CGHS Medical Claim Reimbursement
Delightfully simple, the ‘Medical 2004 Form for Reimbursement of Medical Claims of CGHS beneficieries’ is a breeze to fill-in and the submission process is extraordinarily simple. NOT.
If your near and dear is a CGHS beneficiary and received emergency in-patient treatment at a CGHS ‘non-recognised’ hospital, you are generally advised by well-wishers to buy yourself a pair of good quality sport shoes. The number of times you have to visit the offices of CGHS to seek clarification is astounding.
If your near and dear gets hit by a medical malady and requires emergency treatment, if admitting to a CGHS recognized hospital, beware that you can only admit the patient to the hospital that is recognized for that specialty. For ex: if Hospital A is recognized for nephro disorders, Hospital B for gynae disorders and Hospital C is a branch of Hospital A, for nephro emergency, you must admit the patient to Hospital A only. Admission to Hospital B & C can render your claim invalid.
In case of emergency hospitalization to a ‘CGHS non-recognized hospital’, you are generally advised to continue the treatment till the emergency subsides and you can either transfer the patient to a CGHS recognised hospital (with prior approval) or discharge the patient and bring him/her home. A ‘CGHS non-recognized’ hospital is simply a corporate hospital that charges way more than what CGHS is willing to reimburse. You may claim reimbursement and receive it on CGHS discretion only. No obligations on CGHS’s part.
Post transfer/discharge, you must obtain the ‘Medical 2004 Form for Reimbursement’ from the CGHS dispensary that your patient is attached to. Photocopies or downloaded versions from the Internet are not valid. The Medical 2004 Form requires (*=undocumented):
- ‘Certificate of Emergency Treatment’ clearly specifying that patient’s life could have been lost if treatment was delayed. * Attested by Doctor in-charge of treatment.
- ‘Copy of Discharge Certificate/Summary’ from the hospital clearly outlining the patient’s condition, treatment received and medication advised. * Attested by Doctor in-charge of treatment.
- Photocopy of both sides of the CGHS membership card. * Attested by CMO I/C of Dispensary.
- * Receipts of payments made to the hospital and other agencies involved in the treatment. Attested by Doctor in-charge of treatment.
- Itemized bill from hospital, divided into sections by department. For ex: Room Charge, Pharmacy, Radiology … … * Attested by Doctor in-charge of treatment.
- Itemized bill from Pharmacy detailing every medicine issued and billed. * Attested by Doctor in-charge of treatment.
- Diagnostic reports from Labs.
- Nursing bills (if private nurses were required). * Attested by Doctor in-charge of treatment/Matron office.
- * Bed Head Ticket (BHT). * Attested by Doctor in-charge of treatment.
- * Covering letter for the form, giving details of treatment and pleading for reimbursement.
- * If the claim form has place for Bank Details, you may receive re-imbursement via pay-order made directly to your bank account. In such case, submit a ‘Cancelled Cheque’. It is not yet clear if the cheque should be signed or not.
You will generally be provided with photocopy of the BHTs by the hospital. Be sure to get the BHTs attested by the Doctor in-charge of treatment. Also, hospitals take a lot of time to process BHT generation request and charge quite a bit for the photocopies. So, request early and visit the hospital with a load of cash on the day of collection.
* In case, you are unable to submit the reimbursement claim within the stipulated 90 days, write a letter to the Additional Director, CGHS of your city; explaining reasons for the delay obtain written permission to submit the claim within a new deadline. You must include this permission letter as an annexe in your claim-form.
When you have compiled the file with the above mentioned annexes, (*) make 2 + photocopies of the entire file. You are required to submit the original file and 1 photocopy to the CGHS Headquarters of your city and keep at-least 1 copy for your reference. CGHS will provide you a reference number on your copy. Your future communication with CGHS must include this reference number. Submission is required within 90 days from date of discharge and is accepted at the HQ only at specific dates. For ex: at CGHS HQ Kolkata; submission is accepted only on Mondays and Thursdays between 9.30a and 1.30p.
Best of luck with your claim, hope this document helped.
Download:
Filed under: CGHS
It did help.. However, I have submitted a claim for my father’s treatment (with all supporting documents) in August 2006!!
