CGHS Rules For Pensioners | CGHS Guidelines For Pensioners
FAQ on CGHS – Central Government Health Scheme
FREQUENTY ASKED QUESTIONS WITH ANSWERS ABOUT CGHS
(FAQs on CGHS are intended to provide general information and guidance needed for the CGHS beneficiaries to avail CGHS facilities. The contents must be read in conjunction with OMs/Office orders as issued from time to time. The contents are not intended to be applicable to specific/exceptional cases and no such claims may be made under it. Whenever any difference in interpretation of meaning and/or content of the facts stated here vis-a-vis the original OM/office order arises, the latter will be treated as final and binding).
1. Who are eligible for CGHS facilities?
Persons Eligible under the C.G.H. Scheme
1. All Central Government employees paid from the Central Civil Estimates (except Railways and Delhi Administration), including their families.
2. Pensioners of Central Government (except pensioners belonging to Railways and the Armed Forces) and their families.
3. Central Government Pensioners retiring with Contributory Provident Fund benefits and their families.
4. Widows of Central Government pensioners, in receipt of family pension.
5. Delhi Police personnel and their families, in Delhi only.
6. Railway Board employees.
7. Civilian employees of Defence paid from Defence Service Estimates.
8. Child drawing pension on death of a Central Government employee including minor brothers and sisters of such child.
9. Ex-Governors and Lt. Governors and their families.
10. Ex-Vice Presidents and their families.
11. Central Government servants who are deputed to semi-government and autonomous bodies receiving substantial grant from, or financed by the Central Government.
12. Central Govt. employees on deputation to statutory/autonomous during the period of deputation.
13. Military Officers while on deputation to civil departments and getting their emoluments from Central Civil Estimates.
14. Families of Governments servants transferred to a non-CGHS area, for a maximum period of six months on deposit of CGHS contribution (for the period of 6 months) in advance.
15. Families of IAS Officers on North-Eastern Cadre, who continue to stay back in Delhi even after repatriation of the IAS Officer to the North Eastern Cadre, provided that they continue to occupy Government accommodation in Delhi/New Delhi, on deposit of CGHS contribution in advance (one to three years). The same also applies to families of IAS Officers of J&K Cadre.
16. Parliamentary Secretaries of the Central Government and their families.
17. Members of Parliament and their families.
18. Ex-Members of Parliament.
19. Sitting Judges of Supreme Court and High Court of Delhi and former Judges of Supreme Court and High Courts.
20. Work Charged and Industrial Staff working in establishments run by various Ministries/Departments of Central Government, immediately from the date of their joining the service.
21. Employees of Kendriya Vidyalays Sangathan stationed at Delhi & NCR, Kolkata, Chennai, Hyderabad, Mumbai and Bengaluru.
22. Employees of Ordnance Factory Board Headquarters, Kolkata and Ordnance Equipment Factories Headquarters, Kanpur.
23. All India Service pensioners who retire while serving under the State at their option.
24. Freedom Fighters and members of their family receiving Central Pension under the Swatantrata Sainik Samman Pension Scheme.
25. Family members of the Deceased Ex-Members of Parliament.
26. Pensioners of Ordnance factories.
27. Members of Staff Side of the National Council of the Joint Consultative Machinery, even though not serving as Central Government employees.
28. Persons employed in semi-government and autonomous bodies who are permitted to join the CGH Scheme.
29. An Accredited Journalist who produces a certificate from the Press Council of India stating that he is a member of the Press Association, New Delhi (for OPD and at RML Hospital).
30. Retired Divisional Accountants of the Indian Audit and Accounts Department and those whose pay and pension are entirely borne by the State governments.
31. PSU absorbees who had commuted 100% of their pension and have been restored 1/3rd portion of their pension after 15 years.
32. Absorbees of Statutory Bodies/Autonomous Bodies of Central Govt. (including those who proceeded on deputation initially or were on deemed deputation and then absorbed), who are in receipt of Central
33. Serving and retired Railway Audit Staff.
34. Serving and retired Divisional Accounts Officers and Divisional Accountants posted in the Office of Accountant Generals in States.
35. CISF personnel (and their families) and CAPF (Central Armed Police Forces) personnel posted in CGHS cities.
36. Employees of Supreme Court Legal Services Committee.
37. Employees of India Pharmacopoeia Commission, and their families.
38. Family and dependent members of a Central Govt. employee (a CGHS beneficiary) who stay back in CGHS covered area after posting of the employee to N.E. region (including Sikkim), Andaman & Nicobar Lakshadweep or Ladakh region and CAPF personnel posted in Left Wing Extremist areas, on payment of annual CGHS contribution in advance.
39. Defence Industrial Employees of Naval Dockyard Central Ordnance Depot and AFMSD, in Mumbai.
‘Residence’ alone (and not the Headquarters) is the criterion for determining eligibility of a Central Government servant for availing medical facilities under the Central Government Health Scheme. Thus, Central Government employees and their family members etc. residing in any of the notified cities (list given in previous chapter) are covered under the Scheme.
2. What are the facilities available under CGHS
1. OPD Treatment at WCs including issue of medicines.
2. Specialist Consultation at Polyclinic/Govt. Hospitals and at CGHS empanelled hospitals after referral by CGHS.
3. OPD/Indoor Treatment at Government and Empanelled Hospitals.
4. Investigations at Government and Empanelled Diagnostic centers.
5. Cashless facility available for treatment in empanelled hospitals and diagnostic centers for Pensioners and other identified beneficiaries.
