EMPLOYEES’ STATE INSURANCE CORPORATION *PANCHDEEP BHAWAN’, C.I.G. ROAD, NEW DELHI — 110 002. www.esic.nic.in (23231629 No, Pt. D-12/17/1/7/11-E.1V Dated: 10.08.2018 OFFICE MEMORANDUM Subject: Relaxation of Rules for consideration of reimbursement in excess of the approved rates pertaining to medical claims — Reg. ‘The Office Memorandum No, Z-15025/38/2018/DIR/CGHS/EHS dated 22.05.2018 issued by Ministry of Health and Family Welfare, Govt. of India on the above subject stands adopted in ESIC. This issues with the approval of Financial Commissioner. Encl:- As above. ya” \ \ MANISH KUMAR) ASSISTANT DIRECTOR To, All the Regional Directors/Directors/Joint Directors T/c, All Medical Superintendent of ESIC Hospital/EST Model Hospitals. D(M)D /Director (Medical) Noida. All Joint Directors(Finance)/Deputy Directors(Finance) in Regional Offices/Sub Regional Offices/ESIC Hospitals/ESI Model Hospitals. 5. NTA, Dwarka, New Delhi. Director (E.VI)/Director (E.V)/Director(Finance) Hars. Office, 7. Website Content Manager, ESIC Hars. Office with the request to upload the same on ESIC website, eyenn -201@n525.ANIZ2Iea mest Government af India rinistry of Heulih aud Fanily Welfare Department of Health & Fancy etfare 15 Section Noi fal B(DTRICGHSIEHS Nirman Bh: Dated the OKFICE MEMORANDUM Suiyjects ~ Retananion of Rakes for cousides ste of reinsbursement in excess of He ‘approved rates pertaining to medical cis indersigned iv directed to drew a imtentos to tke OMice Memorandum No, 41872005- C&P (Vol. 1-2 {Ay}, dated the 29" With reference t0 the sbove mentioned sulject | Teimuary 2009 und fo stage that jt has wow bees decided to modify the Para 3G) nF the Abov “amet Oiice Memranauu as por the cas given canlr te susceetn parageapbs. defined eriteriss SHS) for ay The requests fo full senbarsenea oobi Ra under the Te" salt be exansined by Dineetorate General of CGHS emt submitied t9 ASADG (C copsidensiion of approval After the recommendation of ASRNG (CGHS), the conewereness 9f Seoretary, Ministry of Health & Family Wellare ate Internal Finance Division and approvsl — GHS ra S———— Tpursement in excess af Pesquired for re} fe uncvoognized hospital under emergeney and dhe patiene vag_admised by oles when the DeneTicing unconscious oF severe 1) Treatment was obeained in 2 priv in pacitaged anal was hospitalized for a protonged petiod 2) ‘Treatment as obtained in a private unrecognized hospital under emergency and Was dmiued for prolonged period (or treatment of Hend tajury, C ‘oma . Septicen ‘organ failure. ete "treatment was obtained in a private anrecoyniaed hospisl under emergency %F rcaiment of weanced inalignaney 4) “Lreatment was taken und} smergeney in higher type of accommodation a8 Fam = perhisther entitiement are not available daring chat peti) 5) Trottnvent was taken in higher type nf aecartmodation under specific conditions for jsolation of patients to avoid eooteeting infectionsina. 20180525.WA002 po 4) Treaumem wos obtained in private unrecognized hosp under emereensy ven there isa strike in Govt. hospitals. 4) Treatment wus obtained in a private unrecognized mospiua under emergency while on oificial war to non COHS covered wren. by The cequests from CGHS beneficiaries, having « valid COHS Card atthe TS of eatin si respect of the following conditions shall be considered by a High Powers’ Commitee constituted by Ministry of Health & Family Welfare: @ Jerent of medical claims in reluxatian of rules (ia) Approval for airttve with or without aids on the advice of treating doctor oF roarment io another city even though heishe is not etigible for air waved # treaiment facilities are available in city of residence ii) Representations from COHS beneficiaries seeking full reimburseremts under spevial Circumstances. which arenot notified ©) The other terms and conditions meutioned in the OM Nu. 418/200: Pa(1)] dated the 20! February 2009 shall semaia wnehanges, (ajees Acer) Under Secretary tv Goverment of Lids Tel No. 01 306 1883 Te. 1. Secretary, Ministry of Health & F auily Welfare, Nirman Bhawan, New Deli Director General of Llealth Services, Ninman Ghawun, New Delhi 3. Special Direcior General of Health Servic 4, Addi. Scomtary & DG,CGHS , Nirman Bhawan, New Selht 5. AU Mi Nirman Bhawan, New Delhi isis / Depariments. Government of ludit 6. Director, CGHS. Nirman Bhawan, New Delhi 1. CGMS Desiel/Desk-AUCCHS-}CGHS-H, Dte.GRS, Nirman Bhawan, New Delhi Eat? Bar UV Boul! Dot. fV Sections, Ministry uf Health & Gamily Welfare ns of (e.GHS 10, Rajya Sables / Lok Sabha Seerelurist 9, Adma.! 7 Admadl Sect 1A. Registrar, Supreme Court of tadia (Punjab & Haryana Ligh Court, Chandigarh 12, Under Seeruary, UPS. 1. Unde Secretary Finance Division 14, Deputy Secretary (Civil Service News), Department af Personnel & Trainings Sth Floor. 8 jar Patel Bhawan, New Dell,