Government introduce a new Medical Scheme for Central Government Employees and Pensioners



Government introduce a new Medical Scheme for Central Government Employees and Pensioners as in the name of Central Government Employees and Pensioners Health Insurance Scheme (CGEPHIS). In all over India, pensioners are getting meager amount of Rs.100 as Medical Allowance (except CGHS beneficiaries). It is estimated that approximately 17 lakh serving employees and 7 lakh pensioners shall be offered this Scheme and Government plan to enroll all serving employees and pensioners on compulsory / optional basis.

Some key points regarding the scheme:-

CENTRAL GOVERNMENT EMPLOYEES AND PENSIONERS HEALTH INSURANCE SCHEME (CGEPHIS)

BENEFICIARIES:
CGEPHIS shall be compulsory to new Central Government Employees who would be joining service after the introduction of the Health Insurance Scheme.

CGEPHIS shall be compulsory to new Central Government retirees who would be retiring from the service after the introduction of the Insurance Scheme.

CGEPHIS would be available on voluntary basis for the following:
Existing Central Government Employees and Pensioners who are already CGHS beneficiaries. In this case they have to opt out of CGHS scheme. They will also have the option of choosing both CGHS and Insurance policy. In such case the total insurance premium has to be borne by the member.

Existing Central Government Employees and Pensioners who are not CGHS beneficiaries but are covered under CS (MA)

INSURANCE COVERAGE:
In-patient benefits – The Insurance Scheme shall pay all expenses incurred in course of medical treatment availed of by the beneficiaries in an Empanelled Hospitals/ Nursing Homes (24 hours admission clause) within the country, arising out of either illness/disease/injury and or sickness.

NOTE: In case of organ transplant, the expenses incurred for the Donor are also payable under the scheme.

Pre & Post hospitalization benefit: Benefit up to 30 days Pre Hospitalization & up to 60 days Post Hospitalization respectively which would cover all expenses related to treatment of the sickness for which hospitalization was done.

FAMILY SIZE:
Serving/Retired Employees: Self, Spouse, Two dependent children and up to Two Dependent Parents. New born shall be considered insured from day one till the expiry of the current policy irrespective of the number of members covered subject to eligibility under maternity benefit.

Any additional dependent member in addition to above [Sr. No. 5 (1)] can be covered under the Scheme by paying the fixed amount of premium. This additional full premium shall be borne by the beneficiary.

IDENTIFICATION OF FAMILY:
Beneficiaries shall be identified by a “Photo Smart Card” issued by the insurer to all beneficiaries which would have all personal details, medical history, policy limits etc. of the CGEPHIS members. This card would be used across the country to access Health Insurance Benefits. The photograph embedded in the chip of the Smart Card will be taken as the proof for determining the eligibility of the beneficiaries.

SUM INSURED AND BUFFER / CORPORATE SUM INSURED
SUM INSURED:
The Scheme shall provide coverage for meeting all expenses relating to hospitalization of beneficiary members up to Rs. 5, 00,000/- per family per year in any of the Empanelled Hospital/Nursing Home/Day Care Unit subject to stated limits on cashless basis through smart cards. The benefit shall be available to each and every member of the family on floater basis i.e. the total reimbursement of Rs. 5.00 lakh can be availed by one individual or collectively by all members of the family.

Entitlements for various types of wards: CGHS beneficiaries are entitled to facilities of private, semi-private or general ward depending on their pay drawn in pay band / pension. These entitlements are amended from time to time and the latest order in this regards needs to be followed. The entitlement is as follows:-

Pay drawn in pay band/Basic Pension - Entitlement
Rs. 13,950/-(up to)……………………………… General Ward
Rs. 13,960/- to 19,530/- …………………… Semi-Private Ward
Rs. 19,540/- and above ……………………… Private Ward

CASHLESS ACCESS SERVICE:
The Insurer has to ensure that all CGEPHIS members are provided with adequate facilities so that they do not have to pay any deposits at the commencement of the treatment or at the end of treatment to the extent as the Services are covered under the Scheme. The service provided by the Insurer along with subject to responsibilities of the Insurer as detailed in this clause is collectively referred to as the “Cashless Access Service.”

The services have to be provided by the Empanelled Hospitals/Nursing Homes/Day Care Clinics to the beneficiary based on Photo Smart Card authentication only without any delay. The beneficiaries shall be provided treatment free of cost for all such ailments covered under the Scheme within the limits/sub-limits of defined package rates and sum insured, i.e., not specifically excluded under the scheme.
ENROLMENT PROCESS
The process of enrolment shall be as under:
Serving Employees:
1. Departments and offices will call for options from employees to join voluntary CGEPHIS with or without existing CGHS/CS (MA) benefits.

2. Head of Department of the Administrative Ministry/Department would be the contact point for the Insurance Companies.

3. Enrolment forms giving details about self and family and authorization to the department for recovery of premium on a monthly basis would be consolidated by the Administrative Ministry / Department. The data of the beneficiary and dependent members to be covered along with 2 recent passport size photo and copy of enrolment form will be forwarded to Insurance Company on monthly basis.

