Central Government Health Scheme (CGHS) Claim Rules Revised

In a major update for lakhs of central government employees, pensioners, and their dependents, the Ministry of Health and Family Welfare has changed key rules under the Central Government Health Scheme (CGHS).

This change directly affects hospitalization claims. If you fail to follow the new guidelines, your reimbursement claim may get rejected – even if your treatment is valid and eligible.

Let’s break down what’s new, what you must do, and how to protect your benefits.

🚨 What Has Changed?

The government has made it mandatory to get referral permission BEFORE availing treatment at a private CGHS empaneled hospital.

Earlier, in emergency cases or during off-hours, many beneficiaries used to get admitted first and then apply for reimbursement. Under the new rules, pre-approval is now essential in most non-emergency cases.

📝 New CGHS Rule Highlights:

• Referral is compulsory from the nearest CGHS Wellness Centre before treatment at a private hospital.

• Without a referral, your claim may be rejected.

• Only life-threatening emergencies are exempt (heart attack, trauma, stroke, etc.).

• Online referral system has been improved for faster approvals.

🛑 What Happens If You Ignore the Rule?

If you go directly to a private CGHS-empaneled hospital without a referral, you may:

• Not be eligible for reimbursement

• Face complete rejection of your hospital bills

• Lose out on lakhs in medical expenses

✅ What You Should Do

To make sure you’re covered under CGHS:

1. Visit your CGHS Wellness Centre first (unless it's an emergency).

2. Get a valid referral for the hospital/specialist.

3. Ensure the hospital is CGHS empaneled.

4. Carry your CGHS card at all times.

5. In emergencies, inform CGHS authorities within 48 hours of admission.

💡 Exceptions (No Referral Needed):

The rule has relaxations for emergencies, which include:

• Cardiac arrest

• Serious accidents or trauma

• Unconsciousness

• Uncontrolled bleeding

• Acute respiratory distress

• Life-threatening complications

But you must still notify your CGHS center post-admission to validate your claim.

🖥️ Online Referral Facility

CGHS has also updated its portal to make it easier to:

• Apply for referrals online

• Track claim status

• Access the list of empaneled hospitals

Visit https://cghs.nic.in for details.

📄 Documents Required for CGHS Hospital Claims

To file a claim successfully:

• Referral letter from CGHS

• Original hospital bills and discharge summary

• CGHS card copy

• Medicine bills with prescription

• NEFT mandate for bank transfer

🧾 Final Thoughts

This is a crucial update. Don’t assume that your hospital expenses will be reimbursed automatically. Even if you're a long-time CGHS user, failing to follow the new rules could mean losing your entitlement.