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 DELHI GOVERNMENT EMPLOYEES HEALTH SCHEME

Delhi Government Employees Health Scheme (DGEHS) was launched in April 1997 with a view to provide comprehensive medical facilities to Delhi Government employees and pensioners and their dependents on the pattern of Central Government Health Scheme. All health facilities (hospitals / dispensaries) run by the Govt. of NCT of Delhi and autonomous bodies under Delhi Government, local bodies viz. MCD, NDMC, Delhi Cantonment Board, Central Government and other Government bodies [such as AIIMS, Patel Chest Institute (University of Delhi) etc.] are recognized under the scheme. In addition, some Private Hospitals/Diagnostic centers notified from time to time are also recognized/ empaneled as referral health facilities. The scheme has been modified for the benefit of beneficiaries vide O.M. No. F.342/81/2003/H&FW/3264 Dated 06.10.2003, dated 21.2.2005, dated 25.10.2007 and dated 28.07.2010.
1. Salient features
  • To provide comprehensive medical care services to the beneficiaries through network of Delhi Government Dispensaries, Hospitals and recognized private hospitals and diagnostic centers in Delhi and NCR.
  • To benefits of the scheme are based on CGHS.
  • Membership is compulsory for serving employees and is optional for pensioners.
  • Cash less facility is available for all beneficiaries in emergent conditions however it is available to pensioners in emergent and non-emergent conditions.
2. Eligibility
Membership is compulsory for serving employees and is optional for pensioners Government of NCT of Delhi. The scheme is also available for Ministers, MLAs, Ex. MLAs of Government of NCT of Delhi, Judges and Ex. Judges of High court of Delhi, Employees of fully funded autonomous bodies of Govt. of NCT of Delhi. It is compulsory for Delhi Government employees and Mandatory monthly contribution is deducted from the salaries as per salary slabs. Pensioners have the option of becoming member of the scheme by depositing contribution equal to 10 years installments as a lump some amount or in six monthly installments from January to June and July to December for 10 years.
3. Dependent family members
For availing medical facilities under DGEH Scheme spouse (wife / husband), children, parents, sisters, widowed/ divorced / separated daughters, brothers, stepmother shall be deemed to be dependent on the government servant if they are normally residing with him/her and their income from all sources including pension and pension equivalent to DCRG benefit/family pension, does not exceed Rs. 3500 plus amount of dearness relief thereon drawn as on the date of consideration (w.e.f. 1.1.2009), as per provisions contained in CS(MA) and CGHS rules issued from time to time. Any addition / deletion in family must be informed immediately by the beneficiary to his / her office, Authorized Medical Attendant (AMA) and SPO of DGEHS
4. Facilities under D.G.E.H. scheme
1)   Out patient care facilities in all systems (i.e. Allopathy, Homeopathy, Ayurvedic, Unani, Yoga and Sidha) can be availed at government dispensaries, government hospitals and empanelled hospitals with the permission of AMA as per provisions of the scheme.
2)   Indoor services in non-emergent conditions Indoor treatment as per entitlement shall be available in private recognized hospitals of the choice of beneficiary during non-emergent conditions on the advice of the concerned AMA or on the advice of doctors of other recognized health facility duly endorsed by the concerned AMA. The concerned AMA shall issue a referral / authorization to the opted Hospital / Diagnostic center for treatment. Follow up treatment subsequent to any specialized procedure or for illness shall ordinarily be valid for six months. No claim form non-recognized / non- empanelled private hospital / diagnostic centers shall be entertained. Treatment in any central government, state government, autonomous hospital under government and any government body can be availed without referral from AMA.
3)      Treatment in emergent conditions by the beneficiary can be availed in any recognized institution of his / her choice directly with out being formally referred by AMA. Cashless treatment facility in emergent conditions will be available to all working beneficiaries in recognized empaneled private hospitals / diagnostic center of Delhi on production of valid DGEHS card. Follow up subsequent to any emergent treatment / procedure or for the illness shall be on authorization of concerned AMA.
Treatment in private not recognized / not empaneled under the scheme in medically emergent conditions will also be admissible when treatment is necessitated in such hospitals being situated near the place of illness / trauma and when no other recognized facility is available nearby or due to circumstances beyond the control of the beneficiary. However reimbursement shall be made by concerned department within the ceiling of DGEHS rates,
4)   Specialized consultation and treatment specialized treatment in private empaneled hospitals of choice of the beneficiary shall be available on the advice of the concerned AMA for a period not exceeding six months in each instance. Any OPD treatment in private hospitals not recognized / empaneled under the scheme shall not be admissible for reimbursement.
5)  Free supply of drugs prescribed by doctors of Government dispensaries and hospitals and recognized hospitals. In case of chronic illnesses requiring prolonged treatment, medicines may be supplied for one month at a time. However, in case of senior citizen beneficiaries with chronic conditions, requiring prolonged treatment, the same may be dispensed up to three months also on the decision of the in-charge of the attached dispensary / hospital. The medicines to the beneficiaries shall be provided by the concerned attached dispensary / hospital. In, any medicine is not available in hospital / dispensary, the same dispensary / hospital authorities shall supply it to the eligible beneficiary an din case this is not possible, the beneficiary would be allowed reimbursement of such medicines.
6)   Special treatment for diseases like TB, Cancer, Kidney Transplant, Liver Transplant and by-pass surgery etc. are provided in specialized centers.
7)   Cashless treatment facility as per entitlement in recognized empaneled private hospitals / diagnostic centers in Delhi will be available to serving employees in emergent conditions on production of valid DGEHS card. These hospitals will be sending the bills to concerned departments (where employee is serving) for making payments which have to be made within 60 days as per terms and conditions of the agreement entered into with these hospitals / diagnostic centers. The itemized bills will have to be accompanied by the following documents (in duplicate)-
a)    Photocopy of valid DGEHS card of the beneficiary
b)   Referral / authorization from AMA or emergency certificate issued by the hospitals concerned, as the case may be.
c)   Essentially certificate as per CS(MA) rules.
d)   Certificate by the hospital to the effect that
o   The treatment given by the hospital has been as per entitlement of the beneficiary and the rates charged have been as per DGEHS approved rates.
o   The treatment given was absolutely essential and in accordance with CS(MA) rules and was not cosmetic in nature.
e)   Stickers / invoices indicating serial number / manufacturer etc. of implants etc. as per practice being followed under CGHS.
The bills should be item-wise and should be authenticated / verified by the beneficiary or in case of inability / death of patient, the bills should be authenticated / verified by the next of kin / legal heir of the beneficiary or attendant of the beneficiary.





