Presentation On Medical

Attendance Rules

CHITRA VENKATESHWARAN
What is Central Services Medical Attendance
Rule?

• Medical Attendance Rule is about reimbursement of

expenses on Medical treatment of employees and their
families not covered by CGHS scheme.

• It includes Medical Attendance and hospitalization

expenses.
Applicability

• It applies to:-

• 1) All Government Servants who are not covered by CGHS Scheme, except
railway employees, Defense Service personnel, All India Service Officer

• 2) Railway employees on their deputation to offices under Central Government.

• 3) Government pensioners on their reemployment under Central Government.

• 4) State Government employees on deputation to Central Government.

• 5) Civilians paid out of Defense Estimate.

 CS(MA) RULES 1944- Not applicable
1. INDIAN RAILWAY
2. DEFENCE SERVICE PERSONNEL
3. [Link] ON DEPUTION ABROAD
4. RETIRED GOVT. SERVANTS
5. OFFICERS OF ALL INDIA SERVICES
6. NON OFFICIALS SENT ON DEPUTATION TO ABROAD
7. GS. WHO COVERED UNDER CGHS WHILE IN STATIONS WHERE CGHS
FUNCTIONING
•
[RULE 2]
Deputation to State

1. Central Govt. Staff on Deputation to State, Medical Rule of State

will apply
2. But, if the State Govt. desires, State Govt. can apply the CSMA
Rules for such deputationists
• (Note 4 under Rule1( 2)
 Simultaneous Treatment in Two Systems

1. Same disease - treatment in one System (Allopath or Aurveda or Unani etc.) at a

time
2. Different Diseases – Treatment in two systems permissible
(GID 23 under Rule 2)
Facilities available under CS(MA) Rules

1. Consultation with AMA

2. Consultation with Specialist
3. Treatment at Residence
4. Treatment in Hospital
5. All type of Pathological Test including CT Scan
6. Intra Ocular Lens
7. Re-imbursement of Oxygen Concentrators (GID
11 under Rule 8)
• Contd…
Facilities available under CS(MA) Rules

8. Re-imbursement of cost artificial appliances –

Purchase/Repair/Replacement
9. Hearing Aid/ Cochlear
10. Purchase of CPAP/ BIPAP machine for domiciliary use
11. Neuro Implants
12. Transplant of Liver, Kidney, Heart etc,
13. Coronary Stents
14. Post Operative Care for Kidney Donor
15. Dental Treatment
16. Treatment for Special Diseases
17. TA for Patient & Attendant
Authorized Medical Attendant

• 1) Medical Officer appointed by Department of Health Government of India.

• 2) Any other Department of Government of India in respect of its Employees.
• 3) Appointed by an authority declared to be the Head of Department under
Service Rules.
• 4) Chairman of the Central Government Employer welfare Committee in that
station.
• 5)Medical Officers under the employment of state Government or Union
territory shall not be appointed without the permission of the Government
• 6) If no Medical Officers as above is appointed.
• a) Principal Medical Officers of the District in respect of Central
Government group ‘A’ Service or whose pay is not less that Rs. 2500/-
• B) Assistant Surgeon grade I in respect of Government Servant whose pay is
Less than Rs. 2500/- more than Rs. 1200/-.
• C) Assistant Surgeon grade II in respect of all other employees.
(Rule-2 of AMA Rules)
Who is UR AMA

• Govt. servants must normally consult an authorised medical

attendant nearest to his residence.
• Incase of emergency where the official or member of his fly fell ill, he
or she may take treatment from any other empanelled authorised
medical attendant
• Incase of govt official and or entitled member's of the fly going
outside the normal duty station they should obtain the treatment
from the nearest govt and other hospitals/ dispensaries recognised
under CSMA rules not from the private medical practioners
appointed as AMA outside the normal duty station
• The AMA is determined with reference to the place at which he falls
ill whether it is his residence, place of causal stay or place where he
may be spending his leave
Medical Attendance

