The beneficiary shall submit a request in his/her office for addition of a name in the list of dependents along with required documents. The administrative department shall take a decision in view of dependency rules. The name shall be added by the concerned administrative office in the family and intimation of the same shall be sent to AMA and DGEHS branch at DHS (Head Quarters).
- First find out who is your Authorized Medical Attendant.
- Whenever you need medical attendance and /or treatment for yourself or your family, please consult your Authorized Medical Attendant first. As the Medical Attendance Rules turn round him, you will not be entitled to any reimbursement unless you consult him and proceed in accordance with the advice. You should also strictly follow the instructions laid down.
- When you go to the hospital for admission of yourself or any member of your family as in-patient, inform your being a Delhi Government servant and of your pay so as to enable the authorities of the hospital to allot to you accommodation as per your entitlement. Always keep your valid medical facility card as a proof of your DGEHS membership and your entitlement.
- Once you are admitted as in-patient in a hospital, you are bound by the rules and procedure in that particular hospital. Rules and procedure vary from hospital to hospital.
- At the time of leaving the hospital after treatment, please get the hospital bill and receipts, vouchers etc., duly signed or countersigned for the purpose of claiming refund of expenses incurred.
- In emergent cases involving accidents, serious nature of disease, etc., the patient can be admitted in a private hospital in case no Government or recognized hospital in available nearer than the private hospital and the case is one of real emergency necessitating and circumstances beyond control for such admission and treatment.
- Prefer your claims for refund of medical expenses incurred, in the relevant application form, giving full particulars call for therein and also attaching all the certificates required to be produced under the rules. This will avoid as far as possible any delay in settling your claims.
- You can draw advance of money from Government in order to enable you initially to meet expenditure on medical attendance and treatment for yourself and members of your family as per CS(MA) rules and the provisions of the scheme.
MODE OF TREATMENT
Referral system
The attached dispensary /hospital shall be the single window for taking care of health requirement of the beneficiary (Primary health care, referrals, supply of medicines etc.). The Authorized Medical Attendant (AMA) at the attached Delhi Govt. allopathic dispensary / hospital will be competent to accord permission / authorization for treatment / tests in DGEHS empanelled private hospitals / diagnostic centers. There will not be any need of permission of the concerned department from where the beneficiary is working in such cases.
The AMA for referral purposes will be the CMO/ MO of the dispensary / hospital where the beneficiary is attached. For this purpose all hospitals shall designate a officer who will function as AMA for beneficiaries attached to the hospital.
For treatment at any of the center / state government hospital / dispensary, Autonomous hospitals of center / state government, hospitals / dispensaries of other government bodies like MCD, NDMC, Delhi cantonment board etc. no referral from concerned AMA is required.
If the treating doctor feels that specialist treatment is required, the AMA may refer/authorize the patient for taking treatment at private empanelled hospitals / diagnostic centers, however, the beneficiary will have the option of availing facility of treatment / diagnostic procedures etc. in empanelled institutions of his/ her choice for the said purpose.
The referral is valid for OPD treatment for a particular disease for a period not exceeding six months from the date of issue for allopathic treatment and 40 days for treatment in ISM.. For indoor and follow up treatment in empanelled private hospitals referral from concerned AMA is required separately.
It has now been decided and Referral system has been simplified by dispensing away with the requirement of authorization for investigations, before actually undergoing these tests, which are necessary to arrive at diagnosis provided the tests have been advised by the specialist of the empanelled hospital to which the patient has been referred to by Authorized Medical Attendant (AMA) or the doctors of Government hospitals / dispensaries. The investigations must be undertaken from an empanelled diagnostic center approved for particular tests under DGEHS. Authorization for undergoing Specific operative / IPD procedure shall continue to be obtained from AMA before actually undergoing the same.
In emergent conditions beneficiary can go to any of the Govt./pvt. empanelled institution near to residence or place of illness directly without being formally referred by AMA. Cashless treatment facility in emergent conditions will be available to all working beneficiaries in empanelled private hospitals / diagnostic centers on production of valid DGEHS card. Follow up treatment subsequent to any emergent treatment / procedure or the illness shall be available on authorization of concerned AMA.
