FREQUENTY ASKED QUESTIONS

MEDICAL REIMBURSEMENT CLAIMS:

1. What is the procedure for reimbursement of medical claim in CGHS?

Pensioners

You are supposed to apply within six months of discharge /

completion of treatment procedure, to CMO i/c of the Wellness
Centre, where your CGHS card is registered, along with the
following documents:

1) Medical Reimbursement Claim(MRC) forms duly filled in

2) Checklist
3) Copy of Discharge summary
4) Copy of referral / Permission slip
5) Copy of emergency certificate, if any.
6) Original Hospital bills with break-up details
7) Receipts in original
8) Copy of the valid CGHS Card
9) Copy of cancelled Cheque showing bank details for ECS
payment or mandate form if name of beneficiary is not
printed on Cheque.

Serving employees

Serving employees shall submit the medical claim to their Department/

Ministry.

MRC forms may downloaded from CGHS website- cghs.gov.in

under the heading Downloads.

Steps to download MRC forms:

i) Please type - cghs.gov.in - in the web browser and enter
Home page of CGHS website shall open
 ii) Place the cursor of mouse on the Heading ‘Downloads’ and a
list of downloadable forms appears.
iii) Click on the option MRC Forms –
Drop down list appears
1. MRC Forms for Pensioners
2. MRC Forms for Serving Beneficiaries
Choose your option and click –

Another window pops up shows the MRC Form , which may

be downloaded / printed

Link for MRC Forms for Pensioners is

https://cghs.gov.in/CghsGovIn/faces/ViewPage.xhtml?id=MTgxNA
==
Link for MRC Forms for Serving Beneficiaries
https://cghs.gov.in/CghsGovIn/faces/ViewPage.xhtml?id=MTgxNQ
==

2. Whether treatment taken in an emergency at non empanelled private

hospital reimbursable? If yes what is the procedure?

CGHS also considers reimbursement at CGHS rates in case the treatment

taken in an emergency from private non empanelled hospitals.

OM- Z.15025/79/DIR/CGHS, dated 5th October, 2016.

3. What are the guidelines for submission of MRC?

The medical reimbursement claim is to be submitted within six months of

discharge from Hospital/availing treatment. Relevant OM is available on
CGHS website at cghs.gov.in.

OM No 1-60/2007/CGHS(P)/EHS dated 1st June 2020

Link
https://cghs.gov.in/CghsGovIn/faces/ViewPage.xhtml?id=MTUzMQ==
 4. My spouse was a CGHS main cardholder. He/she was undergoing
treatment in hospital and expired. How do I get the medical claim
reimbursed?

You are supposed to apply to CMOI/c of Wellness Centre with the

following documents:

1) Medical Reimbursement Claim(MRC) forms duly filled in

2) Checklist
3) Copy of Discharge summary/Death Summary.

4) Copy of referral / Permission slip, if any

5) Copy of emergency certificate, if any.
6) Original Hospital bills with break-up details
7) Receipts in original
8) Copy of the valid CGHS Card
9) Copy of cancelled Cheque showing bank details for ECS
payment
10) Copy Death Certificate
11) Affidavit on non judicial Stamp paper of yourself being
Legal Heir and NOC from other legal heirs, if any in
favour of claimant.

In case, the claimant is eligible for receipt of family pension, they may
apply for Family Pensioner CGHS card at the office of Additional
Director CGHS of concerned City.

5. My original claim papers having bills, receipts of hospital treatment are

lost. Can I claim reimbursement on duplicate papers?

Yes, it can be claimed with affidavit on non-judicial stamp paper. The

Standard template for Affidavit may be seen in the instructions sheet
appended(Annexure –I) to MRC forms, which may be downloaded from
CGHS website- cghs.gov.in under the heading Downloads.
 Link for MRC Forms for Pensioners is
https://cghs.gov.in/CghsGovIn/faces/ViewPage.xhtml?id=MTgxNA

==
Link for MRC Forms for Serving Beneficiaries
https://cghs.gov.in/CghsGovIn/faces/ViewPage.xhtml?id=MTgxNQ
==

6. I went to Bengaluru on a personal visit and sustained fracture of leg bone.

I received treatment from a private non empanelled hospital. I will stay in
Bengaluru for another six months. Can I submit the medical claim to
CGHS in Bengaluru or should I submit the Claim papers in Lucknow,
where the card is registered?