I have yet to receive any response / reimbursement from CGHS (in New Delhi). Are you aware of any email id of any responsible higher official, where I can lodge a complaint (and save my sports shoes)
Rgds
Manoj
To the best of my knowledge, CGHS is required to process the entire claim within a period of 90 days. In your case, almost 18 months have passed. I suggest that you write a ‘Registered Letter’ to the inquiring about the progress of the file. If no response is received or ambiguous response is received, you can use the ‘Right To Information’ act to your advantage.
Contact details of CGHS officials are available on the Min. of Health (CGHS) website (http://mohfw.nic.in/cghs.htm) and the CGHS Head Office where you submitted your claim.
In most cases, writing a letter to ‘Additional Director, CGHS, Your City’ would suffice.
Do keep me updated with any information that you feel I ought to include in the site.
TIA
list of area comes under cghs should be added to check the eligibility of employee
SIR,
I HAVE APPLIED FOR MEDICAL REIMBURSEMENT OF MY WIFE’S SPINAL OPERATION. IN THIS CONNECTION KINDLY GIVE DETAILS OF TAMILNADU GOVT. APPROVED RATES FOR DISECTOMY.
Approved rates for CGHS Chennai are available at: http://mohfw.nic.in/cghs.htm
Direct link: http://mohfw.nic.in/CGHS%20RATES,CHENNAI..xls
Please note that:
1. Rates are revised all the time using internal circulars and the website is hopelessly outdated.
2. A quick search within the rates file for ‘Disectomy’ didn’t turn up any results. You will have to look carefully to determine the exact name of the procedure. In case, the rate for the procedure is not mentioned, CGHS is obliged to refund you fully, since the rates are only intended to be published where a cap is applied. i.e. rates only exist for procedures where CGHS applies a limit for refund.
HTH
Sir,
My husband was suffering from cancer of larynx. he got his treatment from PGI chandigarh. Later reccurence was detected at the time of strike in PGI and we with proper permission took him to Rajiv Gandhi Cancer institute Delhi, where he recieved further treatment. When we claimed for reimbursment the amount was less than what we had paid to the hospital bills. The reason given was that we were not charged the CGHS rates by hospital authorities even though we had given the letter of reference from CGHS. Can we claim the dues from the hospital or CGHS. My husband was a class I officer from MES
Dear Mrs. Harjit,
My best wishes for your husband’s full and speedy recovery.
w.r.t. CGHS rates, currently there is a controversy regarding CGHS treatment being ‘cashless’ like private medical insurance.
The only hospitals that charge on par/below CGHS approved rates are the Central Govt. & State Govt. Hospitals. Most private hospitals that are recognised by CGHS charge more than the CGHS applied rate.
During refund, CGHS re-imburses only upto the limit they have specified. The rest have to be borne by the patient. In US, this system is called Co-Pay where the insurance company pays only upto a ceiling limit per procedure or a percentage of the cost of the treatment. This system is likely to be implemented in India by the private medical insurers too.
CGHS has been revising it’s rates annually. Most of the times the rates are not keeping in sync with the actual market conditions. Hospitals in Hyderabad-Secunderabad launched a court case against CGHS demanding fair revision of rates. As a result, not even a single Pvt. hospital in th twin cities is now recognised under CGHS.
Admissions to these hospitals can be taken under emergency. During refund, CGHS will use ceiling limits they have prescribed. Also, ‘Certificate of Emergency’ is required also with ‘Essentiality Certificate’ for expensive procedures and medicines.
Hope this helps.
I really appreciate your efforts for helping people who are struggling for there reimbursement from CGHS .
Kindly also help me …
Unfortunately my father is detected with Prostrate cancer Stage4, We came to know about this on 8th March when he complained that he has swear pain in his back we went to Rajiv Gandhi cancer hospital (Rohini - New Delhi ) which is near to our house , they did a Bone scan and detected that my father has prostrate cancer . We stayed there for Ten days where we also went under minor surgery of his testicles .
Rajiv Gandhi staff told us that if we do not go under surgery we can use the benefits of the CGHS , the moment we go for surgery from Rajiv Gandhi they will not give any benefits from CGHS to us and they will charge full money from us , as we did not had any option we blindly followed what they said and payed them all the amount in cash .
Can you pls tell me
1) Can I reimburse this money from CGHS if yes then
2) Where should I go
3) What forms and formalities I need to do ….
Thanks a Lot for the Help !!!!!
Continued ….
My father is 69 years old pensioner retired from govt Job and is a CGHS member
Dear Amit,
Step 1 would be to find out if Rajiv Gandhi Cancer Hospital under CGHS Recognized Hospital. You can contact the CMO of the CGHS dispensary that your father visits to find this out.
