CGHS Letter dated 25 Sep, 2013 and Nomination Form:
Government of India
Ministry of Health & Family Welfare
Department of Health & Family Welfare
Nirman Bhawan, Maulana Azad Road New Delhi 110108
*************
No. S11011/12/2013-CGHS (P)
Dated: the 25th September, 201 3
OFFICE MEMORANDUM
Sub: Nomination facility under CGHS for claiming medical reimbursement in the event of death of the principal CGHS card holder – reg.
The undersigned is directed to state that the Ministry has been receiving representations from CGHS beneficiaries to introduce nomination facility whereby a person duly nominated by the principal CGHS cardholder can claim the reimbursement of expenses incurred on the medical treatment of the beneficiary in the event of unfortunate death of the principal card holder.
2. The matter has been examined in this Ministry in the context of difficulties being faced by the family members of a deceased CGHS cardholder in completing the prescribed formalities for claiming reimbursement of medical expenses. Accordingly, it has been decided with the approval of the competent authority to simplify the procedure and provide an option to the principal CGHS cardholder beneficiary to nominate a person to claim reimbursement of medical expenses in the event of his/her unfortunate death.
3. The nomination facility shall be subject to the following conditions:-
a) The nomination facility shall be available only to the CGHS pensioner card holders.
b) Beneficiaries who wish to exercise this option shall submit their declaration of nomination in the prescribed ‘Nomination Form’ duly filled up and complete in all respect, to the CMO In-charge of the CGHS Wellness Centre where the beneficiary is enrolled. [Proforma of Nomi nation Form enclosed]
c) CMO In-charge shall maintain a separate register – ‘Nomination Register’ to record the particulars of the nomination submitted by the CGHS beneficiary in exercise of this option. Once the nomination details are recorded, the CMO In-charge shall forward the ‘Nomination Form’ to the card issuing authority, i.e., Addi. Director (HQ), CGHS in the case of Delhi and respective Additional/Joint Director, CGHS in the case of other CGHS covered cities for making necessary entries in the CGHS database after due scrutiny and approval of Additional Director, CGHS concerned.
d) The nomination shall be treated as valid only if the same has been entered in the CGHS database.
e) Only one person shall be allowed to be nominated as the original nominee or first nominee. In addition, another person can also be nominated as ‘alternate nominee or second nominee’ who can claim reimbursement in case of unfortunate death of the first nominee.
f) The principal CGHS card holder beneficiary can nominate any natural or juristic person as his/ her nominee for this purpose, whether related or unrelated to him/ her.
g) This option can be exercised at any time during the lifetime of the beneficiary: However, this option can be exercised only twice in the lifetime of the pensioner card holder.
h) In case, no option has been exercised during the life time of the CG HS pensioner beneficiary, the existing CGHS provision for claiming reimbursement of medical expenses, requiring submission of Affidavit by the claimant and NOCs from other legal heirs shall continue to apply.
4. This Office Memorandum will be effective from the date of its issue.
5. Hindi version will follow.
Encl: Proforma of Nomination Form
(V.P.Singh)
Deputy Secretary to the Government of India
[Tel: 2306 1 83 1 ]
CENTRAL GOVERNMENT HEALTH SCHEME
NOMINATION FORM
(APPLICABLE ONLY IN RESPECT OF PRINCIPAL CGHS PENSIONER CARD HOLDERS
as per OM No S 11011/12/2013-CGHS(P) dated the 25th September 2013)
( When the pensioner CGHS beneficiary wishes to nominate a person to claim the medical reimbursements fom CGHS in the event of his/her death)
I ………………………… ………………………. hereby nominate the person/persons mentioned below and confer him/her the amount of medical reimbursement(s) in the event of my death, as have become admissible as per the laid down guidelines under CGHS and remained unpaid at the time of my death.
| Name | Complete Address | Relation if
any |
Age
(Date of Birth) |
Gender | Mobile No. | Ben ID,if any | Aadhar No.
{optional) |
|
ALTERNATE NOMINEE, IF ANY (Name and details of person if any, to whom the right conferred on the nominee shall pass in the event of nominee predeceasing the CGHS beneficiary or the nominee dying after the death of the CGHS beneficiary but before receiving the medical reimbursement from CGHS) |
|||||||
| Name | Complete Address | Relations if any | Age (Date of Birth) | Gender | Mobile No. | Ben ID,if any | Aadhar No.
{optional) |
Dated this ………day of……………………20………at (Place) ………………………
(Signature of the Beneficiary)
Name:…………………………….. CGHS Card Ben ID No………………………
Address: ………………………….. Mobile No………………………..
Witnesses:
Signature of Witness
Name & Address
Signature of witness
Name& Address
FOR OFFICIAL USE
Particulars of the nomination received and entered in Nomination Register at S.N………………….:… Dated…………………..
Signature of CMO In-charge (with Seal)
Dated
CGHS Wellness Center:
COMMENTS