CGHS has come up with Revised Guidelines for settlement of the Medical Claims of Pensioner – New Timeline, Procedure for relaxation of Rules, constitution of Committee etc
Government of India
Ministry of Health and Family Welfare
Department of Health & Family Welfare
No: Z.15025/51/2018 /DIR/CGHS/EHS
Nirman Bhawan, New Delhi
Dated the 6th June, 2018
Subject :- Guidelines for settlement of Medical claims of pensioners and others
With reference to the above subject the undersigned is to draw attention to the revised timelines and constitution of High Powered Committee in compliance of the directions of Hon’ble Supreme Court of India in their Judgement in the WP(Civil) No 694 of 2015 between Shiva Kant Jha Vs UOI delivered on 13th April 2018 and to state that it has been decided to issue guidelines to the Additional Directors of CGHS for implementing these decisions. The new guidelines are enclosed for perusal and compliance.
Encl as above.
GUIDELINES TO PROCESS THE REQUESTS FOR SETTLEMENT OF THE MEDICAL CLAIMS
1. New Timelines for settlement of the Medical Claims
The new timelines prescribed for settlement of normal medical claims are 30 days from the date of submission to the payment by Pay & Accounts Office. Every effort must be made to avoid delay at any stage. Proper calculation sheet must be prepared in the file, so that the same could be shared with the beneficiaries, if there are requests for reasons for the deductions.
2. Full reimbursement case /Cases for relaxation of Rules
As per the new guidelines they fall into two categories
(a) Full reimbursement – Non-HPC (Non- High Power Committee) cases
(b) Full reimbursement – HPC (High Power Committee) cases
a) Full reimbursement – Non-HPC cases
The following cases fall under this category;
i) 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.
ii) 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.
iii) Treatment was obtained in a private unrecognized hospital under emergency for treatment of advanced malignancy
iv) Treatment was taken under emergency in higher type of accommodation as rooms as per his/her entitlement are not available during that period.
v) Treatment was taken in higher type of accommodation under specific conditions for isolation of patients to avoid contacting infections
vi) Treatment was obtained in a private unrecognized hospital under emergency when there is a strike in Govt. hospitals.
vii) Treatment was obtained in a private unrecognized hospital under emergency while on official tour to non-CGHS covered area.
Although the new OM has not mentioned about STC recommendation, it is advisable to have expert Committee meetings under the Chairperson of Addl. DGHS (as in the case of earlier STC meetings) in respect of item Nos. i), ii),iii) and v) before arriving at a decision. The conditions mentioned at Nos. iv),vi) and vii) are administrative in nature and do not require meetings of expert committees and may be recommended by Addl. Director, if conditions are satisfied.
In Delhi the expert committee meetings shall be organized by respective CMO(R&H) and by AD(R&H) in case of claims of serving employees of Delhi. Such meetings in respect of other cities shall be organized by Sr. CMO in the office of Addl.DDG(HQ).
The requests for full reimbursement as examined by Additional Director (HQ)/ Addl. DDG(HQ), in consultation with expert committee meetings, wherever deemed necessary and recommended for full reimbursement shall be submitted to Director, CGHS and concurrence of IFD may be obtained after approval of AS&DG, CGHS before the seeking the approval of Secretary for reimbursement in excess of CGHS rates.
If the above criteria are not satisfied (including the regrets by expert committees) the requests may be regretted by Addl. Director of concerned City, with a covering letter explaining the reasons and referring to the concerned OM.
In case there is a representation to consider as a special case then only it may be placed before the High Power Committee.
Addl. Directors shall prepare a self-contained note giving details of case and submit the files with relevant documents to Director, CGHS though AD(HQ)/Addl. DDG(HQ)
Source – Gconnect