CGHS and CS (MA) Rules

Employees may avail the medical facilities under the Central Government
Health Scheme (CGHS) wherever available, Employees not so covered are
entitled to similar facilities under Central Services (Medical Attendance) Rules,
1944.

> CENTRAL GOVERNMENT HEALTH SCHEME

The Scheme is available in all major cities and several minor cities of India.

> Family Includes

> Eligibility
All employees (except Railways & Delhi Administration employees) having H.
Qrs and their families in any CGHS covered city and who are paid from Civil
Estimates.

A Government employee can avail CGHS facility if he residing in a CGHS city,

whereas a Government pensioner residing anywhere may get himself registered
with any dispensary.

Employees absorbed in or on deemed deputation in statutory bodies/

autonomous bodies

Delhi Police employees and their families. Defence employees except at

Mumbai.

> Conditions for Availing the Scheme

The employee should reside in the area of operation of the Scheme.
Pensioners residing anywhere may get registered in any dispensary.

In case of CGHS bene ciary falling sick outside CGHS area, treatment is
allowed under CS (MA) Rules in Govt. Hospitals/Referral Hospitals/Recognised
Hospitals.

If both husband and wife are employees and contribute for CGHS, parents of
both can be included for the bene ts.
When both husband and wife are Central Govt. Employees- Either of them
may prefer claim for self and family according to the status of the claimant. If
both make their respective CGHS contribution
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 If husband and wife both are Govt. Employees, the CGHS contribution shall
be normally- Paid by the one whose Pay Level is higher

Family of the employee can avail the facility if the employee is transferred to
another CGHS area or goes to serve abroad and leaves the family at the old CGHS
station.

Family of the employee who continues to stay back at the old station in a CGHS
covered area can avail CGHS facilities even after the transfer of the employee to a
non-CGHS area, for a maximum period of six months on payment of CGHS
contribution in advance for that period. *

An employee can opt out of CGHS, if his/her spouse is employed in Defence,

or Railway Services, State Government or corporations or Government owned
bodies, local bodies and private organisation, which provide medical facilities to
its employees and their family members. The option can be exercised only
twice during the entire service and the same shall be recorded in the Service
Book of the employee.

A female Govt. Employee may include either her parents or parents-in-law and
The option of a female Govt. Employee to include her parents or her parents-in-law,
in her family, can be exercised Once in the entire service

In case of employee's transfer, his family staying at the old station can
continue to avail the CGHS facility- For a maximum period of six months, if the
employee is transferred to a non-CGHS area

In case a CGHS bene ciary is going abroad, he may be issued medicines for a
period up to Six months

CGHS contribution is payable according to - The basic pay of the employee

Pensioner bene ciaries can avail CGHS facility for life time - By paying 10
years' contribution

Pensioners, Family pensioners, Pensioners under National Pension System

residing in areas not covered by CGHS granted xed medical allowance of Rs.
1000 p.m.

In absence of package rates, the entitlement for room rent in a private ward
of a private hospital empanelled under CGHS is Rs. 3000 per day

> Claims
Final claims of reimbursement of medical expenses of Central Government
servants in respect of a particular spell of illness should ordinarily be preferred
within Six months from the date of completion of treatment.
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 Power to condone delay in submission of medical claims ha been delegated
to-
➣Heads of Departments
➣Joint Secretaries
➣Comptroller and Auditor General of India

When the medical reimbursement claim of an employee is rejected by the

Controlling O cer the claimant may submit an appeal to the Central Government
within 45 days of receipt of the rejection order from the date

Medical reimbursement claim under CS (MA) Rules is to be submitted in Form

Medical 97

An Essentiality Certi cate is not required to be accompanied with a medical

reimbursement claim- Under CGHS

> MEDICAL ATTENDANCE RULES

CS(MA) rule do not apply to :-
(i) Defence services personnel,
(ii) Government servants on leave or deputation abroad, and
(iii) retired Government servants.

Central Services Medical Attendance Rules do not apply to- Government

servants covered under CGHS

Under CS (MA) Rules hospitals are recognised by the- Authorised Medical

Attendant which include-
(a) All State Government recognised hospitals
(b) All Railway hospitals
(c) Hospitals maintained by Public Sector Undertakings

A male child of a Government servant may receive medical attendance and

treatment in a recognised women's hospital, up to the age of Six years

AMA is the short form of- Authorised Medical Attendant appointed under rule
Rule 2 (a)

The AMA of a Government servant is determined with The place at which he

falls ill

In respect of one single and continuous spell of illness, a AMA may provide
medical attendance at his consulting room for a maximum period of 10 days and
under Indian System of Medicine may provide medical attendance for a maximum
period of 20 days
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 Number of consultations allowed in respect of one spell illness is maximum- 4

Treatment can not be obtained from an AMA even when he is on regular

leave.

Government employees working in interior/remote areas where no AMA is

available within a radius of 5 kms., are granted a Fixed Medical Allowance and
provided Private Registered Medical Practitioners (RMPs)

> Advance for medical treatment

All Central Government employees irrespective of their pay are eligible to draw
advance for medical treatment.

Medical advance for indoor treatment can be drawn-

(a) Irrespective of major or minor diseases
(b) Up to 90% of the approved CGHS package rates
(c) On furnishing a certi cate from the treating physician of Government/
recognised hospital

Medical advance for outdoor treatment can be drawn if The total estimate of
expenditure including test investigations is more than Rs. 10,000

Medical advance shall be released within 10 days from the receipt of the
request.

> Treatment and Charges

Reimbursement of charges for special nurse is allowed rate of Rs.150 per
shift of 12 hours

Reimbursement of expenses on In-Vitro Fertilization (IVF) treatment is allowed

if the age of woman undergoing treatment is between 21 and 39 years for a
maximum of Three fresh cycles

For mental diseases, a patient may be allowed to receive indoor treatment for a
maximum period of Three years

Reimbursement can not be claimed for cost of vaccination charges for Malaria
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 > Miscellaneous
A Govt employee shall be entitlement for accommodation in private ward, if
his basic pay (under VII CPC) is Rs. 63,101 and above

Age limit for contractual engagement of doctors in CGHS is 70 years

CGHS bene ciaries may obtain direct OPD consultation from specialists of
private empanelled hospitals, without referral from CGHS Wellness Centre, if such
bene ciaries are 75 years

A CGHS bene ciary going abroad may obtain supply of OPD medicines for a
period up to 6 moths by submission of Copy of valid CGHS card and value
prescription and Documentary proof of going abroad like ticket, visa etc.

The name of newly launched CGHS mobile application is myCGHS

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