Treatment in private hospitals not empanelled under the scheme near the place of illness / trauma in medically emergent conditions will also be admissible, subject to ceiling DGEHS rates applicable as per entitlement, when treatment is necessitated in such hospitals being situated near the place of illness / trauma and when no other empanelled/government facility is available nearby or due to circumstances beyond control of the beneficiary. The genuineness of the emergent condition shall be evaluated on case to case basis. Merely getting admitted through emergency, without any justifiable emergent condition, shall not make beneficiary entitled for the benefit.
Beneficiaries residing in NCR areas outside Delhi are allowed to get treatment even during non-emergent conditions from Government Institutions and Government / CGHS empanelled centers after referral from Government institutions in concerned areas or in Delhi as per provisions of the scheme.
OPD / INDOOR / SPECIALIZED TREATMENT
Out Patient Care – The facilities in all systems (i.e. Allopathy, Homeopathy, Ayurvedic, Unani, Yoga and Sidha) can be availed at government dispensaries, government hospitals. There is no need to get authorization from AMA for treatment in any Govt. and Autonomous hospitals / dispensaries. The facilities can also be availed in private empanelled hospitals/ diagnostic centers with the prior permission of AMA as per provisions of the scheme.
Validity of the Authorization – The authorization issued by the AMA is valid for six months for a specific purpose in allopathic private empanelled hospital. Further the validity for the treatment in ISM system is for forty days only.
Indoor services in non-emergent conditions – Indoor treatment as per entitlement shall be available in private empanelled hospitals as per provision of the scheme during non-emergent conditions on the advice of the concerned AMA or on the advice of doctors of other recognized health facility duly endorsed by the concerned AMA. The concerned AMA may issue a referral / authorization to the opted private empanelled hospital / Diagnostic center for treatment on the advise of treating doctor. No claim form non- empanelled private hospital / diagnostic centers shall be entertained under any circumstances for the treatment underwent in non emergent conditions. Treatment in any central government, state government, autonomous hospital under government and any government body can be availed without referral from AMA.
Treatment in emergent conditions can be availed in any empanelled institution directly with out being formally referred by AMA. Cashless treatment facility in emergent conditions will be available to all working beneficiaries in empanelled private hospitals of Delhi on production of valid DGEHS card. However for follow up subsequent to any emergent treatment / procedure or for the illness shall be on authorization of concerned AMA and no cashless facility for follow up treatment in provisioned in the scheme for serving beneficiaries.
Treatment in private not empanelled hospitals under the scheme in medically emergent conditions will also be admissible when treatment is necessitated in such hospitals being situated near the place of illness / trauma and when no other Govt./ empanelled facility is available nearby or due to circumstances beyond the control of the beneficiary. However reimbursement shall be made by concerned department within the ceiling of DGEHS rates,
Specialized consultation and specialized treatment in private empanelled hospitals shall be available on the advice of the concerned AMA
REIMBURSEMENT OF SPECIALIZED TESTS AND TREATMENTS TAKEN
AT AUTONOMOUS HOSPITALS UNDER DELHI GOVT.
DGEHS beneficiaries on production of a valid DGEHS card can avail of treatment facilities at AIIMS and Autonomous Hospitals under GNCT of Delhi viz. Institute of Liver and Biliary sciences (ILBS), Delhi State Cancer Institute (DSCI), Institute of Human Behavior and Allied Sciences (IHBAS) and Maulana Azad Institute of Dental Sciences (MAIDS) etc. No prior permission / approval is necessary from concerned Authorized Medical Attendant (AMA) for this facility. The expenditure on treatment is reimbursed as per entitlement of the beneficiary, as per DGEHS/AIIMS rates or actual, whichever is less.
REIMBURSEMENT OF TREATMENT AT AIIMS FOR DGEHS BENEFICIARIES
The DGEHS beneficiaries possessing a valid DGEHS Medical facility card can avail treatment facilities in the ALL India institute of Medical Science for which no prior permission/approval is be necessary from concerned Department/AMA.
- The reimbursement of expenditure incurred for such treatment will be done from the concerned department as per the rates of AIIMS and as per entitlement of the beneficiary.