Option is provided to CGHS pensioner beneficiaries to submit the medical

reimbursement claim in the city where treatment is taken, in Bengaluru in
your case. Additional Director, Bengaluru shall process the medical
reimbursement claim and reimburse the admissible amount to you.
However, if you so desire, the option to submit medical claim in Lucknow
is also available.

OM No Z15025/2/2023/DIR/CGHS dated 8th may 2023.

7. Are ambulance charges reimbursable?

Yes. Ambulance charges are reimbursable within the city, if there is a

certificate from the treating doctor that conveyance by any other mode
would endanger the patient’s life or would grossly aggravate his/her
condition.

OM No. S.4924/2010/CGHS (R&H)/CGHS(P), dated 17th January,

2011.

8. I have a Medi-claim Insurance Policy. Due to emergency, I took

treatment in a private hospital. Part of the expenditure has been paid by
Medical Insurance Co. Can I get the balance amount reimbursed from
CGHS?
 Yes, the Original bills are to be submitted to the medical Insurance
Company. Duplicate bills and vouchers are to be duly verified by Insurance
Company, with the Seal. A certificate is to be taken from Insurance
Company indicating the amount for which the beneficiary has
received credit from them. The duly verified duplicate bills along with
the certificate shall be submitted to CGHS enclosing the MRC forms and
other requisite documents.

These are to be submitted to CGHS by Pensioner CGHS beneficiaries

and to the Ministry/Department by serving beneficiaries.

Admissible amount is at CGHS rates, which shall be calculated on the total

expenditure incurred and the reimbursement would be considered at
CGHS rates or actuals whichever less is.

However, the total reimbursement from both sources, i.e. CGHS and
Insurance Company should not exceed actual expenditure.

OM-No. S.11011/4/2003-CGHS (P), dated 19th February, 2009.

Example

Total expenditure incurred Rs 9,00,000/

Insurance company paid Rs. 4,50,000/-

Let us say, that the Admissible amount on CGHS rates on

Rs.9,00,000/- is Rs 4,00,000/- Rs 4,00,000 /- shall be reimbursed
to beneficiary under CGHS.

However, if admissible amount under CGHS is Rs.5,00,00/- , the

reimbursement under CGHS shall be limited to Rs. 4,50,000/-

9. What are the ceiling rates for reimbursement of Expenses on purchase

of Hearing Aids?
 The revised ceiling rates fixed for various types of hearing aids (for one
ear) are as under
Digital BTE Rs.8,000/-

Digital ITC/CIC Rs.9,000/-

The cost of hearing aids shall include all taxes including GST and shall
carry 3 year warranty. The cost of Digital BTE/ITC/CIC type hearing
aid shall also include the cost of hearing aid mould/ customized shell.

OM – No S .11011 /37/2019-EHS dated 1st December 2020.

10. What are the guidelines for consideration of reimbursement over and above
the approved CGHS rates?

The requests for full reimbursement which fall under the following defined
criteria shall be examined by Directorate General of CGHS in consultation
with Expert Committee and submitted to DG, CGHS for consideration of
approval. After the recommendation of DG, CGHS, the concurrence of
Internal Finance Division and approval of Secretary, Ministry of Health &
Family Welfare are required for reimbursement in excess of CGHS rates:

1) Treatment was obtained in a private unrecognized hospital under

emergency and the patient was admitted by others when the
beneficiary was unconscious or severely incapacitated and was
hospitalized for a prolonged period.
2) Treatment was obtained in a private unrecognized hospital under
emergency and was admitted for prolonged period for treatment
of Head Injury, Coma , Septicemia, Multi-organ failure , etc.
3) Treatment was obtained in a private unrecognized hospital under
emergency for treatment of advanced malignancy
4) Treatment was taken under emergency in higher type of
accommodation as rooms as per his/her entitlement are not available
during that period.
 5) Treatment was taken in higher type of accommodation under
specific conditions for isolation of patients to avoid contacting
infections
6) Treatment was obtained in a private unrecognized hospital under
emergency when there is a strike in Govt. hospitals.
7) Treatment was obtained in a private unrecognized hospital under
emergency while on official tour to non-CGHS covered area.

