Employee eligible for reimbursement even if hospital not under CGHS: Delhi HC

The Delhi High Court in a recent ruling stated that employees are eligible for medical reimbursement in emergencies, regardless of whether the hospital where they received treatment is part of the Central Government Health Scheme (CGHS). This decision was made following a case involving Seema Mehta, an employee of a supported school, who was initially denied reimbursement for her emergency medical expenses after a severe accident.

According to a report by Live Law, Seema Mehta, who has been an employee since 2000, was involved in an accident on September 18, 2013, which resulted in critical head injuries. She first received treatment at Guru Tegh Bahadur Hospital and was later transferred to Sir Ganga Ram Hospital for a major brain surgery. 

The report said the Petitioner claimed that she had spent approximately Rs.5,85,523/- on the medical treatment and sought reimbursement for the said amount from the school authorities. Despite a prolonged hospitalisation and slow recovery, Mehta's medical expenses were initially not reimbursed. She made the claim before the Directorate of Education as well, however she was not reimbursed. 

A single Judge Bench comprising Justice Jyoti Singh concluded that the Petitioner had the right to seek medical reimbursement even if the hospital was not listed under CGHS, provided the admission took place during an emergency. The court ruled that the Petitioner should not be deprived of reimbursement as she had suffered severe injuries and was unable to reach hospitals under the scheme. 

CGHS benefits, charges

The CGHS offers comprehensive medical care to government employees and pensioners enrolled in the program. Currently, CGHS covers approximately 4.2 million beneficiaries in 80 cities across India, with plans for further expansion to additional cities to improve service accessibility.

All central government employees and their dependent family members residing in CGHS-covered areas are eligible to receive benefits under this scheme.

At the time of retirement, beneficiaries must make a one-time contribution equivalent to 120 times the existing CGHS contribution rate. The contribution rates are as follows:

Levels 1 to 5: Rs 30,000 for a whole life CGHS card
Level 6: Rs 54,000 for a whole life CGHS card
Levels 7 to 11: Rs 78,000 for a whole life CGHS card
Level 12 and above: Rs 1,20,000 for a whole life CGHS card

New CGHS card

To apply for a new CGHS card, pensioners eligible for CGHS benefits can now utilize the online portal available on the CGHS website (www.cghs.nic.in). The application process begins with the generation of a temporary reference number on the website.

For the application, certain documents are required:

• Proof of age for dependent son, if applicable.
• Self-attested copy of disability certificate issued by a government hospital's medical board for dependent sons aged 25 and above.
• Self-attested copy of PPO/provisional PPO or last pay certificate and Bharatkosh Challan for CGHS subscription payment.
• Evidence of availing/non-availing FMA.
• Identification proof of dependent family members such as Passport, PAN card, masked Aadhar, voter ID card, etc.
• Address proof
• Documents proving dependency of family members (wherever applicable)

Retiring employees may apply for a pensioner card and submit their pension papers 6 months prior to their Retirement date through an online application process. The office will follow the standard procedure used for active employees to prepare and issue their CGHS card(s).

These documents must be submitted following the specific requirements outlined in the application process.

To access their CGHS card electronically, pensioners can do so through the CGHS website, myCGHS app, or Digilocker. The digital card carries the same validity as the physical one and simplifies the verification process.

For CGHS card renewal, central government pensioners must submit Form AA or BB with the Bharatkosh Payment challan of Rs 100 to the additional director in their residing city.