- Drugs prescribed by the AIIMS during OPD treatment will be obtained from concerned DGEHS dispensary on the basis of prescriptions from the specialist in AIIMS as per provisions of the scheme.
PRIOR SPECIAL PERMISSION OF DIRECTOR OF HEALTH SERVICES IS
REQUIRED FOR –
- Procurement of equipments / machines like BIPAP, CPAP, AICD, Oxygen Concentrator, Neuro-Implants, Cochlear Implant etc. Reimbursement shall be made by the concerned Head of The Department as per prevalent CS(MA) / CGHS Rules.
- Costly treatments like Liver Transplant and Bone marrow Transplant etc.
- Prior special Permission of Head of the Department is required for In Vitro Fertilization (IVF) treatment on the recommendations of Head of the Department of Gynecology of Government Hospital.
PROVISION OF MACHINES FOR BENEFICIARIES
Reimbursement of the cost of various artificial appliances (Initial Supply, replacement and repair) including the cost of Heart Pace Maker and replacement of pulse generator (except AICD), cost of replacement of diseased Heart Valves, Hearing Aids, Artificial Electronics Larynx, Knee and Hip implants, Intraocular lenses, Coronary Stents and Brain implants etc. shall be made by the concerned Head of the Department as per rules defined in CS(MA) Rules 1944 and CGHS Rules applicable at the time of procurement.
PACKAGE RATES
Package rates for allopathic treatment is defined as lumpsum cost of inpatient treatment or diagnostic procedure for which a patient has been referred by the competent authority. This include all charges pertaining to a particular treatment / procedure including admission charges, accommodation charges, ICU/ICCU charges, monitoring charges, operation charges, anesthesia charges, OT charges, procedural charges/ surgeon fee, cost of disposable, surgical charges and cost of medicine used during hospitalization, related routine investigation and physiotherapy charges etc.
Package rate does not include diet, telephonic charges, TV charges and cost of cosmetics, toiletries, tonics and medicines advertised in mass media. Cost of these, if offered on request of patient will be realized from the patient.
The Package rates for indoor treatment mentioned in rate lists are for semi-private ward. For private ward there will be increase of 15% and for general ward there will be a decrease of 10%. The implants shall be reimbursed as per actual except for the items where ceiling defined. If one or more minor treatment procedures form part of the major treatment procedure package charges would be made against the major procedure. Only half of the actual charge quoted for the minor procedure would be added to the package charges of the first major procedure.
PACKAGE RATES FOR EMPANELLED AYUSH HOSPITALS / CENTERS FOR
AYURVEDIC, UNANI, YOGA AND NATUROPATHY TREATMENT
Package rates for many treatments are defined under DGEHS. Package rate means rates for a package of treatment of standard set of procedures that are administered to the patient while undergoing treatment for a pre-diagnosed disease condition for the specified time period. This includes all charges pertaining to the particular treatment. Any OPD treatment in private hospitals not empanelled under the scheme shall not be admissible for reimbursement.
CASHLESS TREATMENT FACILITY
The cashless facilities as per entitlement in empanelled private hospitals / diagnostic centers in Delhi will be available to serving employees and pensioners in emergent conditions on production of valid DGEHS card. The cashless facilities will also be available to the pensioner beneficiaries even in non-emergent conditions on the authorization of the AMA. Cashless treatment is also available to self and dependent family members of Ministers, MLAs, Ex. MLAs and Ex. Metropolitan Councilors for routine & emergent treatments and investigations on production of valid DGEHS card in original. Credit / Cashless facility is also available to dependents of IAS (AGMUT) & DANICS officers posted on deputation / transfer to outside Delhi.
SPECIAL PROVISIONS FOR MINISTERS / MLAS / METROPOLITAN COUNCILORS /
IAS/DANICS OFFICERS AND HEAD OF DEPARTMENTS
Ministers of Govt. of NCT of Delhi, MLAs, Ex. MLAs, Ex. Metropolitan Councilors, IAS/DANICS officers in the grade pay of Rs. 7600 or above and Heads of the Departments of GNCT of Delhi are allowed to avail direct treatment from private empanelled hospitals under DGEHS with out the permission of Authorized Medical Attendants in the specialties for which the empanelled hospital is recognized for and as per entitlement.
