The Central Government Health Scheme (CGHS) is available for comprehensive medical care including indoor and outdoor treatment facilities to Central Government employees and civilian pensioners’. The scheme covers 24 cities of the country. 2.57 lakh pensioners with 5.67 lakh beneficiaries were registered with the CGHS as of March, 2008. The CGHS facilities are provided to the pensioners through a network of 329 dispensaries. 19 polyclinics, 65 laboratories, 17 dental units. 5 allopathic first aid posts and maternity hospital/centers. In addition, CGHS refers, where necessary, cases to State! Central Government hospitals and referral hospitals.
CGTTS has also recognized a number of private hospitals and diagnostic centres in the CGHS covered cities, where the beneficiaries can avail medical health facilities as per the package rates approved by the CGHS for a particular treatment. The recognized private hospitals and diagnostic centers are required to provide credit facilities to pensioners and their dependants holding valid CGHS card and valid permission from CGHS authorities. In case of an emergency, the recognized private hospitals and diagnostic centers are required to extend credit facility on production of only the CGHS card. Medical claim is also reimbursable in case treatment had to he taken by a pensioner in emergency in an unrecognized hospital.
This performance audit attempts to evaluate the performance of CGHS in reimbursement of the claims of pensioners.