• Medical Attendance means :-

• 1)Attendance in his consulting rooms or Government Hospital to
which he is attached or at the residence of the patient.
• It Includes
• 1) Consultation with specialist.
• 2) Cost of pathological, bacteriological, radiological or other
methods of examination, provided they are done in Government
Hospitals/Laboratories.
• 3) If such test procedure are not available in govt hospitals
reimbursement upto Rs. 500 can be made on the ceritificate of
medical officer and beyond Rs. 500 on the certificate of
superintendent of the hospital
• 4) Physiotherapeutic and occupational therapeutic treatment if it is
meant for improving physical weakness.
• 5) Cost of Consultation charges at the prescribed rates.
• 6) Cost of Injection and Medicines .
• 7) Does not includes preparation which are primarily food, tonics,
laxative and expensive drugs.
 RATES
[Link] Details AMA Post- AMA with MBBS
Graduate/Specialists graduates

1 First Consultation 100 70

2 Subsequent 60 40
Consultation
3 Intramuscular 20 20
Injection
4 Intravenous Injection 40 40

No separate charges for Day & Night

Order No. 14025/10/2010/MS. Dt. 17.03.2011
Admissible Items/medicines
1. Vitamins A & D drops for developing and growing children
0-5 years
2. Vitamin B Complex tab. Whenever antibiotic is being
administered
3. Injection- Vitamin B-12, Tablet Folic Acid in case of
Pregnancy
4. Injection-Vitamin B or Tab. B in case of pl polyneuritis
peripheral
5. Dextrose in case of In-patients
• (Annexure XVI Para 2)
Inadmissible Items
1. Preparations which are not medicine but primarily food like:
2. Foods
3. Tonic
4. Toilet/cosmetic preparations
5. Disinfectants as specified in Schedule I
6. Expensive Medicines, tonics, laxatives and other elegant
preparations specified in Schedule for which equal
therapeutic value is available
7. Vitamins, Glucose, Baby Food
• (Rule 2 (h)(iii) & Appendix XVI
 Restrictions on Medical Attendance
• 1) Medical Attendance can be in the consulting room / Hospital / OPD of the any
Government /recognized Hospital/ at the Residence of the patient.
• 2) Medical Attendance does not include repeat consultation. One Consultation at the
rate of one per day is allowed .
• 3) Only Four Consultations are allowed and the treatment should be completed within
10 days of the Commencement of the treatment. Maximum 15 Injections are
allowed.
• 4) In case Indian system of it can go up to 40 days and four consultation.
• 5) There should be reasonable gap between closing of the first spell of illness and
recurrence of the same disease.
• 6) Whether the Medical Attendance is the fresh one or continuous one is based on the
prescription etc.
• 7) Prolonged treatment should be referred to OPD of the Government
Hospital/Recognized Hospital.
• 8) Consultation at the OPD of the Government/ Recognized Hospital can be held
without prior approval of AMA.
• 9) In case of tuberculosis disease which does not require admission in hospital can be
had at the OPD of the Government/ Recognized/ Special Hospitals or at the consulting
room of the authorized Medical Attendant.
 Hospital means:
HOSPITAL:

1. All State Govt./Municipality hospitals

2. All hospitals/centers recognized by State Govt. for
their employees
3. All hospitals of PSU/Port Trusts
4. All Railway Hospitals
5. All hospitals recognized by CGHS/ MA rules
6. Pay clinics in certain States
7. Cantonment Hospitals where Govt. Hospital not available
(GID 13)
[RULE 2. d & GID 12 under Rule 2]
Entitlement of Hospital Wards
[Link]. Basic Pay/Pension Entitlement
(without GP)

