1. What is this ‘Delhi Government Employees Health Scheme’ all about?

Delhi Government Employees Health Scheme is a welfare scheme of Delhi Government to provide medical facilities to Delhi Government employees and pensioners on the pattern of Central Government Health Scheme on the basis of monthly contribution by the beneficiaries.

2. Who can become the member and how?

The membership of scheme is compulsory for all employees .

The membership of the scheme for pensioners is optional. Employees will give an option at the time of retirement for becoming a member of the scheme. The subscription will be deducted in lumpsum (equal to 10 year subscription) from those who opt for lifetime membership at the time of retirement.

Retiring officers of Indian Administrative Service/Indian Forest Service of AGMUT cadre, officers of DANICS/UTCS cadres including their family pensioners can also opt for the scheme.

Autonomous/statutory bodies fully funded by Delhi Govt. may opt for Delhi Government Employee Health Scheme.

The scheme is not applicable to employees/pensioners who are entitled for any other medical allowance/medical facilities.

In case of expiry of the main pensioner beneficiary who has deposited contribution for lifelong benefits, the family pensioners of such expired pensioners will continue to get benefits of the scheme.

The membership of the scheme is prospective in nature i.e. from the date of becoming the member. By contributing the stipulated contribution/subscription one can become the member of the scheme. For becoming member, one can approach the office from where the employee is working or has retired from. On becoming the member, the beneficiary will be issued a medical facility card, that will entitle the beneficiary the benefit s of scheme at empanelled hospitals.

The pensioners who do not opt for the scheme are eligible to get fixed medical allowance at Rs. 100/- per month.

3. What is the subscription of the scheme ?

Subscription of the scheme is as per OM dated 25.10.2007 as per following list:

In case of employees, this contribution is deducted from the salary on monthly basis.

In case of pensioners, this subscription can be deposited AS A LUMPSUM equal to 120 month subscription to avail life long benefits under the scheme for the pensioners.

4. I am a pensioner, whether I can become Life member for the scheme?

There is a provision for becoming a life member for pensioners only. A lump sum payment of 120 months (10 years) membership contribution by the pensioners (as per eligible category) will enable them to avail such medical facilities/benefits under the scheme for life long with prospective effect.

5. I have deposited a lumpsum of 60 months contribution in 1997 before the modified scheme was notified in 2003. Will I be getting the medical benefits?

For those pensioners who have deposited 60 months contribution as per scheme orders in 1997, the medical facilities will be provided to such pensioners under the scheme on life long basis.

6. From where the Medical Facility card will be issued to me?

The medical facility card will be issued from the office where the employee is working or from the office from where retired in case of pensioners. In case of eligible pensioners who have not retired from Government of NCT of Delhi, the DGEHS cards shall be issued by Directorate of Health Services.

For this purpose, DGEHS Cards shall be provided by Directorate of Health Services. All Heads of Department may send their consolidated requirement directly to Director, Health Services. The cards to the beneficiaries will be issued by the concerned departments (where serving or retired from).

The concerned department should indent such Medical Facility Card/Index Cards from State Programme Officer (DGEHS), Directorate of Health Services (HQ), F17, Karkardooma, Delhi 32.

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 office subordinate offices may get their requirement of DGEHS Cards.

7. What are the hospitals recognized empanelled under the scheme ?

i. 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/ empanelled as referral health facilities.

ii. Pensioner 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.

iii. The list of private recognized hospitals/diagnostic centers in Delhi has been displayed on Delhi Govt. web site. Any changes in the list shall be notified from time to time. An updated list may be seen on Delhi Government web site at http://admin.delhi.gov.in/wps/wcm/myconnect/DoIT_Health/health/home/dhs/delhi+g.+health+scheme?contentIDR=4ad93c804d4bb20b9e2e9ee5c2d81d78&useDefaultText=0&useDefaultDesc=0.

iv.Private recognized hospitals/diagnostic centers in NCR region outside Delhi for beneficiaries residing in these areas will be same as for CGHS beneficiaries as notified by CGHS from time to time. (list of CGHS recognised centres available at CGHS website : ( http://mohfw.nic.in/cghs.htm). These hospitals will be providing treatment/diagnostic facilities at CGHS rates to the beneficiaries of the scheme. During emergency conditions the hospitals will be providing credit facilities to the beneficiaries of the scheme.

8. Do I need a referral to avail treatment facilities in these hospitals?

All beneficiaries are supposed to get attachment to one of the Delhi Government Dispensary/Hospital, the Medical Officer Incharge/Medical Superintendent will be the Authorised Medical Attendant for the respective beneficiaries. In non-emergent/routine cases for getting treatment/diagnostic facility from the recognized private hospitals/diagnostic centres, prior permission from competent on medical advise from Authorised Medical Attendant (AMA) is required. However, during emergency the patient can directly approach the private hospitals.

