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Clarification / modification of the guidelines issued regarding simplification of referral system under CGHS vide OM dated 15/01/2018

Z 15025164/2018/DIR/CGHS

Government of India 

Ministry of Health & Family Welfare

Department of Health & Family Welfare

545-A Nirman Bhawan, New Delhi 

Dated the 31st July, 2018.

OFFICE MEMORANDUM

Sub: Clarification / modification of the guidelines issued regarding simplification of referral system under CGHS vide OM Z-15025/117/2017/DIR/CGHS dated 15/01/2018.

***

With reference to the above mentioned subject the undersigned is directed to draw attention to the guidelines issued vide OM No. Z 15025/117/2017/DIR/CGHS dt. 15/01/2018 under para no (i) and to state that the matter has been reviewed by Competent Authority and it is now decided to modify para (i) in supercession of the earlier guidelines of the above referred to OM as under

(i) All CGHS beneficiaries (in all CGHS Cities) shall be permitted for seeking OPD consultation from Specialists at Private hospitals empanelled under CGHS after being referred by any Medical Officer of CGHS Wellness Centre. The referral may be mentioned on the computer generated Prescription slip. After consultation at empanelled hospital, beneficiary shall report back to concerned Wellness Centre, where MO/ CMO would endorse listed investigation / listed treatment procedure and issue medicines as per the guidelines mentioned in the OM dated 15.01.2018. For unlisted investigations/unlisted treatment procedures CMO lncharge shall submit the prescription to Competent Authority for consideration in case of pensioner beneficiaries . Serving employees shall seek permission for unlisted investigation/unlisted treatment procedure from their department as per prevailing guidelines.

The other terms and conditions of OM No. Z 15025/117/2017/DI R/CGHS Dated 15/01/20 18 shall remain unchanged.

Sd/-

[Dr. Atul Prakash ] 

Director, CGHS

Source: https://cghs.gov.in/showfile.php?lid=5106

Guidelines for settlement of medical claims of pensioners & others

Guidelines for settlement of Medical claims of pensioners and others – CGHS

Government of India
Ministry of Health and Family Welfare
Department of Health & Family Welfare
EHS Section

No: Z.15025/51/2018 /DIR/CGHS/EHS

Nirman Bhawan, New Delhi
Dated the 6th June, 2018

OFFICE MEMORANDUM

Subject :- Guidelines for settlement of Medical claims of pensioners and others

With reference to the above subject the undersigned is to draw attention to the revised timelines and constitution of High Powered Committee in compliance of the directions of Hon’ble Supreme Court of India in their Judgement in the WP(Civil) No 694 of 2015 between Shiva Kant Jha Vs UOI delivered on 13th April 2018 and to state that it has been decided to issue guidelines to the Additional Directors of CGHS for implementing these decisions. The new guidelines are enclosed for perusal and compliance.

Encl as above.

sd/-
(Dr.D.C.Joshi)
Director,CGHS

GUIDELINES TO PROCESS THE REQUESTS FOR SETTLEMENT OF THE MEDICAL CLAIMS

1. New Timelines for settlement of the Medical Claims

The new timelines prescribed for settlement of normal medical claims are 30 days from the date of submission to the payment by Pay & Accounts Office. Every effort must be made to avoid delay at any stage. Proper calculation sheet must be prepared in the file, so that the same could be shared with the beneficiaries, if there are requests for reasons for the deductions.

2. Full reimbursement case /Cases for relaxation of Rules

As per the new guidelines they fall into two categories
(a) Full reimbursement – Non-HPC (Non- High Power Committee) cases
(b) Full reimbursement – HPC (High Power Committee) cases

a) Full reimbursement – Non-HPC cases

The following cases fall under this category;

i) Treatment was obtained in a private unrecognized hospital under emergency and the patient was admitted by others when the beneficiary was unconscious or severely incapacitated and was hospitalized for a prolonged period.

ii) Treatment was obtained in a private unrecognized hospital under emergency and was admitted for prolonged period for treatment of Head Injury, Coma , Septicemia, Multi-organ failure , etc.

iii) Treatment was obtained in a private unrecognized hospital under emergency for treatment of advanced malignancy

iv) Treatment was taken under emergency in higher type of accommodation as rooms as per his/her entitlement are not available during that period.

v) Treatment was taken in higher type of accommodation under specific conditions for isolation of patients to avoid contacting infections

vi) Treatment was obtained in a private unrecognized hospital under emergency when there is a strike in Govt. hospitals.

vii) Treatment was obtained in a private unrecognized hospital under emergency while on official tour to non-CGHS covered area.