Cashless facility is available to self and dependent family members of Ministers, MLAs, Ex. MLAs, Ex. Metropolitan Councilors of GNCT of Delhi and to dependents of IAS (AGMUT) & DANICS officers posted on deputation / transfer to outside Delhi in all empanelled hospitals in the specialties the hospitals are recognized for and as per entitlement.
SUBMISSION OF BILLS BY PRIVATE EMPANELLED HOSPITALS FOR CASHLESS TREATMENT
Such hospitals will be submitting the bills to :
| Sr.No. |
Category |
Submission of bills to |
|
1 |
Ministers of GNCT of Delhi |
General Administrative Department |
|
2 |
Ex. and sitting MLA and Ex. Metropolitan Councilors |
Delhi Legislative Assembly |
|
3 |
Retired and sitting judges of Delhi High Court |
Registrar, Delhi High Court |
|
4 |
Delhi Govt. serving employees |
Concerned Department from where drawing the salary |
|
5 |
Delhi Govt. Pensioners |
DGEHS Cell, DHS (HQ) |
|
6 |
IAS (AGMUT) & DANICS officer on deputation / transfer |
DGEHS Cell, DHS (HQ) |
- The itemized bills will have to be accompanied by the following documents (in triplicate)-
- Photocopy of valid DGEHS card of the beneficiary
- Referral/authorization from AMA or emergency certificate issued by the hospitals
concerned, as the case may be.
- Copy of Discharge / Death summary of the patient, in case of indoor treatment.
- Certificate by the hospital to the effect that
- The treatment given by the hospital has been as per entitlement of the beneficiary
and the rates charged have been as per DGEHS approved rates.
- The treatment given was absolutely essential and in accordance with CS(MA)
rules and was not cosmetic in nature.
- Photocopy of valid NABH / NABL certificates
- Stickers / invoices indicating serial number / manufacturer etc. of implants etc. as per
practice being followed under CGHS.
The bills should be item-wise and should be authenticated / verified by the beneficiary or
in case of inability / death of patient; the bills should be authenticated / verified by
the next of kin / legal heir of the beneficiary or attendant of the beneficiary.
ADMISSIBLE ROOM RENT FOR INDOOR TREATMENT
The maximum room rent to be charged by Private Empanelled Hospitals for different categories is as under
General ward Rs. 1000 Per day
Semi Private ward Rs.2000 Per day
Private ward Rs.3000 Per day
Room rent is applicable only for treatment procedures for which there are no prescribed package rates.
FREE SUPPLY OF DRUGS PRESCRIBED BY DOCTORS OF GOVERNMENT
DISPENSARIES AND HOSPITALS-
In case of chronic illnesses requiring prolonged treatment, medicines may be supplied for one month at a time. However, in case of senior citizen beneficiaries with chronic conditions, requiring prolonged treatment, the same may be dispensed up to three months also on the decision of AMA. The medicines to the beneficiaries shall be provided by the concerned attached dispensary / hospital. If, any medicine is not available in hospital / dispensary, the same dispensary / hospital authorities shall supply it to the eligible beneficiary if it is not possible, the beneficiary would be allowed reimbursement of such medicines.
MEDICAL ADVANCE
The heads of the departments of Delhi Government are competent to sanction medical advance to the extent of 90% of the estimated cost of treatment for major / serious illnesses in accordance with the provisions of CS(MA) Rules 1944. Medical advance may be issued by the concerned HOD on production of copies of valid Medical card, Estimate provided by Government / Private empanelled Hospital, OPD card and an application for the same.
SETTLEMENT OF MEDICAL CLAIMS
For the settlement/reimbursement of medical claim the beneficiary should submit an application to the concerned department for claiming reimbursement of medical expenditure and settlement of any advance. The claim should be filed within 3 months of discharge from the hospital / treatment taken. The application should be submitted along with the following documents-
- Covering letter/self representation by the beneficiary
- Modified Medical claim Form 2004 and checklist for reimbursement.
- Summary of medical bills claimed.
