BPS Affiliate AIOP writes

AIOP one of BPS affiliates writes :

On 22-04-2022, Sri. Pramod Kumar, Director, Pension and Pensioners' Welfare, New Delhi convened video conference to discuss exclusively the issues relating to CGHS in which Sri. Titus Philip, the General Secretary and me participated representing AIOP. We had brought to his notice several issues we are facing as regards CGHS and put forth so many suggestions such as revision rates of empanelled hospitals, non-payment of huge amount of arrears due to them, etc. Another suggestion we put forth was that CGHS Pensioner beneficiaries residing in all areas irrespective of CGHS or Non-CGHS areas may be permitted to avail treatment from ECHS empanelled HCOs under proper referral from the WC concerned and claim the reimbursement of expenses from the Addl. Director as applicable to the beneficiaries residing in Non-CGHS areas. After presenting all our suggestions, the Director asked us to send an email explaining our suggestions in detail. Accordingly we sent an email to him on the next day which is reproduced below:-

From

The General Secretary,

All India Organisation of Pensioners(Civil&Military),

Thiruvananthapuram.

To

Sri. Pramodkumar,

Director,

DoP&PW,

New Delhi.

Sir,

Sub: VC on issues relating to CGHS conducted on 22-04-2022 at 04.30 pm.

As you are aware, we participated in the above said VC called by you to discuss the issues pertaining to CGHS. We presented several issues regarding CGHS and at the end you had asked us to send an email explaining the issues pointed out by us in the VC. The major issues are explained below.

*1. Revision of rates payable to empanelled HCOs*

The rates were last revised in 2014 and it has been 8 years since the last revision. Unless the rates are revised, the empanelled HCOs may withdraw from the empanelment. Therefore action is to be taken to revise the rates suitably.

*2. Huge arrears of amount payable to empanelled HCOs.*

Apart from the lower rates fixed as early as in 2014, prompt payments are not also being made to empanelled HCOs resulting in huge arrears of amount payable to them as in the case of SK Hospital, Thiruvananthapuram where the arrears is so huge as ₹7 crore. Action is to be taken to release at least a portion of the arrears.

*3.Treatment in ECHS empanelled HCOs.*

As per OM. No.S 11011/7/99-CGHS(P) dated 27-04-2011, CGHS Pensioner beneficiaries residing in non-CGHS areas shall be eligible to obtain treatment from ECHS empanelled HCOs and submit the medical reimbursement claim to the Add. Director (para(a)(i)). According to para(a)(ii) ibid, it is necessary to obtain prior approval from the CMO of the Wellness Centre where the CGHS card is registered for obtaining treatment in ECHS empanelled HCOs in non-emergency cases. Further para(c) of the OM stipulates that a certificate from the hospital that they have not charged more than the approved ECHS rates should be submitted. As seen from the above, CGHS Pensioner beneficiaries residing in non-CGHS areas are entitled for treatment in ECHS empanelled HCOs at ECHS rates and reimbursement of the claim. In this connection we submit the following suggestions for your kind consideration.

(i)The number CGHS empanelled HCOs are much less than the ECHS empanelled HCOs and major private hospitals such as KIMS Hospital, Thiruvananthapuram, Karithas Hospital, Kottayam, Amrutha Hospital, Kochi, etc. are not empanelled under CGHS whereas these hospitals are empanelled under ECHS. To enable treatment from such major hospitals, our suggestion is that CGHS Pensioner beneficiaries residing in all areas irrespective of CGHS or Non-CGHS areas may be permitted to avail treatment from ECHS empanelled HCOs under proper referral from the WC concerned and claim the reimbursement of expenses from the Addl. Director as applicable to the beneficiaries residing in Non-CGHS areas. 

(ii) In respect of beneficiaries residing even in Non-CGHS areas, the Wellness Centres are reluctant or rather do not give referral to ECHS empanelled HCOs which is against the order contained in the OM dated 27-04-2011. Kindly give instructions to all the Wellness Centres to implement the orders.

(iii) It is learnt that there is slight difference between the CGHS and ECHS rates which can be made uniform without much difficulty. If the rates are made uniform reciprocal referral can be made from CGHS Wellness Centres to ECHS empanelled HCOs and vice versa and claim the reimbursement from the respective CGHS/ECHS Wellness Centres since in such cases, providing cashless treatment may not be possible.

(iv) For ECHS beneficiaries, once a referral is made to an empanelled HCO, a second referral is not needed for undergoing investigations suggested by the Specialist there whereas for CGHS beneficiaries a second referral for undertaking such investigations is to be taken by visiting the Wellness Centre again which serves no purpose and is a time consuming process. Our suggestion is to extend the facility available to ECHS beneficiaries in this case to the CGHS beneficiaries also.

*4. Fixed Medical Allowance(FMA) in areas where new Wellness Centre is established.*

In places like Kozhikode and Kannur Pensioners have been availing FMA in lieu of treatment facility under CGHS, since no Wellness Centre was functioning there. During 2019, Wellness Centre was established in these cities and those residing in the area covered by the Wellness Centres have become ineligible for FMA by which they automatically become eligible for CGHS facility for which there is no need of change of option. If they have to change the option already furnished, they will lose the last chance of change of option. So necessary instructions may kindly be issued not to insist for change of option for beneficiaries residing in CGHS covered areas where new Wellness Centre is established.

 *5. Special provisions for the benefit of 80+ beneficiaries*

As per OM.No.Z-16025/98/2017CGHS -III dated 11-07-2017 guidelines were issued for special provisions for the benefit of 80+ beneficiaries such as visiting doctors without standing in queue, doctors visiting them, settlement of medical claims on priority basis, etc. However, it was noticed that the special provisions envisaged in the above guidelines are not being implemented in the Wellness Centres. So strict instructions have to be issued to follow strictly the guidelines.

*6. Wellness Centre in the city of Kollam*

There is a proposal to establish a Wellness Centre in the city of Kollam, as there are numerous CGHS beneficiaries who belong to Kollam. If a new Wellness Centre is established in Kollam, it would be of great help to the aged beneficiaries in and around Kollam.

*7.Polyclinic in Thiruvananthapuram*

In Kerala, we are at present having six Wellness Centres and we have become eligible for a Polyclinic. If a Polyclinic is established referrals to private empanelled HCOs could be reduced considerably thereby saving a good amount of money. Our suggestion is to start a Polyclinic in Thiruvananthapuram.

Thanking you,

Yours faithfully,

Titus Philip

General Secretary.