Next Topic WHAT IS F.R. & S.R.? GENERAL CONDITIONS OF SERVICE
DELHI GOVERNMENT EMPOYEES HEALTH SCHEME(DGEHS)
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| DELHI GOVERNMENT EMPOYEES HEALTH SCHEME (DGEHS) |
Delhi Government Employees Health Scheme (DGEHS) was launched in April 1997 with a view to provide comprehensive medical facilities to Delhi Government employees and pensioners and their dependants on the pattern of Central Government Health 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. The scheme has been modified for the benefit of beneficiaries vide Office Memorandums dated 06.10.2003, dated 21.2.2005, dated 25.10.2007, dated 28.07.2010, 31.01.2012 and 27.04.2012.
It is a
welfare scheme with the objective to provide comprehensive medical care
facilities to the Delhi Government employees/ pensioners and members of their
families on the lines of CGHS.
Comprehensive
health Care services to employees and pensioners of Delhi Government through
network of Delhi Government dispensaries, Hospitals and Govt./Private
empanelled Hospitals and Diagnostic Centers.
It is based
upon CGHS pattern
All Hospitals/Dispensaries under Delhi Govt., its autonomous bodies and under local self Governance Bodies (viz. Municipal Corporation of Delhi, New Delhi Municipal Council and Delhi Cantonment Board) are recognized for the purpose of medical attendance. Under the scheme it is envisaged to empanel Private Hospitals and Diagnostic Centers in addition to already existing Government facilities for the beneficiaries for availing hospital care and diagnostic facilities. These Private Hospitals/ Diagnostic centers are also envisaged to provide cashless facility in case of medical emergencies to the beneficiaries.
Membership is compulsory for all eligible serving employees of GNCTD and for retired employees they have to opt the scheme or Fixed Medical Allowance at the time of retirement.
Each beneficiary (employee/pensioner) to get attached to Delhi Government Allopathic Dispensary/ Hospital and that would be his/her AMA for all the purpose
The need for
Authorization/Referral for entitled treatment for self and dependent family
members in private recognized hospitals for all subscribers/beneficiaries of
DGEHS is not required for serving employees and pensioner beneficiaries vide
O.M dated 17/08/15
Benefits of the scheme are prospective in nature.
• Treatment facilities – cashless facility for
all beneficiaries during emergency in empanelled private hospitals, and for
pensioners’ cashless facility is available even in non emergent
conditions.
• Treatment facility to beneficiaries residing outside Delhi/NCR or while travelling from any govt./govt. empanelled hospital subject to approved rates of CGHS
FACILITIES TO MEMBERS
The following
facilities are being provided to the beneficiaries through the recognized health
facilities under DGEHS i.e Govt. dispensaries/ hospitals & Private
empanelled hospitals:
•
Out Patient care facilities in all systems.
•
Emergency services in Allopathic system
•
Free supply of necessary drugs
• Lab. and Radiological investigations
•
Super specialty treatment i.e. Kidney
transplant, CABG, Joint replacement etc.
•
Family Welfare Services
•
Specialized treatment/Diagnosis in hospitals,
both in Govt. and private empanelled hospitals /Diagnostic centers under DGEHS.
FACILITIES NOT ADMISSIBLE FOR PENSIONERS
•
Treatment outside India.
•
Administration of routine injections,
dressing at one’s residence
•
Orthodontic treatment.
•
Treatment for obesity due to indigenous
factors.
ELIGIBILITY
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 scheme has been made open ended i.e the
pensioner can become the member of the scheme at any time.
DEFINTION OF FAMILY
•As per CSMA rules/CGHS Guidelines for Serving
Employees “Family” means
•Husband or wife as the case may be
•Wholly dependant Parents(excluding step
parents)
• In case of adoption, adoptive parents &
not real parents.
• If adoptive father has more than one wife,
only the first wife.
• Wholly dependent/minor children, including
adopted children (Unmarried son- up to age limit of 25 yrs,
•Unmarried daughter & widowed/divorced daughters without any age limit.
Sisters unmarried/ widowed/divorced/abandoned or separated from their husband irrespective of any age.
• Step children.
• Step mother wholly dependant on the govt.
servant.
• Brothers – Minor however permanent disabled
dependent brother irrespective of any age limit provided he is unmarried, not
having his own family and residing with the principal CGHS cardholder
beneficiary.
•
Minor children of widowed/separated daughters
dependant on CGHS beneficiary and normally residing with him, eligible up to
the age of 18 years.
• A member of the family shall be deemed to be dependant only if his/her income from all sources including pension is less than Rs.9000/- p.m. plus amount of dearness relief on pension on the date of consideration.
•
The dependant members should be normally residing with the govt.
Servant. However as an exception,
parents can live away from the employee in another station with other members
of the family.
• A female government servant has the choice to either include her parents or her parents-in-laws for availing the benefits under these rules. She can however change her option only once during the entire period of service
•
The female government employee should
immediately after her marriage give a declaration as to whether she should like
to include her parents or parents-in-law
for the purpose of availing benefits under this scheme
Government employees(both male & female) on marriage to give a joint
declaration of their option indicating the details in r/o each member of family
as considered sufficient in respect of whom the claim is to be preferred by the
spouse concerned.
•
A copy of the declaration may be retained by the office of each spouse
•
It is permissible to change the declaration as often as the
circumstances require taking into account the change of place of posting.
•
Judicially separated wife is entitled to receive the medical concessions
admissible under the rules even if she is in receipt of maintenance allowance.
AGE LIMITS OF DEPENDANTS
•
Son up to the age of 25 years or gets married or starts earning.
•
Daughter till she starts earning or gets married whichever is earlier
irrespective of age.
•
Sons suffering from any disability(physical or mental) without any age
limit.
