Service Law – Central Government Health Scheme (CGHS) – Claim under, for reimbursement of medical bills – Denial of – CGHS pensioner beneficiary, underwent treatment in a non-empanelled hospital for cardiac ailments and also for cerebral stroke and paralytic attack – He claimed reimbursement of the medical bills – Out of the total bills amounting to Rs. 13,84,440/-, he was paid Rs. 5,84,885/-, while he was denied Rs. 7,99,555/- – Writ petition filed by him u/Art.32 of the Constitution – Supreme Court directed the respondent to pay a sum of Rs. 3,00,000/- to the petitioner as an interim relief – Held: Government employee during his life time or after his retirement is entitled to get the benefit of the medical facilities and no fetters can be placed on his rights – Right to medical claim cannot be denied merely because the name of the hospital is not included in the Government Order – The real test must be the factum of treatment – Once, it is established, the claim cannot be denied on technical grounds – In the present case, the writ petitioner was admitted in the hospital in emergency conditions – Law does not require prior permission to be taken in such situation where the survival of the person is the prime consideration – CGHS is responsible for taking care of healthcare needs and well being of the Central government employees and pensioners – In the facts and circumstances of the case, the treatment of the petitioner in non-empanelled hospital was genuine because there was no option left with him at the relevant time – Respondent directed to pay the balance amount of Rs. 4,99,555/- to the writ petitioner – However, the said decision is confined to this case only – Further, directions issued with regard to timely disposal of Medical Reimbursement Claim (MRC) by CGHS in case of pensioner beneficiaries – Constitution of India – Arts. 14, 21 and 32.
Disposing of the writ petition, the Court
HELD: 1.1 The Government employee during his life time or after his retirement is entitled to get the benefit of the medical facilities and no fetters can be placed on his rights. It is acceptable to common sense, that ultimate decision as to how a patient should be treated vests only with the Doctor, who is well versed and expert both on academic qualification and experience gained. Very little scope is left to the patient or his relative to decide as to the manner in which the ailment should be treated. Speciality Hospitals are established for treatment of specified ailments and services of Doctors specialized in a discipline are availed by patients only to ensure proper, required and safe treatment. The right to medical claim cannot be denied merely because the name of the hospital is not included in the Government Order. The real test must be the factum of treatment. Before any medical claim is honoured, the authorities are bound to ensure as to whether the claimant had actually taken treatment and the factum of treatment is supported by records duly certified by Doctors/Hospitals concerned. Once, it is established, the claim cannot be denied on technical grounds. In the present case, by taking a very inhuman approach, the officials of the Central Government Health Scheme (CGHS) have denied the grant of medical reimbursement in full to the petitioner. [Para 13][299-C-F]
1.2 This is hardly a satisfactory state of affairs. The relevant authorities are required to be more responsive and cannot in a mechanical manner deprive an employee of his legitimate reimbursement. CGHS was propounded with a purpose of providing health facility scheme to the central government employees so that they are not left without medical care after retirement. It was in furtherance of the object of a welfare State, which must provide for such medical care that the scheme was brought in force. In the facts of the present case, it cannot be denied that the writ petitioner was admitted in the hospitals in emergency conditions. Moreover, the law does not require that prior permission has to be taken in such situation where the survival of the person is the prime consideration. The doctors did his operation and had implanted CRT-D device and have done so as one essential and timely. It cannot be denied that the petitioner was taken to hospital under emergency conditions for survival of his life which requirement was above the sanctions and treatment in empanelled hospitals. CGHS is responsible for taking care of healthcare needs and well being of the central government employees and pensioners. In the facts and circumstances of the case, the treatment of the petitioner in nonempanelled hospital was genuine because there was no option left with him at the relevant time. Therefore, the respondentState is directed to pay the balance amount of Rs. 4,99,555/- to the writ petitioner. The said decision is confined to this case only. [Paras 14, 15][299-G-H; 300-A-B, C-E]
1.3 Further, with regard to the slow and tardy pace of disposal of Medical Reimbursement Claim (MRC) by the CGHS in case of pensioner beneficiaries and the unnecessary harassment meted out to pensioners who are senior citizens, affecting them mentally, physically and financially, all such claims shall be attended by a Secretary level High Powered Committee in the concerned Ministry which shall meet every month for quick disposal of such cases. It is hereby directed that the concerned Ministry device a Committee for grievance redressal of the retired pensioners consisting of Special Directorate General, Directorate General, 2 (two) Additional Directors and 1 (one) Specialist in the field which shall ensure timely and hassle free disposal of the claims within a period of 7 (seven) days. The concerned Ministry is further directed to take steps to form the Committee as expeditiously as possible. The above exercise would be futile if the delay is occasioned at the very initial stage, i.e., after submitting the relevant claim papers to the CMO-I/C, therefore, there shall be a timeframe for finalization and disbursement of the claim amounts of pensioners. After submitting the relevant papers for claim by a pensioner, the same shall be reimbursed within a period of 1 (one) month. [Para 16][300-F-H; 301-A]
As published in the Supreme Court Reports, Supreme Court of India. Text from the Indian Supreme Court Judgments open data set (Dattam Labs), CC BY 4.0.
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