Delegation of powers for settlement of reimbursement claims/Permissions ex-post-facto approval in respect of Pensioner CGHS beneficiaries
Government Of India
Ministry Of Health and Family Welfare
Department of Health & Family Welfare
Nirman Bhawan, New Delhi 110 108
No.Z.15025/79/2/DIR/CGHS
Dated the 5th October, 2016
OFFICE MEMORANDUM
Subject: Delegation of powers for settlement of reimbursement claims/Permissions ex-post-facto approval in respect of Pensioner CGHS beneficiaries, etc.
With reference to the above subject the undersigned is directed to state that that the matter has been reviewed by the Ministry in view of the difficulties faced by the CGHS pensioner beneficiaries Therefore, with a view to streamline and to simplify the procedures. it has now been decided to further delegate powers to the Addl. Directors of CGHS Cities / Zones in respect of CGHS pensioner beneficiaries. etc. as under:
i) Permission / ex-post facto approval in non-empanelled hospitals / Diagnostic Labs /Imaging Centre:
Requests for permission ex-post facto approval for elective treatment / investigations in non-empanelled hospitals / diagnostic centres in respect of Pensioners/ex-MF’s/freedom Fighters, etc. shall be considered by Addl. Director of concerned CGHS city / Zone subject to the reimbursement being restricted to CGHS package rates or actual expenditure, whichever is less
ii) Permission / ex-post facto approval in cases involving procedural lapse:
Requests for approval of elective treatment l investigations in empanelled hospitals / diagnostic centres without recommendation of Govt. Specialist or CMO and without prior permission in respect of Pensioners/ex-MPs/freedom Fighters, etc, shall be considered by Addl. Director of concerned CGHS city / Zone subject to the reimbursement being restricted to CGHS rates or actual expenditure whichever is less.
iii) Delegation of Powers for Settlement of Medical Reimbursement Claims (at approved rates) of Individual Pensioner Beneficiary. etc,
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Revised Delegated Powers |
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| a) | Additional Director, CGHS of City /Zone | Rs.7,00,000/- |
| b) | Director, CGHS | Rs.15,00,000/- |
| c) | Addl. Secretary & DG, CGHS | Rs.25,00,000/- |
iv) Delegation of Powers for settlement of Hospital Bills (at approved rates) for the Treatment given to Pensioner Beneficiaries, etc,
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Revised Delegated Powers |
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| a) | Additional Director, CGHS of city/zone | Rs.7,00,000/- |
| b) | Director, CGHS | Rs.15,00,000/- |
| C) | Addl. Secretary & DG, CGHS | Rs.25,00,000/- |
v) Delegation of Powers for Permission / ex-post facto Approval / Settlement of Medical Reimbursement Claims of Individual Beneficiaries / Hospital Bills in respect of Unlisted procedures / Implants (no CGHS rates)
If there is no CGHS package rate for treatment I CGHS Ceiling rate for implant approval shall be granted as per AIIMS package rate (if only procedural charge. it shall not be considered as package rates)/ AIIMS rate for implant and if there is no CGHS/AIIMS rate approval shall be granted as per actual rate.
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Revised Delegated Powers |
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| a) | Additional Director, CGHS of city/zone | Rs.1,00,000/- |
| b) | Director, CGHS | Rs.1,50,000/- |
| c) | Addl Secretary & DG.CGHS | Rs.1,50,000/- |
2. The revised delegations mentioned above will be subject to the conditions that it will not include any case involving relaxation of rules, irrespective of the amount involved. Further, cases where the amounts exceed the monetary limits prescribed above will have to be referred to the Ministry of Health & Family Welfare for obtaining the concurrence of Integrated Finance Division in the Ministry of Health & Family Welfare.
3. The above delegations are in supersession of all the earlier instructions in the matter in respect of the delegations now being conveyed.