6. Reimbursement of expenses for treatment availed in Govt. /Private Hospitals under emergency and specific treatment advised by Govt. Specialist or Specialist of Pvt. HCOs duly endorsed by CMO/MO of WCs.
7. Reimbursement of expenses incurred for purchase of hearing aids, artificial limbs, appliances etc., after obtaining permission.
8. Family Welfare, Maternity and Child Health Services.
9. Medical consultation and dispensing of medicines in Ayurveda, Homeopathy, Unani and Siddha system of medicines (AYUSH)
3. What are the timings of Wellness Centres/Polyclinics
Wellness Centers are open from 7:30 AM to 2:00 PM on all working days except emergency services wherever applicable.
Emergency services are available in following 4 identified WCs in Delhi
- South Avenue
- North Avenue
- Zakir Hussain Road
- Kingsway Camp
Timings of WCs with emergency services are as follows WC timing 7:30AM to 1:30 PM
Limited Emergency services 1:30PM to 7:30AM
The Wellness Centres remain closed on all Central Govt. holidays. However in case of three consecutive holidays occurring together, Wellness Centres will not be closed for more than 2 consecutive days.
Registration Timings: The registration is stopped 15 minutes before scheduled closing time of dispensary. However, no serious patient is left unattended from the WC.
There are also nine First Aid Posts ( FAP) at following locations in Delhi
o Nirman Bhawan
o Central Secretariat
o Vitthal Bhai Patel House
o Shastri Bhawan
o Narmada House opposite RML Hospital
o Supreme Court and
o New Moti Bagh
o PHA- for Hon’ble MPs and Ex. MPs only. o PH- for Hon’ble MPs and Ex. MPs only.
The timings of these FAPs is from 9:00 AM to 5:00 PM
4. In how many cities CGHS is presently operational?
Following Cities have CGHS facilities at present
7. ALLAHABAD (PRAYAGARA)
23. DELHI & NCR
*Soon to be started
5. For the purpose of making CGHS cards, who are ‘dependant’, and what is definition of the word “family”?
In the term ‘family’ means and includes-
Husband or wife, as the case may be, and other dependant family members. Dependant Family Members include: parents (female employee can have either her parents or her parents-in -law as dependents), sisters, widowed sisters, widowed daughters, minor brothers and minor sister, children and step-children wholly dependent upon the Government Servant and are normally residing with the Government Servant (son upto the age of 25 or till his marriage whichever is earlier and daughter till she gets married). Also now ‘dependent’ includes, dependent divorced /separated daughters (including their dependant minor children) and step-mother.
The term ‘dependent’ means that income from all sources including pension and pension equivalent of DCRG benefit is less than Rs. 9000 +DA per month. This clause is to be fulfilled for all ‘dependent’ family members. However, there is no such clause as dependency in respect of spouse.
OM – https: / /cghs.gov.in/showfile.php?lid=4482
6. Is there any age limit for sons / daughters as dependant in CGHS Card?
Son is eligible till he starts earning or attains the age of 25 years or gets married whichever is earlier.
However, in case the son is suffering from any permanent disability of any kind (physical or mental) he is eligible for CGHS benefits even after 25yrs, provided the disability occurred before the age of 25 years.
A daughter is eligible till she starts earning, or gets married; whichever is earlier (irrespective of age).
7. Who is responsible for deletion of the names of ineligible dependents?
It is the responsibility of various departments/offices forwarding the application for CGHS card to ensure that the names of only genuine and eligible persons are included in the CGHS token cards. It is the responsibility of the employees concerned to apply for a deletion of the name of the dependent from the CGHS card, when the ward is no more entitled to the benefit under the scheme for example a son /daughter getting married, son attaining age of 25 or the son getting employed.
8. What is the role of a beneficiary in providing information regarding any change in data regarding his card?
It is the responsibility of the beneficiary to provide information to CGHS authorities regarding any changes required in the beneficiary database especially related to death, marriage, earning status (see dependency criteria) of any card holder in the family.
9. Are the family members of Central Government Servant not residing with him eligible for CGHS facilities?
Family members who are wholly dependent upon the Central Government employee are normally expected to reside with the primary card holder. However, during a visit to another CGHS covered city they are eligible for CGHS facilities on the basis of individual Plastic Card issued to the dependent family member.
10. What is the grace period for getting CGHS card for availing treatment facility/ reimbursement for indoor treatment by pensioners immediately after retirement?
Pensioners are permitted a period of three months from the date of superannuation to obtain a CGHS pensioner Card for consideration of reimbursement for the treatment taken during grace period, subject to the condition that Application complete with all documents and requisite CGHS subscription is submitted to the office of Additional Director during the fourth month after retirement for issue of CGHS pensioner card. In case, CGHS pensioner card is not made in the 4th month after retirement, no reimbursement for the expenditure incurred for treatment during the period prior to making CGHS card, including grace period.