1 Up to 43600/- General Ward

2 43601/- to 63000/- Semi-Private

3 63001/- onwards Private

S.14021/41/2016-EHS dt. 01/06/2017

Treatment Govt/Recognized Hospital

1. AMA will refer to Govt/Recognized Hospital if patient requires hospitalization

2. Consult AMA before admitting in Hospital
3. Consultation is not required if admitted in Govt./Municipality Hospital
4. If patient requires prolonged treatment but not hospitalization, AMA should
refer him to OPD of Govt/Recognized Hospital
5. GS is eligible to get re-imbursement
6. If admitted in Hospital, all certificates including Essentiality Certificate B should
be obtained from Hospital
7. Not to admit the hospital even in emergency cases run by AMA
8. HOD has to permit for indoor treatment in a Private Hospital on the prescription
of AMA (Order 5.6.14)
• (Rule 6 and Decisions)
Hospitalization Benefit
• 1) Treatment can be had in any Government Hospital/
Recognized Hospital.
• 2) Treatment in Hospital can be had without reference
from AMA, Reimbursement will be as per the approved
rates of Government Hospital or rates prescribed in
respect of recognized hospital.
• 3) In emergency treatment can be held in any private
Hospital nearest to the place where the patient fell ill.
• 4) Rates should be restricted to rates for the non-NABH
accredited hospitals of CGHS.(order dated 11/6/13).
• 5) In case of admission into CGHS recognized hospital,
rates should be restricted to rates prescribed by CGHS.
• 6) Coronary Bypass Surgery and Angioplasty can be had
from Bombay Hospital / Nanavati Hospital,
reimbursement will be as per prescribed rates.
Package Rates
1. Package rate for major illness for treatment in recognized hospital is available
2. Package rates includes:
a) Lumpsum cost of impatient treatment
b) Diagnostic procedure
c) Registration/admission charges/diet/dressing
d) Operation charges/Operation Theatre charges
e) ICU/ICCU charges/Monitoring charges/Nursing
f) Fees for consultancy/Surgeons fee
g) Anesthesia
h) Cost of disposables/sundries
i) Procedural charges/routine investigation
j) Physiotherapy charges
3. Cost of Implants/Stents/Grafts reimbursable in addition to package charges
Package Rates

4. Maximum duration of indoor treatment:

a. 12 days for Specialized/Super-speciality treatment
b. 7 days for major surgeries
c. 3 days for Laparoscopic surgeries/Normal deliveries
d. 1 day for day care/minor OPD surgeries
5. If required more stay than allowed under Package rate,
the same is admissible on certification as per entitlement
– Investigation, Doctors visit(limited to 2 visits in a day-
Cost of Medicine
6. If extended stay is required due to infection subsequent
to surgical procedure: Not allowed
Package Rates

7. Not admissible: Telephone/Toiletries/Sanitary

Napkins/ Talcum Powder/Mouth Fresheners
8. Expenses incurred on medicines/ consumables/
sundry equipments etc. which are purchased
outside on specific prescription is reimbursable
• ([Link].2-1/2012/CGHS/(P), dated 1.8.2013)
 In-Vitro Fertilization (IVF)
• Admissible on the following conditions:
1. Treatment only on the basis of advice by Head of
Dept. of Gynecology & Obstetrics
2. HOD of Ministry should given permission
3. Procedure allowed only in Govt. Medical Institution
4. There should be clear evidence of failure of
conventional methods before permitting IVF
• Contd…
In-Vitro Fertilization (IVF)

5. Age of woman should be between 21 & 39 years

6. The woman must have married and living with her husband
7. Couple has no living issues
8. Maximum Rs 65,000/- per cycle –inclusive drugs & other
monitoring, disposable costs
9. Re-imbursement is permissible only if prior approval by the
Ministry/Dept. is obtained
10. One time permission for IVF treatment consisting 3 cycles test
in total
11. Get an undertaking that such treatment not claimed earlier.
• OM No. 15025/2011-CGHS/III/CGHS (P) 22.11.11 & GID 31
under Rule 2)
When Treatment is taken in Emergency cases in
Private unrecognized Hospital
1. General Ward : Rs. 1000/-
2. Semi-Private Ward: Rs. 2000/-
3. Private Ward : Rs. 3000/-
• (S.11011/23/2009-CGHS/[Link]/Hospital Cell (Part 1), dt. 16.11.2010)
Emergency Treatment
1. Patient in emergency,(Accidents, Illness etc.) can be
admitted to any Private hospital, if Govt. hospital not
available nearer than such private hospital
2. Nursing Home run by AMA is not allowed
3. Controlling Authority will decide on merit of the case. If
they have any doubt, they can refer to DGHS
4. If emergency condition is crossed, the patient can be
transferred to Govt./Recognized Hospital at the advice of
attending doctor
5. Re-imbursement as per Govt. Hospital/nearest CGHS
recognized Hospital Rates
• Contd….
 Emergency Treatment
• 6. Advance payment is permissible directly to Hospital
7. Cost of inadmissible medicines will be borne by GS
8. GS can also make payment to Hospital and get re-
imbursement
9. Delegation Rs. 2000/- & 5000 in case of OPD & IPD Under
Secretary or equivalent. Above the charges by HOD([Link].
11.1.2011)
• (Appendix VIII of CSMA Rules)
 ADVANCES
• Rs. 10000/- or amount recommended by the Physician for
indoor treatment / outpatient treatment for diseases like
cancer, etc, if the duration of the treatment is less than three
months.
• In case of major illness like bypass surgery, kidney transplant,
cancer treatment, etc 90% of the package deal or according to
estimate submitted by Govt / recognised hospitals.
• Rs. 36000/- in case of T.B. when the duration of treatment is
more than three months.
• Advance can be paid to wife or legal heirs.
• Advance can also be paid for purchase of replacement of
artificial appliances.
SPECIAL DISEASES

• TREATEMENT IN SPECIALLY RECOGNISED HOSPITALS

 CANCER
 T.B.
 LEPROSY
 MENTAL
 THALASSAEMIA MAJOR
[ORDERS IN SECTION 3]
Cancer Treatment
1. GS is permitted to get themselves treated in the hospital
listed in [Link]. 23.2.15
2. Re-imbursement will be as per rate fixed in
the Regional Cancer Centers under Central Govt. or actual
whichever is less
3. In cities where there are no facilities for treatment in any
empanelled hospital, powers are delegated to HOD/HO for
grant of permission for treatment in any hospital. Re-
imbursement is limited to CGHS rate or actual whichever is
less
4. Permission by HOD/HO can also be granted for post-
operative follow up treatment (OM. 18.2.15)
Cancer Treatment-Hospitals as per
[Link].18.2.15
1. Delhi: AIIMS, Ambedkar Cancer Institute, Rotary Cancer Hospital,
New Delhi
2. Gujarat: Gujarat Cancer Research Institute, Ahmedabad
3. Maharashtra: Rashtrasant Tukdoji Regional Cancer Hospital,
Nagpur and Tata Memorial Hospital, Mumbai
4. Many more in other States
KIDNEY TRANSPLANTATION

Surgical/ clinical charges incurred and post operative

care for kidney donors are eligible for reimbursement.
If undertaken at private recognized hospital,
reimbursement will be restricted to CGHS approved
rates (GID(12), below rule 8.
Dental treatment

1. Govt. / Private recognized hospitals( OM dt.7.12.16)

2. Surgical operations needed for removal of Odon-tomes and impacted
wisdom tooth, treatment of gum boils extraction.
3. Scaling and gum treatment including Pyorrhea and Gingivitis,
4. Filling of teeth root canal treatment.
5. Complete denture acrylic based is reimbursable (Rs. 13000/- approx)-
if certified by Dentist in Govt. Hospital
6. Treatment in Private Recognized Hospital is also reimbursable
• (GID 1, 1A & 2 under Rule 8)
1. INTRA-OCULAR LENS IMPLANTATION
a) Actual cost of implantation and treatment thereto
reimbursable if undertaken at Government hospital.
b) If undertaken at private recognized hospital reimbursement
of actual cost will be limited to
Hydrophobic foldable IOL- Rs. 5800/-
(Multi piece/Single piece Aspheric)
Hydrophobic Acrylic IOL – Rs. 4500/-
PMMA IOL (AC/PC) - Rs. 500/-
Scleral Fixated IOL – Rs. 3500/-
Reimbursement for LASIK surgery and INTACS rings not
recommended
[section 1]
Other Facilities
1) Reimbursement of various artificial appliances on the
recommendation of the specialist in Government . Recognized
Hospital.
2) Payment to be made directly to the Agency.
3) Purchase of hearing AID and other appliances which are generally
not available with Rehabilitation Centre can be purchased from the
Agency after obtaining Quotation as per the specification of the
specialist.
4) Traveling Allowance for the Government Servant / Family and one
attendant for obtaining appropriate Medical Attendance at the other
District/ State.
5) Ambulance charges as per conditions.
6)Group A officers above 40 years may have annual check up ,the
amount should be restricted to Rs 2000/- for men and Rs 2200/- for
women.
Reimbursement of medical expenses under Indian
system of medicine

