Central Government Health Scheme (CGHS Mumbai)

MRC FAQ's

Question Answer

Why mandate form should be submitted with each MRC and every time?

Generally, a mandate form has more information compared to a cancelled cheque. So it is always preferable to attach the same. However if the cheque contains all the details which a mandate form has, then only cancelled cheque will suffice and there will be no need to submit the mandate form.

Why should a beneficiary submit a sets of Xeroxed MRC documents along with the original one?

Because the original set is to be submitted to the Pay and Accounts Office whereas the Xerox one is kept at the Office of Addl. Director, CGHS Mumbai for records.

Can we submit MRC at any Wellness Center?

Yes, it can be submitted at any Wellness center, but preferably at the parent Wellness Center.

Can we claim reimbursement for the investigations done during medical emergencies?

Yes, but they will be reimbursed only as per the CGHS rates only.

Where should serving employees submit their MRCs

They should submit it to their respective offices.

I have a Mediclaim Insurance Policy. Due to emergency, I received treatment in a private hospital. Some amount was paid by Insurance Co. Can I claim the balance amount from CGHS?

Yes, first the bills are to be submitted to Insurance Company. Xeroxed bills & vouchers duly stamped and verified by the Insurance Company along with a certificate from Insurance Company indicating the amount which the beneficiary has received from them are to be submitted along with the MRC form and the checklist. These documents are to be submitted to the CGHS by pensioner CGHS beneficiaries and to the department by serving beneficiaries. Reimbursement would be done as per CGHS/AIIMS rates or actuals, whichever is less. However, the total reimbursement from both sources will not exceed actual expenditure incurred.

Why was my medical reimbursement claim returned ( with expectation of resubmitting the again?

They might have been returned due to one or multiple reasons enlisted below -

  1. Emergency certificate/advise by the Government or CGHS Specialist /Original permission letter issued from a CGHS Wellness Centre has not been enclosed.
  2. Justification letter for delay in submitting the claim and seeking condonation for the same is not enclosed.
  3. Original Emergency Certificate is not enclosed.
  4. Detailed consultation notes/ OT notes that are required for examination in certain cases is not enclosed.  
  5. Original invoice (or photocopy of invoice in case of bulk purchase duly certified by the treating specialist along with seal and stamp of the hospital) of Stent/Implant/Mesh/costly chemotherapy drug is not enclosed.
  6. The amount claimed does not match with the total amount of the bills enclosed.
  7. Succession Certificate/Legal heir Certificate not enclosed in case the beneficiary has expired.
  8. Notarized No Objection Certificate from other legal heirs (if applicable). In case nomination certificate was not submitted by the Principal Card Holder during his lifetime.
  9. Duly filled MRC Claim form signed by the principal card holder is not enclosed.
  10. If a single MRC was submitted for multiple admissions. In such cases, separate MRCs should be submitted for each ospitalization/admission.
  11. Bank Mandate form or cancelled cheque is not enclosed.
  12. Break up details for the consolidated bill is not enclosed.

Why was my medical reimbursement claim not considered (rejected) for reimbursement?

It might be due to one or multiple reasons enlisted below -

  1. Non-emergency treatment/ investigations in empaneled/ non-empaneled hospital was undertaken without due permission from CGHS Wellness Centre.
  2. Documents enclosed are not suggestive of emergency nature.
  3. Medicines purchased on outpatient basis are not admissible for reimbursement.
  4. The card holder was not a bonafide CGHS beneficiary at the time of availing emergency treatment.
  5. The bills do not pertain to the period of emergency (as per the enclosed documents).
  6. Claim against the amount spent for non-admissible items (eg. toiletries, sanitary napkins, talcum powder, mouth fresheners, certain vaccines etc.) during credit treatment at a private hospital.
  7. The interim /running/provisional bill is not payable.

What is the time limit within which my medical claim is to be reimbursed?

If the documents of the submitted MRC are complete in every aspect, then it is reimbursed within 45 days.

What can I do if my claim is unnecessarily delayed?

Pensioner beneficiaries can contact the CMO In Charge of the MRC section in the Office of the Additional Director, CGHS during office hrs.

I am a Pensioner and CGHS beneficary. My wife was admitted in a Pvt hospital during emergency. May I know how to reimburse the amount spent on her treatment?

Apply to the CMO Incharge of any CGHS Wellness Centre for reimbursement with the following documents:

  1. MRC form duly filled as per Check list. These forms are available at CGHS Wellness Centre or they can also be downloaded from our website http://cghsmumbai.gov.in
  2. Copy of the discharge summary
  3. Hospital bills along with their detailed break-up
  4. All original receipts of the payment to the hospital for treatment.
  5. Xerox copies of CGHS Cards belonging to the patient as well as the parent card holder
  6. Xerox copies of all other documents issued by the hospital.

It should be noted that serving employees who are CGHS beneficiaries should submit the medical claim to their own department.

My original papers i.e. hospitalization bills, receipts of their payment, etc have been lost. In such cases , how can I apply for MRC? claim on duplicate papers?

In such cases, MRCs can be processed based upon duplicate documents. However bills & their receipts have to be submitted in an affidavit on a stamp paper of hundred rupees.
Details of Draft for Affidavit may be seen in the instructions sheet appended to Medical Claim Form available at CGHS website.