Although the new OM has not mentioned about STC recommendation, it is advisable to have expert Committee meetings under the Chairperson of Addl. DGHS (as in the case of earlier STC meetings) in respect of item Nos. i), ii),iii) and v) before arriving at a decision. The conditions mentioned at Nos. iv),vi) and vii) are administrative in nature and do not require meetings of expert committees and may be recommended by Addl. Director, if conditions are satisfied.

In Delhi the expert committee meetings shall be organized by respective CMO(R&H) and by AD(R&H) in case of claims of serving employees of Delhi. Such meetings in respect of other cities shall be organized by Sr. CMO in the office of Addl.DDG(HQ).

The requests for full reimbursement as examined by Additional Director (HQ)/ Addl. DDG(HQ), in consultation with expert committee meetings, wherever deemed necessary and recommended for full reimbursement shall be submitted to Director, CGHS and concurrence of IFD may be obtained after approval of AS&DG, CGHS before the seeking the approval of Secretary for reimbursement in excess of CGHS rates.

If the above criteria are not satisfied (including the regrets by expert committees) the requests may be regretted by Addl. Director of concerned City, with a covering letter explaining the reasons and referring to the concerned OM.

In case there is a representation to consider as a special case then only it may be placed before the High Power Committee.

Addl. Directors shall prepare a self-contained note giving details of case and submit the files with relevant documents to Director, CGHS though AD(HQ)/Addl. DDG(HQ)

If the proposal is approved by AS&DG,CGHS , concurrence of IFD and approval of Secretary , Health & Family Welfare are solicited for reimbursement in excess of approved rates.

b) Full reimbursement – HPC cases

The Composition of High Power Committee, shall be as under:

1. Special Director General —– Chairperson
2. Directorate General, CGHS or his Nominee —- Member
3. Additional Director, CGHS(HQ) / Addl. DDG(HQ),CGHS —- Member
4. Addl. Director, CGHS(R&H) —- Member Secretary
5. One Government Specialist (of concerned Speciality) —- Member

The High Powered Committee shall consider the representations of only those CGHS beneficiaries having a valid CGHS Card.

The High Powered Committee shall consider representations received from CGHS beneficiaries holding valid CGHS cards only at the time treatment, in respect of the following conditions:

1. Approval for air-fare with or without attendant on the advice of treating doctor for treatment in another city even though he is not eligible for air travel / treatment facilities are available in city of residence

2. Representations from CGHS beneficiaries seeking full reimbursements under special Circumstances.

3. Relaxation of Rules

High Powered Committee shall meet once in a month and action on the decisions taken shall be completed within seven days of meeting, with the concurrence of the IFD , wherever , it is deemed necessary.

Addl Directors shall submit the files with relevant documents to the AD(HQ) / Addl. DDG(HQ) for placing the representations before High Power Committee.

AD(R&H) shall be Member Secretary , who shall with the help of Sr. CMO of the Office of Adl.DDG(HQ) shall issue meeting notices including notices to concerned Govt. Specialists and organize meting for the Meetings of High Power Committee.

The requests received upto the 15th of the month shall be placed before the Committee.

If the High Power Committee does not recommend the regret letters shall be issued explaining the reasons.

If the High Power Committee recommends full reimbursement / relaxation of rules, Concurrence of IFD and approval of Secretary (H&FW) shall be obtained within 7 days.

