Kerala HC upholds CGHS reimbursement for emergency treatment at non-empanelled hospital

The tribunal's order related to a respondent whose wife underwent an emergency life-saving surgery at a non-empanelled hospital. By dismissing the petition, the High Court upheld the direction for full reimbursement of the medical expenses incurred for the treatment.

The High Court observed that the patient had to undergo emergency surgery and did not have sufficient time to go in search of a hospital empanelled with the CGHS. In such circumstances, the declarations laid down in Shiva Kant Jha (supra) would apply, which stated that under dire circumstances, “Taking treatment in Speciality Hospital by itself would not deprive a person to claim reimbursement solely on the ground that the said Hospital is not included in the Government Order.”

The case pertains to a woman who was suffering gravely even when she had been admitted to “V.G.Saraf Memorial Hospital,” and she was bleeding. The suspicion at that time was malignancy in the rectum; and a biopsy had also been taken. The patient was discharged from the said hospital on 14.01.2021; however, to be taken to another hospital, namely the “Aster Medcity”, on 27.01.2021, to be then subjected to an emergency life-saving surgery. It has been on record that she underwent “Laparoscopic ultra low anterior resection with coloanal anastomosis and covering stoma under GA.”

The respondent sought full medical reimbursement under the Central Government Health Scheme (CGHS), which led the appellants to contest the claim and stated that the order is incorrect and based solely on surmises because, the disease and treatment suffered and endured by the wife of the petitioner, was not serious enough to force her to take treatment in a Non-Empanelled Hospital, to thus suffer a larger bill than authorised under the CGHS.

The learned counsel for the respondent pointed out that, even as per the documents, the patient was in a very precarious medical condition, requiring urgent and incisive action, including surgery.

After considering the submission, the court stated, “In such factual scenario, we cannot find the contentions of the petitioner to be deserving approval in any manner, particularly that the surgery conducted on the patient was an “elective” one. We have nothing before us to disbelieve the certificate issued by “Aster Medcity”, especially when it is not under challenge. In the aforesaid circumstances, we obtain no reason to intervene; and consequently, dismiss this petition.”

To view the official order, click on the link below: