Punjab and Haryana HC directs CGHS to frame SOP for medical reimbursement claims

Chandigarh: Criticising the delay in clearing a retired employee’s medical reimbursement, the Punjab and Haryana High Court directed the Central Government Health Scheme (CGHS) to put in place a comprehensive standard operating procedure (SOP) for processing such claims.

Taking a tough stand, Justice Harpreet Singh Brar imposed a cost of Rs 1 lakh on the Punjab State Power Corporation Limited (PSPCL) for what the court described as an "inordinate, unreasonable and undignified" delay in settling a retiree’s medical claim.

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The Tribune reported that the case involved a retired employee who had spent over Rs 3.69 lakh on his wife’s medical treatment. Despite submitting all required documents, his reimbursement was kept pending for a long period. The delay in this case occurred after the Health and Family Welfare Department sought an item-wise breakup of the hospital package. However, the court pointed out that this was not the retiree’s responsibility.

While hearing the matter, the bench said, "The long-term service rendered by the petitioner before retirement entitles him to be reimbursed for medical expenses incurred by him. Denying him this right by taking an insensitive and lackadaisical approach cannot be condoned by this court in any way."

To address this, Justice Brar directed the CGHS Director to frame a comprehensive Standard Operating Procedure (SOP) covering the entire reimbursement process.

"The policy shall clearly lay down the procedure for the submission, verification and approval of medical bills, including the list of documents, along with their issuing authority, necessary for processing such claims," Justice Brar ruled.

The Bench also made it clear that the policy might also prescribe a fixed timeline for disbursement. The court gave three months to prepare this policy and asked for an affidavit confirming compliance.

Justice Brar asserted that "The delay arose solely due to the respondent-hospital’s inability to provide an item-wise breakup, which, in any case, the petitioner could not be compelled to obtain. An MoU existed between the corporation and the hospital prescribing CGHS package rates for the treatment of retired employees and their dependents. Once such an MoU was in force, the respondents could not deviate from the same."

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