This issues with the concurrence of Integrated Finance Division, Ministry of Health & Family Welfare, vide Dy. No C- 3373 dt. 20.09.2016
(Dr.D.C.Joshi)
Director, CGHS
Asokan TP says
The suggestion proposed is fully endorsed
MURALI SOMAYAJULA says
SIR,
THIS APPEARS TO BE ANOTHER EYE WASH AS THE EFFECT IS ONE AND THE SAME EXCEPT THE POWER IS TRANSFERRED FROM ONE PLACE TO ANOTHER. THIS DELEGATION OF POWER TO AD,CGHS, OF THE CGHS CITY /ZONE DOES NOT CONFER ANY BENEFIT TO PENSIONERS IN THE NON-CGHS CITY ZONE AS THE POWER IS LIMITED TO REIMBURSEMENT OF BILLS FOR THE TREATMENT TAKEN IN ‘ENLISTED HOSPITALS’ ONLY. ENLISTED HOSPITAL ARE AVAILABLE ONLY IN CGHS AREAS /ZONES AND NONE IN OTHER AREAS. I DON’T KNOW WHAT THIS DELEGATION MEANS AND WHAT WAY IT IS BENEFICIAL TO THE PENSIONERS AS THEY ALSO HAVE TO FIRST PAY AND GET REIMBURSEMENT. GOD ONLY KNOW WHEN THE AD, CGHS CIRCLE/ZONE WOULD PASS THE CLAIM /REIMBURSE THE AMOUNT?
WHEREAS, PENSIONERS RESIDING IN NON-CGHS COVERED AREAS COULD GET REIMBURSEMENT ONLY IF THEIR TREATMENT IS TAKEN IN ANY HOSPITAL (NON ENLISTED OR NON EMPANELLED) OF THEIR CHOICE AND ON CERTIFICATION BY THE SUPDT OF THE HOSPITAL AS SUCH. WITH A RIDER THAT THE HOSPITAL CHARGES HAVE TO PAID BY PENSIONER FIRST AND GET HIS REIMBURSEMENT FROM AD, CGHS.
THIS IS AGAIN A DISCRIMINATION.BETWEEN THE (1) PENSIONERS RESIDING IN THE CGHS AREA/ZONES AND (2) PENSIONERS LIVING IN NON-CGHS AREAS/ZONES.. AT LEAST IF THE RULE IS RELAXED, WITHOUT ATTACHING THE TAG, ‘EMERGENCY’, THIS DELEGATION OF POWER TO AD, CGHS WOULD BE BENEFICIAL TO THE PENSIONERS LIVING IN NON-CGHS AREAS, AS THEY HAVE TO ANY HOW SHELL DOWN THE HOSPITAL CHARGES BY HOOK OR CROOK.. TIME LIMIT TO REIMBURSE IS ANOTHER BIG PROBLEM, EVEN THOUGH THE GOI GUIDELINES IMPOSES AN OBLIGATION TO GIVE REIMBURSE THE CLAIM WITHIN 4 MONTHS, THEY SAY IT IS ONLY A GUIDLINE BUT NOT A MUST!!!!
HENCE I REQUEST YOU TO TAKE UP THIS MATTER WITH THE MOH&FW, NEW DELHI TO APPLY THIS RELAXATION TO NON-CGHS AREA /ZONE PENSIONERS ALSO, IRRESPECTIVE OF THE HOSPITALIZATION IS EMERGENCY OR NOT, AT LEAST IN CITIES /PLACES WHERE THERE ARE CGHS WELLNESS CENTERS ARE ESTABLISHED BUT THE PRIVATE CORPORATE HOSPITALS ARE NOT YET APPROVED, DUE TO THE REASONS BEST KNOWN TO THEM..
AS PER THE 7TH PCR AND ALSO THE RECOMMENDATIONS OF THE EMPOWERED COMMITTEE OF SECRETARIES, IT IS ONCE AGAIN URGED TO IMPRESS UPON THE SECRETARY(FINANCE) TO EMPANEL THE PRIVATE CORPORATE HOSPITALS APPROVED BY THE GOVT OF THE STATES CONCERNED AT LEAST WHERE THERE ARE CGHS WELLNESS CENTERS.
WITH REGARDS.