- All original bills
- Photocopy of Valid DGEHS Medical card
- Prescription slip and diagnostic reports.
- Non Availability certificate from concerned AMA for drugs prescribed in OPD by private empanelled or Government hospital.
- Discharge Summary (For admitted patients)
- A detailed list of all medicines, Laboratory tests, investigations, No. of doctor visits etc. with dates.
- In case treatment is taken in emergency, a self explanatory letter from the beneficiary, explaining the emergency circumstances. Emergency treatment certificate from the concerned hospital must also be submitted.
- Photocopy of cheque of bank account to which online transfer of money is preferred.
- Photocopies of claim papers and an affidavit on stamp paper, in case original papers have
been lost.
- Affidavit on stamp paper by claimant, no abjection from any other legal heirs on stamp paper and the copy of death certificate, in case of death of the card holder.
Note – There is no need for essentiality certificate signed by the treating doctor to be submitted
for the reimbursement of medical claim.
Such reimbursement is restricted to the limits prescribed by the Government from time to
time. The expenditure incurred in excess of the limits prescribed in CS(MA) Rules / CGHS
guidelines has to be borne by the beneficiary himself. For the items non-admissible as per
CS(MA) Rules / CGHS guidelines the expenditure thereof shall be borne by the beneficiaries
themselves. There will be no reimbursement for these items.
GUIDELINES FOR EXAMINATION OF MEDICAL CLAIMS
- They should go to their attached AMA for treatment; Prior permission/authorization from
AMA is required for taking treatment in private empanelled hospitals under DGEHS.
There is no requirement of permission from concerned Head of the Department.
- If they are advised by the AMA for some specialized treatment from Referral/Private
empanelled hospital, they should take authorization form from the concerned AMA
which is to be handed over to the private empanelled hospital for treatment.
- No permission/authorization is required for treatment from Central/State Government
hospitals and hospitals under other Government Bodies. If teats/investigations are carried
out privately by DGEHS beneficiary on the advice of a Government specialist no
referral is required from AMA. The tests should be carried out from a empanelled laboratory only.
- The claims are to be preferred within 3 months period from the date of discharge from the
hospitals / treatment taken. If the claim becomes time barred, then request for
condonation of delay may be made to the Department concerned. Power has been
delegated to all Head of the Departments for the condonation of delay. Period of three
months for submission of medical claim should strictly be followed.
- The admissible amount should be worked out on the basis of beneficiary’s entitlement.
- The expenditure incurred for purchasing medicines from open market while getting OPD
treatment are not reimbursable without taking Non-availability certificate from AMA.
- Cost of all medicines are reimbursable in full except preparations classified as food,
tonics, vitamins, disinfectants, cosmetic, antioxidants, disinfectants, toilet preparation etc.
- Blood transfusion charges are reimbursed in full, subject to certification by the treating
physician that the specific blood group was not available in the hospital, and the charges
for blood are comparable with the rates of Red Cross, State/Central Govt. hospitals.
- Medicines prescribed for outdoor treatment is reimbursable only after taking Non-
availability certificate from concerned AMA.
- Expenditure on investigations and tests done in Government hospital/
referral hospital / recognized hospitals may be reimbursed, if such tests/investigations have been done on
the advice of the specialist of Government / private empanelled hospitals provided the
patient has been referred to private empanelled hospital by AMA.
- In cases where the claim pertains to treatment taken in a private empanelled hospital in
emergent condition with out referral the case should be sent to concern Head of the
department for examining and taking a decision in the matter i.e if the treatment is taken
in emergency from the Private Empanelled hospital, for granting the ex post facto
approval for DGEHS beneficiaries, the power is delegated to the Head of the Department
- If a Delhi Government employee is admitted in a hospital before retirement and is
discharged from there after his superannuation medical claim will be reimbursed
from his own office.
- If a Delhi Govt. employee or a member of his family covered under DGEHS falls ill at
a place not covered under DGEHS, the treatment can be taken from Government /
Government empanelled hospitals. The Reimbursement will be at DGEHS / CGHS /
AIIMS rates or actual whichever is less.
PAYMENT/REIMBURSEMENT TO MEDICAL EXPENSES TO THE DELHI GOVT.