• Govt. servant can opt for treatment under Indian system of

medicines.
• General medicines can be prescribed by authorised medical
attendant including pvt. Doctors appointed as AMA’s by
central govt. employees welfare committee
• Costly and restricted medicines which are deemed to be
essential life saving medicine may be prescribed by Group A
Group B officers of Ayurveda, Unani Siddha, and
Homeopathy medical services of the state or central govt
Continued…
• Treatment of Panchkarma therapy may be prescribed only
by Group A officer or director of equivalent rank
• Treatment to be had at the empanelled hospitals and at the
rates prescribed
• Medicine to be purchased only from authorised pharmacies/
firm or their authorized dealers
• Certificate regarding rates for medicines are as per the latest
catalogue of medicines is to be recorded
TA for Medical Attendance
1. When patient fell ill 5 KMS away from AMA, TA can be
claimed to visit consulting room and back
2. If the patient cannot travel, the AMA is entitled to travel
expenses to visit patient
3. Conveyance charges to Compounder or Lab attendant etc.
not payable
4. Production of certificate from AMA is required to claim TA
(Rule 4)
T.A. for medical attendance and treatment

• Employees and members of their families are entitled to TA for their

journey to obtain appropriate medical attendance and treatment if it
is certified by AMA/ Specialists/M.O.
• Patient and also 1 attendant is entitled to TA plus DA for the period of
journey undertaken by rail, road, sea and air.
• NO DA for halt.
TA incurred for Kidney Donor

• If the donor is a private person, T.A. is admissible at

the rates of the recipient Government Servant;
• If the donor is another Government servant or his
family members, TA is admissible at the rates
applicable to the donor Government Servant. [Link]
• Advance of TA. To the extent admissible may be
granted adjustable against the subsequent claim for
TA on completion or 31st March, whichever is earlier.
Time limit for submission of claims

• Claim for reimbursement of medical expenses to be submitted within

six months of the completion of treatment or discharge from
hospital.
• Delay in submission of bills can be condoned by H.O.D.
FAMILY

