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Central Government Health Scheme

Achint Kumar Nisha Singh

Introduction
The Central Government Health Scheme (CGHS)
provides comprehensive health care facilities for the Central Govt. employees and pensioners and their dependents residing in CGHS covered cities. Started in New Delhi in 1954, Central Govt. Health Scheme is operational in 24 cities. It provides service through following categories of systems:Allopathic Homeopathic Indian System of Medicines e.g. Ayurveda, Unani, Yoga, Sidha System

Beneficiary
All Central Govt. Servants paid from Civil
Estimates (other than those employed in Railway Services and those employed under Delhi Administration except members of Delhi Police Force). Pensioners drawing pension from Civil Estimates and their family members. Hon'ble Members of Parliament

Hon'ble Judges of Supreme Court of India Ex- Members of Parliament Employees & Pensioners of Autonomous
Bodies covered under CGHS (Delhi) Ex- Governors and Ex-Vice Presidents Former Prime Ministers Former Judges of Hon'ble Supreme Court of India and Hon'ble High Courts Freedom Fighters

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Family means employees: Husband/Wife including more than one wife and a
lso judicially separated wife.

Parents and Stepmother. In the case of adoption,


only the adoptive and not the real parents. If the adoptive father has more than one wife, the first wife only.

A female employee has a choice to include either


her parents or her parents-in-law; option exercised can be changed only once during service.

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Widowed daughters and dependent
divorced/separated daughters.

Children including legally adopted children, stepchil


dren and children taken as wards subject to the following conditions : Son -Till he starts earning, irrespective of age limit.

Daughter -Till she starts earning or gets married,


whichever is earlier, irrespective of age-limit.

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Son suffering from Permanent disability of any kind
(physical or mental)(No age limit)

Sisters including widowed sisters. Minor brothers and dependent brothers.


But the above persons should reside with the government servants and their income from all sources should not be more than Rs.1500/- per month.

Service Package

The main components of the Scheme are: The dispensary services including domiciliary care. F. W. & M.C.H. Services Specialists consultation facilities both at dispensary, polyclinic and hospital level including X-Ray, ECG and Laboratory Examinations. Hospitalization. Organization for the purchase, storage, distribution and supply of medicines and other requirements. Health Education to beneficiaries. Coverage of Pre-existing diseases

Contribution
A compulsory monthly contribution is charged
from all the entitled classes of government servants on the basis of rates fixed by the government from time to time. The present rates of contribution are as under:
Upto 3000..15 Rs.3001 to 6000/- ................40/Rs.6001 to 10000/-...............70/Rs.10001 to 15000/-...........100/Rs.15001/- and above-.......150/-

When both husband and wife are Central


Government servants covered by the scheme, the contribution will be recovered from only one of them whose pay is higher

Grant
Grant of medical advances:- Delegation of
power for settlement medical reimbursement / grant of medical advances. Up to Rs.2 Lakhs (Serving Employees) - Head of Department Up to Rs.2 Lakhs (Pensioners) - Head of Concerned CGHS covered city Claim exceeding Rs.2 Lakhs - Ministry / Department in consultation with internal Financial Division

The entitlement for indoor treatment would be


as under:

Basic Pay upto Rs.7500/-

General Ward

Basic Pay Rs.7501/- to 10500/-

Semi-pvt Ward

Basic Pay Rs. 10501/- and above

Private Ward

The maximum room rent for different categories would be:

General Ward

Rs.500/- per day

Semi private Ward

Rs.1000/- per day

Private Ward

Rs. 1500/- per day

Day Care

Rs. 500/- per day

TREATMENT AT PLACES NOT COVERED BY


THE CGHS:

If the Central govt. servant or a member of his


family covered under CGHS falls ill at a place not covered under CGHS, the treatment shall be admissible under CS(MA) Rules. The reimbursement in such cases shall be restricted to the amount which would have been incurred had the treatment been taken in a Govt / State government hospital in that city.

CGHS FACILITIES IN CASE GOVT.


EMPLOYEES WHO ARE TRANSFERRED TO NON-CGHS AREAS AND THEIR FAMILIES CONTINUE TO STAY BACK AT THE OLD DUTY STATION: Families of Government servant can avail CGHS facilities at old duty station for a maximum period of six months from the date of transfer of the government servant to nonCGHS area on advance payment of CGHS contributions to his old office.

Settlement of Claim The government servant is required to


prefer claim/bill within 3 months, from the date of discharge from the hospital. If the claim gets time barred, relaxation of delay is allowed by the department depending on the circumstances of delay.

SUM ASSURED The Scheme shall provide coverage for meeting all
expenses relating to hospitalization of beneficiary members up to Rs. 5, 00,000/- per family per year in any of the Empanelled Hospital/Nursing Home/Day Care Unit subject to stated limits on cashless basis through smart cards. BUFFER / CORPORATE SUM INSURED: An additional Sum Insured of Rs.25 Crore shall be provided by the Insurer as Buffer/Corporate Floater in case hospitalization expenses of a family (per illness or annual) exceed the original sum insured of Rs 5.00 lakhs. Insurer is required to inform the Nodal Agency with the details on case to case basis.

CGHS plastic cards


The production of CGHS Card is obligatory at every visit to
enable correct identification of the patient and to prevent misuse of card.

Card Holder must deposit the Index Card in the dispensary and
obtain receipt from the receiving clerk. The receiving clerk, will

initial the token card in confirmation.

Every Card Holder must certify that the parents /Dependents


whose names have been included in the token card, normally reside with him

The certificate must also state that the income from all sources
does not exceed Rs. 3500 + DA p.m.