11. Who is defined as a ‘Person with disability’?
A ‘person with disability’ as defined in ‘The Persons with Disabilities (Equal Opportunities, Protection of Rights and Full Participation) Act, 1995’ as, a person suffering from not less than forty percent (40%) of any disability (as given below), certified by a medical authority. “Medical authority” means any hospital or institution specified for the purposes of this Act by notification by the appropriate Government. A disability certificate from Medical Board of a Government Hospital is required to be submitted in CGHS with application form to continue availing facilities for disabled dependant and unmarried son beyond 25 years of age.
Disability means blindness, low vision, leprosy-cured, hearing impairment, locomotor disability, mental retardation, mental illness. Details may be seen at the following link –
OM No. 4-24/96-C&P/CGHS (P)/EHS, dated 7th May, 2018- hyperlink-2
https: / /cghs.gov.in/showfile.php?lid=4992
12. Are step-children allowed CGHS facilities?
Yes, if they are dependent on card holder and other conditions being fulfilled as in case of dependant sons and daughters.
13. Can dependent in-laws be included under family members for CGHS facilities
A lady Government servant has the option to include either her parents or parents -in-law for the purpose of availing the benefits under CGHS subject to the condition of dependence and residence, etc., being satisfied.
14. My wife and I are both central Government employees and have dependant brothers / sisters and parents. Can we make separate cards and include family members?
Yes. If both husband and wife are in central Govt. service, spouse has the choice to make his/ her parents and brothers/sisters as dependants in his/her separate CGHS card.
However, if wife is in service then she has the choice to make either her parents or her parents – in-law as dependants in her card.
15. What is the procedure to register with the CGHS?
One can get a CGHS card made from the office of Additional Director of the City. Forms can be downloaded from CGHS Website. They are also available in the office of Additional Director of city (Additional Director Headquarter in case of Delhi).
1. Application in prescribed format
2. Proof of residence
3. Proof of stay of dependents
4. Proof of age of son
5. Disability certificate, if any in case of sons aged 25 & above, who would otherwise cease to be a beneficiary.
6. Individual passport size photos of eligible family members
7. Surrender Certificate of CGHS Card while in service ( only in those cases where CGHS Card was issued while in service)
8. Attested copies of PPO & Last Pay Certificate
9. Draft for required amount towards CGHS contribution – in the name of ‘P.A.O., CGHS New Delhi’ in Delhi and in the name of ‘Additional Director, CGHS’ of the city.
In case PPO is not ready for any reason, there is option to get a provisional card on the basis of Last Pay Certificate. The data uploaded in the data base and a print out is issued on the same day for immediate use. Plastic cards are sent to the Wellness Centres and the beneficiaries collect the cards from there. The plastic card numbers are displayed on the notice board of the Wellness Centre for the information of the beneficiaries. SMS is sent to the mobile number of the beneficiaries reminding them to collect their plastic cards.
Serving employees: –
Serving employees submit the forms in prescribed format enclosing photos of eligible family members and submit to the Ministry/ Department/ Office, where he/ she is employed. The application form shall be forwarded by the Ministry/ Office /Department to the office of Additional Director CGHS of city for preparation of card. The plastic cards are distributed through the Wellness Centres as in case of pensioners. SMS is sent in case of serving employees also.
16. Can I print my own CGHS card?
Yes, the facility to print your own card is available for CGHS beneficiaries by visiting CGHS portal cghs.nic.in. A colored print out on the card may be taken and laminated for use as a plastic card. The services can also be availed by showing the printout of index card is issued on the day the application is submitted.
However, computerized printout of index card is issued on the same day. Usually, it takes 3 to 4 weeks for the plastic card to be made after which it is delivered to the Wellness Centre, for collection by beneficiaries.
OM No. Z.15025/1/2016/DIR/CGHS, dated 31st March, 2016- hyperlink
17. Whom should I approach in case the CGHS Card is not issued to me in the prescribed time?
You may contact Additional Director CGHS (HQ), in case of Delhi and Additional Director of City in case of other cities.
18. What should I do if I lose my CGHS Card?
Application is to be submitted to Additional Director of the city (Additional Director, CGHS Headquarters in case of Delhi) along with two photographs and an IPO for Rs. 50/- for issue of duplicate card. Copy of FIR for the lost cards is also to be submitted with the application.
Indian Postal Order payable to “P.A.O. CGHS Delhi” if in Delhi or “Additional Director of the CGHS City “in respect of other cities. Option of “Print you own card” is also available on CGHS website.
19. What should I do if the details on the Card viz. name, date of birth, entitlement, etc. are wrong?
Kindly bring the anomalies to the notice of Additional Director, CGHS (HQ), in Delhi and to the Additional Director of concerned CGHS City in other cities, along with the necessary documents to rectify the error.
20. Is there a colour scheme for plastic cards? What are they?
CGHS Plastic cards have any one of the following colour strips at the top indicating the category:
Serving Government employees -Blue
Pensioners, exMPs ,Freedom Fighters, etc. -Green
Member of Parliament -Red
Beneficiaries of Autonomous Bodies/Journalists -Yellow
21. Are CGHS facilities free of cost?
No, they are not. For serving Central Government employees residing in CGHS covered area, obtaining a CGHS card is compulsory.
The following deductions from salary of the employees are made by the department, every month, depending upon their pay in the pay matrix of 7th Pay commission (wef 1/1/2017)
|Corresponding levels in Pay Matrix as per 7th CPC
|Contribution per month
|Level 12 and above
Pensioners who want to avail CGHS facilities can make contribution either on yearly basis or one time (ten yrs) contribution for whole life validity.