1. HUSBAND / WIFE (INCLUDeS MORE THAN ONE WIFE)

2. SPOUSE IS ALWAYS DEPENDENT!
DEPENDENT……( UP TO EARNING PM. 9000/- + DA= O.M. 08.11.2016
1. PARENTS
2. STEP MOTHER (STEP FATHER NOT INCLUEDED)
• CHILDREN:
1. UNMARRIED SON: TILL 25 YEARS OR TILL OR GETS MARRIED WHICHEVER IS EARLIER
2. DAUTHER: TILL EARNING OR GETS MARRIED WHICH IS [Link] NO BAR
3. UNMARRIED SON SUFFERING PERMANENT DISABILITY-NO AGE LIMIT
4. ABANDONED/DIVORCED DEPENDENT DAUGHTERS –NO AGE LIMIT
• SIBLINGS
1. SISTERS INCLUDING WIDOWED/DIVORCED/ABANDONED
2. MINOR BROTHER
3. DISABLED MAJOR(Unmarried) BROTHER WITHOUT AGE CAP (ORDER 19.6.14, conditions
apply)
4. Family members need not stay with GS [SECTION 4]
 Both Spouse are employed??
b) Spouse Employed in State Government / Autonomous bodies
/ Private Organizations providing Medical facility can choose
the facility provided by the
organization. Certificate to the effect to be given.
If both husband/ Wife are covered under AMA rules,
Government Servants has to give join
declaration and claim facility as per their status.
c) When spouse is governed by different Medical rules or
residing in another station, Husband/ Wife can avail
medical facility as per the rules of the organization in which
they are employed for self and family members residing with
Him/ Her.
d) The declaration regarding income and residence of the
parents should be furnished once in the beginning of every
calendar year.
Useful tips to GS
1. Find out your AMA as decided by Place of Illness & Kind of
Illness
2. Consult AMA take treatment as per his advice
3. No re-imbursement is permissible unless treatment is taken
under AMA/Govt. Hospital
4. Treatment is for 10 days. Injections up to 15 is permissible.
Consultation up to 4 permissible
5. Pay the prescribed charges to AMA
6. Obtain Prescription/Cash Memo/Receipt for other charges
7. Obtain Essentiality Certificate “A’ for treatment with AMA
and ‘B’ for Inpatient treatment from Hospital
Useful tips to GS
8. Get countersign from AMA on Cash Memo/Other receipts
etc.
9. Only reimbursable cost of medicine is admissible in claim
10. Cash Memo should contain all details, batch No.,
Manufacturing firm etc.
11. Obtain Essentiality Certificate within time
12. Ensure Essentiality contain the Designation of Dr, period of
treatment, name of illness, date of consultations and
injections etc.
13. Prefer the bill in the prescribed form with enclosures within
3 months from the date of completion of treatment
Useful tips to GS
14. For prolonged treatment visit Govt. Hospital or recognized Hospital
with the recommendation of AMA
15. For In-patient treatment:
a) Inform your AMA & get recommendation for hospital treatment
b) Admit in normal case only in Recognized Hospital
c) Inform your pay and entitlement to Hospital
d) Get admitted in appropriate Ward
e) Obtain all bills from hospital & Essentiality Certificate
f) All bills should be countersigned by MO
16. Employee having Mediclaim can claim charges from two sources
with certain conditions
Useful tips to GS
17. In emergency case, you can admit any private hospital
in case no Govt. Hospital nearby but not hospital run
by your AMA
18. Enclose to your bill: a) Essentiality Certificate (A or B)
b) Prescription c) Cash Memo for medicine or
pathological tests
19. Adjust any advance is drawn
20. Last but least – BE HONEST
• (Appendix – X for 1 to 19)
Useful Tips to Controlling Officers
1. Create an awareness among staff about Medical Claim
& Manner in which it is to be claimed.
2. List of AMAs in various areas should be obtained from
CGEWCC & placed in Notice Board
3. Orders & Instructions from time to time are brought to
notice of Employees
4. Unofficial files regarding expenses incurred by a GS
etc. should not be shown to GS
5. Ensure that medical claim is preferred is genuine
6. Make references to Min. of Health if you have any
doubt of geniuses
7. Claim submitted in prescribed form
Useful Tips to Controlling Officers
8. Check whether GS/Family consulted the AMA concerned or
MO in hospital
9. If there is any consultation of Specialist; if so; whether AMA is
recommended
10. Fees paid to AMA/Specialists are as per rates prescribed
11. Whether Essentiality Certificate (A or B) filled up properly
12. Ensure Prescriptions & all Cash Memo duly countersigned by
AMA are attached
13. If a treatment for In-patient whether patient is admitted in the
appropriate ward as per entitlement
Useful Tips to Controlling Officers
14. Ensure that the bill is preferred within 3 months from date of
completion of treatment
15. Allow only admissible medicines with reference to list of
Inadmissible/Admissible medicines
16. Disallow any items like Vitamins (conditions apply) Foods, tonics,
toilets/cosmetics, Glucose, Baby Food etc.
17. Allow consultations, injections up to prescribed limit
18. Check charges paid by patient for each item as per Rules
19. Check whether the treatment is for Prolonged Illness; if so the
patient should have referred to Hospital
20. Ensure all claims are entered in Medical Register & their expenditure
is monitored
21. Check if you have the power delegated under DFPR to sanction the
expenditure & countersign
• (Appendix XII)
Guidelines to Controlling Authorities to Prevent Abuse of
Medical Reimbursement
1. Bills of the 5% of the individuals whose total claim in
a year exceeds Rs. 1000/- shall be subject to careful
scrutiny
2. In case of doubtful nature, investigation should be
done through vigilance
3. In case if bribery & corruption, complaints should be
lodged with CBI
4. Time limit of 3 months for presenting bills should be
strictly adhered.
5. Ensure Maintenance of Control Register
6. Review of the Control Register done superior to
Controlling officer
Guidelines to Controlling Authorities to Prevent Abuse of
Medical Reimbursement
7. Ensure that Sl. No. of Cash Memo entered in
Control Register
8. A specimen signature of AMA may be
obtained & compare with the claim
9. Scrutinize dependency declarations
10. Discretionary powers exercised judiciously
11. Institute investigation against GS & Druggists
in case found any mal fide intention on their
part
• (Appendix XII)
THANK
YOU