All bills on account of providing cashless facility to the pensioner beneficiaries by the hospital / diagnostic centers shall be submitted to DGEHS cell at DHS (HQ) on monthly basis as per guidelines communicated vide OM dated 25/10/2007. However, the payment to hospital / diagnostic centers for cashless treatment to serving employees shall continue to be processed through their respective department / offices.
8. Reimbursement of specialized tests and treatments
DGEHS beneficiaries on production of a valid DGEHS card can avail of treatment facilities at AIIMS and Institute of Liver and Biliary sciences Delhi. No prior permission / approval is necessary from concerned Authorized Medical Attendant (AMA) for this facility. The expenditure on treatment is reimbursed as per entitlement of the beneficiary, as per AIIMS, DGEHS rates or actual, whichever is less. Where ceiling has been prescribed, reimbursement will be limited to the ceiling rates or actual expenditure, whichever is less, as per provisions contained in Office Memorandum dated 25/10/2007.
Entitlement of ward in the Institute of Liver and Biliary sciences, New Delhi
 Sr. No.
Basic pay + Dearness Pay / Basic Pension + Dearness Pension (P.M.)
Ward entitlement
1
Up to Rs. 11,250
General ward / Triple shared ward
2
Rs. 11251 to Rs. 15750
Non AC sharing room
3
Rs. 15751 to Rs. 20,250
Non AC sharing room / Non AC single room
4
Rs. 20,251 and above
AC single room


5. Treatment in Government / Referral / Private Empanelled Hospitals
In addition to treatment and provision of prescribed medicines from the Delhi Government Dispensaries, all categories of the beneficiaries under the Scheme, including their eligible family members, are entitled to treatment in Government/Referral/Private Empaneled hospitals with the permission of AMA. The expenditure incurred on this account is reimbursable by the respective Departments. Such reimbursement is restricted to the limits prescribed by the Government from time to time. The expenditure incurred in excess of the limits prescribed has to be borne by the beneficiary himself. Cashless treatment facility is available to Ministers of Government of NCT of Delhi, MLAs, Ex. MLAs, pensioners and their dependents in all recognized hospitals. Reimbursement to pensioners shall be made by DGEHS cell of DHS on submission of the bills through concerned department for treatment in recognized / government hospitals. The concerned department shall verify the validity of the card and dependent members of pensioners.
Package rates for reimbursement of indoor treatment expenses for various treatment / tests under package deals have been specified. Reimbursement shall be made as per provisions of the scheme.

