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Saturday, December 4, 2010

Reimbursement of the medical claims

No. S-14025/46/92-MS
Government of India
Ministry of Health and Family Welfare
Nirman Bhawan, New Delhi – 110011

Dated the 4th February, 1993

Office Memorandum

Subject – CS (MA) Rules, 1944 – Reimbursement of expenditure involved on emergent cases for the treatment taken at private nursing home/clinic – Delegation of powers – Regarding.

1. The undersigned is directed to say that under the CS (MA) Rules, 1944, vide Miscellaneous Important Decisions No. 5 under Section VII of the compilation of the CS (MA) Rules and further modified vide O.Ms. No. S- 14012/9/75-MC (MS) dated 23.2.77, 7.5.79 and 18.6.82, powers have been delegated to the Heads of Departments to allow reimbursement of the medical claims in respect of the treatment obtained under emergency at private hospitals, as distinct from private nursing home/private clinic, subject to item-wise ceilings as per the rates prescribed in the Annexure to the O.Ms. referred to above without any financial limit on the total amount to be reimbursed.

2. However, although the broad guidelines provided in para 1 (iv) of the O.M. dated 18.6.82 referred to above are only indicative and not exhaustive, a large number of cases are being referred to this Ministry/Dte. C.G.H.S. for seeking relaxation of the rules stating that the hospital is not run on ‘No profit and No Loss Basis’, which otherwise could have been settled by the concerned Department under the delegated powers.

3. It has now been decided by the Government that in order to eliminate the confusion regarding distinction between the private hospital and a private nursing home Clinic, the delegated powers referred to above are applicable to all private medical institutions without making any distinction between a private hospital and a private nursing home/clinic.

4. the medical claims for specialized treatment for heart diseases, kidney transplantation, etc. may be settled as per the schedule of rates approved for the treatment of C.G.H.S beneficiaries from time to time at private recognized hospitals under that Scheme or the actual charges, whichever is less, and all other cases may be settled as per the item wise ceilings prescribed in the Annexure to the O.Ms. referred to above. No. references should be made to this Ministry/Dte. G.H.S. in the matter for further relaxation of the Rules and may be settled by the concerned Ministry/Department.

5. In this connection it may be reiterated that as already stated in para (iii) of the O.M. dated 18.6.82 referred to above, reimbursement of expenses incurred on treatment obtained in the private clinics/nursing homes of the Authorised Medical Attendants would not be admissible under the above provisions and also in relaxation of the CS(MA) Rules even in emergent cases.

6. All pending cases may be decided accordingly, However, the cases which are already settled or decided, may not be re-opened.

7. This issues with the concurrence of the Department of Pension and Pensioners’ Welfare vide their U.O. No. 272/92 P& PW (K) dated 19.10.1992 and the Ministry of Finance Deptt. Of Expenditure) vide their U.O. No. 1441/E.V/92 dated 17.11.1992.

8. In so far as persons serving in the Indian Audit and Accounts Deptts. are concerned, this issues with the concurrence of the office of the comptroller and Auditor General of India vide their U.O. No. 27-Audit-I/72-90, dated 25.1.1993.

(Braham Dev)
Under Secretary to the Govt. of India

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