Payment can be made by Demand Draft in favour of “ P.A.O. CGHS Delhi” if in Delhi or “ Additional Director of the CGHS City “
Contribution to be made by the Pensioners/Family Pensioners would be the amount that they were subscribing at the time of their retirement or at the time of the death of government servant. Contribution amount as applicable on the date of applying for Card is to be paid.
22. What are the criteria for Entitlement of ward endorsed on CGHS Card in CGHS Empanelled Hospitals?
Entitlement of wards in private hospitals empanelled under CGHS is as under
|Corresponding Basic pay drawn by the officer in 7th CPC per month
|Upto Rs. 47,600/-
|Semi Private Ward
|Rs. 47,601 to 63100/-
|Rs. 63101 and above
23. I am a serving employee residing in a place close to a city covered under CGHS. Can I get CGHS card issued from the nearest CGHS city?
There is no provision to avail CGHS facilities in respect of serving government employees residing in non-CGHS covered areas. They are covered under CS (MA) Rules 1944.
24. How can the family members of Central Armed Police Forces personnel who are transferred out from CGHS covered areas to J&K State and Left Wing Extremism affected areas, avail CGHS services if they stay back?
• CGHS facilities are extended to the eligible dependent family members of such CAPFs personnel.
• CGHS contributions shall be paid in advance on annual basis, by the CGHS beneficiary through bank DD, drawn in favour of the AD/JD of the concerned CGHS city where his family is residing/place where the CGHS beneficiary was last posted.
• The annual CGHS subscription will have to be paid within two months from the date of posting of the CAPF personnel.
• A certificate from the Ministry of Home Affairs confirming the residence of the family and dependent members in CGHS covered city/area will be required, along with the posting order.
25. What are the different options for availing CGHS services to pensioners?
• Pensioners Residing in CGHS covered areas:
a) They can get themselves registered in CGHS dispensary after making requisite contribution and can avail both OPD and IPD facilities.
b) Such Pensioners are not eligible for Fixed Medical Allowance in lieu of CGHS.
• Pensioners residing in non-CGHS areas have the following option –
a) They can opt for availing Fixed Medical Allowance (FMA) @ Rs. 1000/- per month.
b) They can also avail benefits of CGHS (OPD and IPD) by registering themselves in the nearest CGHS city after making the required subscription. In such cases no Fixed Medical Allowance is given
C) They also have the option to availing FMA for OPD treatment and CGHS only for IPD treatments after making the required subscriptions as per CGHS guidelines.
26. I have retired from Delhi. Now I want to settle at city where no CGHS facility is available. How do I cover my family for medical care?
Pensioners are eligible for CGHS facilities and can obtain CGHS card from the nearest CGHS covered city.
27. I retired in 1998 from Central Government service but, I never made a CGHS card. Can I get a CGHS card now?
Pensioners can apply for CGHS card with relevant documents. However, the subscriptions as applicable at current rates shall have to be paid.
28. My husband/wife is also employed under Central Government and is eligible for a separate CGHS Card. Is it necessary that separate cards are to be obtained?
No. Spouse drawing higher pay shall make the card and other spouse is eligible to avail CGHS benefits as member.
29. My husband / wife retired in 2009. He /she was paying CGHS subscription every year. After his death can I get the card transferred in my name ? Do have I to pay extra ? Shall I get Life Time Valid card?
Yes, the ownership of card can be transferred in the name of spouse on submission of required documents. Additional Director of concerned city shall transfer the ownership of Card in the computer database and same CGHS plastic cards with same Beneficiary ID can be used.
No extra payment is to be made, in case of life time cards. However in other cases one has to pay total 10 years subscription for life time card
For example, if the spouse had contributed for seven years before he expired , balance payment for the remaining three years is to be paid for a life time card.
i) Application in prescribed format
ii) Proof of Family Pension with its break up from the bank having his/her pension account.
30. How to transfer CGHS card from one Wellness Centre to other in the same city?
If there is any change in residential address, CMO I/c may be approached with proof of residence for transferring the data on-line from one Wellness Centre to another in the same city. CMO I/c of the new Wellness Centre will accept on-line, the data of transferred card.
In respect of serving employees the request is to be forwarded by his/her office / department.
31. Whether serving employees on transfer to another CGHS covered city can get the same CGHS Cards transferred online?
Yes. There is provision for online transfer of same CGHS cards of serving employees of Central Government on transfer from one CGHS city to another CGHS city is as per the details given under:
1. Serving employees on transfer from one CGHS city to another CGHS City shall submit an application to the Additional Director of CGHS City (forwarded by the Ministry /Department from where he /she is being transferred) along with copy of the transfer / relieving order for transfer of CGHS Cards to another CGHS City with an undertaking that he shall avail CGHS facilities from the nearest CGHS Wellness Center in the new CGHS City.
2. Addl. Director, CGHS of city transfers the card online and issues an acknowledgement slip to the serving employee. CGHS Plastic cards shall be retained by the serving employee.
3. Serving employee in the new CGHS City submits an application duly forwarded by his /her Ministry /Department, certifying that CGHS contribution is being deducted , to the Additional Director of new CGHS City for acceptance of the transit CGHS Cards to the data base of new City and allocation of a CGHS Wellness Centre in new CGHS City.
