Defence: RELAXATION OF RULES FOR CONSIDERATION OF REIMBURSEMENTS IN EXCESS OF THE APPROVED RATES PERTAINING TO MEDICINAL CLAIMS UNDER ECHS

Defence: RELAXATION OF RULES FOR CONSIDERATION OF REIMBURSEMENTS IN EXCESS OF THE APPROVED RATES PERTAINING TO MEDICINAL CLAIMS UNDER ECHS

File No.22 A(37)/2018/WE/D(Res-l)

Government of India
Ministry of Defence
(Department of Ex-Servicemen welfare)
Sena Bhavan, New Delhi

Dated- 15 January, 2019

To
The Chief of Army Staff
The Chief of Naval Staff
The Chief of Air Staff

Subject: RELAXATION OF RULES FOR CONSIDERATION OF REIMBURSEMENTS IN EXCESS OF THE APPROVED RATES PERTAINING TO MEDICINAL CLAIMS UNDER ECHS.

Sir,
With reference to Gol, MoD letter No 22(1)/01/US(WE)/D(Res) dated 30 Dec 2002 and Gol, MoD letter No. 24(8)/03/US(WE)/D(Res) dated 19 Dec 2003 and in light of M/o Health and Family Welfare order No. Z.15025/ 38/ 2018/ DIR/ CGHS/ EHS dated 22nd May 2018 and No. Z15025/ 51/ 2018/ DIR/ CGHS/ EHS dated 6-6-2018, partial amendments are hereby made to the procedure for payment and reimbursement of medical expenses under ECHS with relaxation of rules for consideration of reimbursement in excess of the approved rates as per the details given under the succeeding paragraphs.

2. The request for full reimbursement which fall under the defined criteria indicated in para 3 below and cases indicated in para 4 below shall be examined by a High Powered Committee whose constitution is indicated in para 5 below. After recommendation of HPC, the concurrence of MoD (Finance/Pension) and approval of Secretary, ESW will be required in all these cases.

3. The request for full reimbursement which fall under the following defined criteria would be considered by the High Powered Committee.

• Treatment was obtained in non empanelled hospital under emergency condition and the patient was admitted by others when the beneficiary was unconscious or severely incapacitated and was hospitalized for a prolonged period.
• Treatment was obtained in non empanelled hospital under emergency and was admitted for prolonged period for treatment of head injury, coma, septicaemia, multiorgan failure etc.
• Treatment was obtained in non empanelled hospital under emergency and was admitted for prolonged period for treatment of head injury, coma, septicaemia, multiorgan failure etc.
• Treatment was obtained in a non empanelled hospital under emergency for treatment of advanced malignancy.
• Treatment was taken under emergency in a higher type of accommodation as rooms as per his/her entitlement were not available during that period.
• Treatment was taken in higher type of accommodation under specific conditions for isolation of patients to avoid contacting infections.
• Treatment was obtained in a non-empanelled hospital under emergency when there was a strike in Govt. Hospitals.

4. Cases falling in the following categories would also be considered by the High Powered Committee.

• Settlements of medical claims in relaxation of rules.
• Approval of air fare with or without attendant on the advice of the treating doctor, for treatment in another city even though he/she is not eligible for air travel/treatment facilities are available in city of residences.
• Representation from ECHS beneficiaries seeking full reimbursement under special circumstances, which are not covered under para 3 above

5. Composition of the High Powered Committee would be as follows :

• JS, ESW - Chairman
• Government Hospital Specialist Doctor (of concerned speciality) - Member
• Director/DS/US, DoESW - Member
• Director(Medical), CO, ECHS - Member-Secretary
• Representative of MoD(Fin/Pen) - Member

6.. The other terms and conditions mentioned in the procedure for payment and reimbursement of medical expenses under ECHS vide Gol, MoD letter No.24(8)/03/US(WE)/D(Res) dated 19 Dec. 2003 shall remain unchanged.

7. This has the concurrence of Ministry of Defence(Finance/Pension) vide their U.O. No32(23)/2018/Fin/Pen dated 3-1-2019.

