Clarification regarding admissible / non-admissible items under CGHS

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:

Telephone charges

Toiletries

Sanitary napkins

Talcum powder

Mouth fresheners

[V.P.Singh]

Deputy Secretary to the Government of India

Source: http://msotransparent.nic.in/cghsnew/index.asp