CGHS expands coverage: Now these relations will also be covered in Central govt Helath Scheme

The Central Government Health Scheme (CGHS) has expanded its coverage to include adopted sisters of beneficiaries, while married sons and brothers who are critically or terminally ill can also continue to receive medical benefits under revised eligibility rules. The changes have widened the group of family members who can receive CGHS benefits without increasing the contribution paid by the primary cardholder, a TOI report stated.

Adopted sisters now eligible under CGHS

The health ministry issued an office memorandum on September 7 extending CGHS eligibility to adopted sisters of scheme beneficiaries. The move followed references received by the ministry "regarding the eligibility of adopted sisters (i.e. sisters adopted by parents of a CGHS beneficiary) for inclusion as dependent family members under CGHS".



The provision applies to sisters who have been legally adopted by the parents of a CGHS beneficiary. They must also meet the existing conditions applicable to biological sisters. This includes the dependency requirement, under which they should stay in the same house as the CGHS cardholder. Their income must not exceed Rs 9,000 per month plus the applicable dearness allowance. They must also be unmarried, divorced, abandoned or separated, as applicable.

Married sons and brothers can retain CGHS benefits

The health ministry had also changed the eligibility rules for dependent sons and brothers through an office memorandum issued on September 1. Earlier, CGHS coverage for sons and brothers was available only to unmarried dependents. There were also age limits of 25 years for sons and 18 years for brothers.

An exception existed for people with permanent disabilities, who could receive coverage for life. The revised rules state that "marriage shall not constitute a ground for cessation of CHS/medical attendance facilities in respect of dependent son or brother covered under these provisions whether on account of critical/terminal illness or permanent disability..."

This means marriage by itself will not end the medical benefits of a dependent son or brother covered under the specified provisions.

Lifetime coverage extended for certain illnesses

The September 1 memorandum also expanded the scope of lifetime coverage to include people suffering from certain serious health conditions. The provision covers "chronic, severe, critical or terminal illnesses resulting in substantial and continuing functional impairment or inability to earn a livelihood/self-sufficiency". The change further expands the circumstances under which dependent sons and brothers can remain covered.

No increase in contribution for additional beneficiaries

The expansion of CGHS eligibility differs from the way private health insurance generally works. Under health insurance, adding another beneficiary, particularly an elderly or ill person, can increase the premium. Under the CGHS changes described in the source, the contribution paid by the cardholder remains unchanged even as eligibility is expanded.

The inclusion of critically or terminally ill family members could have financial implications for government spending because there is no stated ceiling on the amount spent on CGHS beneficiaries.

For a person with a critical or terminal illness, the expanded provision can provide access to CGHS benefits when they otherwise may not be able to obtain health insurance coverage. However, eligibility depends on having a parent or sibling who is a CGHS cardholder and meeting the applicable dependency conditions.

Rules for daughters and biological sisters

Dependent daughters and sisters have not been subject to an age limit under the existing CGHS rules. However, their coverage ends if they marry or take up employment with income above the prescribed limit. Unmarried, divorced, abandoned or separated daughters and sisters can continue to receive coverage for life as long as they meet the dependency and income requirements.

Children and siblings must "normally reside" with the primary CGHS cardholder to qualify for benefits. The latest changes continue a broader expansion of CGHS eligibility for dependent family members while retaining conditions related to dependency, income and residence.