FAQ on Central Government Health Scheme : More questions clarified as FAQ

FREQUENTY ASKED QUESTIONS WITH ANSWERS ABOUT CGHS
Source: http://msotransparent.nic.in/cghsnew/index.asp

Who are entitled for CGHS facilities
All Central Govt. employees and their dependent family members residing in CGHS covered areas.

Central Govt Pensioners and their eligible family members getting pension from Central Civil Estimates

Sitting and Ex-Members of Parliament

Ex-Governors & Lt. Governors

Freedom Fighters

Ex-Vice Presidents

Sitting and Ex-Judges of Supreme Court & High Courts

Employees and pensioners of certain autonomous organizations in Delhi

Journalists (in Delhi )Accredited with PIB
( for OPD & at RML Hospital)

Delhi Police Personnel in Delhi only

Railway Board employees

In how many cities CGHS is presently operative?
CGHS facilities are available in 25 cities in India
1. Ahmedabad 2 Allahabad 3 Bengaluru 4 Bhopal 5 Bhubaneshwar 6. Kolkata 7. Chandigarh 8 Chennai 9.Dehradun 10.Delhi & NCR 11.Guwahati 12. Hyderabad 13. Jabalpur, 14. Jaipur 15 Jammu 16. Kanpur 17. Lucknow 18. Meerut 19. Mumbai 20. Nagpur 21 Patna 22.Pune 23. Ranchi 24. Shillong 25. Thirruvananthapuram

For CGHS cards , as dependant , what is the meaning of the word “ family “
The term ‘family’ means and includes:-

“Husband or wife as the case may be and other dependant family members.

Dependant Family Members: parents, sisters, widowed sisters, widowed daughters, minor brothers and minor sister, children and step-children wholly dependent upon the Government Servant and are normally residing with the Government Servant”.

Also now include , dependent divorced / separated daughters ( including their dependant minor children) and step-mother.

The term dependency means that income from all sources including pensions and pension equivalent of DCRG benefit is less than Rs.3500/- plus amount of DA on Basic pension of Rs3500/- per month. However, there is no such clause as dependency in respect of spouse.

What is the procedure to register with the CGHS?
Pensioners:
One can get a CGHS card made from the office of AD / JD of the City. Forms can be downloaded from CGHS Website or can be taken from office of AD / JD of city between 1000 am to 1230 pm.

Documents required
Application in prescribed format
Proof of Residence
Proof of Stay of dependents
 Proof of age of son
Disability certificate, if any in case of sons aged 25 & above, who would otherwise cease to be a beneficiary.
Photos of eligible family members
Surrender Certificate of CGHS Card while in service ( only in those cases where CGHS Card was issued while in service)
 Attested copies of PPO & Last Pay Certificate
Draft for required amount towards CGHS contribution – in the name of ‘P.A.O., CGHS New Delhi’ in Delhi-and in the name of ‘AD, CGHS of the city’.
In case PPO is not ready for any reason there is option to get a provisional card on the basis of Last Pay Certificate.
The data is entered through computers and entered in data base and a print out is issued same day for immediate use. Plastic cards are subsequently sent to the residence of the card holder by post.

Serving employees:-
Serving employees submit the forms in prescribed format enclosing photos of eligible family members and submit to the Ministry / Department/Office , where he / she is employed. The application form shall be forwarded by the Ministry / Office /Department to the office of Addl. Director CGHS of city for preparation of card. Print out is issued for immediate use and

How long does it take to get the CGHS Cards?
Normally computerized printout of index card is issued on the same day. Plastic cards are sent to the residence in ‘3’ weeks time.

Whom Should I approach in case the CGHS Card is not issued to me in the prescribed time?
Contact Joint Director (HQ), CGHS, Bikaner House, New Delhi in case of Delhi and Addl. Director of City in case of other cities.

What should I do if I lose my CGHS Cards ?
Application is to be submitted to AD/JD along with two photographs and a IPO for Rs. 50/- for issue of duplicate card.
Indian Postal Order payable to “ P.A.O. CGHS Delhi” if in Delhi or “ Additional Director of the CGHS City “ in respect of other cities

What should I do if the details on the Card viz. name, date of birth, entitlement, etc. are wrong?
Kindly bring the anomalies to the notice of Joint Director, CGHS (HQ), and Bikaner House in Delhi and to the Addl. Director, Joint Director of concerned CGHS City in other cities.

