Reimbursement of Medical Expenses-Frequently asked Questions


Dependency condition not applicable to spouse for reimbursement of medical expenses under CGHS

Q I am a Government employee and beneficiary of CGHS. In my Service Book, I have shown my husband as not employed, as he was not employed at that time. Later on, he started a small business. When my husband suffered heart attack CGHS doctor referred my husband to a CGHS approved hospital where he was conducted angiography and by-pass surgery of heart. I submitted the bills for the same for reimbursement. However my Officer-in-Charge informed that no claim for medical reimbursement for my husband will be accepted since he is an income tax assessee and not my dependent. Kindly clarify.

A As per the definition of family for CGHS, the condition of dependency does not apply to husband/wife. Hence, you are entitled to reimbursement of medical expenses incurred in respect of your husband vide G.I.,M.H.,O.M. No. S-11012/1/98-CGHS(P), dated 14-3-2001 (Sl.No.133 of Swamy’s Annual, 2001).

When both husband and wife are Govt. Servants both can claim reimbursement of medical expenses for their respective parents

Q Both the husband and wife are employees of a Central Government Organization and claiming the medical benefits under CS(MA)Rules, 1944. They have furnished joint declaration according to which husband has preferred to claim the concession for himself, wife, children and his parents and wife has preferred to claim for her parents. Since both the employees belong to same organization and staying at the same station, a doubt has arisen whether the female employee can claim medical reimbursement for her parents and her other dependent family members. Kindly clarify.

A When both husband and wife are Govt. employees, both of them can claim medical reimbursement for their respective parents subject to the condition that the income from all sources of such parents should be less than Rs 1,500 and they should reside with the concerned Govt. servant or with the rest of the family members.

Dependent married son is entitled to medical facilities

Q As per Circular No.4-24/96-C&P/CGHS (P), dated 17- 9-1999 of dept. of Health, a dependent son irrespective of his age is entitled to CGHS medical facilities. There is no mention of his marital status. However, a CGHS authorities in a particular region are refusing to include the name of a married dependent son in the CGHS card of a pensioner on the plea that the son is married. Kindly clarify.

A While defining dependency for son/daughter vide G.I., Ministry of Health and Family Welfare O.M.,dated 31- 12-1992 – Order (a) below Note-2 of the Definition of Family under Chapter 4 of “Swamy’s Compilation of Medical Attendance Rules”, the clause `married’ has been included to the conditions only in the respect of daughter and NOT in respect of son. Hence, the CGHS establishment is not correct.

A Govt. Servant cannot claim medical reimbursement for his father who is in receipt of fixed medical allowance

Q pensioner is residing outside CGHS area and therefore granted Rs 300 per month towards medical allowance. He is residing with his son who is a Govt. employee. The son is claiming medicalreimbursement for OPD treatment of his father on the plea that hisfather’s income is less and therefore dependent upon him. Will you please clarify whether his son can claim medicalreimbursement?

A When the father, who is a pensioner is drawing fixed medical allowance of Rs 300 per month, his son is not entitled to claim medicalreimbursement for the OPD treatment of his father.

Restriction of two children is not applicable for claiming medical reimbursement

Q As per existing rules, reimbursement of Children Education Allowance, LTC, etc., are admissible for two dependent children only. Whether an employee is entitled to reimbursement of the medical expenditure incurred for his wife during the pregnancy of third child and also admissibility of Paternity Leave in such cases.

A There is no ban under the CS(MA) Rules, 1944 or CGHS Rules for reimbursement of medical expenses incurred during the pregnancy of third child. However, Paternity Leave is not admissible if the employee has more than two surviving children vide OM, dated 16-7-1999 (now Rule 38-A of CCS (Leave) Rules, 1972).

Admissibility of medical facilities to the parent residing with family members away from headquarters

Q I am working in a city and family members reside in another city for various reasons. My parents are also residing with my family. In such situation, whether my parents will be eligible for medical treatment under CS(MA) Rules.

A Medical facilities are available to the parents of a Govt. servant even when they reside with the rest of his family members at a place other than his dutystation for whatever reason. In such cases, the conditions regarding residence of the parents with the Govt. servant is waived.

Air travel for medical treatment, admissible to all irrespective of pay scales.

Q If a Government Employee officer is not entitled to travel by air on tour, LTC etc., whether he is entitled for air travel for medical treatment or not.

A TA by air for medical treatment is totally different from TA entitlement on tour/transfer. TA by air for medical attendance is admissible to all the Govt. servants irrespective of their pay, etc., if condition that as air travel was absolutely essential otherwise the life of the patient would have been in danger is fully satisfied. This condition is also applicable employees who entitled for Air Travel during their regular tours and LTC.

Official under suspension is eligible for all medical facilities.

Q Whether a Government Employee who is under suspension is entitled for reimbursement all the Medical expenditures involved at par with working employees.

A The official under suspension is covered by CS(MA) Rules and he is eligible for all the facilities as if he had not been suspended.