OM No: Z.15025/38/2018 /DIR/CGHS/EHS dated 22nd May 2018

11. Is there any High Power Committee for consideration of representations of

CGHS beneficiaries?

A High Powered Committee for Grievance redressal of CGHS beneficiaries

pertaining to their medical claims is operational.

2. The High Powered Committee considers the grievances pertaining to the

settlement of medical claims of CGHS beneficiaries holding a valid CGHS
card at the time of treatment and to examine the requests pertaining to
approval of reimbursement under the following conditions:

a. Settlement of medical claims in relaxation of rules

b. Approval for air-fare with or without attendant on the advice of
treating doctor for treatment in another city even though he/she is
not eligible for air travel / treatment facilities are available in city of
residence
c. Representations from CGHS beneficiaries seeking full
reimbursements under special Circumstances, which are not notified

OM No: Z.15025/38/2018 /DIR/CGHS/EHS dated 22nd May 2018

12. What are the ceiling rates for reimbursement of Expenses on Cardiac Pace-
makers and other devices?
Ceiling rates for reimbursement of the cost of Cardiac pacemaker, AICD,
Combo-device, Rotablator and Aortic Stent Graft for beneficiaries of
CGHS/ CS (MA) Rules are as per the details given under:

S.No. Cardiac Device Ceiling Rate

1 Single Chamber Cardiac Pacemaker without Rate Rs. 34,840/- + GST

Response

2 Single Chamber Cardiac Pacemaker with Rate Rs. 44,928/-+ GST

Response

3 Dual Chamber Cardiac Pacemaker Rs.83,200/-+ GST

4 Bi-Ventricular Cardiac Pacemaker Rs.1,95,000/-+ GST

5 Implantable Cardioverter Defibrillator (Single Chamber) Rs.1,75,786/-+ GST

(ICD/AICD-Single Chamber)

6 Implantable Cardioverter Defibrillator (Dual Chamber) Rs. 3,75,000/-+ GST

(ICD/AICD-Single Chamber)

7 Combo Dvice (CRT-D) Rs. 4,90,000/-+ GST

8 Aortic Stent Graft (expandable, bifurcated and including Rs. 4,40,960/- + GST
delivery system)

9 Rotablator with Advancer Rs.49,920/-+ GST

10 Rotablator Burr Rs.23,920/-+ GST

13. Is there is any provision for CPAP Bi-Pap under CGHS?

There is a provision for reimbursement of cost of CPAP, Bi-PAP Machines

and Oxygen Concentrator under CGHS.

Permission to purchase CPAP/ Bi-PAP Machines / Oxygen Concentrator is

issued after approval by a Standing Committee .
Reimbursable amount
i) CPAP -- Rs.45,000/-+ GST
ii) Bi-PAP - Rs.68,000/-+GST
iii) Bi-Level Ventilatory System- Rs.1,05,000/- + GST
iv) Oxygen Concentrator - Rs.45,000/-+ GST
Note: For further clarifications on any of the aforementioned issues please
contact:

1. CGHS Helpline- 24x7 Toll Free No 1800-208-8900

2. Addl. Director (R&H) CGHS Hq, New Delhi - 011- 20863437
3. Additional Directors, CGHS of Cities – contact details are available at the
following Link

https://cghs.gov.in/CghsGovIn/faces/ViewPage.xhtml?id=NDQ5MQ==

CGHS team
Ensuring Effective
Health service
delivery