Bombay HC Slams Centre, CGHS for Denying Heart Transplant Surgery Reimbursement, Orders Rs 30 Lakh Payout

Mumbai: The Bombay High Court recently slammed the Central Government Health Scheme (CGHS) for its refusal to fully reimburse a patient's heart transplant costs, amounting to Rs 30 lakh. The court termed the decision a violation of the officer’s right to critical healthcare, highlighting the inhumane and overly rigid approach taken by the authorities in handling the urgent medical procedure.

Emphasising that retired government employees must not be treated differently when it comes to genuine and realistic health expenditure, the Bombay High Court granted relief to the patient who is a retired Central Government employee, seeking reimbursement of expenditure incurred by him for a heart transplant.

The HC Division Bench slammed the Union Government and the Central Government Health Scheme (CGHS) for refusing full medical reimbursement to the officer, who was forced to undergo the procedure at a private hospital to save his life since such facilities were not readily/timely made available in all the empanelled hospitals.

Ruling that the refusal to reimburse the medical expenses violated his fundamental rights and demonstrated an inhumane, overly technical approach to critical healthcare claims, the HC Division bench comprising Justices G.S.Kulkarni and Advait M.Sethna observed,

"In many of such reimbursements, there may not be any issue or dispute on the amount of reimbursement, however, this would not mean that in very peculiar, serious, specialized cases of medical treatment, the reimbursement needs to be only as per the rates which are pre-determined. This would be most unrealistic, unfair and discriminatory as in the present situation. Any employee, merely because he has retired, ought not to be differently treated when it comes to genuine and realistic health expenditure. There is another aspect that the reimbursement rates are not revised from time to time in the absence of which, they are rendered unrealistic."

The matter concerned a senior citizen and a pensioner who obtained a voluntary retirement from the post of Assistant Commissioner, Central Excise and Customs, Pune. The question that involved the plea was whether, in the inescapable and pressing situation, the petitioner could be denied full reimbursement of the medical expenses for having undergone a heart transplant at a private hospital.

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Another question that required consideration was whether the rigours of the normal rule of medical reimbursement should make a way for the case to be considered as a special case, for the grant of full reimbursement.

The petitioner, who was based in Mumbai, had voluntarily retired from Central Excise and Customs, Pune, as an Assistant Commissioner in March 2008 and was receiving a pension. Back in 2011, the Government of India, Ministry of Health and Family Welfare (MoHFW) notified a fresh empanelment of private hospitals and a corrected list of package rates applicable for empanelled hospitals under the Central Government Health Scheme (CGHS).

Since 2009, the petitioner was suffering from Cardiomyopathy and in 2019, upon a significant deterioration in the Left Ventricle Ejaculation Function (LVEF), which declined to 12-15%, a team of doctors along with a Heart Transplant Surgeon, advised the petitioner to undergo a heart transplant. 

It was argued that at that time, neither Government Hospitals nor the CGHS-empanelled Super Speciality Hospital, namely Wockhardt Hospital situated at Mumbai Central, was performing heart transplant surgeries. Therefore, having no alternative, the petitioner available treatment at the private hospital. 

Thereafter, he addressed a letter to the Additional Director of CGHS Mumbai in 2020 recording that an estimate of Rs 25,00,000 was received by him towards the cost of heart transplant and requested due consideration for such medical reimbursement. Further, it was contended that numerous correspondences were exchanged between the Petitioner and the CGHS. Being aggrieved by the rejection of his request for full reimbursement, the petitioner approached the High Court.

Taking note of this, the HC bench observed, "...we are of the opinion that the impugned decision as taken by the High Power Committee denying the petitioner full reimbursement of the medical expenses incurred by the petitioner for the heart transplant on the ground that CGHS permitted rates are required to be followed, is not the correct and a legal stand of the respondents. Also the observation of the High Power Committee that the procedure of heart transplantation was a planned surgery and not an emergency, hence, the reimbursement has been done as per CGHS extant rules and guidelines, are the only reasons on which full reimbursement under relaxation of rules has been rejected."

