CGHS medical reimbursement rules clarified: What employees, pensioners need to know about Rs 3,000 limit

The Union Public Service Commission (UPSC) recently asked for some clarifications from the Central Government Health Scheme (CGHS) regarding its rules for the beneficiary employees. The CGHS has responded with clarifications on various topics, including consultations, tests, investigations, special investigations, diagnosis, eye consultation fee, and the need for prior permissions from the department.

In an office memorandum (OM) dated August 11, 2026, the UPSC said that it had sought clarification from the CGHS after noticing recurring issues with reimbursement of medical claims during their review process. The UPSC says that such issues were noticed due to the lack of clarity in the existing CGHS instructions. Let’s take a closer look at the CGHS clarifications provided for the UPSC beneficiaries.

1.Follow-up treatment should be in the same hospital


The CGHS says that if a CGHS beneficiary goes to an empanelled hospital for primary consultation, their subsequent follow-up consultations, investigations or minor procedures should also be done at the same hospital

It means if the beneficiary consults a doctor at an empanelled hospital and the doctor prescribes a test, the beneficiary should get the test done at the same hospital rather than going to another hospital.

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2. Instructions for tests costing up to Rs 3,000

An important instruction is that if any investigation amounting to up to Rs 3,000 is prescribed by a specialist doctor of an empanelled hospital, it should be undertaken at the same hospital where the beneficiary had gone for the primary consultation.

3. Instructions for tests done at other CGHS hospitals

There may be a situation where a CGHS beneficiary may want to get the investigation at a CGHS-empanelled hospital or diagnostic centre other than the one where they had gone for primary consultation. The OM says a prior referral from the CGHS Wellness Centre is required in such cases.

It means if the beneficiary wants to get the investigation done at another CGHS-empanelled hospital, HCO or diagnostic centre, they need to obtain prior referral/endorsement from the CGHS Wellness Centre.

To put it in perspective, no referral is needed if consultation and tests are done at the same hospital. However, if the patient wants to get the test done at another hospital, they need to take a referral from the CGHS Wellness Centre.

4. Rules for investigations above Rs 3,000

The OM says that for any other investigation costing more than Rs 3,000, such as a computed tomography (CT), magnetic resonance imaging (MRI) and Positron Emission Tomography (PET), a referral from the CGHS is required.

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5. Consultation valid only for 7 days

The OM clarifies that a consultation will be considered valid only for a period of 7 days, provided it pertains to the same speciality.

It means if you go to a cardiologist for consultation on Monday, the consultation will remain valid till Sunday at the same speciality.

6. Eye consultation fee includes three examinations

The OM specifically says that the eye consultation fee includes three procedures-

Refraction

Tonometry

Fundus examination

7. Prior permission required for unlisted investigation

The OM clarifies that if a specialist at a CGHS-empanelled facility recommends an unlisted investigation or procedure to a CGHS beneficiary, they need to take prior permission from the concerned department or office.