Relaxation of Rules for Consideration of Reimbursement in Excess of the Approved Rates pertaining to Medical Claims

Relaxation of Rules for Medical Claims Reimbursement

The Central Government Health Scheme has recently announced a relaxation of rules for medical claims reimbursement. This new policy includes the consideration of reimbursement in excess of the approved rates for medical claims. These changes were made in response to the increasing cost of healthcare and the need to provide better support to individuals seeking medical treatment. The CGHS Orders have been updated to reflect these new policies, which are designed to ensure that individuals receive the medical care they need without financial strain.

Government of India
Ministry of Health and Family Welfare
Department of Health & Family Welfare
EHS Section

No.Z.15025/38/2018/DIR/CGHS/EHS

Nirman Bhawan, New Delhi
Dated the 22nd May, 2018

OFFICE MEMORANDUM

Subject: – Relaxation of Rules for consideration of reimbursement in excess of the approved rates pertaining to medical claims

With reference to the above mentioned subject the undersigned is directed to draw attention to the Office Memorandum No. 4-18/2005- C&P [Vo]. l-Pt (1)], dated the 20th February 2009 and to state that it has now been decided to modify the Para 3 (2) of the above referred Office Memorandum as per the details given under the succeeding paragraphs.

a) The requests for full reimbursement which fall under the following defined criteria shall be examined by Directorate General of CGHS and submitted to AS&DG (CGHS) for consideration of approval. After the recommendation of AS&DG (CGHS), the concurrence of Internal Finance Division and approval of Secretary, Ministry of Health & Family Welfare are required for reimbursement in excess of CGHS rates:

1) Treatment was obtained in a private unrecognized hospital under emergency and the patient was admitted by others when the beneficiary was unconscious or severely incapacitated and was hospitalized for a prolonged period.

2) Treatment was obtained in a private unrecognized hospital under emergency and was admitted for prolonged period for treatment of Head Injury, Coma , Septicemia, Multi-organ failure , etc.

3) Treatment was obtained in a private unrecognized hospital under emergency for treatment of advanced malignancy

4) Treatment was taken under emergency in higher type of accommodation as rooms as per his/her entitlement are not available during that period.

5) Treatment was taken in higher type of accommodation under specific conditions for isolation of patients to avoid contacting infections

6) Treatment was obtained in a private unrecognized hospital under emergency when there is a strike in Govt. hospitals.

7) Treatment was obtained in a private unrecognized hospital under emergency while on official tour to non-CGHS covered area.

b) The requests from CGHS beneficiaries. having a valid CGHS Card at the time of treatment, in respect of the following conditions shall be considered by a High Powered Committee constituted by Ministry of Health & Family Welfare:

(i) Settlement of medical claims in relaxation of rules

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

(iii) Representations from CGHS beneficiaries seeking full reimbursements under special Circumstances, which are not notified.

c) The other terms and conditions mentioned in the OM No. 4-18/2005- C&P[Vol. l-Pt(1)] dated the 20 February 2009 shall remain unchanged.

sd/-
(Rajeev Attri)
Under Secretary to Government of India

More orders issued by CGHS…

• Entitled to CGHS Facility Even After Attaining the Age of 25 years
• Issue of Medicines to CGHS beneficiaries Prescribed by Specialists Beyond the Period
• Delhi CGHS Hospitals – New list including Dental Clinics & Eye Centres
• Demarcation of coverage area under CGHS Wellness Centre
• Empanelment and De-Panelling of Private Hospitals under CGHS
• CGHS Facilities to Retired KV Employees
• Providing CGHS facilities at Vijayawada, state Capital of Andhra Pradesh
• Retired Doctors on Contract Basis – CGHS Advertisement
• New CGHS dispensary at Faridabad, Haryana
• Engagement of Retired Doctors on Contract Basis for CGHS

All the individuals covered by the medical reimbursement policies are eligible for this relaxation if their claim exceeds the approved rates.

It is a recently introduced policy that provides relaxation in rules for considering reimbursement of medical claims that exceed the approved rates.

Approved rates are the pre-decided rates on which reimbursement is approved. If a medical claim exceeds the approved rate, it usually gets rejected, but with this relaxation policy, such claims might be considered.

This relaxation helps in the smooth processing of claims and provides financial relief to individuals who incur higher medical expenses than the pre-approved rates.

The policy was introduced recently, and as of now, there is no information on whether it will be permanent or temporary.