CGHS Claim Denied? How to Appeal Central Government Health Scheme Rejections

The Central Government Health Scheme (CGHS) provides comprehensive healthcare to central government employees, pensioners, and their families across India's major cities and towns. Over 40 lakh beneficiaries rely on CGHS Wellness Centres, empanelled private hospitals, and CGHS-approved diagnostic centres. But CGHS reimbursement denials and cashless authorization rejections are disturbingly common — even for legitimate, medically necessary treatments.

If your CGHS claim was denied, this guide walks you through every step of the appeal process.

Who CGHS Covers

• Current central government employees (central secretariat, ministries, PSUs in CGHS cities) and their families
• Central government pensioners and their dependents
• Autonomous body employees where the body is covered under CGHS
• MPs, sitting and former and their dependents
• Sitting and retired constitutional functionaries and their families (ex-Presidents, Vice Presidents, Governors, Judges)

CGHS operates in over 75 cities and towns across India through Wellness Centres (formerly Dispensaries) and empanelled hospitals.

Common Reasons CGHS Claims Are Denied

Reimbursement Denials

• Bill exceeds CGHS package rate: You were billed by the empanelled hospital above the applicable CGHS package rate, and the excess is denied
• Non-referral from Wellness Centre: Treatment at an empanelled specialist or hospital without prior referral from the CGHS Wellness Centre CMO (Chief Medical Officer)
• Non-empanelled facility: Treatment at a hospital not on the CGHS empanelled list — even if it is well-regarded in your city
• Specific procedure excluded: Certain cosmetic, dental, or elective procedures are outside CGHS coverage
• Document deficiency: Missing prescription chain, investigation reports, or hospital bill without proper headers

Cashless/Referral Denials

• CMO referral refused: The Wellness Centre CMO declined to issue a referral to a specialist or hospital
• Emergency referral disputed: CGHS disputes whether the emergency admission was truly an emergency
• Second opinion refused: CGHS does not support seeking second opinions at personal expense and then claiming under CGHS

Step 1: Wellness Centre CMO

For referral denials, approach the Chief Medical Officer (CMO) of your CGHS Wellness Centre first. If the CMO persists in refusing a referral for a condition you believe requires specialist care, request the refusal in writing.

For reimbursement claims, submit the full file to the Wellness Centre with all original bills, discharge summary, and investigation reports. The Wellness Centre processes the claim and forwards it to the CGHS office.

Step 2: CGHS Office Grievance

If your claim is denied by the CGHS office, file a formal grievance with the Additional Director (AD) of CGHS in your city. CGHS has regional offices in all cities where it operates.

Your grievance should include:

• The denial letter and claim reference number
• A medical certificate from the treating doctor
• All original bills, discharge summary, and prescription chain
• A statement of why the denial is incorrect under CGHS rules

Step 3: Ministry of Health and Family Welfare Grievance Portal

File on the Centralised Public Grievance Redress and Monitoring System (CPGRAMS) at pgportal.gov.in. CGHS complaints filed on CPGRAMS are routed to the Ministry of Health and Family Welfare (MoHFW) and must be resolved within 30 days.

CGHS also has its own online portal at cghs.gov.in with a complaint submission facility.

Step 4: Emergency Treatment Reimbursement

CGHS rules provide for reimbursement of treatment at non-empanelled hospitals during genuine emergencies — when the nearest empanelled hospital was not accessible or the emergency was life-threatening. To claim:

• Document the emergency nature of the admission
• Get a treating doctor's certificate confirming the emergency
• Submit to the CGHS office within the prescribed time limit (typically 6 months of discharge)
• Reimbursement is limited to CGHS package rates for the equivalent treatment

Step 5: Super-Specialty Referrals

CGHS pensioners and serving employees in non-CGHS cities or towns are entitled to treatment at the nearest CGHS city on referral. If you are in a non-CGHS city:

• Your employer's head of office issues the referral
• Treatment at AIIMS, PGI Chandigarh, or other central government hospitals is generally at CGHS rates

Using RTI for CGHS Disputes

If CGHS denies your claim without adequate explanation, file an RTI application with the CGHS office under the Right to Information Act, 2005, requesting:

• The specific CGHS rule and schedule under which your claim was denied
• The name and designation of the officer who decided
• The applicable package rate for your procedure
• Whether the empanelled hospital was paid at a different rate than what was applied to your reimbursement

CGHS vs. Private Insurance

Many central government employees and pensioners also hold private health insurance. If CGHS denies a claim and your private insurance covers the same treatment, file with the private insurer under IRDAI's IGMS at igms.irda.gov.in if the private insurer also denies.

Fight Back With ClaimBack

CGHS bureaucracy should not stand between you and the healthcare benefits you have earned through years of central government service. ClaimBack helps you structure a compelling CGHS appeal.

Start your appeal with ClaimBack

Related Reading

• How to Write an Insurance Appeal Letter
• What Is Medical Necessity in Insurance Claims?
• India Insurance Ombudsman Guide