Relaxation of Rules for Medical Claims in excess of approved rates under ECHS

Relaxation of Rules for Medical Claims in excess of approved rates under ECHS

File No.22A(37)/2018/ WE/D(Res-1)
Government of India
Ministry of Defence
(Department of Ex-Servicemen welfare )
Sena Bhavan, New Delhi

Dated 15th January, 2019

To,
The Chief of Army Staff
The Chief of Naval Staff
The Chief of Air Staff

Subject: RELAXATION OF RULES FOR CONSIDERATION OF REIMBURSEMENT IN EXCESS OF THE APPROVED RATES PERTAINING TO MEDICAL CLAIMS UNDER ECHS.

Sir,

With reference to GoI, MoD letter No 22(1)/01/US(WE)/D(Res) dated 30 Dec 2002 and GoI, MOD letter No. 24(8)/03/US(WE)/D(Res) dated 19 Dec 2003 and in light of Mo Health and Family Welfare order No. Z. 15025/ 38/2018/DIR/ CGHS/EHS dated 22nd May 2018 and No. 215025/51/2018/DIR/ CGHS/EHS 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.

2.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.

3.The request for full reimbursement which fall under the following defined criteria would be considered by the High Powered Committee.

(i) 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.

(ii) 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.

(iii) Treatment was obtained in a non empanelled hospital under emergency for treatment of advanced malignancy.

(iv) Treatment was taken under emergency in a higher type of accommodation as rooms as per his/her entitlement were not available during that period.

(v) Treatment was taken in higher type of accommodation under specific conditions for isolation of patients to avoid contacting infections.

(vi) 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.

(i) Settlements of medical claims in relaxation of rules.

(ii) 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.

(iii) 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 ( of concerned spaciality) – Member

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 19th 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.

Yours faithfully
(A.K. Karn)
Under Secretary to the Govt. of India