Covered under CGHS scheme. Should you also buy a health insurance policy?

Should one buy a health insurance policy if already covered under the CGHS subscription scheme?

The Central Government Health Scheme (CGHS) though comprehensive and widely available may not be enough, as healthcare landscape evolves and costs go up, say experts.

The CGHS is a comprehensive medical benefit plan for government employees, pensioners and their dependents, which provides access to a network of hospitals, wellness centres and dispensaries across the country.

“It is advisable to have a separate health insurance policy from any insurer,” said Bhaskar Nerurkar, head-health administration team, Bajaj General Insurance. He explains that CGHS coverage is limited to empanelled hospitals in select cities and designed primarily for treatment within its network. “If treatment is required outside the areas where CGHS-empanelled hospitals exist or at a speciality facility, access and reimbursement can become cumbersome.”

A private health insurance policy can offer cashless hospitalisation in thousands of hospitals nationwide. This provides flexibility and convenience, especially during emergencies or when specialised care is needed. “A private policy ensures smoother access to quality healthcare when and where you need it,” Nerurkar said.

Siddharth Singhal, head of health Insurance at Policybazaar, shares similar views. “A personal health insurance policy typically provides cashless access to up to 15,000 hospitals across the country,” he said, adding that this can be particularly useful during medical emergencies or when travelling.

Continued protection after retirement

Another advantage of having an independent policy is continuity of coverage. “Having an independent health insurance policy ensures continued protection even after retirement, in case of relocation to non-CGHS cities, or if one’s dependent family members are not eligible under CGHS,” Nerurkar said.

A standalone plan also allows policyholders to enhance their sum insured or include additional covers such as critical illness or personal accident, which CGHS typically doesn’t offer.

Private insurers now cover several modern treatments like robotic surgeries, newer oncology therapies, and specialised procedures, ensuring access to cutting-edge medical care.

Filling the gaps in CGHS coverage

An insurance buyer should pay attention to room rent restrictions, sub-limits, and OPD or maternity coverage in any health plan. “It’s advisable to have a plan with no room rent limits and minimal sub-limits. These small details can make a big difference at the time of claim,” Nerurkar said.

If gaps such as limited hospital access and missing cover for dependents is found, a personal health insurance plan can help bridge those areas. “Having both CGHS and a personal policy can prove beneficial in situations like medical emergencies while travelling, or when CGHS limits are exhausted,” Singhal said.

Experts agree that the key is to use both covers wisely. For routine or planned treatments within CGHS cities, beneficiaries can continue using the scheme facilities. Personal policy can be used when quick treatment, specialised care or private rooms are needed.

“In essence, CGHS offers a strong foundation of healthcare support, while an additional health insurance policy enhances financial protection, accessibility, and continuity of care,” Nerurkar said.

The combination of CGHS and private health insurance ensures a comprehensive safety net. “CGHS gives you dependable coverage, but a personal policy gives you freedom of choice, wider reach, and peace of mind," Singhal said.