Medical facilities if spouse employed in other organization at the same/different station.

Q Please clarify whether the spouse employed in a Bank can avail the medical facility for himself /herself alone from the Bank while the spouse employed in Government department can avail facilities under CS(MA)Rules for self and other family members.

A In such cases medical facilities can be availed either under CS(MA) Rules or from the organization where the other spouse is employed, for all the family members. In the case, cited the spouse employed in the Bank cannot avail the facility for himself/herself alone while the other members avail facilities under CS(MA) Rules. The entire family can avail the facilities from only one source as a unit and for this purpose a joint declaration should be given by the couple to their respective departments. However, if the spouse employed in other organization is stationed at differentstation he/she can avail the facilities from the organization for self only, while the spouse and the family members living with him/her can avail facilities under CS(MA) Rules.

Members of family residing away from the place of posting of the Govt. Servant are entitled to avail medical facilities under CS(MA)Rules

Q A Govt. servant was transferred from one station to another on his own request. His wholly dependent family members are residing in his own house at the old station. He could not shift his family to the new place of posting. His family members are taking treatment at old station. Kindly clarify whether he can avail the facility of medical reimbursement in respect of his family members.

A The concerned Govt. servant can avail the facility in respect of the family members who are residing away from the place of duty. However, the dependent parents should reside either with the Govt. servant or with the other members of family to avail the facility. Please refer to Para 2 (c) under Section 4 of “Swamy’s Compilation of Medical Attendance Rules” (C-7).

Spouse can claim the medical expenses incurred prior to the death of the deceased employee.

Q The wife of a deceased Central Govt. employee has submitted the claims in Form CS(MA) Rules in respect of the said employee and his dependents for the period before his death. There is no clear rule in Medical Attendance Rules on the above issue. Please Clarify.

A Pay and allowances of all kinds claimed on behalf of a deceased Govt. servant may be paid without the production of usual legal authority under the order of Head of Office in which the Govt. servant was employed at the time of his death, provided the Head of Office is otherwise satisfied about the right of the claimant. On receipt of the claim for payment of arrears of pay and allowances of all kinds (including traveling allowances claims) on behalf of a deceased Govt. servant from his heir(s), the Head of Office in which the Govt. servant was last employed should draw the amount in the appropriate bill. On the same lines medical claim also may be paid to the legal heir(s) of the deceased Govt. servant. [ Rule 95 of CGA Receipts and Payment Rules]

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10 thoughts on “Reimbursement of Medical Expenses-Frequently asked Questions

  1. My father retired from govt. body which do not provide CGHS cover to pensioners. But they are entitled for reimbursemnt for treatment taken at govt.or CGHS authorized hospital as per CGHS rates. Recently he undergone the neuro surgery as an emergency case at CGHS recognized hospital. Now his office refuse to reimburse the expenses as per CGHS rates by saying that the particular hopital is meanat for general purposes not for neuro surgery.Please clarify

    1. What is the defination of ‘General Purpose hospital’.
    2. If he is not entitled for CGHS rates than which reimburse rules would applicable to him ?

    1)

  2. Q. Husband and wife both are in State Government Service in same department and different stations. If the wife is taking madical treatment at her place of duty and the Re-imbursment of medical bill is submitted by her hunband at his place of duty, Are the husband is entitled to get the benefit of Reimbursment of medical claim ? please clerify.

  3. mY MOTHER IS GETTING FAMILY PENSION OF rS. 3500/= pLUS USUAL da AS ADMISSIBLE UNDER RULES. sHE IS ALSO GETTING FIXED MEDICAL ALLOWENCE OF rS. 300/=.sHE IS SUFFERING FROM CADIOLOGY,(HAVING PACE MAKER) DIABITIES ETC AND IS ON LIFE LONG MEDICAL TREATMENT.
    KINDLY COMMUNICATE IF I CAN CLAIM FOR HER MEDICAL REIMBURSEMENT (EXPENCES INCURRED ON RECRING BASIS) FROM MY DEPARTMENT.

  4. My father expired on 16th July 2011. He was a pensioner. He got treatment in Kailash Hospital Noida. All documents are with me for claiming reimbursement. The problem is the stipulated time period of 90 days has expired. Kindly advise.

    • Sorry for the delay in replying. Please make a specific request to the competent authority to condone the delay, factually explaining the reason for delay and to admit the claim for reimbursement.

  5. If both husband and wife are govt. servant of different organization and husband want to take medical facilities from wife’s organization,and parents medical facility from his own organization can it is possible please reply with rule number

    • If both of you are contributing to CGHS then you both can independently avail medical benefits for your parents from your respective organisation, which obviously means that both of you should also be availing the benefit for yourself, from your respective organisations.In brief,you can avail the benefit for yourself and your parents from your organisation and she can avail it for herself and her parents from her organisation and the eligible children can avail from either of the organisation as per your option.

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