OM – https: / /cghs.gov.in/showfile.php?lid=4925
32. I am CGHS beneficiary at Kanpur and I am visiting Mumbai for 6 months. Can I get CGHS facilities at Mumbai? Can the same card of Kanpur continue or is a separate card to be made? From where do I get permission for the same?
Subsequent to computerization no separate permission is required and CGHS card is valid for availing facilities from any CGHS Wellness Centre in India. For any assistance, Additional Director of the city (Additional Director CGHS HQ in case of Delhi) may be contacted.
33. After retirement in 2007 I got a Life time Pensioner CGHS card issued in Delhi. Now I am shifting to Dehradun. Can I use the same card? Do I pay again?
Pensioners shifting from one CGHS covered city to another, will have to apply to the Additional Director of concerned city for transfer of card. The card shall be transferred online and a receipt will be issued to the beneficiary, on the basis of which, Additional Director of new city ( say Dehradun) shall receive the data. The same Plastic cards and same Ben ID will be valid in the new city. No contribution is required to be paid in respect of pensioner beneficiaries holding life time cards.
34. I live in Gurgaon but my office is in Saket. Can I avail facilities from both the places because it is convenient for me?
Yes. Subsequent to computerization CGHS facilities can be availed from any Wellness Centre in India.
35. What are the rules on domiciliary visit?
The Medical Officer will pay domiciliary visit wherever considered necessary owing to the inability of the patient to attend the dispensary.
Domiciliary visits except in case of emergency will normally be made before or after the dispensary working hours.
36. What are the Special provisions for CGHS beneficiaries aged 80 years and above?
The special provisions under CGHS to the beneficiaries aged 80 years and above are as given under:
a) Consultation of Doctor at CGHS Wellness Centre without standing in Queue
b) CGHS Doctors shall enquire by phone, at least once in a month to enquire about their wellbeing / make a home visit if residing within 5 K.M.s of CGHS WC
c) Settlement of medical claims on priority out of turn.
d) Follow up treatment from same specialist in non-empanelled hospital from where he/she was earlier taking treatment- as a special case in view of advanced age and difficulty to change physician subject to the reimbursement limited to CGHS rates and collection of medicines as per CGHS guidelines.
OM – https: / /cghs.gov.in/showfile.php?lid=4714
37. Can a non CGHS beneficiary get First Aid at the Wellness Center?
During working hours First Aid treatment is given to all emergent cases irrespective of the fact that the patient is a CGHS beneficiary or not.
38. What are the guidelines on issue of medicines from CGHS?
Guidelines regarding issue of medicines vide OM, dated 16.02.2016 is linked below-
https: / /cghs.gov.in/showfile.php?lid=3760
39. What types of medicines/items are not supplied under CGHS?
OM is linked below –
https: / /cghs.gov.in/showfile.php?lid=3792
40. What are the guidelines for vaccines under CGHS?
The vaccines covered under Universal Immunization Programme (UIP) are administered as per schedule. Rest of the vaccines admissible as per the advice of Govt. Specialist.
41. What is the procedure for getting life saving drugs?
Delhi/NCR- The CMO I/c of WC shall submit the indent online based on a valid prescription of Govt. /Empanelled Hospital Specialist for life saving and other restricted drugs. These are to be collected on next working day from MSD Gole Market Delhi and are made available at Satellite Centre in NCR i.e. Ghaziabad, NOIDA, Gugugram and Faridabad.
Outside Delhi – Based on a valid prescription of Govt. / Empanelled Hospital Specialist for life saving and other restricted drugs, these are procured by the Additional Director of city.
https: / /cghs.gov.in/index1.php?lang=1&level=2&sublinkid=6046&lid=3667
42. Is there any provision for issue of medicines by empanelled hospitals at the time of discharge?
The private hospitals empanelled under CGHS are required to provide medicines for a period of upto (cost not exceeding Rs 2000/-) at the time of discharge from hospital.
i. Only essential medicines in generic name shall be provided.
ii. No non-drug items shall be provided
iii. No nutritional supplements, tonics, cough syrups, Vitamins, Injections shall be supplied.
The hospital shall raise the bill separately for the medicines and submit bills to CGHS in case of pensioner CGHS beneficiaries.
In case of serving CGHS beneficiaries taking treatment on payment basis the hospital may supply the medicines on payment basis to the beneficiary and he/she can claim reimbursement from his/her Ministry / Department. However, it is the choice as per convenience of the serving beneficiary either to buy such medicines from the hospital at the time of discharge or to obtain from CGHS Wellness Centre. The relevant OM is linked below –
https: / /cghs.gov.in/showfile.php?lid=4133
43. Is the prescription of specialists of empanelled hospitals valid in the Wellness Centre?
Yes, Beneficiaries in all CGHS Cities can seek OPD consultation from Specialists in any of the CGHS empanelled hospitals after being referred by the Doctors of the Wellness Centre. The relevant OM is linked below –
https: / /cghs.gov.in/showfile.php?lid=4921
44. What are the guidelines for Specialist Consultation from CGHS empanelled Hospitals?
i) There is a provision to avail consultation from Specialists of private hospitals empanelled under CGHS after a CGHS beneficiary is referred by CGHS Doctors / Specialist of CGHS to any empanelled hospital.
