27 February 2011

Conditions for reimbursement of medical fee in Private Hospitals

General Concepts of Medical Rules

Employees and their family members are entitled to reimbursement for medical attendance and treatment.

3 Categories of Hospital facilities are admissible for employees.
  • CGHS Hospitals.
  • Recognized Private Hospitals.
  • Private Hospitals (Other than Recognized).

What are the Medical facilities available for reimbursement ?

In India

  • Operation for sterilization.
  • Treatment of sterility
  • Venereal diseases and Delirium Tremens
  • Avitaminosis and Hypovitaminosis.
  • Correction of eye.
  • Treatment for immunizing and prophylactic purposes.
  • Diseases causing General debility and secondary anemia.
  • Confinement including at residence if attended by Child Welfare and Maternity Centres staff; Pre-natal and Post-natal Treatment.
  • Testing of eyesight for glasses for employees only.
  • Blood and blood transfusion charges.
  • Dental Treatment
  • Anti-rabic treatment
  • cost of hepatitis Vaccine B, C & D.

Outside India

  • Cardio Vascular Surgery
  • Kidney transplant
  • Other organ transplant
  • Joint replacement and surgery
  • Bone-marrow transplant
  • Certain types of medical and ontological disorder, such as leukemia and neoplastic conditions.
  • Micro vascular surgery and neuro surgery.
  • Treatment with Laser which obviates the need of open surgery.
  • Treatment with laser which obviates the need of open surgery.
  • Extra corporeal stone disintegration by ultrasonic shock waves.

What are the recognized Hospitals for Medical Treatment ?

  • All State Government Hospitals including District Hospitals and Municipal Hospitals
  • All Hospitals recognized by primary health centres and dispensaries recognized by state government for treatment of their employees and or members of their family.
  • All maternity and child welfare centres with facilities for indoor treatment and recognized by state government.
  • Cantonment hospitals in cantonment areas where there are no government hospitals.
  • All railway hospitals
  • All Government hospitals recognized by state government / CGHS rules / CS(MA) Rules
  • Hospitals funded by Central / State government.
  • Pay clinics in Bihar, Punjab , Haryana, UP ,MP, Rajasthan and Chandigarh.

How to Get medical Reimbursement when treated in a Private Hospital ?

An employee has to go to nearest CGHS or Government hospital for treatment. But in some emergency cases they may be forced  to go to nearby Private hospital which may not be a recognized hospital.
In such cases the employee has to obtain an emergency certificatefrom the doctor of this private hospital. In this emergency certificate,  the reason for choosing the private hospital should be specified and it should be duly signed by the doctor.

How much  amount can be reimbursed for medical treatment for employees ?

There is no limit for the reimbursable amount. Full amount for the medicines will be reimbursed and for other expenses including lab tests, scanning, operation, doctors fee etc specific rates approved according to CS(MA) rules will be given.



Who are eligible for medical reimbursement ?

  • Central Government employees.
  • Dependant family members of employees.

Who are the Dependant Family Members eligible for Medical Reimbursement ?

  • Husband / Wife
  • Parents / Stepmother
  • For female employee, either her parents or parents-in-law.
  • Children including adopted children.
  • For unmarried son, Till he starts earning or attains the age of 25.
  • For Daughter, Till she starts earning or gets married.
  • No age limit for  son suffering from permanent disability.
  • Widowed daughters and dependent divorced / separated daughter.
  • Sisters including unmarried / divorced / abandoned or separated from husband / widowed sister irrespective of age limit.
  • Minor brothers.

Forms required for Medical Reimbursement 

What are the things to remember when claiming for Medical Reimbursement ?

  • Forms selected are correct or not.
  • All the certificates are duly signed by the Doctor.
  • Seal of the hospital is included in all the bills and the certificates.
  • In case of Private hospital, emergency certificate is also present.
  • If insurance policy is also claimed, then total reimbursement should not exceed the total expenditure.