PENSIONERS FROM TWO SOURCES VIZ. FROM THE INSURANCE COMPANIES
AND THE DGEHS
The beneficiaries who have subscribed to Medical Insurance Policies in addition to
availing DGEHS facilities may be allowed to claim reimbursement from both the sources subject
to the condition that the reimbursement from such sources not exceeds the total expenditure
incurred by the beneficiary on the treatment. The beneficiary will make the first claim to the
insurance company and the second claim to the DGEHS or the department concerned. The
medical claim against the original vouchers / bills would be raised by the beneficiary first on the
insurance company, which would issue a certificate indicating the amount reimbursed to the
DGEHS or Head of the Department concerned. The insurance company will retain the original
vouchers / bills in such cases. The beneficiary would then prefer his / her medical claim along
with photocopies of vouchers / bills duly certified in ink, along with stamp of the insurance
company on the reverse of the vouchers / bills to the concerned organization. Reimbursement
from DGEHS or Department concerned will be restricted only to the admissible amount as per
approved package rates subject to the condition that the total amount reimbursed by the two
organizations does not exceed the total expenditure incurred by the beneficiary.
FREQUENTLY ASKED QUESTIONS
1. What is this ‘Delhi Government Employees Health Scheme’ all about?
Delhi Government Employees Health Scheme is a welfare scheme of Delhi Government to provide comprehensive medical facilities to the eligible Delhi Government employees and pensioners, Ministers, Ex and sitting MLAs, Ex Metropolitan Councilors and Retired and sitting Judges of Delhi High Court, on the pattern of Central Government Health Scheme on the basis of contribution by the beneficiaries.
2. Who can become the member of the scheme?
- All Delhi Government working and retired employees (including family pensioners)
and their dependent family members (As per CS (MA) rules are eligible for becoming the
member of Delhi Govt. Employees Health Scheme.
- The family pensioners are also eligible to become the members of the scheme.
- Ministers, MLAs, Ex. MLAs, Ex. Metropolitan Councilors of GNCT of Delhi.
- Judges and Ex. Judges of Hon’ble High court of Delhi
- The membership of the scheme is compulsory for all employees.
- The membership of the scheme for pensioners is optional. Employee at the time of
retirement can opt for the scheme by depositing the contribution in lump sum or in annual
installments. Deposition of lump sum contribution equal to ten years contribution shall
make the pensioner and dependents beneficiary for the life term. The contribution to be
paid is calculated on the basis of the prevalent monthly rates of contribution applicable.
- Retiring officers of Indian Administrative Service/Indian Forest Service of AGMUT
cadre, officers of DANICS/UTCS cadres including their family pensioners can also opt
for the scheme. IAS & DANICS officers on deputation outside Delhi can also opt for the
scheme as per provisions of the scheme.
- Autonomous/statutory bodies fully funded by Delhi Govt. may opt for Delhi Government
Employee Health Scheme.
- The benefits of the scheme are prospective in nature i.e. from the date of becoming the
member.
- The pensioners have the option either to opt the scheme or opt the fixed medical
allowance at the time of retirement.
3. From where the Medical Facility card will be issued to me?
| Sr.No. |
Category |
Submission of bills to |
|
1 |
Ministers of GNCT of Delhi |
General Administrative Department |
|
2 |
Ex. and sitting MLA and Ex. Metropolitan Councilors |
Delhi Legislative Assembly |
|
3 |
Retired and sitting judges of Delhi High Court |
Registrar, Delhi High Court |
|
4 |
Delhi Govt. serving employees |
Concerned Department from where drawing the salary |
|
5 |
Delhi Govt. Pensioners |
Concerned Department from where retired |
|
6 |
IAS (AGMUT) & DANICS officer on deputation / transfer |
DGEHS Cell, DHS (HQ) |
4. What are the rates of subscription of the scheme?
| Sr.No. |
Grade pay drawn per month |
Rate of monthly Subscription |
|
1 |
Up to Rs. 1,650 |
Rs.50.00 |
|
2 |
Rs.1,800, Rs.1,900 and Rs.2400,
Rs.2,400 and Rs.2,800 |
Rs.125.00 |
|
3 |
Rs.4,240 |
Rs.225.00 |
|
4 |
Rs.4,600, Rs.4,800 Rs.5,400 and
Rs.6,600 |
Rs.325.00 |
|
5 |
Rs.7600 and above |
Rs.500.00 |
Contribution shall be recovered from the monthly salary bills. Pensioners / Family pensioners
shall pay contribution at prevalent rates equal to ten years contribution in lump sum.