If the hospital is recognized under CGHS, typically you are required to obtain permission at-least 24 hours in advance of any medical procedures. Permission is not required in case the procedure was performed under emergency. However, you are then required to inform the CGHS dispensary of the treatment that your father is undergoing.
To inform CGHS, you need to write a simple letter addressed to the CMO; informing him of the medical condition and treatment in progress. Include photo-copies of all documents such as admission certificate, doctor’s prescription, medical bills, bed-heat tickets etc. The photo-copies must be attested by the doctor in-charge of treatment and manager of the hospital.
In case, the treatment happened in a non-CGHS-recognized hospital, you need to obtain an ‘Emergency Certificate’ stating that the admission and subsequent treatment was on an emergency basis and required to save the life of the patient.
The actual process of claim is similar whether the patient received treatment in CGHS recognized hospital or not. The difference lies in the fact that in case of recognized hospital, the claim file is generally honored. In case of non-recognized hospital, the claim file maybe honored only if emergency can be proven. In non-emergency cases, reimbursement is limited to CGHS discretion and will depend on how you petition the officials in the cover-letter of your claim form.
I wish you best of luck with your claim and my best wishes to your father for a speedy recovery.
sir,
i want to know whether the grandparents are covered under the list of cghs benefeciares dependent list. Is there any order or rule about that.
kindly tell me.
Hi, My mother in law is diagnosed for a liver disease and advised to go for a liver transplantation.
She is a family pensioner, (father in law was working in telecom)
1. Whether CGHS facility is available for liver transplantation treatment?
2. She is not having CGHS card, is it possible to apply for now and avail the sheme?
3. Please let me know the CGHS card application process and how to get it, how long it will take to get the card
Thanks in advance
Regards
Prabu
Hi Prabhu,
Step 1, please verify that employees of the telecom department are eligible for CGHS Membership. If your father had a CGHS card, then your mother is eligible as a pensioner.
Typical CGHS Membership documentation requires:
1. Proof of eligibility - Husband’s pension record, clearly mentioning your mother as dependent.
2. Identity Proof (Photo ID) - Voter ID / Passport / PAN Card / Ration Card with family Photo
3. Address Proof - Telephone (BSNL) / Water / Electricity Bill
Forms are generally available on all days, but accepted and returned only on specific days. Enquire with the CGHS HQ of your town/city. Please note that patient must be present at CGHS HQ during form submission.
CGHS Membership Fee can be paid either in monthly installments or one-time for life.
CGHS Membership can take upwards of a week. Don’t expect a quick turn-around.
While CGHS doesn’t deny any specific treatment to any patient, specifics like Liver Transplant etc. need prior approval. The process of prior approval is documented elsewhere in this blog.
HTH
Hello!
Can someone tell me if there is a upper limit for reimbursement of claim?My father has been running for his reimbursement for the last one year but every time he is given a new reason for non-disposal of the case.
The most recent argument is that the maximum payment for a treatment is 25,000. He had hip-replacent and the cost was approx. 70,000.
By the way, he is a freedom fighter.
I shall be grateful for inform,ation on this.
CB
Hello,
According to latest CGHS rates, “Partial Hip Replacement” is reimbursed to a max of Rs. 14000/- and “Total Hip Replacement” is reimbursed up-to Rs. 45000/-.
These rates are applicable for A-1 Cities and Semi Private Ward. Rates for other category cities will be lower. Rates for General Ward will be lower. Rates for private ward will be higher.
Reimbursement also covers hospitalisation and treatment expenses. So in case your father had Partial Hip Replacement, 25K could be a approx amount that you will receive.
Latest Rates at: http://mohfw.nic.in/CGSH%20Approved%20rates%20for%20%20A%201%20%20class%20cities.xls
Hello,
I’m a retired Himachal Pradesh Govt. employee. I got my wife treatedat Ganga Ram Hospital, New Delhi for total hip raplacement . The total expense on treatment is 2lac. H.P. Govt. employees are entitled to get reimbursement at CGHS rates. can u kindly help me to know the maximum amount which I can get reimbursed.
Dear Dr. Chaudhary,
If your wife’s treatment was performed with prior approval of CGHS, you will be eligible to receive maximum compensation as per CGHS norms.
CGHS applies a ceiling limit for all procedures, supplies and fees depending on the Class of the city where the treatment was performed.
