Rules of ECHS Reimbursement – In Excess of the Approved Rate

It has been experienced that in some cases where the actual rate of the treatment in empanelled/non empanelled hospitals are more than the approved ECHS/CGHS rate. In such case there are provision to claim the actual rate subject sanction obtain from the competent authority. Detailed procedures is reproduced below –

With reference to Gol, MoD letter No 22(1)/01/US(WE)/D(Res) dated 30 Dec 2002 and Gol, MoD letter No. 24(8)/03/US(WE)/D(Res) dated 19 Dec 2003 and in light of Ministry of Health and Family Welfare order No. Z.15025/ 38/2018/DIR/CGHS/ECHS dated 22^nd May 2018 and No. Z15025/51/2018/DIR/CGHS/ECHS dated 6-6-2018, partial amendments are hereby made to the procedure for payment and reimbursement of medical expenses under ECHS with relaxation of rules for consideration of reimbursement in excess of the approved rates as per the details given under the succeeding paragraphs:-

• The request for full reimbursement which fall under the  defined criteria
  indicated in para 3 below and cases indicated in para 4 below shall be examined by a High Powered Committee whose constitution is indicated in para 5 below. After recommendation of HPC, the concurrence of MoD (Finance/Pension) and approval of Secretary, ESW will be required in all these cases.
• The request for full reimbursement which fall under the following defined criteria would be considered by the High Powered Committee.
• Treatment was obtained in non empanelled hospital under emergency condition and the patient was admitted by others when the beneficiary was unconscious or severely incapacitated and was hospitalized for a prolonged period.
• Treatment was obtained in non empanelled hospital under emergency and
  was admitted for prolonged period for treatment of head injury, coma, septicaemia, multiorgan failure etc.
• Treatment was obtained in a non empanelled hospital under emergency
  for treatment of advanced malignancy.

• Treatment was taken in higher type of accommodation under specific conditions for isolation of patients to avoid contacting infections.
• Treatment was obtained in a non-empanelled hospital under emergency
  when there was a strike in Govt. Hospitals.

4.    Cases falling in the following categories would also be considered by the High Powered Committee.

Settlements of medical claims in relaxation of rules.

• Approval of air fare with or without attendant on the advice of the treating
  doctor, for treatment in another city even though he/she is not eligible for air travel/treatment facilities are available in city of residences.
• Representation from ECHS beneficiaries seeking full reimbursement
  under special circumstances, which are not covered under para 3 above

5.      Composition of the High Powered Committee would be as follows :

1. JS, ESW   –            Chairman
2. Government Hospital Specialist Doctor  – Member
   ( of concerned speciality)
3. Director/DS/US, DoESW     –                     Member
4. Director(Medical), CO, ECHS    –               Member-Secretary
5. Representative of MoD(Fin/Pen)       –      Member

6.         The other terms and conditions mentioned in the procedure for payment and reimbursement of medical expenses under ECHS vide Gol, MoD letter No.24(8)/03/US(WE)/D(Res) dated 19^th Dec. 2003 shall remain unchanged.

7.      This has the concurrence of Ministry of Defence(Finance/Pension) vide their U.O. No32(23)/2018/Fin/Pen dated 3-1-2019.

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