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Tuesday, July 15, 2014

Relaxation of procedures to be followed in considering requests for medical reimbursement claims in respect of CS(MA) beneficiaries

Relaxation of procedures to be followed in considering requests for medical reimbursement claims in respect of CS(MA) beneficiaries


No.H.11022/01/2014-MS
Government of India
Ministry of Health and Family Welfare
Department of Health & Family Welfare

Nirman Bhawan, New Delhi
Dated 15th July , 2014

OFFICE MEMORANDUM

Subject: Relaxation of procedures to be followed in considering requests for medical reimbursement claims in respect of CS(MA) beneficiaries

Ministry of Health & Family Welfare received several representations from CGHS beneficiaries for issue of guidelines to be followed in considering requests for relaxation of procedures in considering requests for medical reimbursement over and above the approved rates. The matter was examined by the Ministry and Office Memorandum No.4-18/2005-C&P {Vol-I Pt.(1)} dated the 20th February, 2009 was issued prescribing the procedures and guidelines to be followed for consideration of requests received from CGHS beneficiaries seeking reimbursement of expenditure incurred on medical treatment over and above the approved rates. The requirement of essentiality certificate in respect of CGHS beneficiaries was also done away with.


However, no such guidelines were issued under CS(MA) Rules, In this regard Department – related parliamentary Standing Committee on Health and Family Welfare in the seventy first report impressed upon the department to immediately address this issue and extend same facilities to those covered under CS(MA) Rules and to issue a fresh circular clarifying the procedures in this regard and dispelling misgivings, if any, Ministry was also in receipt of representation from several quarters in this regard.

2. The matter has been examined in consultation with Dte.GHS and it has been decided to revise the guidelines for reimbursement by the competent authority to issue guidelines under CS(MA), on similar patterns as under CGHS as per the following,

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/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. In the event of any doubt, the concerned Ministry/Authority can always get verification done from the hospital concerned.

(2) It is clarified that essentiality certificate/counter signature of treating doctor in a hospital would not, henceforth, be necessary. However, essentiality certificate would be required when the treatment is taken from an AMA on OPD basis.

(3) All cases involving requests for relaxation of rules for reimbursement of full expenditure will henceforth be referred to the Technical Standing Committee, to be chaired by the DGHS/Spl.DGHS and Specialists of concerned subject as members. Addl. DDG (MG-Section), Dte.GHS shall be member secretary for organizing the meetings of Technical Standing Committee. If 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 & Family Welfare) in consultation with IFD. A check list for consideration of requests for reimbursement in excess of the approved rates may include:

a.   The treatment was obtained in a private hospital not empanelled under CS(MA)/ CGHS under emergency and the patient was admitted by others when the beneficiary was unconscious or severely incapacitated and was hospitalized for a prolonged period;

b.   The treatment was obtained in a private hospital not empanelled under CS(MA)/ CGHS under emergency and was admitted for prolonged period for treatment of Head injury, Coma, Septicemia, Multi-organ failure, etc.;

c.    Treatment was obtained in a private hospital not empanelled under CS(MA)/ CGHS under emergency for treatment of advanced malignancy;

d.   Treatment was taken in a private hospital not empanelled under CS(MA)/ CGHS under emergency in higher type of accommodation as rooms as per his/her entitlement was not available during that period;

e.   Treatment was taken in higher type of accommodation under specific conditions for isolation of patients to avoid contacting infections;

f.    Treatment was obtained in private hospital not empanelled under CS(MA)/ CGHS under emergency while on official tour to another city;

g.   Treatment was obtained in a private hospital not empanelled under CS(MA)/ CGHS under emergency when there is a strike in Govt, hospitals;

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/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 .No.C-695 dated 07.07.2014.


Sd/-
(Arun Chowdhury)
Under Secretary to the Government of India.
        Tele: 23061436.



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