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Good news for pensioners: Medical reimbursement cannot be denied because treatment was in non- empanelled hospital

The Supreme Court bench of Justice RK Aggarwal and Justice Ashok Bhushan, in the matter of Shiva Kant Jha versus Union of India, vide judgement dated 13.04.2018, has held that Central Government Health Scheme (CHGS) medical claim cannot be denied merely because treatment was in a non- empanelled hospital.

The brief fact of the case is that the petitioner is a CGHS beneficiary (retired pensioner) having a CGHS card valid for whole life for medical treatment in private ward. The petitioner submitted two sets of his medical bills under the CHGS for reimbursement on account of his treatment done in Fortis Escorts Hospital, New Delhi, for Rs 986,343, and another set of bill amounting to Rs 398,097 for his treatment at Jaslok Hospital, Mumbai. The first set of bill was rejected by the various authorities where it was submitted and finally, in the fourth attempt, it was considered by director general of CGHS and an amount of Rs 490,000 was credited in petitioner’s account. In the second set of bill, the petitioner received only one-fourth of the claimed amount – that is, Rs 94,885. Thus, the petitioner was denied an amount of Rs 496,343 from the first claim and Rs 303,212 from the second. As per this Court’s direction dated 01.02.2016, a sum of Rs 300,000 has also been paid by the respondent. Hence, a sum of Rs 499,555 is the claim of the petitioner, for which the petitioner has filed a writ petition under Article 32 of the Constitution of India, claiming that he being in his late ‘70s needs money to meet his survival needs.

The government stated that it had empanelled several hospitals under the CGHS and the petitioner did not approach any of these. Further, it said that CGHS had to deal with a large number of such retired beneficiaries. If the petitioner is compensated beyond the policy, it would have large-scale ramification as none would follow the procedure to approach the empanelled hospitals and would rather choose a private hospital as per their own free will.

The Supreme Court also observed that another reason for rejection was that prior approval for such device implant was not sought. In this regard, the Court said the law did not require that prior permission had to be taken in such situations where the survival of the person was the prime consideration. The Supreme Court said that it was a settled legal position that a Government employee during his lifetime or after his retirement was entitled to get the benefit of the medical facilities and no fetters could be placed on his rights. The Supreme Court further said that the right to medical claim could not be denied merely because the name of the hospital was not included in the Government Order. Before any medical claim is honoured, the authorities are bound to ensure whether the claimant had actually taken treatment and whether the factum of treatment was supported by records duly certified by doctors/hospitals concerned. Once this was established, the claim could not be denied on technical grounds.

The Supreme Court said that it was a very inhuman approach of the CGHS officials in denying the grant of medical reimbursement in full to the petitioner, forcing him to approach this Court. The relevant authorities are required to be more responsive and cannot act in a mechanical manner, thereby depriving an employee of his legitimate reimbursement.

The Supreme Court said that the CGHS was responsible for taking care of healthcare needs and well being of Central Government employees and pensioners. The Supreme Court granted relief to the petitioner and said that the treatment of the petitioner in a non-empanelled hospital was genuine because there was no option left with him at the relevant time and directed the respondent-State to pay the balance amount of Rs 499,555 to the writ petitioner.

The court also took note of the slow and tardy pace of disposal of medical reimbursement claims (MRCs) by the CGHS in case of pensioner beneficiaries and the unnecessary harassment meted out to pensioners who were senior citizens, affecting them mentally, physically and financially. It opined that all such claims should be attended to by a secretary-level high-powered committee in the concerned ministry.

Thereby, the Supreme Court directed the concerned ministry to set up a high-powered committee consisting of special directorate general, directorate general, two additional directors and one specialist in the field. The committee shall ensure timely and hassle-free disposal of the claims within a period of seven days.

While disposing the present petition, the Supreme Court also said there shall be a timeframe for finalization and disbursement of the claim amounts of pensioners, and directed that the claim shall be reimbursed within a period of one month after submission of relevant papers.

Since the Supreme Court decision is final and applicable to all bodies in the Centre and states and their state undertakings, it is likely to have wider ramifications.

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