Entitlement of ward for indoor treatment in recognized hospitals


Sr. No.
Pay in pay band / Pension / Family Pension drawn per month
Ward entitlement
1
Up to Rs. 13,950
General ward
2
Rs. 13960 to Rs. 19,530
Semi-Private ward
3
Rs. 19,540 and above
Private ward

Package rates for empaneled AYUSH Hospitals / Centers for Ayurvedic, Unani, Yoga and Naturopathy treatment
           Package rate means rates for a package of treatment of standard set of procedures that are administered to the patient while undergoing treatment for a pre-diagnosed disease condition for the specified time period. This includes all charges pertaining to the particular treatment.
Admissible room rent for indoor treatment
           The maximum room rent to be charged by Private Empaneled Hospitals for different categories is as under


General ward
Rs. 1000  Per day
Semi Private ward
Rs. 2000  Per day
Private ward
Rs. 3000  Per day

Room rent is applicable only for treatment procedures for which there are no prescribed package rates
6. Contribution
Rates of contribution for serving Delhi Government employees

Sr. No.
Grade pay drawn per month
Ward entitlement
1
Up to Rs. 1,650
Rs. 50.00
2
Rs. 1,800, Rs. 1,900 and Rs. 2000, Rs. 2,400 and Rs. 2,800
Rs. 125.00
3
Rs. 4,200
Rs. 225.00
4
Rs. 4,600, Rs. 4,800 Rs. 5,400 and Rs. 6,600
Rs. 325.00
5
Rs. 7,600 and above
Rs. 500.00


Contribution shall be recovered from the monthly salary bills of the employees.
Contribution by pensioners
Pensioners/Family pensioners have an option to get their DGEHS Pensioner card made by paying a lump sum amount equivalent to 10 years contribution as due on the date of retirement. Pensioners / Family pensioners who are making contribution on an annual basis and wish to continue to avail benefits will have to contribute at the revised rates up to the time of contribution needed to cover a period of a total to ten years from the time pensioner was issued pensioners card for the first time. The beneficiary is covered under the scheme during the period for which contribution has been paid. The scheme has been made open ended for the pensioners i.e. the Pensioners who are not members of the scheme can opt for scheme at any stage by paying its contribution.
7. Fixed Medical Allowance
Pensioners who do not opt for DGEH Scheme or who are not staying in areas covered by the DGEHS shall be paid Fixed Medical Allowance at the rate of Rs. 300.00 per month.
8. Identity cards
The DGEHS cards are issued to the employee / pensioners by the concerned administrative department.
Guideline For Offices For Issuing The Health Card
  1.  Blank health cards [Index Cards (3 copies) and Medical Facility Card(1) for each beneficiary] are being supplied by Directorate of Health Services to respective departments for issue to their employees/pensioners who have opted for the health scheme. In case of pensioners, the issuing authority will be concerned department from where the pensioner has retired.
  2. After being filled up, the first copy of the index slip is to be retained by issuing authority and kept in the services book/personal file of the employee. The second copy of the card is to be sent to the Medical Officer In-charge of the dispensary/ hospital, to which the employee wants to be attached. The third copy is sent to State Program Officer (DGEHS), Directorate of Health Services (HQ) F-17, Karkardooma, Delhi- 110032.
  3.  Duly properly filled in Medical facility Card, clearly showing validity and updated list of dependents, is to be issued to the employees and pensioners attached to the particular department. This card shall be used by the employee and pensioners for availing medical facilities. The beneficiary has the option to opt for hospital / diagnostic center of his / her choice.
  4. The dispensary to which the beneficiary wants to be attached should be clearly mentioned on the index card as well as on the medical facility card. In case of pensioners the validity of cards and eligibility of ward for indoor treatment should clearly be mentioned. The administrative department must clearly indicate the validity of the card in case of pensioners on the basis of the subscription paid by the pensioner.
  5. Family photograph of the employee / pensioner must be affixed on the health card.
  6. In case of loss of health card the issuing department shall issue duplicate health card on receiving an application, a copy of FIR / Complaint lodged with police regarding loss of health card, payment of Rs. 10 for issue of duplicate card and two latest family photographs of the beneficiary.
  7. An account of blank index cards and medical facilities cards received from Directorate of Health Services and details of cards issued to employees/pensioners have to be maintained in every office.
# In case of EDUCATION DEPARTMENT, the cards are issued by Directorate of Health Services to DDEs/RDEs only, from where concerned/subordinate schools can indent their requirement of DGEHS Cards.


