Government of India
Ministry of Health and Family Welfare
Department of Health and Family Welfare
Nirman Bhawan, New Delhi
Dated the 1st October, 2012.
Subject: Clarification regarding admissible / non-admissible items under CGHS.
The undersigned is directed to refer to the directions given by Hon’ble High Court of Delhi in the case of Sh. Kanhiya Singh Vs UOI and others [W.P.(C)9044/2011], regarding admissibility and non-admissibility of certain items under CGHS, the following clarifications are issued:-
2. “CGHS Package Rate” means and includes lump sum cost of inpatient treatment / day care / diagnostic procedures 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 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.
3. Cost of Implants / Stents / Grants is reimbursable in addition to package rates as per CGHS ceiling rates for Implants / Stents / Grafts or as per actual, in case there is no CGHS prescribed ceiling rate.
4. 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 / equipments 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.
5. 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) for any item.
6. 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
1day for day care / Minor (OPD) surgeries.
7. However, if the beneficiary is required to stay in the hospital for his / her recovery for a period more than the period covered in the prescribed package rate, in exceptional cases, supported by relevant medical records and certified as such by the hospital, the additional reimbursement shall be limited to accommodation charges s 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.
8. The above list is however not exhaustive. Some patients may require additional facilities/ procedures, which are admissible depending upon the medical requirements as advised by the treating doctors/specialists, with proper justification. Therefore, it is not possible to indicate a comprehensive list of items, which are not admissible. However, the following items are not admissible for the purpose of reimbursement under CGHS:
Deputy Secretary to the Government of India
Permission for treatment / investigations in respect of CGHS beneficiaries availing treatment for Diabetes, Hypertension & other Cardiac Diseases, Dialysis and Cancer
Government of India
Ministry of Health & Family Welfare
Department of Health & Family Welfare
Nirman Bhawan, New Delhi
Dated the 1st October, 2012
Sub: Permission for treatment / investigations in respect of CGHS beneficiaries availing treatment for Diabetes, Hypertension & other Cardiac Diseases, Dialysis and Cancer.
The undersigned is directed to refer to the subject mentioned above and to state that at present the CGHS beneficiaries undergoing treatment for Diabetes, Hypertension & other Cardiac Diseases. Dialysis and Cancer require repeated investigations / treatment procedures over a period of time and as per the existing guidelines they are required to procure permission every time to get the prescribed treatment / investigations done at CGHS empanelled hospitals /diagnostic centres.
2. With a view to alleviate the inconvenience to CGHS beneficiaries in obtaining the requisite permission(s) every time, this Ministry has decided to permit issue of permission (referral) letters by competent authorities with a validity of six months from the date of issue of the original prescription for undergoing the prescribed treatment /investigation procedures to be conducted at the prescribed intervals over a period of six months as advised by a Government Specialist. The same permission (referral) letter shall be valid for undergoing the prescribed treatment procedures / investigations on multiple times during the six months, at intervals as advised by the Government Specialist.
Deputy Secretary to Government of India