Patients in emergencies cannot wait for empanelled hospitals, Punjab and Haryana HC directs full reimbursement

The Court criticised the government for approving only a small part of the total medical claim. It noted that medical reimbursement cannot be denied just because the hospital was not on the government’s approved list. Once it is clear that genuine treatment was taken, the claim cannot be rejected on technical grounds.

The State had approved only Rs 43,005 out of the total claim of Rs 4,63,770. The Court called this decision "arbitrary, illegal and violative of Article 21 of the Constitution of India."

Allowing the writ petition, Single Bench Justice Sandeep Moudgil affirmed that the right to medical reimbursement derives directly from the fundamental right to life under Article 21, which encompasses health as an integral facet.

"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… Once it is established, the claim cannot be denied on technical grounds. The petitioner has suffered undue and prolonged delay of several years... such delay is wholly unjustifiable... and amounts to a dereliction of the statutory and constitutional duty of the State," the Bench observed. 

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Background of the case

The dispute dates back to August 2014, when Smt. Poonam, the wife of the petitioner Suresh Kumar, a government employee under the Haryana administration, was rushed to Indraprastha Apollo Hospital in Delhi in a critical condition. She was admitted to the Obstetrics and Gynaecology department during late hours and underwent urgent surgery involving the removal of her uterus and gallbladder, along with hernia repair. 

According to the petitioner, the medical records confirmed that the treatment was emergent, with no opportunity to transfer to an empanelled government hospital or obtain prior approval, as her life was at immediate risk.

Following the procedure, Suresh Kumar submitted a reimbursement claim of Rs 4,63,770.51 in 2014 to the Sub Divisional Officer (Civil), Karnal. The bills were forwarded to the Civil Surgeon, Karnal, who raised objections on January 12, 2015, citing the hospital's non-empanelled status under the Haryana Medical Reimbursement Policy (dated May 6, 2005, as amended on June 24, 2013) and the absence of an emergency certificate. 

After being informed, Kumar applied for the emergency certificate, which was issued more than seven months later on August 19, 2015. He resubmitted the claim with all required documents in November 2015. Despite follow-up letters on January 28, 2016, and September 30, 2016, the authorities informed him that the bills had been escalated to the Director General, Health Services, Haryana, in Panchkula, with no further progress.

In January 2017, additional objections were raised regarding the bills, which Kumar addressed immediately. Frustrated by the inaction, he filed an earlier writ petition (CWP No. 6846 of 2017) in the Punjab and Haryana High Court, which was withdrawn on July 22, 2019, with liberty to file afresh.

Meanwhile, the respondents partially sanctioned Rs. 43,005 on May 18, 2020, denying the balance without providing any reasons or hearing opportunity. This left Kumar pursuing the matter since October 2014, enduring mental agony and financial strain. The present petition under Article 226/227 of the Constitution sought to quash the impugned order to the extent of the denial and direct full reimbursement, as reported by Supreme Today. 

Opposing the petition, the State’s counsel argued that the government had acted as per its 2005 medical reimbursement policy, amended in 2013. He said that in emergency cases treated at non-empanelled hospitals, reimbursement is limited to PGIMER or AIIMS rates, even if an emergency certificate is issued. He argued that since Indraprastha Apollo Hospital was not empanelled in 2014, the petitioner was not eligible for full reimbursement at private hospital rates.

Court's ruling

Taking notes of the arguments, the Court noted that her condition was critical and there was no time to seek permission or shift her to a government-empanelled hospital. The bench observed that in such situations, saving the patient’s life is the first priority, and formalities cannot come in the way of urgent medical care.

Rejecting the stand of reimbursement limited to government hospitals, the Court said, as per the Indian Express, "Such a stand is wholly misconceived, arbitrary, and unsustainable in law. Government institutions are often overburdened, leading to long waiting periods, and in life-threatening situations, a patient or attendant has no real or meaningful choice but to wait for admission or treatment at PGIMER."

The Bench relied on several Supreme Court judgments. Citing State of Punjab v. Mohinder Singh Chawla (1997), the Court reiterated that the right to health is part of the right to life under Article 21 and that the government has a constitutional duty to provide medical facilities.

The bench also relied on Paschim Banga Khet Mazdoor Samity v State of West Bengal (1996), where the Supreme Court had held that “preservation of human life is thus of paramount importance” and that providing adequate medical facilities is an essential obligation of a welfare state.

Further, placing reliance on Shiva Kant Jha v. Union of India (2018), the High Court observed that medical reimbursement cannot be denied merely because the hospital was not included in the government list. Once genuine treatment is proved, the claim cannot be rejected on technical grounds.

Justice Moudgil further criticised the prolonged delay in processing the claim, noting that despite the submission of all required documents, including an emergency certificate, the petitioner had been pursuing the matter since 2014. 

"The petitioner has suffered undue and prolonged delay of several years… solely on account of the callous and indifferent approach of the authorities," the judgment read, adding that such delay amounted to "a dereliction of the statutory and constitutional duty of the State."

The court concluded that denying full reimbursement in genuine emergency cases defeats the purpose of the medical reimbursement policy and penalises employees for circumstances beyond their control.

Ordering the state to pay the balance amount with interest, the bench said, "The respondents are ordered to reimburse the remaining medical bill claim of the petitioner of Rs 4,20,766 along with 6% interest from the date it fell due till its actual realization, within a period of 4 weeks from the receipt of a certified copy of this order."

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