Text of MH & FW, O.M. F. No. Misc. 10001/2000/JD/R&H/CGHS/CGHS(P),dated 30/4/2001

Reimbursement of the cost of OPD medicines for treatment in post operative conditions like Cardiac Surgery, Organ transplantation, Knee/hip replacement, Neuro surgical/neurological cases and cancer.

The issue of reimbursement of the cost of OPD medicines in certain conditions has been under consideration in the Ministry of Health and Family Welfare for some time. As per existing procedure the cost of OPD medicines are not reimbursable except in cases of maintenance Haemodialysis. However, keeping in view the difficulties and financial hardship faced by the CGHS beneficiaries, it has now been decided that reimbursement of the cost of OPD medicines may be considered for the following cases:

    1. Post operative cases of major Cardiac Surgery/Cardiology.

    2. Oncology cases.

    3. Post Operative Organ transplant cases.

    4. Post operative Joint replacement cases.

    5. Post operative Major Neurosurgical/Neurology cases

2. As drugs are costly, a utilization certificate from the treating specialist should be obtained by the beneficiary while preferring claims.

3. The reimbursement will be permissible only if the initial treatment has been taken with prior permission of competent authority in a Government Private recognized hospital.

4. The reimbursement will be allowed for an initial period of six months from the date of discharge from the hospital and in case further extension is required, fresh recommendation from a Government Specialist will have to be obtained for further continuation of the treatment.

5. This issues with the concurrence of Finance Division vide their Dy. No. 2780/2001-JS (FA), dated 26/4/2001.