Health Benefit Update
CGHS REIMBURSEMENT RULES 2026
(Package Rates, NABH & Ward Entitlement)
(Bill ₹1 Lakh, Refund ₹60k? Here is why.)
⚡ Quick Answer: How is refund calculated?
CGHS reimbursement is restricted to the “CGHS Package Rate” fixed by the Government, NOT the actual bill charged by the private hospital.
If the hospital charges more than the Package Rate, the extra amount must be paid by the employee (Out of Pocket), unless it was a life-threatening emergency.
⚠️ Golden Rule: Always go to an Empanelled Hospital with a Referral. They are legally bound to charge only CGHS rates (Cashless for Pensioners, Reimbursement for Serving).
📢 Help Colleagues Save Money:
The most painful surprise for a government employee is seeing a “deduction” in their medical claim. To avoid this, you must understand your Ward Entitlement and the difference between NABH and Non-NABH rates.
1. Ward Entitlement (Pay Level Based)
Your reimbursement for Room Rent is strictly capped based on your Pay Matrix Level. If you choose a higher room, you pay the difference.
| Pay Level | Ward Entitlement | Room Rent Ceiling |
|---|---|---|
| Level 1 to 6 | General Ward | ₹ 1,000 / day |
| Level 7 to 11 | Semi-Private Ward | ₹ 2,000 / day |
| Level 12 & Above | Private Ward | ₹ 3,000 / day |
*Trap Alert: If you stay in a Private Ward but are entitled to General Ward, not only is the Room Rent cut, but Doctors’ Fees and Lab Charges are also proportionately deducted.
2. NABH vs Non-NABH Rates
The government has two separate rate lists. Hospitals accredited by NABH (National Accreditation Board for Hospitals) get higher rates.
Non-NABH Hospital
Rate: Standard CGHS Rate.
Example: ICU Charge = ₹5,400/day.
(Lower reimbursement)
NABH Hospital (Accredited)
Rate: 15% Higher than Standard.
Example: ICU Charge = ₹6,210/day.
(Higher reimbursement allowed)
3. Emergency in Non-Empanelled Hospital
⚠️ Emergency Rule: In a genuine medical emergency (e.g., Heart Attack, Accident), you can go to ANY hospital (even non-empanelled).
The Catch: You must pay the bill first. Reimbursement will be restricted to CGHS Package Rates. If the private hospital charges ₹2 Lakhs but CGHS rate is ₹1.2 Lakhs, you get only ₹1.2 Lakhs. The remaining is your loss.
📥
Official Reference (MoHFW):
🧮 CHECK PACKAGE RATES:
❓ Reimbursement Questions
What if I don’t have a referral?
For planned treatment in private empanelled hospitals, a Referral from CGHS Wellness Centre is mandatory. Without it, the claim will be rejected (except for pensioners who can go directly for consultation).
Are consumables like gloves/masks reimbursed?
Generally, No. Dietary charges, toiletries, and non-medical consumables are considered “Non-Admissible” and are deducted from the claim.
🇮🇳 हिंदी में सारांश (Summary in Hindi)
पूरा पैसा वापस क्यों नहीं मिलता?
CGHS केवल “Package Rate” के हिसाब से पैसा वापस करता है, न कि अस्पताल के बिल के हिसाब से। अगर प्राइवेट अस्पताल ज्यादा चार्ज करता है, तो वह पैसा आपको अपनी जेब से देना होगा।
- 🚑 इमरजेंसी (Emergency Rule): हार्ट अटैक या एक्सीडेंट जैसी इमरजेंसी में आप किसी भी अस्पताल (Non-Empanelled) में जा सकते हैं। लेकिन रिफंड सरकारी रेट पर ही मिलेगा।
- 🛏️ वार्ड का नियम: अपने Pay Level के हिसाब से ही रूम लें (General/Semi-Private/Private)। अगर आप महंगे रूम में रुकते हैं, तो डॉक्टर और लैब का खर्चा भी काट लिया जाएगा।
- ✅ सही तरीका: हमेशा “Empanelled Hospital” में ही जाएं और रेफरल (Referral) जरूर साथ ले जाएं।
Verified By: Health Rules Analyst
Context: CGHS Guidelines 2026
✓ Updated Jan 2026