Medical Facilities to CGHS beneficiaries in non-CGHS Areas

Central Government Health Service (CGHS) Rules with regard to serving and pensioner CGHS beneficiaries residing in non-CGHS areas have been liberalized. To enable them to avail medical facilities for in-patient treatment and postoperative follow-up treatment, certain guidelines have been put in place. Prominent among them are:

(i) CGHS pensioner beneficiaries along with their dependant and eligible family members, who are holding a valid CGHS card and are residing in a non-CGHS areas shall be eligible to obtain treatment from Government hospitals / hospitals recognized under Central Services (Medical Attendance) Rules, 1944 /hospitals and clinics empanelled under Ex-Servicemen Contributory Health Scheme (ECHS) and submit the medical reimbursement claim to the Additional Director / Joint Director of CGHS of the CMO in charge of concerned Wellness Centre where the CGHS card is registered;

(ii) In case of non-emergency treatment from hospitals approved under Central Services (Medical Attendance) Rules, 1944 and ECHS, it is necessary to obtain prior approval from CMO in charge of concerned Wellness Centre, where the CGHS card is registered;

(iii) Reimbursement is to be limited to the CGHS rates of the city where the card is registered and as per the

ceiling rates and ward entitlements or as per actual whichever is lower;

(iv) CGHS pensioner beneficiaries /serving Central Government employees and their dependant and eligible family members and holding a valid CGHS card and on a visit to non-CGHS covered area may obtain treatment under emergency from government hospitals / hospitals recognized under Central Services (Medical Attendance) Rules, 1944 / hospitals and clinics empanelled under ECHS and submit the medical reimbursement claim to the Additional Director / Joint Director of CGHS of the CMO in charge of concerned Wellness Centre where the CGHS card is registered, in case of pensioners, etc., and to the concerned Ministry / Department /

office in case of serving employees;

(v) CGHS pensioner beneficiaries and their dependant and eligible family members, with valid CGHS card

and residing in a non-CGHS area will be eligible to obtain post operative follow-up treatment from Government hospitals / hospitals recognized under Central Services (Medical Attendance) Rules, 1944 /hospitals and clinics empanelled under ECHS. The follow-up cases will be in renal transplant surgery, knee and hip joint

replacement, cancer treatment, neuro and cardiac surgery. However, prior permission is to be obtained from the CMO in charge of the concerned Wellness Centre, where the CGHS card is registered;

(vi) Permission is to be issued for 3 to 6 months at a time and may be extended on medical requirement.

Reimbursement for consultation, procedures and investigations are to be limited to CGHS rates of the city

where the CGHS card is registered and as per the ceiling rates and ward entitlements or as per actual

whichever is lower;

(vii) The contents of this OM supersedes the earlier OM dated September 30, 1999 on the subject. This

arrangement is provisional and would be valid till such time the proposed Health Insurance Scheme is made effective for the Central Government employees and pensioners. These are effective from April 27, 2011.

Details are available in Department of Health and Family Welfare OM No:S.11011 / 7 / 99 – CGHS (P) dated April 27, 2011.

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