Clarification
regarding admissible non-admissible items under CGHS
F.No.
2-1 /2012/CGHS/VC/CGHS(P)
Government
of India
Ministry
of Health & Family Welfare
Department
of Health & Family Welfare
Nirman
Bhawan, New Delhi
Dated
the 1st August, 2013.
OFFICE
MEMORANDUM
Subject : Clarification
regarding admissible non-admissible items under CGHS
With reference to the above mentioned
subject the undersigned is directed to draw attention to the Office Memorandum
of even number dated 1st October 2012 issued by this Department in compliance
of the directions of Hon'ble High Court of Delhi in the case of Shri Kanhiya
Singh Vs U01 and others [W.P.(C) 9044/2011] clarifying admissibility /
inadmissibility of items of expenditure for claiming reimbursement under CGHS.
The same are being reproduced for a wider circulation and information in
compliance of Hon'ble High Court's latest direction issued on 16.05.2013 in
this case. The requisite clarifications regarding admissible and non-
admissible items under CGHS are provided herewith as under:-
a) "CGHS Package Rate" shall
mean and include lump sum cost of inpatient treatment / day care / diagnostic
procedure for which a CGHS beneficiary has been permitted by the competent
authority or for treatment under emergency from the time of admission to the
time of discharge including (but not limited to) — (i) Registration charges,
(ii) Admission charges, (iii) Accommodation charges including patients diet,
(iv) Operation charges, (v) Injection charges, (vi) Dressing charges, (vii)
Doctor / consultant visit charges, (viii) ICU / ICCU charges, (ix) Monitoring
charges, (x) Transfusion charges, (xi) Anesthesia charges, (xii) Operation
theatre charges, (xiii) Procedural charges / surgeon's fee, (xiv) Cost of
surgical disposables and all sundries used during hospitalization, (xv) Cost of
medicines, (xvi) Related routine and essential investigations, (xvii)
Physiotherapy charges etc. (xviii) Nursing care and charges for its services.
b) Cost of Implants / stents / grafts is
reimbursable in addition to package rates as per CGHS ceiling rates for
Implants / stents / grafts or as per actual, whichever is lower, in case there
is no ceiling rate prescribed under CGHS,
c) During In-patient treatment of the
CGHS beneficiary, the hospital will not ask the beneficiary or his / her
attendant to purchase separately the medicines / sundries / equipment or
accessories from outside and will provide the treatment within the package
rate, fixed by the CGHS which includes the cost of all the items.
d) In cases of conservative treatment /
where there is no CGHS package rate, the above mentioned items are
admissible-items wise at CGHS rates or as per AIIMS rates (if there is no CGHS
rate) or as per actual (if there is no CGHS / AIIMS rate) available for any
item.
e) Package rates envisage up to a
maximum duration of indoor treatment as follows:
12 days for Specialized (Super
Specialties) treatment;
7 days for other Major Surgeries;
3 days for Laparoscopic surgeries /
normal deliveries; and
1 day for day care / Minor (OPD)
surgeries.
However, if the beneficiary has to stay
in the hospital for his / her recovery for a period more than the period
covered in package rate, in exceptional cases, supported by relevant medical
records and certified as such by hospital, the additional reimbursement shall
be limited to accommodation charges as per entitlement , investigations charges
at approved rates, and doctors visit charges (not more than 2 visits per day
per visit by specialists / consultants) and cost of medicines for additional
stay).
No additional charge on account of
extended period of stay shall be allowed if that extension is due to infection
on the consequences of surgical procedure or due to any improper proceed.
f) In addition to the above mentioned
items, some patients may require additional facilities/ procedures, which are
admissible with proper justification in deserving cases. Therefore, it is not
possible to give a comprehensive list of items, which are not admissible.
However, the following items are not admissible:
Telephone charges
Toiletries
Sanitary napkins
Talcum powder
Mouth fresheners
2. It has also been decided to clarify
that expenses incurred on medicines, consumables, sundry equipments and accessories
etc., which are purchased from outside, based on specific authorization of
treating doctor / staff of the concerned hospital will be reimbursable if they
are not falling under the list of non-admissible items. In case the empanelled
hospital has asked a CGHS beneficiary for purchase of the said items over and
above the package rates, reimbursement shall be made to the beneficiary and the
amount shall be recovered from the pending bills of hospital.
3. This Office Memorandum is
issued in compliance of the directions of Hon'ble High Court of Delhi in W.P.
(C) 9044/2011 [Sh. Kanhiya Singh Vs UOI and others].
sd/-
[V.P.
Singh]
Deputy
Secretary to Government of India