5. I am a pensioner and did not opt for the scheme at the time of retirement. Whether
now can I join the scheme?
Yes, the scheme is open ended now and a eligible pensioner can become member of the scheme at any time by paying in the requisite contribution, as applicable on the date.
6. I have deposited a lump-sum of 60 months contribution before the modified scheme
was notified in 2003. Will I be getting the medical benefits?
For those pensioners who have deposited 60 months contribution as per the provisions of the scheme before 2003, the medical facilities will be provided to such pensioners under the scheme on life long basis.
7. My spouse is also in service, whether he/she can also avail the benefits?
As per CS (MA) rules in Case spouse of employee is also Govt. servant then if only one of
the spouses wants to avail the benefits of the scheme, the other spouse being considered
dependent for the purpose of medical benefits may be beneficiary provided he/she is not
getting any type of medical benefit/allowance in this regard from his/her office. A joint
declaration in this regard that both of them will be getting the benefits under the scheme
may be obtained from them while issuing the membership/health card.
8. Whether the scheme is applicable to the employee where medical allowance is being
given?
No, dual benefits are not allowed under the scheme.
9. Is the scheme benefits available to pensioners residing outside Delhi also?
Yes Beneficiaries residing in NCR areas outside Delhi are allowed to get treatment even
during non-emergent conditions from Government Institutions and Government / CGHS
empanelled centers after referral from Government institutions in concerned areas or in Delhi as
per provisions of the scheme.
10. What are the hospitals recognized under the scheme?
All health facilities (hospitals/dispensaries) run by the Govt. of NCT of Delhi and
autonomous bodies under Delhi Government, local bodies viz. MCD, NDMC, Delhi Cantonment
Board, Central Government and other Government bodies [such as AIIMS, Patel Chest Institute
(University of Delhi) etc. are recognized under the scheme. In addition, some Private
Hospitals/Diagnostic centers notified from time to time are also empanelled/ empanelled as
referral health facilities.
Beneficiaries residing in NCR areas outside Delhi are allowed to get treatment even
during non-emergent conditions from Government Institutions and Government / CGHS
empanelled centers after referral from Government institutions in concerned areas or in Delhi as
per provisions of the scheme.
DGEHS may not have any agreement with all CGHS empanelled institutions in NCR
therefore the CGHS empanelled hospitals may charge more but reimbursement shall be restricted
to ceiling DGEHS rates.
11. Do I need a referral to avail treatment facilities in these hospitals?
For treatment at any of the center / state government hospital / dispensary, Autonomous
hospitals of center / state government, hospitals / dispensaries of other government bodies like
MCD, NDMC, Delhi cantonment board etc. no referral from concerned AMA is required.
The attached dispensary /hospital shall be the single window for taking care of health
requirement of the beneficiary .The Authorized Medical Attendant (AMA) at the attached Delhi
Govt. allopathic dispensary / hospital will be competent to accord permission / authorization for
treatment / tests in DGEHS empanelled private hospitals / diagnostic centers. There will not be
any need of permission of the concerned department from where the beneficiary is working in such cases.
12. Whether referral is necessary for investigations advised in OPD by empanelled
private hospital or government institutions?
Referral system has been simplified by dispensing away with the requirement of
authorization for investigations, before actually undergoing these tests, which are necessary to
arrive at diagnosis provided the tests have been advised by the specialist of the empanelled
hospital to which the patient has been referred to by Authorized Medical Attendant (AMA) or
the doctors of Government hospitals / dispensaries. The investigations must be undertaken from
an empanelled diagnostic center approved for particular tests under DGEHS. Authorization/
Referral for undergoing Specific operative / IPD procedure shall continue to be obtained from
AMA before actually undergoing the same.
