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

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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 UOI and others [W.P.(C) 9044/2011] 

clarifying admissibility I 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 I day care I 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 I 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 I stents / grafts is reimbursable in addition to package rates 

as per CGHS ceiling rates for Implants I stents I 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 I her attendant to purchase separately the medicines I 

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.

Contd . .2/-

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d) In cases of conservative treatment I where there is no CGHS package rate, 

the above mentioned items are admissible-items wise at CGHS rates or as per 

AllMS rates (if there is no CGHS rate) or as per actual (if there is no CGHS I 

AllMS 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 I normal deliveries; and

1 day for day care I 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 I 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.

Contd...3/-

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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].

[V.P.Singh]

Deputy Secretary to Government of India