EMPANELMENT OF PRIVATE HOSPITALS FOR CGHS BENEFICIARIES – Loksabha Q&A

Question: 3696 . Shri PURNMASI RAM SUSHIL KUMAR SINGH

Will the Minister of HEALTH AND FAMILY WELFARE be pleased to state:-
(a) the terms and conditions for empanelling private hospitals for Central Government Health Scheme (CGHS) beneficiaries;
(b) the number of cases referred to standing technical committee to examine, assess and make suitable recommendation on acceptability/admissibility of medical reimbursement cases together with details and nature of cases in which the committee makes recommendations for full reimbursement of claims;
(c) the details of Memorandum of Agreement (MOA) signed for the purpose which can`t be located on CGHS website;
(d) whether there is no facility for emergency treatment for CGHS beneficiaries in R.K. Puram, New Delhi; and
(e) if so, the reasons thereof and the steps taken by the Government to allow affected beneficiaries to avail emergency treatment in CGHS dispensary located in Sector-8, R.K. Puram for the benefit of beneficiaries?

THE MINISTER OF HEALTH AND FAMILY WELFARE (SHRI GHULAM NABI AZAD)

(a): The broad terms and conditions for empanelment of private hospitals and diagnostic centres are as under:

# they will charge CGHS approved rates for different procedures;
# they will provide cashless treatment to pensioner beneficiaries;
# they will comply with CGHS rules and guidelines issued from time to time; and
# they will strictly follow the terms and conditions of the Memorandum of Agreement (MOA) signed with CGHS.

(b): No. of cases (in financial year 2011-12):- Delhi- 24, Outside Delhi: – 26, Cases falling under the following categories are considered by the Technical Standing Committee for making recommendations for full reimbursement of claims:-

(i) Treatment taken in a private non- empanelled hospital in an emergency and patient was admitted by others when the beneficiary was unconscious or severely incapacitated and was hospitalized for a prolong period.

(ii) When the patient was admitted for a prolonged period of treatment of head injury, Coma, Septicemia, multi organ failure etc.

(iii) In case of emergency treatment of advance malignancy.

(iv) In case of treatment under emergency in higher type of accommodation as room as per his/her entitlement was not available during that period.

(v) In case the treatment was taken in a higher type of accommodation under specific condition for isolation of patients to avoid contacting infections.

(vi) Treatment taken at private non-empanelled hospital under emergency when there is a strike in Govt. Hospitals.

(vii) Treatment taken in a private non-empanelled hospital in an emergency while on official tour to non CGHS covered area.

(viii) Approval for air fares with or without attendant on the advice of a treating doctor for treatment in another city even though he is not eligible for air travel.

(ix) Any other special circumstances.

(c): A Draft of the Memorandum of Agreement (MOA) (pdf file) between CGHS and the hospitals is available at the CGHS website which can be accessed with the following link – http://msotransparent.nic.in/writereaddata/ cghsdata/mainlinkfile/File235.pdf Draft MOA (pdf file) for Diagnostic centres is also available at the following link on CGHS website – http://msotransparent.nic.in/writereaddata/cghsdata/mainlinkfile/ File236.pdf

(d) & (e): CGHS beneficiaries are entitled go to any hospital Government or private, empanelled or non-empanelled for getting treatment under medical emergency.

As per Memorandum of Agreement between CGHS and the empanelled private hospitals, they are to give credit facilities to the CGHS beneficiaries when the treatment is obtained under medical emergency. There are many good quality private hospitals empanelled with CGHS in the vicinity of R.K. Puram which can be accessed in case of medical emergency.