ii) The referral by CGHS is valid for a period of one month for consultation from any one private empanelled hospital and CGHS beneficiary can visit the same empanelled hospital three times during the one month. During each visit, beneficiary can consult upto three different specialists in the same hospital.
iii) There is also provision for post-operative follow up treatment, which includes specialist consultation in the same hospital where , the initial treatment was taken with prior permission in respect six conditions, viz., Cancer treatment, Cardiac surgery, Hip/Knee Implant surgery, Neuro-surgery, Renal transplantation and post Trauma cases. There is a provision for taking permission for post-operative follow up treatment for upto three to six months at a time. Permission for post¬operative follow up treatment is granted by CGHS in respect of pensioners, etc., and by concerned Ministry /Department in respect of serving CGHS beneficiaries.
https: / /cghs.gov.in/showfile.php?lid=4921 https: / /cghs.gov.in/showfile.php?lid=5266
45. How many times CGHS beneficiaries can Consult Specialists at private empanelled hospital on referral by CGHS?
The referral by CGHS is valid for a period of one month for consultation from any one private empanelled hospital and CGHS beneficiary can visit the same empanelled hospital three times during the one month. During each visit, beneficiary can consult upto three different specialists in the same hospital. The relevant OM is linked below –
https: / /cghs.gov.in/showfile.php?lid=5266
46. What is the procedure for undergoing treatment / investigations recommended by Specialist at private empanelled hospital, after referral by CGHS?
The investigations / treatment advised by Specialists of Private empanelled hospitals (after referral by CGHS) may be undertaken in the same hospital, if they are needed in emergency.
If there is no emergency, the investigations advised by Specialists of Private empanelled hospitals are required to be endorsed by the Medical Officer of CGHS as part of checks and balances in the system. The relevant OM is linked below –
https: / /cghs.gov.in / showfile.php?lid=4921
47. What is the maximum period for which medicines can be given in one go?
For treatment of Chronic illnesses medicines upto ‘3’ months are issued in one go, provided there is a valid prescription.
In case of a beneficiary visiting a foreign country , medicines upto ‘6’ months are issued in respect of chronic illnesses , based on valid prescription and documentary support of visit to a foreign country. The relevant OM is linked below –
https: / /cghs.gov.in/showfile.php?lid=3786
48. Is re-registration required if a beneficiary visits WC to just collect indented medicines?
49. Is it mandatory for the Diagnostic Labs to stamp the date and the number of tests performed on original prescription slip?
50. Is treatment taken in an emergency at non empanelled private hospital reimbursable? If yes what is the procedure?
• CGHS considers for reimbursement at CGHS rates in case the treatment taken in an emergency from private non empanelled hospitals. The reimbursement shall be restricted to CGHS package rate or actual expenditure whichever is less.
OM- Z.15025/79/DIR/CGHS, dated 5th October, 2016.
51. What are the guidelines for consideration of reimbursement over and above the approved CGHS rates?
The requests for reimbursement which fall under the following defined criteria shall be examined by Directorate General of CGHS
https: / /cghs.gov.in/showfile.php?lid=4995
52. Is there a provision for collection of medicines from the WC by an authorized person?
Yes, the CGHS beneficiaries can authorize a representative to collect medicines from CGHS Wellness Centre on the basis of valid prescription.
53. What are the guidelines for settlement of MRC?
Normally the medical reimbursement claim is to be submitted within three months of discharge from Hospital/availing treatment. Relevant OM is linked below –
https: / /cghs.gov.in/showfile.php?lid=5037
54. What should I do in case of overcharging by the empanelled pvt. HCOs.
If the empanelled Pvt. HCOs has charged over and above the CGHS approved/package rates, the beneficiary can complain to Additional. Director, CGHS of concerned city/zone, in case of pensioner’s beneficiary and serving employees forward their grievances through the Deptt. with all relevant documents for grievance redressal.
55. Where should I complain for the medical negligence at empanelled HCO’s?
The beneficiary can approach State Medical Council/Medical Council of India with all proof of medical negligence against empanelled HCO’s.
56. What is the system for availing the services of specialists in Wellness Centres?
Prior registration is required for appointment with specialists in CGHS Wellness Centre, where specialist services are available.
Facility of online appointment with CGHS Specialist can be availed by visitingwwwncghs.nic.in
However, in case of emergency contact CMO I/C of the Wellness Centre for consulting specialist without prior appointment.
57. What is the procedure for online appointment?
Online appoint with Medical Officer of the wellness centre or with Specialist who visits a particular Wellness center can be booked by visiting CGHS portal cghs.nic.in through the link Book Appointment.
https: / /cghs.nic.in/ors
58. What is the mechanism for grievance redressal in CGHS?
Complaint/Grievance Redressal The complaints/ grievances can be sent
1. At Wellness center level – to the CMO I/C.
2. At city/zone level -to the Additional Director of the city/zone.
3. Higher administrative level – For Delhi- Addl. Director (HQ).
For Outside Delhi – ADDG (HQ).