3. In addition there are expert committees to consider several cases

Expert Committee meetings for other purposes shall continue to be held as in the past in the following cases:

Expert Committee meetings for Consideration of Liver Transplant cases, Bariatric Surgery,

Bone-marrow / Stem Cell Transplant, Justification of treatment / Implants in selected cases shall continue as before.

Standing Committee meetings for Cochlear Implant shall continue as before.

Expert Committee meetings for approval of Drugs , etc., shall continue

Resolutions proposed by our Association in the 62nd Annual conference of BPS held on 26.11.2017

The following issues are placed in the Resolutions to be adopted.

1. On behalf of all the Pensioners/Family Pensioners  we humbly convey our Gratitude for considering the Right to Health.  Thank the GOI-MOH-F(W) at the helm of affairs for opening New CGHS Wellness Centres at Visakhapatnam, Guwahathi and elsewhere . We had all the praise for the GOI in totality for 7th CPC Report on health aspects for approvals.  We pray for merger of all other Postal Dispensaries into CGHS fold as early as is possible.

1. We are also thankful to raise FMA of Rs.1000/- p.m. recently for the health needs of Pensioners living in Non-CGHS areas.
2. We also pray for grant of FMA to CGHS beneficiaries and others as well residing in CGHS and Dispensaries  of areas to defray additional expenditure to meet with collection of medicines, consultations with Specialists, undergoing monthly / periodical medical check ups etc.
3. We are, further, thankful to allow Indoor Hospital treatment for all pensioners not covered by CS (MA) Rules 1944.  These are to be amended with existing facilities provided by the GOI.
4. We also request for separate monthly contribution fee for getting CGHS benefits separately for Indoor and Medical Treatment instead of entire monthly FMA to forego before joining the CGHS.

    

2. Request allow 50% of Pay as Pension sanctioned in 6th CPC implementations for All Pensioners & 30% for Family Pensioners at par with Pensioners retired on superannuation with 10 years qualifying service for 20 years those Pensioners retired voluntarily as per the Court Orders  ( GOI., DP&PW OM No.38/49/2016-P&PW (A) (ii) dated 04.08.2016 )  for  the period from 1.1.2006 to 31.12.2015.  Further the Govt. have allowed 50% for all from 1.1.2016 as in 7th CPC implementation orders 12-05-2017.  Thus equality may be maintained without any dissolution leaving aside the importance given to Modified Parity earlier.

3. Request anomalous 7th CPC Pay Matrix so far as Level 8 in consideration for revision of whole matrix table in as much as starting pay element is incorrect.  The minimum of 6th CPC pay-in-band in PB-2 is Rs.18750 for 5th CPC (S-14) pay of Rs.7500 multiplied by 1.86+ GP Rs.4800. But the starting pay is found taken as Rs.18150 with Rs.600 less.  Entire corresponding column down the table got affected causing drop in pension for all the Pensioners and Family Pensioners.  This may also be revised accordingly in a correct way as was done in some other cadres after the issue of implementation orders.

4. Request to regularise all the adhoc appointments made so far in all cadres for execution in the interests of services to function  in the absence of delayed DPCs. Large No. of Pensioners are affected by DROP in their monthly pension entitlements with recurring further loss in respective Family Pension.  A thorough review may kindly order in all the departments to restore confidence.

5. All the Pre-1996 pensioners who retired from service while drawing large number of 4th CPC scales of pay are still being affected in their respective monthly pension amounts even in 7th CPC concordance tables of Pay Matrix by following wrong Annexure of Pension Ministry O.M. dated 28.1.2013 issued while implementation of 6th CPC process.  Many CATs and Appex Court also did not approve the down gradation of posts at any stage and reiterated the dictum – equal pay for equal work.  Thankfully the GOI have also rightly and recently declared its view and ordered that there should not be any down gradation of posts while clarifying in Point No.6 in an Annexure-II of Extra Ordinary Gazette Resolution vide G.I., M.F., No.1-2/2016-IC dated 25.07.2016. The concordance table No.28 ( related to 5th CPC scale Rs.7500-250-12000 ) for reference. The Basic Pay drawn by all Gazetted Officers from 01.01.1986 to 31.12.1995 (4th CPC scales) is kept blank as could be seen from all other tables.  The scales drawn earlier are shown some where else against  a non-gazetted post.  The infamous annexure to OM dated 28.1.2013 may not be a valid document and be withdrawn immediately without any hesitation.  This Annexure has inflicted in lesser pension and family pension downwardly. Concerned Heads of Departments only are competent to decide which scale relate to which cadre while equating large number of scales (85 in 4th CPC to 33 in 5th CPC) into less number. Request for equal pension and family pension for all cadres as declared upon.