•
Dependant divorced/abandoned or separated/
widowed daughters and sisters without any
age limit.
•
Minor brothers up to the age of becoming a major.
•
DISABILITY
•
Disability means:-
•
Blindness
•
Low vision
•
Leprosy –cured
•
Hearing impairment
•
Locomotor Disability
• Mental Retardation or Mental illness
RATES OF SUBSCRIPTION
CONTRIBUTION BY PENSIONERS
• Pensioners/Family pensioners have an option
to get the membership of the scheme and get their DGEHS Pensioner card made by
paying a lump sum amount equivalent to 10 years contribution as due on the date
of becoming life time member of the scheme. The beneficiary is not covered
under the scheme during the period for which contribution has not been paid.
The scheme has been made open ended for the pensioners i.e. the Pensioners who
are not members of the scheme can opt for scheme at any stage by paying contribution
at the prevailing rates.
• The subscription fees deposited by the
pensioner and its validity shall be clearly mentioned on the card.
• Entitlement of ward for Indoor Treatment
• Entitlement of ward for Indoor Treatment in
AIIMS
MODE OF TREATMENT
• In emergent conditions beneficiary can go to
any of the Govt./pvt. empanelled institution near to residence or place of
illness. 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.
• 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.
SPECIAL PERMISSION
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.
PROVISION FOR 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.
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.
TREATMENT IN UNANI/AYURVEDIC
•
As per provisions of DGEHS, advise of govt. ayurvedic doctor is required
before taking treatment in ayurvedic empanelled hospitals. No
authorization/opinion of AMA required for getting treatment in any empanelled
private AYUSH hospital for the procedure listed in DGEHS/CGHS list.
• 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 diagonsed disease condition for the specified time period.
•
The package rates which are specified for diagonsed diseases/conditions
should strictly be adhered.
• Procedures other than the package rates which is not mentioned under package rates will be considered as per list and the treatment should not exceed 34 days for ayurveda and 28 days for yoga and naturopathy.
•
No additional charge on account of extended period shall be allowed if
that extension is due to any improperly conducted procedure.
• Reimbursement for treatment/procedure for which prescribed rates have not been indicated will be charged as per actual
•
Procedure/treatment given outside the list will be discouraged, if justification
is not given for doing outside procedure
ADVANCES FOR MEDICAL TREATMENT
•
Head of Office/Head of Department may grant advance to govt. servant to
enable them to meet the expenditure on medical attendance and treatment.
•
Advance up to 90% of the estimated cost of all indoor treatments as per
the CGHS/DGHS approved package rates irrespective of major or minor diseases.
• A certificate has to be given by the treating physician of a government or private empanelled hospital of the estimated cost of the treatment.
•
For outdoor treatment 90% of the estimated expenditure can be sanctioned
subject to the condition that the total estimated expenditure for treatment
including tests/investigations is more than Rs.10000/-
• The advance should be paid directly to the hospital concerned on receipt of an estimate from the treating physician/MS of the hospital.
•
For settlement of advance, the govt. servant may be required to submit the adjustment bill
within a period of one month from the date of discharge from the hospital
• In case of non-utilization of entire advance HOO concerned will correspond with the hospital for refund of the unutilized balance.
•
In case of serious illness/accident when a govt. servant is unable to
apply for the advance, the advance may be sanctioned on the basis of application made in his behalf by the wife
of the employee or other legal heir in writing
TIME LIMIT FOR SUBMISSIONS OF BILLS
• The final claim for reimbursement of medical expenses in r/o a particular spell of illness should ordinarily be preferred within 03 months(now 06 months) from the date of completion of treatment and should be supported with regular vouchers/cash memos.
• Head of the Department may condone the delay in deserving cases subject to the condition:-
- That each case will be considered on its merits and the controlling authority may reject the claim when it is not convinced of the reasons of delay involved in the submission of claims.
- That the treatment has been obtained from authorized medical attendant/ recognized hospital/dispensary/clinic
MISCELLANEOUS
• Card validity, ward entitlement and details of subscription amount deposited in case of pensioners should be clearly mentioned on the card.
• In case of loss of health card the issuing department shall issue duplicate health card on receiving an application, a copy of FIR / Complaint lodged with police regarding loss of health card, payment of Rs. 10 for issue of duplicate card and two latest family photographs of the beneficiary.
DGEHS beneficiaries on production of a valid DGEHS card can avail 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.
Dental treatment has been allowed in private empanelled dental centres and hospitals empanelled for dental facility without referral for the procedures listed in CGHS/DGEHS list w.e.f 28/08/2017.
The condition of obtaining prior advice/ referral of a govt. Dental Specialist has been done away with vide above mentioned circular
Non availability certificate is generally issued for one month, however in chronic diseases it can be issued up to three months at a time on valid prescription.
Ambulance charges are reimbursable within the city, if there is a certificate from treating doctor that conveyance by any other mode would endanger patient’s life or grossly aggravate his condition
The prescription of vitamins, minerals & antioxidants should be restricted as per EML 2016/2017 of Delhi Govt. In case of non availability they may be allowed initially for first 3 months provided that they have been prescribed as essential for therapeutic use along with some medicines.
After 3 months these may be permitted by AMA on the recommendations of Govt. specialist of concerned field only. However this condition shall not apply to the patients with CLD, CKD, Malabsorption Syndrome, Transplant Patients, Cancer patients etc.
Beneficiaries who have subscribed to Medical Insurance policy in addition to DGEHS facility may be allowed to claim reimbursement from both the sources subject to the condition that the reimbursement will be restricted only to the admissible amount as per DGEHS approved rates and further subject to the condition that the total amount reimbursed by the two organizations does not exceed the total expenditure incurred by the beneficiary.