Is there a colour scheme for plastic cards? What are the details?
CGHS Plastic cards have the following colour at the top:
Serving Government employees - Blue
Pensioners, ex-MPs , Freedom Fighters, etc., - Green
Member of Parliament - Red
Beneficiaries of Autonomous Bodies / Journalist - Yellow

Whom should I contact if the doctors are not present in the Wellness Centre / Dispensary?
Contact CMO i/c of the concerned Wellness Centre or Addl. Director, CGHS of concerned city or Director, CGHS.

Can the CMO or the pharmacist give a different brand than the one prescribed by the specialist?
Medicines are issued at CGHS Wellness Centres by the same brand, if available or by generic name or by any available brand name of equal therapeutic value.

What is the procedure for getting life saving drugs ?
In Delhi- through CGHS Medical Store Depot, Gole Market
The documents required are:-
a. Prescription of spl. of Govt.Hospital or CGHS approved private Hospital.
b. Photocopy of his/ her token card/ plastic card.
c. Copy of permission if his prescription is from CGHS approved private Hospital.
d. Utilization certificate in original during subsequent visit.
e. Indent is also placed online through CGHS Wellness centre.
In other cities request is to be submitted to the Addl. Director of City.

What do I do if I am unwell at odd hours, say late in night?
CGHS beneficiaries have the option to go to any of the 24 hr functional dispensaries in Delhi, a nearby govt. hospital / empanelled private hospital or even any private hospital , in case of emergency.

What should I do in case of emergency?
CGHS beneficiaries have the option to go to any of the 24 hr functional dispensaries in Delhi, a nearby govt. hospital / empanelled private hospital or even any private hospital

What is the time within which my medical claim is to be reimbursed?
If all documentation is complete medical claims of pensioners are cleared in 45 days.

What can I do if my claim is unnecessarily delayed?
Pensioner beneficiaries can contact the Additional Directors of concerned city / zone on any Wednesday between 11 A.M. and 1 P.M.

What should I do if the empanelled hospital refuses to entertain or give a step-motherly treatment?
Contact CMO i/c of the concerned Wellness Centre or Addl. Director, CGHS of concerned city or the nodal officer for grievances.

What should I do if the Wellness Centre/Dispensary does not give all the medicines?
Contact CMO i/c of the concerned Wellness Centre or Addl. Director, CGHS of concerned city or Director, CGHS.

How long does it take to get the medicines ?
Medicines available in the dispensary are issued immediately. If any medicine is not available and is to be indented through Authorized Local Chemist the same are issued on the next day.

What are the facilities available to me if I am a pensioner in a non CGHS area ?
a) Pensioner residing in non- CGHS covered areas have the option to become CGHS beneficiary and avail CGHS facilities from the nearest CGHS covered city.

b) Pensioners residing in non-CGHS areas have also the option to avail Fixed Medical Allowance of Rs300/- per month and opt not to avail CGHS facility.

c) Pensioners residing in non-CGHS areas have also the option to avail Fixed Medical Allowance of Rs300/- per month for OPD treatment and obtain CGHS card from nearest CGHS covered city for inpatient facilities under CGHS. No OPD medicines shall be issued in such cases.

d) CGHS pensioner beneficiaries( and their dependant and eligible family members) who are holding a valid CGHS Card and residing in a non-CGHS area shall be eligible to obtain inpatient medical treatment and also follow up treatment from Govt. Hospitals / CS(MA) /ECHS approved hospitals on proper referral from CGHS dispensary and submit the medical reimbursement claim to the Addl.Director/ Joint Director of CGHS of city where the CGHS card is registered.

In case of medical emergency , treatment may be obtained from any hospital and medical claim shall be submitted to AD/JD , CGHS of the concerned city.

Reimbursement shall 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 actuals, whichever may be less.

What is the system for the services of specialists in Dispensaries ?
Prior registration is required appointment with the CGHS Wellness Centre, where specialist services are available.
However, In case of emergency contact CMO i/c of dispensary of Wellness Centre for consulting specialist without prior appointment.

Are the prescription of specialists of empanelled hospitals binding on the dispensary ?
Medicines are issued on the basis of prescriptions of government doctors. However, in permitted cases medicines are issued on the basis of prescriptions of empanelled hospitals and medicines will be issued as per the available brand / generic names.

What is the maximum period for which medicines can be given in one go ?
For treatment of Chronic illnesses medicines upto ‘3’ months are issued in one go , provided there is a valid prescription.
In case of a beneficiary visiting a foreign country , medicines upto ‘6’ months are issued in respect of cronic illnesses , based on valid prescription and documentary support of visit to a foreign country.
Beneficiary is required to submit an application for obtaining permission from AD/JD along with the following documents:-
1. Copy of valid CGHS card/ token card.
2. Valid prescription for six months counter signed by HOD of Specialty of Govt. Hospital.
3. Proof of station leaving like ticket, Visa etc.