4. Insurance Company will issue Smart Cards on the basis of information received of the beneficiaries for enrolment.

5. Such Smart Cards along with the enrollment kit shall be sent by the insurers directly to the insured persons at their respective mailing addresses at insurer’s cost within 7 days.

Insurance Premium:-
The beneficiary will have to pay an annual premium which will be determined after the formal introduction of the Scheme. It will vary according to the grade pay of the officer. The estimated annual premium for a standard family size will be in the range of Rs.8000 to Rs.12000 p.a. It is however proposed to be subsidized by the Government to a considerable extent.

Comments

Anonymous said…
Premium should be paid by employer i.e. Government.Nominal amount on part of employee say 1000/2000 p.a. is o.k. Otherwise this scheme is cheating with employees.

Prem Kumar
Anonymous said…
what about the disesases that doesn't need hospital admission? say, diseases like BP,diabetes or protracted back pain which needs prolonged and costly treatment without any hospitalization. These are now covered by CS[MA]?
Also, why is there no discussion with various associations?? Something is amiss folks!!!
Anonymous said…
with out knowing the details like, amount of premium to be paid by the employee, list of hospitals etc how can we decide?
sanjeev said…
In cities where CGHS facillities are not available, Medical attendance rules have become a sorce of income for corrupt sarkarri babus.Hope, new scheme may open the scope for clean administration
Unknown said…
Each State is having one recognised CGHS centre., i.e. for Gujarat it is Ahmedbad city. What about for Govt servant and Pensioners residing in other cities ? I proposed to give the linking Branch of the Hospital to cover such facilities in other cities of the state. The sterling Hospital is recognised in Ahmedbad so the Branches of this Hospital in other cities will given entitlement to serve the Cetral Govt servant/pensioner recsiding in that city.Instide of recognising one city in the state, the linking Branches of the perticular Hospital will be serve to the majority of the Cetral Govt. servant/pensioners.
Unknown said…
If the Government is really intrested in the welfare of serving and retired central government employees, it should continue with the M.A.Rules and should be allowed to retired central government employees also. The system mooted by the Government is not suitable because the treatment for an insured person and aordinary person is totally different.All the available tests are conducted on the patient resulting in unnecessary pain and worry in the patient.Secondly the MEDICAL officers and all the staff take their own time in treating the insured patients. The Government should also disclose the name of the Insurance company and should not be provided to any private MNC company like Tata AIG ICICI Lombard etc.

Anandan
Palakkad
Anonymous said…
It should be matter of investigation that how many employees are benefitted by present rules.It should be noticed that in present scenerio only few people can go to state govt. hospitals, due to poor services.
Unknown said…
This should also be made applicable to all the existing employees and retired employees of stautory bodies under the Central Government who are covered under CSMA Rules of Rules framed by them with the approval of the Central Government. At present Rs.100/- paid to retired employess per month as medical allowance is not at all enough. Government may disclose the name of the insurance company as also the entire scheme including the premium payable by the retired employees for informaiton.
Unknown said…
how can we decide about policy without knowing full details of policy and about insurence company.and where can i apply for this facility and what will be premium.
the particulars of the Nursing Home empanelled with the scheme is not known. a clarification is requested.
Gautam, Kolkata
Dr. Jai Singh said…
Total reimbursement of Rs 5 lakh per year per family is too less keeping in mind the future cost of treatment in coming years, as the cost of treatment is increasing day by day. This amount of reimbursement is nothing but cheating the Government employees and their family members especially in old age.
Anonymous said…
Generally the private nursing homes and hospitals do unwarented diagnostic tests and delay releaving from hospital when they knew that particular patient is covered under a insurance.
How government would save patients
from such a system !
Anonymous said…
All Gr B,C & D Central Govt. Employees are new breed of Guinea Pigs so that we have to bear these ailments.All MNCs have an eye on the potential business lying in India and they are grabbing one by one with the help of Bureaucracy & Contractors. This insurance scheme is the result of formation of syndicate by Hospitals, Pharmaceutical firms and Insurance companies.In this scheme, Doctor is to play a role of donkey only.All CGEs have no role in the recommendations of Sixth Pay Report as well as in the launching of this insurance scheme.We can't do anything so please accept the destiny and enjoy the life. Goswami Tulsidas said " Koi nrip hoi hamein kaa haani"(King is always a king).
parviz said…
Sir,


Did the above CGEPHIS can a Railway employees who are geting treatmeant in respective Railway Hospital's are eligible. Kindly clarifive. As majority of railway employees are working where Railway hospital is faraway from the place of there posting.....
Anonymous said…
the new cgeps scheme has no provisions for opd consultation /or medicine reimbusment or provisioningas is there in present cghs scheme
Anonymous said…
I am central government employee. I am planning to preserve cord blood of my baby. Can i reimburse the cord blood banking charges under central government health scheme ??
Unknown said…
Pl.guide me to get d card.I am retired official.

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