Text of MH & FW., O.M. No. S-11018/95-CGHS(P) DT. 7/3/1995

Reimbursement of the Cost of Knee and Hip Implants

The issue of fixation of ceilings for reimbursement of the cost of knee and hip implants to beneficiaries covered under CGHS and CS(MA) Rules and the procedure for their reimbursement have been under consideration of the Government. Considering the procedural delay involved in getting reimbursement of their costs, it has been decided to fix the maximum ceilings for reimbursement of the implants to the beneficiaries covered under CGHS and CS (MA) Rules as under :

Item

Maximum Ceiling

Knee Implant

Hip Implant

Rs. 60,000 plus Rs. 5,000 as the cost of Bone cement

Rs. 35,000 plus Rs. 5,000 as the cost of Bone cement

2. The reimbursement of the cost of the implants is subject to fulfillment of the following conditions:

    1. The beneficiary should have taken treatment in a Government/private recognized hospital with prior permission of competent authority.

    2. The beneficiary should have purchased the implant on the recommendations of the Orthopedic Specialist of the recognized hospital and on the bases of the lowest of three quotations.

    3. The treating Orthopedic Specialist of the recognized hospital will give a certificate in writing to the effect that the implant has been implanted successfully and is functioning satisfactorily.

3. The above ceilings will be effective from 1/4/1995 and will remain in operation for a period of five years.

4. Reimbursement of the cost of the implants in respect of working CGHS beneficiaries and the beneficiaries covered under CS(MS) Rules will be done by the respective Ministries/Department fro their Service Heads. As regards retired Central Government employees, Ex-Members of Parliament, retired judges and freedom fighters covered under CGHS, the reimbursement in this regard will be made by the additional Director, CGHS of the city concerned from CGHS Head.

5. Medical advance in this regard may be granted direct to the supplying agent up to 80% of the lowest of the three quotations or 80% of the above maximum ceiling, wherever is less.

6. This issues with the concurrence of Finance Division vide Dy. No. 1375/JS (FA), dated 23/3/1995.