What are the papers to be submitted for any investigation by an empanelled diagnostic centre?
Original or self attested copy of prescription of CGHS Doctor / Government specialist
Copy of CGHS Card of the npatient and main card holder (head of  family).

Which are the categories eligible for cashless treatment ?
Hospitals shall provide credit facility to the following categories of CGHS beneficiaries (including dependant family members, whose names are entered on CGHS Card):
• Members of Parliament;
• Pensioners of Central Government drawing pension from central estimates;
• former Vice-presidents, Former Governors and former Prime Ministers;
• Ex-Members of Parliament;
• Freedom Fighters;
• serving CGHS employees;
• serving employees of Ministry of Health & Family Welfare
(including attached / subordinate offices under the Ministry of Health & Family Welfare); and

Is there any interactive mechanism at dispensary level?
At the Wellness Centre ‘Local Advisory Committees’ are formed. CMO i/c holds a meeting with Local Advisory committee members to discuss local dispensary related issues.

Are CGHS facilities free of cost?
For serving employees residing in CGHS covered area obtaining CGHS card is compulsory
Deduction from salary is made by the department, every month, depending upon their pay  w.e.f 1st June 2009

Grad Pay w.e.f 1st June 2009 Contribution
Upto Rs.1650 /- Rs. 50/-
Rs.1800/-, Rs1900/-, Rs.2000/- , Rs.2400/- and Rs.2800/- Rs.125/-
Rs.4200/- Rs.225/-
Rs.4600/-,Rs.4800/-, Rs.5400/- Rs.6600/- Rs.325/- and Rs. 7600/- and above Rs. 500/-
Pensioners who want to avail CGHS facilities can make contribution either on yearly basis or one time ( ten yrs ) contribution for whole life validity.
Payment can be made by Demand Draft in favour of “ P.A.O. CGHS Delhi” if in Delhi or “ Additional Director of the CGHS City “
Contribution in respect of Pensioners are calculated on the basis of grade pay they are entitled had they been in service , but for superannuation.

What are the criteria for Entitlement of Treatment endorsed on CGHS Card like General ward / Semi-Pvt ward or Pvt. Ward in CGHS Empanelled Hospitals?
Endorsement of entitlement for general/semi- private/private ward facility is done according to their basic pay / basic pension as under :
§ Upto Rs. 13,950/- per month - Entitlement : General Ward
§ Rs. 13,960/- to 9,530/- per month -Entitlement: Semi-private Ward
§ Rs. 19,540/- and above - per month - Entitlement : Private Ward
I am a serving employee residing in a place close to a city covered under CGHS. Can I get CGHS card issued from the nearest CGHS city?
There is no provision to avail CGHS facilities in respect of serving government employees residing in non-CGHS covered areas. They are covered under CS(MA) Rules 1944.

I retired in 1998 from Central Govt. but, I never made a CGHS card. Can I get a card now?
Pensioners can apply for CGHS card with relvant documents. However, the subscriptions as applicable at current rates shall have to be paid.

My husband/wife is also employed under Central Government and is eligible for a separate CGHS Card. Is it necessary that separate cards are to be obtained?
No. Spouse drawing higher pay shall make the card and other spouse is eligible to avail CGHS benefits as member.

I have retired from Delhi. Now I want to settle at city where no CGHS facility is available . How to cover my family for medical care?
Pensioners are eligible for CGHS facilities and can obtain CGHS card from the nearest CGHS covered city.

My husband / wife retired in 2002. He /she was paying CGHS subscription every year. After his death can I get Card on my name. Do have I to pay extra. Shall I get Life Time Valid card?
Yes, the ownership of card can be transferred in the name of spouse on submission of required documents. Addl. Director of concerned city shall transfer the ownership of Card in the computer Data base and same CGHS plastic cards with same Beneficiary ID can be used.
No extra payment to be made, in case of life time cards.
However in other cases one has to pay 10 years subscription for life time card
For example, if the spouse had contributed for seven years before he expired , balance payment for the remaining three years is to be paid for a life time card.
Documents required :
i) Application in prescribed format
ii) Proof of Family Pension with its break up from Bank
iii) Prescribed contribution if, card is not for life time

How to transfer CGHS card from one WC to other in the same city?
If there is any change in residential address, CMO i/c may be approached with proof of residence for transferring the data from one Wellness Centre to another in the same city.

