CGHS: Clarification regarding admissible non-admissible items

F.No. 2-1 /2012/CGHS/VC/CGHS(P)

Government of India

Ministry of Health & Family Welfare

Department of Health & Family Welfare

Nirman Bhawan, New Delhi 

Dated the 1st August, 2013.

OFFICE MEMORANDUM 

With reference to the above mentioned subject the undersigned is directed to draw attention to the Office Memorandum of even number dated 1st October 2012 issued by this Department in compliance of the directions of Hon’ble High Court of Delhi in the case of Shri Kanhiya Singh Vs U01 and others [W.P.(C) 9044/2011] clarifying admissibility / inadmissibility of items of expenditure for claiming reimbursement under CGHS. The same are being reproduced for a wider circulation and information in compliance of Hon’ble High Court’s latest direction issued on 16.05.2013 in this case. The requisite clarifications regarding admissible and non- admissible items under CGHS are provided herewith as under:-

a) “CGHS Package Rate” shall mean and include lump sum cost of inpatient treatment / day care / diagnostic procedure for which a CGHS beneficiary has been permitted by the competent authority or for treatment under emergency from the time of admission to the time of discharge including (but not limited to) — (i) Registration charges, (ii) Admission charges, (iii) Accommodation charges including patients diet, (iv) Operation charges, (v) Injection charges, (vi) Dressing charges, (vii) Doctor / consultant visit charges, (viii) ICU / ICCU charges, (ix) Monitoring charges, (x) Transfusion charges, (xi) Anesthesia charges, (xii) Operation theatre charges, (xiii) Procedural charges / surgeon’s fee, (xiv) Cost of surgical disposables and all sundries used during hospitalization, (xv) Cost of medicines, (xvi) Related routine and essential investigations, (xvii) Physiotherapy charges etc. (xviii) Nursing care and charges for its services.

b) Cost of Implants / stents / grafts is reimbursable in addition to package rates as per CGHS ceiling rates for Implants / stents / grafts or as per actual, whichever is lower, in case there is no ceiling rate prescribed under CGHS,

c) During In-patient treatment of the CGHS beneficiary, the hospital will not ask the beneficiary or his / her attendant to purchase separately the medicines / sundries / equipment or accessories from outside and will provide the treatment within the package rate, fixed by the CGHS which includes the cost of all the items.

d) In cases of conservative treatment / where there is no CGHS package rate, the above mentioned items are admissible-items wise at CGHS rates or as per AIIMS rates (if there is no CGHS rate) or as per actual (if there is no CGHS / AIIMS rate) available for any item.

e) Package rates envisage up to a maximum duration of indoor treatment as follows:

However, if the beneficiary has to stay in the hospital for his / her recovery for a period more than the period covered in package rate, in exceptional cases, supported by relevant medical records and certified as such by hospital, the additional reimbursement shall be limited to accommodation charges as per entitlement , investigations charges at approved rates, and doctors visit charges (not more than 2 visits per day per visit by specialists / consultants) and cost of medicines for additional stay).

No additional charge on account of extended period of stay shall be allowed if that extension is due to infection on the consequences of surgical procedure or due to any improper proceed.

f) In addition to the above mentioned items, some patients may require additional facilities/ procedures, which are admissible with proper justification in deserving cases. Therefore, it is not possible to give a comprehensive list of items, which are not admissible.

2. It has also been decided to clarify that expenses incurred on medicines, consumables, sundry equipments and accessories etc., which are purchased from outside, based on specific authorization of treating doctor / staff of the concerned hospital will be reimbursable if they are not falling under the list of non-admissible items. In case the empanelled hospital has asked a CGHS beneficiary for purchase of the said items over and above the package rates, reimbursement shall be made to the beneficiary and the amount shall be recovered from the pending bills of hospital.

3.  This Office Memorandum is issued in compliance of the directions of Hon’ble High Court of Delhi in W.P. (C) 9044/2011 [Sh. Kanhiya Singh Vs UOI and others].