Denying Medical Reimbursement for Chronic disease Treatment in OPD NOT reasonable: HC

The Division Bench, comprising Chief Justice Sheel Nagu and Justice Sudhir Singh observed that the disease being chronic in nature, the treatment, even if taken in OPD, cannot be termed to be not falling in category of emergency treatment, particularly when the disease relating to renal requires a continuous treatment.

The case arose when a government employee submitted a claim for medical reimbursement for his wife's treatment of Chronic Kidney Disease (CKD) between 2014 and 2016. His wife had undergone continuous medical treatment, including emergency interventions, firstly at Maan Hospital, Rohtak and secondly, at apollo Hospital, New Delhi. The state government, however, rejected his claim, citing that the treatment was provided in an OPD setting rather than hospitalization, and therefore did not qualify for reimbursement under existing policies.

The employee then approached the High Court, arguing that CKD is a life-threatening chronic condition requiring regular monitoring and medical intervention. He contended that medical reimbursement policies should not unfairly differentiate between OPD and inpatient treatments, especially when dealing with chronic diseases.

The single judge ruled in favor of the petitioner, directing the state to reimburse the incurred medical expenses. It observed that, "When the treatment was not denied and when it was essential to life saving and the disease was listed chronic, the ground for rejection was not tenable. However, the payments were directed to be regulated at the rate of PGI/AIIMS for the entire expenditure incurred for the emergency treatment and for outdoor treatment for the relevant period from 07.04.2014 till 20.03.2016."

However, the Haryana government challenged the order through a Letters Patent Appeal (LPA).

The complainant argued that his wife’s CKD treatment required continuous and essential medical care, which was life-saving in nature, even though it was conducted in an OPD setting. He maintained that the rejection of the reimbursement claim was arbitrary, discriminatory, and lacked a reasonable basis, as the condition of CKD necessitates ongoing medical treatment. He further submitted that the treatment was administered by specialist doctors and was essential for survival.

On the other hand, the Haryana government contended that its medical reimbursement policy does not cover OPD treatment unless it falls under emergency care. The state maintained that since the treatment was not availed under hospitalization, it did not qualify for reimbursement. Furthermore, the government emphasized that reimbursement is only allowed when treatment is undertaken in an approved hospital under emergency conditions.

The Division Bench, comprising Chief Justice Sheel Nagu and Justice Sudhir Singh, thoroughly examined the arguments. The Court also referred to the policy on medical reimbursement of the Haryana Government Employees/Pensioners/Dependents, and found that a Government employee will not be allowed reimbursement of medical treatment in respect of himself or his dependents, if such treatment is taken in an emergencey in an "unapproved hospital."

Speaking for the bench, Justice Sudhir Singh observed; “Chronic means a condition that does not get completely better and lasts over a long time. A patient with CKD is also at an increased risk of other ailments like heart attack or stroke.”

After deliberating the matter, the High Court dismissed the state’s appeal and upheld the single judge’s decision, directing the Haryana government to reimburse the medical expenses incurred for CKD treatment. It held;

“The wife of respondent No. 1-writ petitioner was suffering from CKD (Chronic Kidney Disease). The treatment given by the concerned doctors in the OPD was totally dependent upon their expertise. Therefore, the denial of the claim for medical reimbursement on the ground that it was taken in OPD is not based on a reasonable classification. We further find that the disease being chronic in nature, the treatment, even if taken in OPD, cannot be termed to be not falling in category of emergency treatment, particularly when the disease relating to renal requires a continuous treatment. ”

"In view of the above, we do not find the impugned order passed by the learned single judge, suffers from any patent, illegality, or perversity. Hence, finding no merit in the present appeal, the same is hereby dismissed."

To view the original judgement, click on the link below: