CGEPHIS – Central Government Employees Pensioners Health Insurance Scheme

The Central Government is ready to introduce the New Health Insurance Scheme
as in the name of CGEPHIS – Central Government Employees Pensioners Health
Insurance Scheme for Central Government Employees and Central Government
pensioners as recommended in Sixth Central Pay Commission.

The new CGEPHIS is almost a replacement for Central Government Health Scheme,
as introduction of this scheme itself recommends new recruits and pensioners
should be included in this scheme in compulsory basis. There is an option for
serving employees and current pensioners, whether they are interested or not in
joining the new scheme. Serving employees and pensioners will have one more
option to continue in both, the new scheme and CGHS.

Accordingly to this new scheme, a normal family have to pay an annual premium
of Rs.8000 to 12000 for the medical treatment which they take in the government
listed hospitals all over India. (It also says that there is government subsidy
for the premium amount which is not specifically mentioned.)

SCHEME BENEFICIARIES:

The New Scheme shall be compulsory to new Central Government Employees who
would be joining service after the introduction of the Health Insurance Scheme.

The New Scheme shall be compulsory to new Central Government retirees who
would be retiring from the service after the introduction of the Insurance
Scheme.

The New Scheme would be available on voluntary basis for the following:

Existing Central Government Employees and Pensioners who are already CGHS
beneficiaries. In this case they have to opt out of CGHS scheme. They will also
have the option of choosing both CGHS and Insurance policy. In such case the
total insurance premium has to be borne by the member.

Existing Central Government Employees and Pensioners who are not CGHS
beneficiaries but are covered under CS (MA)

MEDICAL INSURANCE COVERAGE:

In-patient benefits – The Insurance Scheme shall pay all expenses incurred in
course of medical treatment availed of by the beneficiaries in an Empanelled
Hospitals/ Nursing Homes (24 hours admission clause) within the country, arising
out of either illness/disease/injury and or sickness.

NOTE: In case of organ transplant, the expenses incurred for the Donor are
also payable under the scheme.

Pre & Post hospitalization benefit: Benefit up to 30 days Pre Hospitalization
& up to 60 days Post Hospitalization respectively which would cover all expenses
related to treatment of the sickness for which hospitalization was done.

BENEFICIARIES FAMILY SIZE:

Serving/Retired Employees: Self, Spouse, Two dependent children and up to Two
Dependent Parents. New born shall be considered insured from day one till the
expiry of the current policy irrespective of the number of members covered
subject to eligibility under maternity benefit.

Any additional dependent member in addition to above [Sr. No. 5 (1)] can be
covered under the Scheme by paying the fixed amount of premium. This additional
full premium shall be borne by the beneficiary.

BENEFICIARIES IDENTIFICATION OF FAMILY:

Beneficiaries shall be identified by a “Photo Smart Card” issued by the
insurer to all beneficiaries which would have all personal details, medical
history, policy limits etc. of the The New Scheme members. This card would be
used across the country to access Health Insurance Benefits. The photograph
embedded in the chip of the Smart Card will be taken as the proof for
determining the eligibility of the beneficiaries.

SUM INSURED AND BUFFER / CORPORATE SUM INSURED

SUM INSURED:

The Scheme shall provide coverage for meeting all expenses relating to
hospitalization of beneficiary members up to Rs. 5, 00,000/- per family per year
in any of the Empanelled Hospital/Nursing Home/Day Care Unit subject to stated
limits on cashless basis through smart cards. The benefit shall be available to
each and every member of the family on floater basis i.e. the total
reimbursement of Rs. 5.00 lakh can be availed by one individual or collectively
by all members of the family.

Entitlements for various types of wards: CGHS beneficiaries are entitled to
facilities of private, semi-private or general ward depending on their pay drawn
in pay band / pension. These entitlements are amended from time to time and the
latest order in this regards needs to be followed. The entitlement is as
follows:-

Pay drawn in pay band/Basic Pension – Entitlement

Rs. 13,950/-(up to)……………………………… General Ward

Rs. 13,960/- to 19,530/- …………………… Semi-Private Ward

Rs. 19,540/- and above ……………………… Private Ward

CASHLESS ACCESS SERVICE:

The Insurer has to ensure that all The New Scheme members are provided with
adequate facilities so that they do not have to pay any deposits at the
commencement of the treatment or at the end of treatment to the extent as the
Services are covered under the Scheme. The service provided by the Insurer along
with subject to responsibilities of the Insurer as detailed in this clause is
collectively referred to as the “Cashless Access Service.”

The services have to be provided by the Empanelled Hospitals/Nursing
Homes/Day Care Clinics to the beneficiary based on Photo Smart Card
authentication only without any delay. The beneficiaries shall be provided
treatment free of cost for all such ailments covered under the Scheme within the
limits/sub-limits of defined package rates and sum insured, i.e., not
specifically excluded under the scheme.

ENROLMENT PROCESS

The process of enrolment shall be as under:

Serving Employees:

1. Departments and offices will call for options from employees to join
voluntary The New Scheme with or without existing CGHS/CS (MA) benefits.

2. Head of Department of the Administrative Ministry/Department would be the
contact point for the Insurance Companies.

3. Enrolment forms giving details about self and family and authorization to
the department for recovery of premium on a monthly basis would be consolidated
by the Administrative Ministry / Department. The data of the beneficiary and
dependent members to be covered along with 2 recent passport size photo and copy
of enrolment form will be forwarded to Insurance Company on monthly basis.

4. Insurance Company will issue Smart Cards on the basis of information
received of the beneficiaries for enrolment.

5. Such Smart Cards along with the enrollment kit shall be sent by the
insurers directly to the insured persons at their respective mailing addresses
at insurer’s cost within 7 days.

Insurance Premium:-

The beneficiary will have to pay an annual premium which will be determined
after the formal introduction of the Scheme. It will vary according to the grade
pay of the officer. The estimated annual premium for a standard family size will
be in the range of Rs.8000 to Rs.12000 p.a. It is however proposed to be
subsidized by the Government to a considerable extent.