My spouse, a CGHS beneficiary expired while undergoing treatment in a non- empanelled hospital. May I know how to apply for MRC?

Apply to the CMO Incharge of any CGHS Wellness Centre for reimbursement with the following documents:

  1. MRC form duly filled as per Check list. These forms are available at CGHS Wellness Centre or they can also be downloaded from our website http://cghsmumbai.gov.in
  2. A Xeroxed copy of the Death Summary
  3. Hospital bills along with their detailed break-up
  4. If the beneficiary was implanted with a coronary stent/cardiac valve/ intra ocular lens etc, then their original vouchers should also be attached .
  5. Xerox copies of CGHS Cards belonging to the patient as well as the parent card holder
  6. A Xeroxed copy of the Death Certificate
  7. An affidavit on a stamp paper as per the standard format stating that the applicant is the Legal Heir of the deceased beneficiary.
  8. NOC from other relatives of the deceased in favour of claimant as per the standard format
  9. Xerox copies of all other documents issued by the hospital.

Draft of the affidavit and NOC is available on our website  http://cghsmumbai.gov.in

My CGHS card got expired when I retired in Dec 2011. Therafter I moved to my native place in Madhya Pradesh and didn’t make pensioner's CGHS card. But in May 2012, after more than 3 months of retiring, when I visited Mumbai I suffered from a Heart Attack.

After retirement, a grace period of three months is given to get CGHS card made.
The treatment taken and expenditure incurred within the grace period of three months from the date of retirement will be allowed and expenditure reimbursable subject to the condition that the beneficiary has either obtained or applied for CGHS pensioner card with all documents and requisite CGHS subscription within one month of expiry of the grace period of three months.
The expenditure on treatment taken after the grace period of three months from date of retirement will not be reimbursable unless the beneficiary has obtained a valid CGHS card or has applied for CGHS pensioner card with all documents and requisite CGHS subscription prior to taking such treatment.

I went to Hyderabad to visit my son and had accidentally fractured bone of my leg.I received treatment from a private non-empanelled hospital. Shall I get full reimbursement from Mumbai?

Reimbursement for treatment taken in a private non-empanelled hospital under medical emergency shall be considered as per CGHS rates only of Hyderabad city only even if the claim is submitted to CGHS Mumbai.

Is treatment for IVF reimbursable?

IVF treatment is approved under CGHS. The details are available in Office Memorandum Z.15025/5/2011/CGHS 111/CGHS(P) dated 22.11.2011 , which can be downloaded from our website http://cghsmumbai.gov.in

Are ambulance charges reimbursable?

Yes. Ambulance charges for shifting the patient within the limits of Mumbai are reimbursable provided that a certificate from the treating doctor stating that conveyance by any other mode would have definitely endangered the patient's life or would have grossly aggravated his/her condition.

I had submitted a MRC regarding hospital bills of Rs. 1 Lac 20 thousand but I was reimbursed only Rs. 45,800/-. May I know why wasn’t I reimbursed the complete amount i.e. Rs. 1 Lac 20 thousand?

Government has agreement with private empanelled hospitals that they will charge CGHS beneficiaries only as per CGHS rates. This is absent in case the private hospital is non-empanelment. In other words, Government has no agreement with private non-empanelled hospitals, for charging CGHS beneficiaries only as per CGHS rates. Such private hospitals have their own rate list different from that of the CGHS.  
However, if treatment is undertaken by a CGHS beneficiary at private non-empanelled hospitals under emergency circumstances, reimbursement will be limited to CGHS/AIIMS rates or actuals, whichever may be lesser. Since, non-empanelled private hospitals often charge at rates different from those of CGHS, there will be difference in the amount reimbursed if the charges of the private hospital are higher than CGHS rates. Hence, complete reimbursement of the amount spent in such hospitals is not possible as per rules of CGHS.

What are the facilities available to me if I am a pensioner in a non CGHS area?

  • Pensioners residing in non- CGHS covered areas have an option to become CGHS beneficiary and avail CGHS facilities from the nearest CGHS covered city.
  • Pensioners residing in non-CGHS areas have also the option to avail Fixed Medical Allowance on monthly basis for OPD treatment and obtain CGHS card from nearest CGHS covered city for inpatient facilities under CGHS. No OPD medicines shall be issued in such cases from any CGHS Wellness Centre.
  • CGHS pensioner beneficiaries (and their eligible dependent family members) who are holding a valid CGHS Card and residing in a non-CGHS area shall be eligible to obtain inpatient medical treatment and also follow up treatment from any Govt. Hospital/CS(MA) /ECHS approved hospital on proper referral from a CGHS Wellness Centre and submit the medical reimbursement claim to the CMO Incharge of any CGHS Wellness Centre for reimbursement
  1. In case of medical emergency, treatment may be obtained from any hospital and medical claim shall be submitted to the CMO Incharge of any CGHS Wellness Centre
  2. Reimbursement shall be limited to the CGHS rate and ceiling rates of the city where the treatment was taken /AIIMS rates or as per actuals and according to the ward entitlement of the CGHS card holder.

 

 

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