The addresses and contact numbers may be found in the contact list.
|CGHS HQ Delhi (AD (HQ) & Zonal ADs) – https://cghs.gov.in/showfile.php?lid=3996
|Contact details of ADs – https://cghs.gov.in/showfile.php?lid=3951
|Contact Details of WCs of Delhi/NCR -https: / /cghs.gov.in/showfile.php?lid=3997
|Contact details of WCs outside Delhi -https: / /cghs.gov.in/showfile.php?lid=3695
|List of Empanelled Pvt. HCOs -https: / /cghs.gov.in/showfile.php?lid=5103
|List of Empanelled Pvt. HCOs- City-wise list available at www.cghs.gov. in
Beneficiaries are advised to approach the authorities normally in the order they are mentioned above, personally, or through phone calls, letters or emails at the contact details on the CGHS website or available on the above link.
Written Complains/ suggestions may also be dropped in the complaint /suggestion box displayed in the Wellness centers.
The grievances at Wellness Centre level can be sorted out in the “Advisory Committee” meetings held normally on every 2nd Saturday of the month.
On all Wednesdays, from 11.00AM to 1.00PM complainants can meet the Additional Directors for grievance redressal.
Beneficiaries may also lodge their complaints/grievances in the “Public Grievance Redressal and Monitoring System (CPGRAMS)” in the Government portal- “pgportal.gov.in” or through email.
https: / /cghs.gov.in/index1.php?lang=1&level=1&sublinkid=6022&lid=3947
59. What is the procedure for reimbursement of medical claim in CGHS?
Apply within 90 days of discharge / completion of treatment procedure, to CMO I/c of the Wellness Centre, where your CGHS card is registered, along with the following documents:
1) Medical Reimbursement Claim (MRC) forms duly filled in
2) Check list
3) Copy of Discharge summary
4) Original Hospital bills with break-up
5) Receipts in original
6) Copy of the valid CGHS Card
7) Copy of cancelled cheque showing bank details for ECS payment or mandate form if name of beneficiary is not printed on cheque.
8) Copies of other documents issued by hospital.
Serving employee in similar cases shall submit the medical claim to his department.
Relevant OM is linked below –
https: / /cghs.gov.in/showfile.php?lid=5037
60. My spouse was a CGHS main card holder. He/she was sick and died while in hospital. How do I get the medical claim reimbursed?
Apply to CMO I/c of Wellness Centre with the same documents as above. In addition, the following need to be enclosed:
i. Copy of Death summary.
ii. Death Certificate
iii. Affidavit on non judicial Stamp paper of yourself being Legal Heir and NOC from other legal heirs in favour of claimant.
It is also to be noted that the CMO I/C is to be informed regarding the death of the card holder but till such time that the claim is settled, the main card holder’s name is not to be deleted from the database as it would then not be possible to submit the MRC on- line.
61. My original claim papers having bills, receipts of hospital treatment are lost. Can I claim on duplicate papers?
Yes, it can be claimed with affidavit on non-judicial stamp paper. Details of Draft for Affidavit may be seen in the instructions sheet appended to Medical Reimbursement Claim (MRC) Form available on the CGHS website and with CMO I/c.
62. I went to Hyderabad on personal visit and sustained fracture of leg bone. I received treatment f r o m a private non empanelled hospital. Will I get reimbursement?
Reimbursement for treatment taken in a non empanelled private hospital under medical emergency shall be considered as per CGHS rates.
63. What are the guidelines for IVF?
IVF treatment is approved under CGHS. The details may be seen as per Office Memorandum Z.15025/5/2011/CGHS-m/CGHS(P), dated
22.11.2011, link given below –
OM- http://cghsnagpur.gov.in/fckimagefile/circular 3.pdf
64. Are ambulance charges reimbursable?
Yes. Ambulance charges are reimbursable within the city , if there is a certificate from treating doctor that conveyance by any other mode would definitely endanger patient’s life or would grossly aggravate his/her condition.
OM No. S.4924/2010/CGHS (R&H)/CGHS(P), dated 17th January, 2011.
65. I have a Mediclaim Insurance Policy. Due to emergency, I received treatment in a private hospital. Some amount was paid by Insurance Co. Can I get balance from CGHS?
Yes, first the bills are to be submitted to Insurance Company. Duplicate bills and vouchers duly verified with the stamp of Insurance Company along with a certificate from Insurance Company indicating the amount for which the beneficiary has received credit from them, needs to be submitted along with the usual MRC forms and checklist. These may be submitted to CGHS by
Pensioner CGHS beneficiaries and to the department by serving beneficiaries.
Reimbursement would be done at CGHS rates or actual whichever is less. However, the total reimbursement from both sources should not exceed actual expenditure.
OM-No. S.11011/4/2003-CGHS (P), dated 19th February, 2009.
66. Is it necessary that the Govt. specialist should specify the name of the empanelled Hospital for the purpose of referral?
67. What are the ceiling rates for reimbursement of Expenses on purchase of Hearing Aids?
The revised ceiling rates fixed for various types of hearing aids (for one ear) are as under
Body worn / Pocket type – Rs. 3000/-
Analogue BTE – Rs. 7000/-
Digital BTE – Rs. 15000/-
Digital ITC/CIC – Rs. 20000/-
The cost of hearing aids shall include all taxes in including VAT and shall carry 3 year warranty. The cost of Analogue BTE /Digital BTE/ITC/CIC type hearing aid shall also include the cost of hearing mould.
OM – https://cghs.gov.in/WriteReadData/l892s/Revision of rates and guidelines for Hearing aids under CGHS CSMA rules- May 2015.pdf
68. I am an accredited journalist with CGHS Card. Can I seek treatment in Private Empanelled Hospitals in emergency and get credit facility?
