FEDERATION OF NATIONAL POSTAL ORGANISATIONS

I went to Hyderabad to visit my son and had fracture of leg bone. I received treatment f r o m a private non empanelled hospital. Will I get full reimbursement?

Reimbursement for treatment taken in a non empanelled private

hospital under medical emergency shall be considered as per CGHS

rates only.

Is treatment for IVF reimbursable?

IVF treatment is approved under CGHS. The details may be seen as

per Office Memorandum Z.15025/5/2011/CGHS III/CGHS(P) dated

22.11.2011 , which can be downloaded from CGHS Website.

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.

Who can avail Preventive Health Check up(PHC)?

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

Beneficiaries who are 40 years ole or above

Who are already not suffering from any chronic ailement like Daibetes Hypertension Heasrt dicease etc.

This check up done once in a year only.

Serving beneficiaries will not require any permission from their respective offices

I am an accredited journalist with CGHS Card. Can I seek treatment in Private. empanelled Hospitals in emergency and get creditfacility?

Journalists are entitled for OPD treatment from Wellness Centres
and treatment from Dr.RML Hospital. Journalists are not entitled for
reimbursement for treatment from empanelled hospitals. They can
however, get in-patient treatment for themselves and their
dependent family members at CGHS Semi-Private Ward rate at
CGHS empanelled hospitals, on payment.
Is insulin pen supplied by CGHS?
Insulin pen is not supplied under CGHS. But, Insulin Pen Cartridges are
supplied under CGHS

What is the procedure for reimbursement if Hearing Aid is purchases on recommendations of an ENT specialist?

Beneficiaries shall be eligible to obtain hearing aid as per the
following guidelines

a. Patients/ Beneficiaries should be preferred to CGHS/Government hospital ENT specialist from the parent CGHS wellness centre.

b. The ENT specialist shall then recommend a hearing aid on basis of Audiometric and Audiological assessment, specifying the type of
hearing aid most suited for the Beneficiary.

c. The ‘Audiogram report’ shall be authenticated by the ENT specialist/Consultant of the CGHS/Government hospital.

d. The permission to procure hearing aid shall be granted by the Additional Director of zone/city or by the HEAD OF
DEPARTMENT/OFFICE in case of serving employees

e. An ‘undertaking’ by the beneficiary that he has not been reimbursed
the cost of hearing – aid in the preceeding five years is to be
submitted.

f. Reimbursement claim shall be submitted to CGHS ZONAL OFFICE
through the CMO – Incharge of the Concerned dispensary by CGHS Pensioner beneficiaries in the prescribed medical reimbursement claim for along with the following documents -Referral letter from parent CGHS Wellness Centre (computerized slip where computerization is done already)

-Copy of ‘prescription’ of ENT consultant (CGHS/Govt. Hospital) with the ‘Audiogram’ report duly authenticated by the treating ENT consultant (CGHS/Govt.).

-Copy of CGHS Card.

-Bill /Receipt (in original) carrying details of the hearing – aid seller i.e. NAME, QUALIFICATION, AND RCI/MCI REGISTRATION NUMBER of the hearing – aid seller.

-The ‘permission letter’ to purchase hearing – aid (in original).

-Empty Box/boxes or the Carton (s) with the label showing details of the hearing aid supplied.

g. In case of the other beneficiaries, the medical claim shall be submitted to the concerned Ministry/Department/Offices.

h. Replacement of hearing – aid may be permitted after 5 years on the basis of condemnation certificate issued by a technical expert and on approval of CGHS/Government ENT Surgeon.

i. Maintenance and repair will be the responsibility of the beneficiary.

I want to get my Cataract Surgery done at Private empanelled hospital. How can I get it done?

Beneficiaries are required to obtain advice from a Government

Specialist for Cataract surgery (except beneficiaries attached to

Wellness Centres in Delhi NCR who can obtain the advice from a

specialist of empanelled hospital after due referral by CMO I/C).