No permission is needed for getting treatment from health facilities/institutions under Delhi Government, its autonomous bodies and those under local bodies (viz. MCD, NDMC and Delhi Cantonment Board) as per CS(MA) rules

9. Are there any credit facilities for the beneficiary under the scheme?

Currently credit/cashless facilities are available at all recognised Private hospitals/diagnostic centres during emergency treatment for all beneficiaries. In this regard, Agreements with these hospitals have been signed. In such cases, the bill will be sent by the empanelled hospital to concerned offices from where the health card to the beneficiary has been issued/ from where retired in case of pensioners.

In case of pensioners, the credit/cashless facility is available during non-emergent conditions also in all private hospitals. For this an authorization/permission from competent authority will be required to the concerned hospital. Agreements in this regard have been entered with all private institutions except Rajiv Gandhi Cancer Institute.

10. Where should I deposit my medical reimbursement bills?

The medical reimbursement bills along with essentiality certificate and other essential supportive documents are to be deposited to the concerned office from where the Medical Facility card have been issued.

11. My spouse is also in service, whether he/she can also avail the benefits?

If both husband and wife are in service, only one of them will contribute to the scheme and both of them will be getting the benefits under the scheme, the spouse being dependent on the contributing member for medical reimbursement purpose, in accordance to CS(MA) rules & the spouse shall not avail medical reimbursement from his/her office.

12. Whether the scheme is applicable to the employee where medical allowance is being given?

No, this scheme is not applicable to the employees who are entitled for any other allowance /medical facility.

13. Is the scheme benefits available to pensioners residing outside Delhi also?

Vide OM dated 21st Feb 2005, the scheme has been extended to cover the DGEHS beneficiaries residing in National Capital Region (NCR) outside Delhi, though on a limited basis. For this all, governmental health institutions in NCR are recognized for the purpose of medical treatment. All CGHS recognized private hospitals/diagnostic centres in these areas are also recognized as referral institutions for which prior permission of competent authority will be required for undergoing treatment.

13.Who is a competent authority to sanction advance?

Under the scheme, now the financial power to sanction advance for medical treatment to the tune of 90% of expected expenditure treatment has been decentralized and delegated to head of the departments vide OM dated 21.2.2005.

14. What is the process to get the permission for treatment in private hospital/cashless treatment?

a. Cashless Treatment/ Credit Facility During  Emergent Conditions:

During emergent conditions the cashless treatment/ credit facilities are available to all DGEHS beneficiaries at all DGEHS recognised Pvt. Hospitals/Diagnostic Centers. In emergent conditions beneficiary (pensioner and serving employee) may go directly to the DGEHS recognized hospital and cashless facility for treatment will be available on production of a valid DGEHS Medical Facility card. The bills for this treatment are thereafter sent to concerned offices/departments in this regard. An emergency certificate in this regard may be issued by the concerned attending doctor to authenticate the emergent conditions.

b. Cashless Treatment/ Credit Facility During Nonemergent Conditions :

Credit facility during nonemergent conditions is available only to pensioner beneficiaries. This facility is available with prior permission and credit authorization to the hospital by AMA of attached dispensary. Agreements in this regard have been entered into with all DGEHS recognized private hospitals/Diagnostic Centers except Rajiv Gandhi Cancer Institute.

c. Payment To The Hospital/Diagnostic Centres By The Department :

These hospitals are under agreement to provide cashless treatment facilities to the beneficiary as described above and the bills are sent directly to the concerned Department and the payment thereof is to be made within 60 days to the concerned hospital/Diagnostic Center directly by the respective departments as per terms and conditions of the agreement.

Cashless treatment facility in emergent conditions will be available to all pensioner and serving employee beneficiaries in recognized empanelled private hospitals/ diagnostic centers in Delhi on production of valid DGEHS Card. Cashless treatment facility in nonemergent conditions for OPD treatment, indoor treatment and for investigations as per entitlement will be available to all pensioner beneficiaries in recognized empanelled private hospitals/ diagnostic center in Delhi with the authorisation of AMA. These hospitals will be sending the bills to concerned departments (from where the DGEHS Card has been issued) 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):

1.      Photocopy of valid DGEHS card of the beneficiary

2.      Referral/authorisation from AMA or emergency certificate issued by the hospital concerned, as the case may be,

3.      Essentiality certificate as per CS(MA) rules

4.      Certificate by the hospital to the effect that

5.      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.

6.      The treatment given was absolutely essential and in accordance with CS(MA) rules and was not cosmetic in nature.

7.      Stickers/Invoices indicating Serial Nos./Manufacturer etc. of implants etc. as per practice being followed under CGHS.

The bills should be itemwise and should be authenticate/ 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.

Presently cashless facility is not available in Rajiv Gandhi Cancer Institute, Mata Chanan Devi Hospital and Shanti Mukund Hospital.