1. I have a
Mediclaim Insurance Policy. Due to emergency, I received treatment in
a private hospital. Some amount was paid by Insurance Co. Can I get balance from
first the bills are to be submitted to Insurance Company. Duplicate bills
and vouchers duly verified with the stamp of Insurance Company along with a
certificate from Insurance Company indicating the amount for which the
beneficiary has received credit from them, needs to be submitted along with
the usual MRC forms and checklist. These may be submitted to CGHS by
Pensioner CGHS beneficiaries and to the department by serving beneficiaries.
Reimbursement would be done at CGHS rates or actual whichever is less.
However, the total reimbursement from both sources should not exceed
2. Why was my medical reimbursement claim returned?
· Re-submit the claim through his/her parent Wellness Centre.
· Emergency certificate/ Government/CGHS Specialist advise/ORIGINAL permission letter issued by CGHS not enclosed.
· Card copy not enclosed.
· Justification letter for delay and seeking condonation for delay not enclosed.
· Original Emergency Certificate not enclosed.
· Detailed consultation notes/ OT notes are required for examination in this case.
· Original invoice (or photocopy of invoice in case of bulk purchase duly certified by the treating specialist along with seal and stamp of the hospital) of Stent/Implant /Mesh/ costly chemotherapy drug.
· The amount claimed does not match with the total amount of bills enclosed.
· Succession Certificate/Legal heir Certificate not enclosed.
· Notarized No Objection Certificate from other legal heirs (if applicable).
· Duly filled MRC Claim form by the principal card holder is not enclosed.
· A separate claim should be submitted for each admission.
· Bank Mandate form or cancelled cheque not enclosed.
· Break up details for the consolidated bill not enclosed.
3. Why was my medical reimbursement claim not considered for reimbursement?
· Non-emergency treatment/ investigations in empaneled/ non-empaneled hospital without permission of CGHS.
· Documents enclosed are not suggestive of emergency nature of treatment.
· Medicines purchased on outpatient basis are not admissible for reimbursement
· The card holder was not a bonafide CGHS beneficiary at the time of availing emergency treatment.
· The bills do not pertain to the period of emergency (as per the enclosed documents)
· Claim towards amount spent towards non-admissible items during credit treatment at private hospital.
· The interim /running/provisional bill is not payable.