6. Request for a  review of  Concordance Tables with Grade Pay of Rs.5400, Rs.4800 and Rs.4200.  These relate to - Superintendents – Asst. Superintendents & Inspectors cadres -  in the Department of Posts in 7th CPC regime.  Postal Pensioners are thankful for 7th CPC and also the Govt. for approving POPA-BPS proposals made in the discussions held with Chairman and also at Hyderabad Visit made on 19.11.2014 reiterating for equal Grade Pay of Rs.5400 for Superintendents in PSS Group B and Group A (Junior) cadres for holding similar duties and responsibilities attached to the post of Superintendents and Senior Superintendents. The GOI by Gazetted Extra-ordinary Notification dated 25th July 2016 under PART-C  (upgraded levels for certain posts in Ministries, Departments & Union Territories approved in Sl.Nos.3 to 5 (Inspector (Postal) Assistant Superintendents and Superintendents posts in Department of Posts from 01.01.2016.  The 7th CPC implementation has to be done according to Pay of Post prescribed from 01.01.2016 against all the related posts listed in the concerned Unit by GOI Notification.  It  is now to follow the same rates of Pay as per the Grade Pay without any minimum service limits or dates of implementation since the date of implementation as on 01.01.2016.  This may kindly be concerned early with suitable amendments to related Concordance Tables.

7. Request  approve Pension Outside In  Net Tax (POINT).  Salaried Citizens alone are found with documentary proof to levy Income Tax.  Kindly exempt Pensioners.  We also strengthen the Central Revenue as Pensioners and Family Pensioners do come under the Senior Citizens for National Progress economically along with other general members of public. Any other Novel Fund creation process along with general public we adopt instead of cumbersome Income Tax.

8. We, the pensioners as a whole appreciate and convey our Gratitude for accepting  7th CPC para 5.1.44 for MACP continue to be administered in Govt. Resolution in Notification dated 25th July 2016 in Annexure – II.  Prior to this, Time Bound Promotions (TBOPand BCR) were also there and implemented in trial and error methods.  In this process, Retd. Postmasters in HSG.Grade II & I are suffering from Drop-In Pension (DIP) without getting their normal promotions before retirement.  Some Postmasters officiated in HSG-I in a few years were not given higher on the plea that the minimum service in promotional post was not put up without giving any show cause notice for such drastic action hitting their economy.  The implementation date of 1.9.2008 did hit their promotions when the scheme was there even before 1.1.2006 but by giving effect from 1.9.2008.  As such natural justice demands that the scheme be given effect from 1.1.2006 and the pension entitlements of those affected by insisting minimum service changing the nomenclature of that post they held while in service.  The service so put up was not at all concerned. Resolve to ponder over for a   review.

9. In the Department of Posts, a large number of E.D. / G.D.S.  Agents were called as Part-time staff.  Literally it is so, but their duties were fixed for 5 years a day and they had to spend very much time of working day. After termination from service,  they are paid with a meagre Severance Gratuity only and at present besides Annuity Bonds from out of the meagre savings they had.  Since these are not commensurate with cost of living, they are praying for Monthly Pension at par with departmental staff.  One ED Agent after getting promotion as Group D had to retire without pension as he put up a qualifying service of 9 Yrs 03 months 29 days which fell short of required 7 months to justify pension.  He filed a case in CAT Madras vide O.A.1264 in 2002.  On an Appeal it was confirmed by High Court, Chennai in WP No.45465 of 2007 dated 4.10.2007.  SLP filed by DOP was also dismissed by Appex Court in case No. CC 13829 of 2008 dated 17.10.2008.  The DOP has also examined the case in detail for formulating a scheme but not found feasible under Rule 49 of CCS (Pension) Rules without putting a minimum of 10 years of qualifying service in the year 2013 ( Lr.No.EST/GDS/Rlgs/09 dated 04.11.2013 ) and treating  that there was no scope for GDS (EDA) Service for others towards regular employment enabling them to make up short fall. It is to ponder over keeping in view of the financial constraints of family members, a minimum monthly consolidated pension as in the case of EPS-95 service personnel for their living with both ends to meet may be granted.