Your Reimbursement Claim will be subject to scrutiny by auditors and the reimbursement granted as per approved rates.
In an earlier comment, you can find the link to the latest CGHS approved rates for Class A cities.
HTH
I have red all your suggessions ad ideas .it was very usefull to me
kindly guide me
I have taken reference chit from gynecologist for my wife’s pregnancy for the out of station treatment (chennai) . but for that is the temprory permit is must or only the permission letter from the office will do?
or otherwise should I take private hospital treatment with preir permission. kindly advise I in the I&B ministry dept.
Hello,
If you have received formal approval from CGHS to get your wife treated at a hospital out of your city, you only need to ensure that all respective departmental permissions are in place. A temporary permit is not required.
Temporary permit is required for CGHS Beneficiaries who move to a different city for at-least 6 months and intend to receive “regular” CGHS treatment. In your wife’s case, it’s an one-time exercise required to obtain “specialized” treatment.
Do inquire with CGHS officials and make sure that all paper-work required is in place before you leave for Chennai. Failure to do so and you could face having to pay for the entire treatment on your own and the specter of chasing CGHS later to recover your money.
HTH
HI Rajib, Thanks for the help its is such a frustrating process. Pls help me with the following. My dad was with Ministry of finance and is a rettired pensioner now he was admitted thrice to Batra hospital on May 14th to May 21st , June 6th to June 25th and then June 27th to July 16th. He was earlier diagnosed with a Lymphoma in his brain and later a systemic Lymphoma with brain involvement , now I was out of India and my sister and bro in law admitted him to Batra (recognised for cancer)and therefore did not get him referred through CGHS, I have been trying to inform CGHS for the last 2 weeks but they were asking for emergency certificate, which the doctors are refusing to give.
Is there a way for me to submit the bills without the emergency certificate ? do i need to get approval from additional director ??
Pls advise,
Thanks,
Sameer
Dear Sameer,
CGHS generally allows admission for reimbursement of treatment done in non-recognised hospital only if admitted in emergency.
However, submission of the emergency certificate is not mandatory along with the CGHS form. You can always meet with the Addl. Director and plead your case so that at-least part reimbursement can be received.
Please realize that it is totally up-to CGHS to grant/refuse reimbursement for such treatment.
HTH
What would be reimbursment for spectacle for the pay grade of Rs. 4000/- (appx.) and what would be reimbusement for hospitalisation accomodation charges.
Dear Rajib
One of our employee got admitted in emergency. he informed the doctor and also asked for an advance, doctor recommended advance. he was granted advance. When the final bill came for reimbursement, the doctors who had recommended the advance said that it was a pre planned surgery. the doctor who had operated also said it was a preplanned surgery. We are governed by CGHS rules but are not covered by CGHS. The question has come to me for decision and i want to help the employee. How the rules of CGHS can be intrepreted liberally to help the employee. We are not a CGHS city and there are no CGHS recognized private hospital in the city. The treatment was taken in a private hospital
thanks for help
Dear Rajib
Kudos to your efforts. It is much needed one for all govt. employees. I hope you will answer my queries too.
1) My wife is pregnant. We are expecting a C-section. How do i get her admitted in Private Hospital, as such there is no CGHS recognized hospitals are offering treatment for pregnancy in my city (Bangalore). Can i get admit her in private hospital and claim only CGHS rates. CGHS doctor said i should claim from my department. they have no role in that it seems. plz explian and help me.
Dear Rajib Sir,
I am sending my query for your kind advice;
I am working in central government and residing in the area not covered by any CGHS dispensaries in terms of office memorandum issued by CGHS.My son was having some ENT problem (CSOM ossicular discontinuing). On doctor’s advice he admitted in a private hospital (recognized by CGHS) for ear surgery. The Hospital is empanelled for single super specialty (ENT with specialized surgeries) by the CGHS as per their O.M..
Now, I want to file a claim for reimbursement of medical expenses incurred in connection with medical attendance and of treatment of central govt. servant and their families. Kindly advice;-
1.Whether any prior permission was required from the Head of department for treatment in private hospital (recognized by CGHS).
2.If yes, is any provision for post facto approval/permission.
3.Whether, administrations can deny to sanction the claim.
4.Please advice, if there is any circular/instruction in the matter, kindly make reference.
5.whether a central government employees and his family can obtain medical service from any private hospital recognized by CGHS of his choice.
sanjay