CMO i/c of the new Wellness Centre will accept the data of transferred card.

In respect of serving employees the request is to be forwarded by his/her office / department.

I am CGHS beneficiary at Kanpur. Visiting Mumbai for 6 months. Can I get CGHS facilities at Mumbai .Can same card of Kanpur continue or a separate card to be made. From where to get permission for the same?
Subsequent to computerization no separate permission is required and CGHS card is valid for availing facilities from any CGHS Wellness Centre in India. For any assistance , Addl. Director of the city may be contacted.

Who is competent to delete name of sons who have crossed age of 25 years?
CMO i/c of Wellness Centre is competent to delete the name of son aged 25 yrs and above. Computer system does not allow sons aged 25 and above to avail medical facilities.

After retirement in 2007 I got a Life time Pensioner CGHS card made in Delhi. Now I am shifting to Dehradoon. Can I use the same card. Do I pay again?
Pensioners shifting from one CGHS covered city to another, will have to apply to the Addl. Director of concerned city for transfer of card. The card shall be transferred online and a receipt will be issued to the beneficiary , on the basis of which , Addl. Director of new city ( say Dehradun) shall receive the data. Same Plastic cards and same Ben ID will be valid. No contribution is required to be paid in respect of pensioner benfciries holding life time cards.

I live in Gurgaon but my office is in Saket. Can I avail facilities from both the places because it is convenient for me.
Yes. Subsequent to computerization CGHS facilities can be availed from any Wellness Centre in India.

Is there any age limit for sons / daughters as dependant in CGHS Card ?
Son is eligible till he starts earning or attains the age of 25 years or gets married whichever is earlier.
However, in case the son is suffering from any permanent disability of any kind (physical or mental) he is eligible for CGHS benefits even after 25yrs .
Disability means blindness, low vision, leprosy-cured, hearing impairment, locomotor disability, mental retardation, mental illness. A disability certificate from Medical Board is required.
Daughter is eligible till she starts earning, or gets married, whichever is earlier (irrespective of age)

Are step-children allowed CGHS facilities?
Yes. If they are dependent on card holder: other conditions as in case of dependant sons and daughters.

Can dependent in-laws be included under family members for CGHS facilities?
A lady Government servant will be given a choice to include either her parents or parents –in-law for the purpose of availing the benefits under CGHS subject to the condition of dependence and residence , etc., being satisfied.

Me and my wife are both central Govt. employees and have dependant brothers / sisters and parents. Can we make separate cards and include family members?
Yes. Your wife can have her parents as dependant in her card.

Can drugs like antibiotics, if not available in WC, be made available urgently from local Chemist?
Yes, beneficiary can collect drugs from the chemist counter on the chemist on the basis of authority form issued by WC

How to get a drug if same is not available in WC & also not supplied by Chemist(ALC)?
Beneficiary, after authorization by CMO i/c can purchase such drugs from open market & claim reimbursement from ALC.

What should beneficiary do, if he/ she notice some deterioration in the quality of drugs?
He /she should return the medicine to WC & get replacement. Samples can be sent for testing through CMOI/C.

My father is a cancer patient and after operation is bed ridden. Doctors have advised Protein powder. Can I get from CGHS?
Dietary supplements are not permissible under CGHS.

I am a CGHS Pensioner.My wife was admitted in pvt hospital in emergency state. How to get reimbursement of money spent on her treatment?
Apply to CMO I/c of WC with :
MRC forms duly filled in as per Check list
Copy of Discharge summary
Hospital bills with break-up
Receipts in original
Copy of the valid CGHS Card
Copies of other documents issued by hospital
MRC forms are available with CMO I/c and can also be downloaded from CGHS Website http://msotransparent.nic.in/cghsnew/index.asp
Serving employee in similar cases shall submit the medical claim to his department.

My original papers having bills, Receipts of hospital treatment are lost. Can I claim on duplicate papers? Yes.With affidavits on Stamp paper.Details of Draft for Affidavit may be seen in the instructions sheet appended to Medical Claim Form available at http://msotransparent.nic.in/cghsnew/index.asp and CMO i/c.