# In case of PWD, the cards are supplied to the Chief Engineers Offices/Engineer in Chief Office, from where the individual subordinate offices may get required number of DGEHS Cards.


9. Traveling allowance for medical treatment
Attendant or escort who is required to travel along with patient, if the Medical Authority attending the patient has certified in writing that it is unsafe for the patient to travel alone and an attendant / escort is necessary to accompany him.
Pensioners permitted for treatment in another city, if such treatment is not available in the same city, on the advice of the Government specialist, shall be entitled for traveling allowance restricted to the distance up to the Referral Hospital available in the nearest city by the shortest route. In case of any deviation, prior permission of the department / DHS must be obtained.
10. Medical Advance
The heads of the departments of Delhi Government are competent to sanction medical advance to the extent of 90% of the estimated cost of treatment for major / serious illnesses in accordance with the provisions of CS(MA) Rules 1944. Medical advance shall be issued by the Director Health Services in case of pensioners on production of copies of valid Medical card, Estimate provided by Government / Private empanelled Hospital, OPD card and an application for the same.
11. Settlement of Medical Claims
A beneficiary should submit an application to the concerned authority for claiming reimbursement of medical expenditure and settlement of any advance. The claim should be filed within 3 months of discharge from the hospital. The application should be submitted along with the following documents-
  1.   Modified checklist for reimbursement of medical claim, Form Medical 2004
  2.  All original bills
  3.  Photocopy of Valid DGEHS Medical card
  4. Discharge Summary
  5.  A detailed list of all medicines, Laboratory tests, investigations, No. of doctor visits etc. with dates.
  6. In case treatment is taken in emergency, a self explanatory letter from the beneficiary, explaining the emergency circumstances. Emergency treatment certificate from the concerned hospital must also be submitted.
  7. Photocopies of claim papers and an affidavit on stamp paper, in case original papers have been lost 
  8.  Affidavit on stamp paper by claimant, no abjection from any other legal heirs on stamp paper and the copy of death certificate, in case of death f the card holder.
  9. Prescription slip and diagnostic reports.
12. Referral system
1.       The attached dispensary /hospital shall be the single window for taking care of health requirement of the beneficiary (Primary health care, referrals, supply of medicines etc.). The Authorized Medical Attendant (AMA) at the attached dispensary / hospital will be competent to accord permission / authorization for treatment / tests in DGEHS recognized private hospitals / diagnostic centers. There will not be any need of permission of the concerned department from where the beneficiary is working in such cases.
2.       The AMA for referral purposes will be the CMO/ MO In-charge of the dispensary / hospital where the beneficiary is attached. For this purpose all hospitals shall designate a staff physician who will function as AMA for beneficiaries attached to the hospital.
3.       The beneficiary will have the option of availing facility of treatment / diagnostic procedures etc. in recognized institutions of his/ her choice.
4.       In emergent conditions beneficiary can go to any of the recognized institution of his / her choice directly without being formally referred by AMA. Cashless treatment facility in emergent conditions will be available to all working beneficiaries in recognized empanelled private hospitals / diagnostic centers on production of valid DGEHS card. Follow up treatment subsequent to any emergent treatment / procedure or the illness shall be on authorization of concerned AMA.
5.       Treatment in private hospitals not recognized / not empanelled under the scheme in medically emergent conditions will also be admissible, subject to ceiling DGEHS rates applicable as per entitlement, when treatment is necessitated in such hospitals being situated near the place of illness / trauma and when no other recognized facility is available nearby or due to circumstances beyond control of the beneficiary. The genuineness of the emergent condition shall be evaluated on case to case basis. Merely getting admitted through emergency, without any justifiable emergent condition, shall not make beneficiary entitled for the benefit.
6.       Beneficiaries residing in NCR areas outside Delhi are allowed to get treatment even during non-emergent conditions from Government Institutions and CGHS recognized centers after referral from Government institutions in concerned areas or in Delhi as per provisions of the scheme. 



      Source : delh govt. Health Site 
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