 

10. Rule 10 (1-B) CCS (TS) Rules 1965 permits Temporary Govt. Servants with 20 years of service are qualified for Voluntary Retirement benefits and get pensioner benefits.  The 20 years was in vogue when  33 years of qualifying service for full pension.  The minimum service required for VR has to be reduced to 13 years or 10 years of justifying grant of pensioner benefits.  Family Pension is also assured for 1 year service.  Such being the case, Terminal Gratuity or Severance Amount only is granted for Departmental and other EDAs/GDAs.  Discussion was made in Sl.No.9 above in which Appex Court directed in the case of a Group D official to take short fall in qualifying service from earlier post of ED/GDS casual labour etc.   A few Group C officials from long ED/GDS service function as Group D / Postman / Postal Assistant in DOP and no pension is granted if they have not put in qualifying service in a departmental post for more than 10 years.  All such Group D and Group C officials after retirement on Superannuation discharged from Service without any Pension and Pensioer benefits except Terminal Gratuity which is not at all adequate to look into the welfare of themselves and  family members. For all such temporary officials, and those having less than 10 years qualifying service may be granted with proportionate monthly pension  on Minimum Pay of the Scale (i) 50%  for Pensioners and (ii) 30% Family Pension on minimum pay though not on the basis of Last Pay Drawn before retirement.  This would to some extent support the welfare of dependent family members.

A case was filed in CAT Madras in O.A.1264 of 2002.  It was confirmed by High Court, Chennai in WP No.45465 of 2007 dated 4.10.2007.  SLP filed by DOP was also dismissed by Appex Court in case No. CC 13829 of 2008 dated 17.10.2008.  Appex Court further directed the Department to formulate a scheme for Pension making shortfall of Qualying Service from lower post in department before entering departmental post.  Pensioners pray for GOI to consider the scheme in a sympathetic and benevolent gesture. 

Registering of email IDs of CGHS beneficiaries

F.N. 44-42/2016/MCTC/CGHS/2451-83

Monitoring Computerization and Training Cell Directorate of CGHS

Ministry of Health & Family Welfare

CGHS Building Kalibari , New Delhi 110001

                                                                      Dated: 17/11/2017

OFFICE MEMORANDUM

Subject: – Registering of Email IDs of CGHS beneficiaries

With the objective of further strengthening the services to CGHS beneficiaries it has been decided to provide following e-services to the beneficiaries through ernails
• Prescription by Medical Officer at the VVC
• Intimation of medicines issued by Pharmacy
• Intimation of medicines indented
• Intimation of issue of indented medicines
• OTP to book online appointment
• Confirmation/ cancellation of online appointment
• Permission letter for procedures/ investigations etc.

 In order to enable above services. it is required that email ids of all CGHS beneficiaries are registered with CGHS. A beneficiary can visit CMO In change of parent Wellness Centre to get his/her email id registered with CGHS or can himself/herself register It by logging on to CGHS portal cahs.nic.in through following steps

. Visit CGHS Portal cghs.nic.in

• Click beneficiary login

• Enter your Ben Id, password and sign in
• Click Update Email
• Enter OTP sent on your registered Mobile
• Enter your email ID
• Update your email ID
• Similarly email ID for other family members can be updated

Vide publicity to this notice may be given through verbal communication and display at the notice boards of Wellness Centers