TREATMENT IN CASE OF EMERGENCIES

 

CGHS beneficiaries have the option to go to a nearby Government hospital / empanelled private hospital or even any private hospital, in case of emergency.

However, if treatment is undertaken at private non- empanelled hospitals under emergency, reimbursement will be limited to CGHS rates or actual, whichever may be lower. Since, non-empanelled private hospitals often charge at rates different from the CGHS rates there will be difference in the amount reimbursed if the private hospital charges are higher than CGHS rates.

 

PROCEDURE FOR EMERGENCY ADMISSIONS          

 

CGHS beneficiaries are advised that they may seek treatment in an emergency at

·       The nearest empanelled Government Hospital of their choice, for the required emergency, like Sri Jayadeva Institute of Cardiology for cardiac problems.

·       Failing the above, they may go to the nearest empanelled private hospital, where on certification by the concerned wellness centres/ nodal officer, they are expected to extend/ provide the necessary credit facility. In case the empanelled private hospital does not provide credit or beneficiary decides to pay the bill for settlement, the reimbursement shall be limited to the CGHS rates as per rules in force.

·       CGHS empanelled hospitals cannot refuse admission in emergency to CGHS beneficiary and have to provide treatment on credit to pensioner beneficiaries and other entitled categories (even if the beneficiary is from outside CGHS city/other CGHS city).

·       Individual beneficiaries may decide to use their own health insurance cards for the hospitalisation. In such cases they are eligible for “dual claim” as per rules where the first claim is made to the insurance company. A set of certified documents submitted/ issued by the insurer may then be submitted to the CGHS for reimbursement as per rules. The limitation being the CGHS rates in force, and in any case, shall not exceed the total expenditure incurred.

·       Departments may provide a letter to the concerned empanelled private hospital, through the beneficiaries, on certification by the concerned wellness centres/ nodal officers, to provide the necessary credit facility, stating that “the bills shall be paid as per rules”.

·       In case the individual cannot approach/ or is not in a position to reach an empanelled private hospital for admission, he may be admitted in an “emergency” at any hospital of his choice or as is dictated by circumstances of the emergency.

·       The bills may be submitted to the concerned department/ Wellness Centre with the detailed bills including breakup for room, laboratory, investigations, pharmacy etc. in duplicate. The same has to be accompanied by a covering letter explaining the nature of “emergency” circumstances. Please refer the MRC section of this website for further details. The new forms have to be downloaded, duly filled up and submitted.