DRAFT DOCUMENT CENTRAL GOVERNMENT EMPLOYEES AND PENSIONERS HEALTH INSURANCE SCHEME (CGEPHIS)

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 DRAFT DOCUMENT CENTRAL GOVERNMENT EMPLOYEES AND PENSIONERS HEALTH INSURANCE SCHEME (CGEPHIS)

  1. NAME OF THE SCHEME: Central Government Employees & Pensioners Health Insurance Scheme (CGEPHIS).

  2. BENEFICIARIES: Applicable to all Central Government personnel, including All India Service officers (serving, newly recruited, retired/retiring) under CGHS and CS(MA) Rules.

  • Compulsory for new recruits post-implementation.

  • Compulsory for retirees post-implementation.

  • Voluntary for existing employees/pensioners under CGHS or CS(MA).

  1. TARGET GROUP: 17 lakh serving employees and 7 lakh pensioners.

  2. INSURANCE COVERAGE: a) In-patient treatment in empanelled hospitals. b) Coverage for all pre-existing conditions from inception. c) Pre-hospitalization (30 days) and post-hospitalization (60 days). d) Domiciliary hospitalization in select conditions. e) Specified Day Care procedures. f) Disabilities treatment covered. g) Maternity and newborn benefits.

  3. FAMILY SIZE:

  • Includes self, spouse, two dependent children, and two dependent parents.

  • Additional dependents allowed with extra premium.

  • Dependency defined by income threshold (Rs. 3,500 + DA).

  1. IDENTIFICATION: Through Photo Smart Cards containing medical and personal data.

  2. SUM INSURED:

  • Rs. 5 lakh per family per year (floater basis).

  • Rs. 25 crore corporate buffer.

  1. PREMIUM PAYMENT:

  • Annual premium subject to adjustment.

  • Pro-rata rates for new joinees.

  • Claim ratio-based loading.

  1. PREMIUM REFUND:

  • 90% refund on surplus after admin cost deduction.

  1. HEALTH SERVICE PROVIDERS:

  • NABH/JCI/ACHS/ISQua accredited public/private hospitals eligible.

  • Must comply with CGHS package rates and guidelines.

  1. CASHLESS SERVICE:

  • Smart Card-based authentication.

  • Pre-authorization mandatory.

  • Emergency and planned hospitalizations covered.

  1. RUN-OFF PERIOD: One-month extension post-policy for pre-authorized treatment.

  2. CLAIM REPUDIATION: Must include detailed justification and shared with all stakeholders.

  3. ENROLLMENT:

  • By insurer, with 180-day window for retirees, 60 days for employees.

  • Smart Cards issued with kits.

  • Auto-renewal unless opted out.

  1. INSURER INFRASTRUCTURE:

  • Dedicated national, zonal, and district offices.

  • Project office in Delhi within 30 days.

  1. MIS SERVICES:

  • Real-time data via secure web portal.

  • Upload to MoHFW central server.

  1. CALL CENTRE SERVICES:

  • 24x7 helpline with national toll-free number.

  • Support in English and local languages.

  1. DISPUTE RESOLUTION:

  • Beneficiary-level: District/State grievance centres.

  • Government-level: Arbitration per Indian Arbitration Act, 1996.

  1. AGREEMENTS:

  • SLAs/MOUs with insurer and intermediaries.

  • Compliance and penalty clauses.

  1. TERMINATION:

  • Rights reserved for Central Government based on performance.

  • Premium refunds and penalties apply.

  1. PERFORMANCE AND PENALTIES:

  • Time-bound deliverables enforced with penalty on premium.

  1. NODAL MINISTRY:

  • Ministry of Health & Family Welfare.

  • Coordination with Finance and Administrative Reforms.

  1. MEDICAL AUDIT:

  • Insurer to ensure audits, inspections, grievance management, and documentation.

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