Opining that the case of the petitioner ought to have been considered by a High-Powered Committee, the HC bench observed, "From the contents of the aforesaid Office Memorandum and even otherwise, we fail to understand as to how a requirement of heart transplant cannot be considered to be an extraordinary and not an emergent and inevitable surgery, as a heart transplant is required only when the heart is failing, the consequences of which are just to be imagined. As to what is the plight of the patient in such situation, would not require any elaboration. It is in these circumstances, the case of the petitioner ought to have been considered by the High Power Committee."

The Court noted that the authorities did not argue that the immediate transplant facility was available or that the organ was available for transplant, in any of its empanelled or CGHS hospitals. "If that be the case, certainly it cannot be said that the petitioner undergoing a heart transplant at a private hospital, where the organ was available and which could be immediately transplanted without any waste of time, was not an emergent and / or wrong decision on the part of the petitioner, and/or nonetheless despite such availability, he ought to have awaited for the heart transplant in the hospital which the CGHS authorities would intend. This would have brought about a situation of the petitioner requiring to unwarrantedly suffer an ordeal of a fruitless wait. The petitioner rightly preferred not to wait in such uncertainty and availed of the heart transplant at the private hospital," noted the Court.

Accordingly, the Court opined that

"...in a situation to save his life, the petitioner was certainly entitled to take a decision to have a heart transplant at a private hospital, in the absence of such facilities being readily / timely made available, in all the empanelled hospitals. Hence, the petitioner was required to be granted full reimbursement of all the expenditure, when such expenditure was not in dispute. Not granting full reimbursement, in these circumstances in our opinion, is not only violative of the fundamental rights but strikes at the very root, purpose and essence of these basic human rights as guaranteed by the Constitution, i.e., Right to Life under Article 21. It was this fundamental right which is being asserted by the petitioner when in such circumstances he demanded reimbursement of medical expenses, and for violation of these rights seeking a remedy to approach the writ Court, cannot be said to be any misconceived approach on the part of the petitioner, more particularly the respondent’s accepting an earlier order passed by this Court on the writ petition filed by the petitioner."

The Court observed that in the absence of any specific legislation, the exercise of such power and more particularly for the preservation of fundamental rights, necessarily has a legitimate constitutional recognition.

"The present case indisputedly is a case of heart transplant which by all standards is a serious ailment. Certainly, the surgery is one of urgency and critical importance, and could not have been postponed. It is a special circumstance. It is imperative that such surgeries are expedited in the interest of human life without an embargo of an expenditure which is secondary to human life," the bench ordered.

Observing that the Central Government has an obligatory position to grant reimbursement on case-to-case basis, the HC bench observed, "Thus, patients like the petitioner, who is a pensioner, cannot be deprived of benefits of medical reimbursement when he received treatment at private hospital, more particularly, when the petitioner’s case is accepted as a genuine case, which in our opinion, was certainly of an urgent nature. In the present case, the respondents in no manner whatsoever dispute the treatment of the petitioner and the expenditure incurred. The respondents have all powers to examine the credentials of the applications and enquire about the genuineness of the claim. Thus, once the facts of the petitioner’s case remained indisputed, i.e., when the medical treatment was not in dispute in the petitioner receiving specialized or urgent treatment and when the amount claimed by the petitioner is the actual expenditure incurred by him is also not in dispute, in these circumstances, to make the petitioner suffer for reimbursement, in our opinion, amounts to travesty of justice and a glaring violation of the fundamental rights guaranteed to a citizen who is the former employee of the Central Government. In such circumstances, in our opinion, the High Power Committee ought to have been humanely sensitive in dealing with the petitioner’s case and ought not to have adopted a mechanical and a narrow-minded approach."

To view the order, click on the link below:

https://medicaldialogues.in/pdf_upload/bombay-hc-order-290689.pdf

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