances payable to an official with reference to himself and to each member of the family and in each case of illness.
20. When advance is paid direct to the hospital, the official should submit the bills for final settlement within one month from the date of discharge from hospital. The Head of the office will correspond directly with the hospital for a refund of the unutilized balance, if any.
21. For Major illness of Bypass surgery, kidney transplant etc, 90% of the package deal wherever it exists, or the amount demanded by the hospital concerned in other cases.
22. In case of serious illness/accidents, the wife or other legal heir may apply for advance on behalf of the Government servant.
23. Reimbursement of ambulance charges:
i) The ambulance should be used within the same city and also belong to Govt./Local Fund or Social service organization.
ii) It should be certified that the conveyance of the patient by any other means would definitely endanger his life or aggravate his health condition. iii) It should be used between one hospital to another for certain medical examinations.
24. Expenses incurred on the surgery and post-operative care of the donor of the Kidney to the employees or to a member of their family for transplantation will be reimbursed. TA is also admissible.
25. In case of emergency treatment, reimbursement shall be allowed in non - NABH rates under CGHS for the city or nearest CGHS City.
26. Requests for relaxation of procedures in considering the claims shall be referred along with specified documents (OM No. S.11024/1/2015 CGHS (P) dated 01.01.2016)
27. Hearing aid can be replaced once in five years
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