Timelines for settlement of Medical Claims under CGHS
CGHS has reviewed the Timelines for settlement of Medical Claims and prescribed time limits in compliance of the directions of Hon’ble Supreme Court of India
Government of India
Ministry of Health and Family Welfare
Department of Health & Family Welfare
Directorate General of CGHS
Office of the Director, CGHS
545-A Nirman Bhawan,New Delhi
Dated the 14th May, 2018
Subject :- Prescription of Timelines under CGHS for settlement of Medical claims of Pensioner CGHS beneficiaries
With reference to the above subject the undersigned is directed to draw attention to the OM No Z 15025/79/1/DIR/CGHS dated the 5th October 2016 and to state that it has now been decided to review the timelines prescribed for processing and settlement of medical claims of pensioner CGHS beneficiaries in compliance of the directions of Hon’ble Supreme Court of India in their Judgement in the WP(Civil) No 694 of 2015 between Shiva Kant Jha Vs UOI delivered on 13th April 2018 and in supersession of the earlier guidelines as per the details given under:
Medical Claims not requiring Special approvals
Pensioner CGHS beneficiaries shall submit the Medical claims to the CMO I/C of the CGHS Wellness Centre , where the CGHS Card is enrolled . CMO I/C of CGHS Wellness Centre issues Serial Number and sends the claim papers to the office of the Addl. Director, CGHS for processing. The Bills shall be processed by the Dealing Asstants and CMO and after the approval by the Additional Director, the bill for payment shall be sent to the Pay & Accounts Office for payment to the beneficiary by ECS. The payment shall be completed within 30 days of submission of the Medical claim papers at the CGHS Wellness Centre.
Medical claims requiring approval of higher authorities
Total time within 45 days in Delhi
Total time within 60 days in other cities
Medical Claims requiring opinion of specialists
Total time 45 days
2. chief Medical Officer in charge shall thoroughly check the papers initially for the completeness of the requisite documents before accepting the claim papers to ensure that the claim papers are not returned subsequently for want of some documents.
3. If approval of Directorate or Ministry is involved, the Addl. Directors shall submit only e-file with self-contained note and recommendation, enclosing only relevant scanned documents. Care shall be taken not to regret medical claims of pensioner CGHS beneficiaries on minor technical objections if, they fall under procedural lapses, which can be condoned.