My husband/wife was a CGHS card holder. He/She was sick and died while in hospital. How do I get MRC?
Apply to CMO I/c of WC with :
MRC forms duly filled in as per Check list
Copy of Death summary
Hospital bills with break-up
Vouchers in original
Copy of the valid CGHS Card
Death Certificate
Affidavit on Stamp paper of yourself being Legal Heir and NOC from other legal heirs in favour of claimant
Copies of other documents issued by hospital
Draft for affidavit may be seen in the instructions sheet appended to the Medical Claim Form available at CGHS Web site at http://msotransparent.nic.in/cghsnew/index.asp

I retired in Dec 2011. Due to certain reasons I had to go to my native place in Uttranchal and could not make pensioner’s CGHS card. In May 2012 I came to Delhi and had Heart attack. In emergency I was treated in pvt hospital .I got CGHS Card made after discharge but I have been refused reimbursement of the expenditure incurred.?
After retirement three months grace period is given to get CGHS card made.

(i) The treatment taken and expenditure incurred thereon within the grace period of three months from the date of retirement will be allowed and expenditure reimbursable subject to the condition that the beneficiary has either obtained or applied for CGHS pensioner card with all documents and requisite CGHS subscription within one month of expiry of the grace period of three months.

(ii) The expenditure on treatment taken after the grace period of three months from date of retirement will not be reimbursable unless the beneficiary has obtained a valid CGHS card or has applied for CGHS pensioner card with all documents and requisite CGHS subscription prior to taking such treatment.

I went to Hyderabad to visit my son and had fracture of leg bone. I received treatment from a pvt hospital. Shall I get full reimbursement?
Reimbursement for treatment taken in a private hospital under medical emergency shall be considered as per CGHS rates only.

Is treatment for IVF reimbursable?
IVF treatment is approved under CGHS. The details may be seen as per Office Memorandum Z.15025/5/2011/CGHS III/CGHS(P) dated 22.11.2011 , which can be downloaded from CGHS Website at http://msotransparent.nic.in/cghsnew/index.asp

Are ambulance charges reimbursable?
Yes. Ambulance charges are reimbursable within the city , if there is a
certificate from treating doctor that conveyance by any other mode would
definitely endanger patient’s life or would grossly aggravate his/her
condition.

I have a Mediclaim Insurance Policy. Due to emergency received treatment in a pvt hospital. Some amount was paid by Insurance Co. can I get balance from CGHS?
Yes.First Bills are submitted to Insurance Company.Duplicate bills with certificate from Insurance Company may be claimed from CGHS by Pensioner CGHS beneficiaries.CGHS shall consider reimbursement at CGHS rates or actual whichever may be less. However, the total reimbursement from both sources should not exceed actual expenditure.
Serving employees shall submit claim to department for reimbursement.

I submitted MRC for Rs. 1 Lac 20 thousand but I was reimbursed only Rs. 45,800/-. Why total amount was not reimbursed?
Expenditure for treatment in private hospitals is considered only if the treatment was taken under emergency at CGHS approved rates.
In emergency who are all entitled to get treatment at Pvt Empanelled Hospital Any beneficiary holding a Valid CGHS card.

I want to get my Cataract Surgery done at Pvt empanelled hospital ?
How can I get it done
Beneficiaries are required to obtain advice from a Govt. Specialist / CMO i/c for Cataract surgery. Pensioners can apply to CMO I/c of WC for permission to obtain the treatment at one of the empanelled hospitals of his /her choice.
Serving employees to apply to his / her Department / office.

Is it necessary that the Govt specialist should write ‘referred to CGHS empanelled Hospital’ for obtaining permission?
Advice of Government specialist is required only for the specific treatment procedure / investigation to be undertaken. There is no need to specifically refer to any empanelled hospital/ diagnostic lab. It is the choice of beneficiary to under treatment / investigations at any of the empanelled hospitals / diagnostic laboratories after obtaining permission from competent authority.

CMO Incharge does not refer me to Pvt. Hospitals on my request?
As per CGHS guidelines there is no provision for OPD referrals to private empanelled hospitals except in satellite towns of NCR

I am an accredited journalist with CGHS Card Can I seek treatment in Pvt. empanelled Hospitals in emergency and get credit facility?
No. Journalists are entitled only for OPD treatment from dispensaries and treatment from Dr.RML Hospital. Journalists are not entitled for reimbursement for treatment from empanelled hospitals.

I am a serving employee of an autonomous body ,holding CGHS card. who will give me permission for treatment on the recommendation of Govt. specialist?
Permission for treatment at empanelled hospitals / diagnostic labs shall be granted by the office of the organization where the employee is serving.

Is Penfill Injection provided under CGHS
Insulin pen is not supplied under CGHS. But, Insulin Pen Cartridges are supplied under CGHS.

Source: http://msotransparent.nic.in/cghsnew/index.asp