Journalists are entitled for OPD treatment from Wellness Centres and OPD treatment and Nursing Home facility at Dr. RML Hospital. However, they are eligible to avail CGHS rates at empaneled HCOs on payment basis. There is no provision for reimbursement under CGHS.
69. Who can avail Preventive Health Check up (PHC) and where are the facilities available?
• In view of the importance of Diagnosis of Chronic Non-communicable Health Problems at the preventive level, facility of Preventive Health Check up (PHC ) is available for
o Beneficiaries who are 40 years old or above o Who are already not suffering from any chronic ailments like Daibetes Hypertension Heart disease etc. o This check up done once in a year only.
o Serving beneficiaries will not require any permission from their respective offices.
• PHC is available in 8 Wellness Centers as follows-
a) CGHS Wellness Centre, R. K. Puram- V(South Zone)
b) CGHS Wellness Centre, Sadiq Nagar (South Zone)
C) CGHS Wellness Center, Chanakya Puri (Central Zone)
d) CGHS Wellness Centre, Pandara Road (Central Zone)
e) CGHS Wellness Centre, Janakpuri-1 (North Zone)
f) CGHS Wellness Centre, Shalimar Bagh (North Zone)
g) CGHS Wellness Centre, Kingsway Camp (East Zone)
h) CGHS Wellness Centre, Shahadra (East Zone)
OM- https: // cghs.gov.in/showfile.php?lid=3828
70. What are the special provision for Consultation at private empanelled hopsitals in respect of elderly CGHS beneficiaries aged 75 yrs. and above?
1.CGHS beneficiaries aged 75 years and above shall be permitted to seek direct OPD Consultation from Specialists of private hospitals empanelled under CGHS without referral from CGHS Wellness Centre.
2. If any investigations / procedures are advised and are required in emergency, no other authorization is required and the same may be undertaken. However, in non-emergency conditions approval of competent authority is required if ,any non-listed investigations / procedures are advised. Medicines prescribed are to be procured from CGHS Wellness Centre.
3. Private hospitals empanelled under CGHS shall provide such facilities on cashless basis at CGHS rates to pensioners, ex-MPs , Members of Parliament and such other Categories of CGHS beneficiaries , who are eligible for treatment /investigations on credit basis. More than 75 year old dependents of serving CGHS beneficiaries, who are otherwise not eligible for Cashless treatment shall claim the reimbursement from concerned Ministry /Department. Beneficiaries of Autonomous Bodies /Statutory Bodies covered under CGHS shall claim reimbursement from the respective organization.
If a Specialist advises a listed treatment procedure / investigation – no permission is required and treatment may be taken.
If a Specialist advises unlisted treatment procedure / investigation and treatment is taken as a medical emergency- no permission is required and treatment may be taken
If a Specialist advises unlisted treatment procedure / investigation and there is no medical emergency- permission from competent authority is required.
71. What are the revised Gudelines for Post-operative follow-up treatment at Empanelled Private Hospitals for critically ill CGHS beneficiaries?
In view of the difficulties being faced by critically ill CGHS beneficiaries in getting post-operative follow-up treatment at CGHS empanelled hospitals, the matter was reviewed and it has now been decided that critically ill CGHS beneficiaries shall be permitted for follow up treatment in CGHS empanelled hospitals as per the details given under:
i. Permission for post-operative follow-up treatment in respect of the following post -operative conditions requiring frequent Consultations from Specialists at private hospitals empanelled under CGHS, need not be re validated from time to time and follow-up treatment may be under taken at CGHS rates without time limit.
ii. The consultation /investigations are permitted under these follow-up cases. The conditions covered are:
a. Post Cardiac Surgery Cases including Coronary Angioplasty
b. Post Organ Transplant Cases (Liver, Kidney, Heart, etc.,)
c. Post Neuro Surgery Cases/Post Brain Stroke cases requiring regular follow-up treatment
d. End Stage Renal Disease/follow up cases of Liver Failure
e. Cancer treatment
f. Auto-immune disorders like Rheumatoid Arthritis requiring regular follow-up
g. Neurological disorders like Dementia, Alzheimer’s disease, Parkinsonism , etc., Medicines prescribed are to be procured from CGHS Wellness Centre.
iii. The beneficiaries shall have to submit a self-attested photo copy of the permission letter to the hospital to enable the hospitals to provide credit facility in respect of pensioners and other categories of CGHS beneficiaries entitled for credit facility. Serving employees (and their dependents) who may not be entitled for cashless facilities shall enclose a self-attested photo copy of permission letter to claim
reimbursement from the concerned Ministry /Department.
iv. Permission in respect of Pensioner CGHS beneficiaries, Ex-MPs (and other categories of CGHS beneficiaries, whose medical expenditure is borne by CGHS) etc., shall be granted by CGHS. Permission in respect of Hon’ble Members of Parliament shall be granted by Rajya Sabha Secretariat/Lok Sabha Secretariat as the case may and by concerned Ministry /Department in respect of serving beneficiaries and by concerned Autonomous Body / Statutory Body in respect of serving /pensioner beneficiaries.
v. However, if any non-listed investigations / procedures are advised permission from competent Authority shall be required, except in emergency.