Yours faithfully
(A.K. Karn )
Under Secretary to the Govt. of India

Source: CGDA

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Relaxation of procedures to be followed in considering requests for medical reimbursement

Doing Away With Need For Verification Of Medical Reimbursement Claims In CGHS and Guidelines for full reimbursement

No: 4-18/2005-C&P [Vol. l- Pt. (i)]

Ministry of Health & Family Welfare

Department of Health 8. Family Welfare

CGHS (P) Division

******

Nirman Bhawan, Maulana Azad Road

New Delhi, Dated the 20th February, 2009

OFFICE MEMORANDUM

Subject: Relaxation of procedures to be followed in considering requests for medical reimbursement.

The undersigned is directed to slate that under the extant instructions, a CGHS card holder. who wishes to apply for reimbursement of the expenditure incurred by him / her on medical treatment of either self or his I her dependent family members. the present reimbursement procedure needs verification of bills and issue of essentiality certificate by the treating doctor, and the Medical Superintendent of the hospital. The process of verification of bills and issue of essentiality certificates are time consuming with the doctor at times being busy or being away from office for whatever reason. This necessitates repeated visits to the hospital for getting the verification done and essentiality certificate obtained. Representations have been received in the Ministry of Health 8. Family Welfare requesting for doing away with the two requirements and for the Ministries i authorities concerned to verify and check the authenticity of the claims on the basis of the prescription slip and the diagnostic report submitted by the Government servant / pensioner. in the event of any doubt, the concerned Ministry / Authority can always get verification done from the hospital concerned.

2. The undersigned is also directed to state that CGHS guidelines currently provide for relaxation of guidelines to cover full reimbursement in individual cases depending upon merits of each case. In the case of Hon’ble Members of Parliament, the powers to relax the guidelines have been delegated to the Lok Sabha Secretariat and Rajya Sabha Secretariat respectively and in the case of Hon’ble Chief Justice of Supreme Court and Judges of the Supreme Court to the Secretary General of the Supreme Court.

3. In order to reduce the burden on the Specialists in individual cases of medical reimbursement claim, it has been decided with the approval of heads of the hospitals to revise the guidelines for reimbursement by the competent authority. as follows:

(1) It has now 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. Ministries i authorities concerned may verify and check the authenticity of the claims on the basis of the prescription slip and the diagnostic report submitted by the Government servant / pensioner. In the event of any doubt, the concerned Ministry / Authority can always get verification done from the hospital concerned. Modified reimbursement claim form. alongwith checklist is annexed.

(2) All cases involving requests for relaxation of rules for reimbursement of full expenditure will henceforth be referred to a Technical Standing Committee. to be chaired by the DGHS /AddIDGHS and consist of Director (CGHS) and subject matter specialists. if the Technical Standing Committee recommends the relaxation of rules for permitting full reimbursement of expenditure incurred by the beneficiary, the full reimbursement may be allowed by the Secretary (Health 8. Family Welfare) in consultation with IFD. 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 hospitalised 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;

(d) The treatment was taken under emergency in higher type of accommodation as rooms as per his I her entitlement are not available during that period;

(e) The treatment was taken in higher type of accommodation under specific conditions for isolation of patients to avoid contacting infections;

(f) The treatment was obtained in a private non-empanelled hospital under emergency when there is a strike in Government hospitals:

(g) The treatment was obtained in a private non-empanelled hospital under emergency, while on official tour to non-CGHS covered area;

(h) Approval for air-fare with or without attendant on the advice of treating doctor for treatment in another city even though he is not eligible for air travel I treatment facilities are available in city of residence and

(i) Any other special circumstances.

4. The Office Memorandum is issued with the concurrence of IFD vide D . No: 908/AS FA12009 dated the 2oth February. 2009.

(R Ravi)

Deputy Secretary to the Government of India

Source: http://msotransparent.nic.in/writereaddata/cghsdata/mainlinkfile/File21.pdf

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