Pensioners can then get the treatment at the empanelled hospital

of his /her choice by submitting required documents as suggested

already ( Question 51).

Is it necessary that the Govt specialist should write ‘referred to xyz CGHS empanelled Hospital’ for investigation/treatment procedure?

Advice of Government specialist is required only for the specific treatment

procedure / investigation to be undertaken. There is no need to specifically

refer to any empanelled hospital/ diagnostic lab. It is the choice of

beneficiary to undertake treatment / investigations at any of the

empanelled hospitals / diagnostic laboratories of his choice.

CMO Incharge does not refer me to Private Hospitals for OPD
consultation on my request. Isthere any provision for this in CGHS?

As per latest guidelines a beneficiary can be referred to any empanelled

hospital of his choice for OPD consultation.

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.

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.

I submitted MRC for Rs. 1 Lac 20 thousand but I was reimbursed
only Rs. 45,800/-. Why total amount was notreimbursed?

Expenditure for treatment in private hospitals is considered only if the

treatment was taken under emergency. Reimbursement is done at CGHS approved rates and as per CGHS guidelines.

In emergency who are all entitled to get treatment at Private
Empanelled Hospital?

Any beneficiary holding a Valid CGHS card

I went to Hyderabad to visit my son and had fracture of leg bone. I received treatment f r o m a private non empanelled hospital. Will I get full reimbursement?

Reimbursement for treatment taken in a non empanelled private

hospital under medical emergency shall be considered as per CGHS

rates only.

Is treatment for IVF reimbursable?

IVF treatment is approved under CGHS. The details may be seen as

per Office Memorandum Z.15025/5/2011/CGHS III/CGHS(P) dated

22.11.2011 , which can be downloaded from CGHS Website.

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.

I retired in Dec 2011. Due to certain reasons I had to go to my native place in Uttaranchal and could not make pensioner’s CGHS card. In May 2012 I came to Delhi and had heart attack. In emergency I was treated in private hospital. I got CGHS Card made after discharge but I have been refused reimbursement of the expenditure incurred.

After retirement three months grace period is given to get the

CGHS card made. There are two conditions which may arise:

(a) Pensioner beneficiary does not have a CGHS card and the

treatment is taken within the grace period of three months from

the date of retirement. This will be allowed and expenditure

reimbursable subject to the condition that the beneficiary has

either obtained or applied for CGHS pensioner card with all

documents and requisite CGHS subscription within one month of

expiry of the grace period of three months.

(b) Pensioner beneficiary does not have a CGHS card and the

treatment is taken after the grace period of three months from date

of retirement- This will not be reimbursable unless the beneficiary

has obtained a valid CGHS card or has applied for CGHS pensioned

card with all documents and requisite CGHS subscription prior the

taking such treatment. The reimbursement in such cases will be

applicable only fronm the date of application for the card with all

documents and subscription.

My husband/wife 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:

1. Copy of Death summary

2. Death Certificate

3. 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.

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.

The duplicate bills need to be verified by the treating doctor.

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

Is there any interactive mechanism at Wellness Centre level to address various issues related to the Wellness Centre including grievances?

At the Wellness Centre ‘Local Advisory Committees’ are formed.

CMO i/c holds a meeting with Local Advisory committee members

once a month on the second Saturday to discuss local Wellness

Centre related issues.

I am a CGHS Pensioner. My wife was admitted in a private hospital in
emergency state. How to get reimbursement of money spent on her
treatment?

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 along with mandate form.

8) Copies of other documents issued by hospital.

The whole set of MRC is to be submitted in duplicate

MRC forms are available with CMO I/c and can also be downloaded from CGHS Website.

The MRC after being scrutinized in the Wellness Centre will be submitted on- line to the Additional Director.

An acknowledgement print out with the computer generated MRC number will be given. This MRC number is to be quoted for any further correspondence related to the claim.

Serving employee in similar cases shall submit the medical claim to
his department.