13. Are there any credit facilities for the beneficiary under the scheme?
The cashless facilities as per entitlement in empanelled private hospitals / diagnostic centers in
Delhi will be available to serving employees and pensioners in emergent conditions on
production of valid DGEHS card. The cashless facilities will also be available to the pensioner
beneficiaries even in non-emergent conditions on the authorization of the AMA. Cashless
treatment is also available to self and dependent family members of Ministers, MLAs, Ex. MLAs
and Ex. Metropolitan Councilors for routine & emergent treatments and investigations on
production of valid DGEHS card in original. Credit / Cashless facility is also available to
dependents of IAS (AGMUT) & DANICS officers posted on deputation / transfer to outside
Delhi.
14. Where should I deposit my medical reimbursement bills?
| Sr.No. |
Category |
Submission of bills to |
|
1 |
Ministers of GNCT of Delhi |
General Administrative Department |
|
2 |
Ex. and sitting MLA and Ex. Metropolitan Councilors |
Delhi Legislative Assembly |
|
3 |
Retired and sitting judges of Delhi High Court |
Registrar, Delhi High Court |
|
4 |
Delhi Govt. serving employees |
Concerned Department from where drawing the salary |
|
5 |
Delhi Govt. Pensioners |
Concerned Department from where retired |
|
6 |
IAS (AGMUT) & DANICS officer on deputation / transfer |
DGEHS Cell, DHS (HQ) |
15. Who is a competent authority to sanction advance?
The heads of the departments of Delhi Government are competent to sanction medical
advance to the extent of 90% of the estimated cost of treatment for major / serious illnesses in
accordance with the provisions of CS(MA) Rules 1944. Medical advance may be issued by the
concerned HOD on production of copies of valid Medical card, Estimate provided by
Government / Private empanelled Hospital, OPD card and an application for the same.
16. Is there any provision of change of dispensary / hospital to which I am attached?
Change of dispensary / hospital is not allowed ordinarily except in case of change of
residence of the card holder, opening of new health facility or any other valid reason to the
satisfaction of card issuing authority. In case of any justified reason necessitating change of
dispensary / hospital, the beneficiary should submit an application in duplicate to the card issuing
authority together with DGEHS Medical Facility Card. The card issuing authority shall make
entry in the appropriate column. The beneficiary then shall submit request to the Officer I/C of
the old dispensary / Hospital, who will make entry in his records and then handover the index
card to the card holder with the direction to hand over the index card to the Officer I/C of new
dispensary / hospital and shall retain a photocopy of the same in record.
17. How can I procure machines / equipments under the scheme?
Reimbursement of the cost of various artificial appliances (Initial Supply, replacement
and repair) including the cost of Heart Pace Maker and replacement of pulse generator (except
AICD), cost of replacement of diseased Heart Valves, Hearing Aids, Artificial Electronics
Larynx, Knee and Hip implants, Intraocular lenses, Coronary Stents and Brain implants etc. shall
be made by the concerned Head of the Department as per rules defined in CS(MA) Rules 1944
and CGHS Rules applicable at the time of procurement.
18. Whether any prior special Permission is required for treatment / equipments –
Prior permission of Director Health Services / HOD is required in following cases:
- For Procurement of equipments / machines like BIPAP, CPAP, AICD, Oxygen
Concentrator, Neuro-Implants, Cochlear Implant etc. Reimbursement shall be
made by the concerned Head of The Department as per prevalent CS(MA)/
CGHS Rules
- Prior special Permission of Director of Health Services is required for Costly
treatments like Liver Transplant and Bone marrow Transplant etc.
- Prior special Permission of Head of the Department is required for In Vitro
Fertilization (IVF) treatment on the recommendations of Head of the Department
of Gynecology of Government Hospital.
Note – The above description is brief and general information about the scheme. For further details refer various office orders issued from time to time about the scheme.
IMPORTANT LINKS
FOR ANY INFORMATION AND SUGGESTION CONTACT
Dr. Virender Kumar Medical Officer
Dr. P.K. Malik, CMO (SAG) - State Program Officer
Ph. No. - 22391435
Local Services 