Right to medical claim cannot be denied merely because hospital is not included in Govt List: Supreme Court

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..

New Delhi: In a bid to protect retired public servants from "unnecessary harassment" in claiming reimbursements under the Central Government Health Scheme (CGHS), the Supreme Court has asked the Centre to "expeditiously" set up a high-powered committee to disburse claims in a month.

A bench of justices R K Agrawal and Ashok Bhushan also directed the Ministry of Health and Family Welfare to form the panel within seven days.

"With regard to the slow and tardy pace of disposal of Medical Reimbursement Claims (MRC) by the CGHS in case of pensioner beneficiaries and the unnecessary harassment meted out to pensioners who are senior citizens, affecting them mentally, physically and financially, we are of the opinion that all such claims shall be attended by a secretary-level high powered committee in the ministry concerned which shall meet every month for quick disposal of such cases," the bench said.

The directions came on a plea of a retired government servant who was denied a medical claim under the CGHS in 2014 for his treatment at Fortis Escorts Hospital in Delhi and Jaslok hospital in Mumbai due to the non-empanelment of the hospitals under the scheme.

The bench, which directed the ministry to give the petitioner Rs 4,99,555 spent by him on his treatment, also observed that the CGHS officials responsible for clearing medical claims took a "very inhuman approach" by denying him the full cost of his treatment.

"Can it be said that taking treatment in speciality hospital by itself would deprive a person to claim reimbursement solely on the ground that the said hospital is not included in the government order.

"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...," it said. The court however made it clear that "the said decision is confined to this case only”....

It observed that authorities must be responsive and ensure medical care to senior citizens after retirement.

"The relevant authorities are required to be more responsive and cannot in a mechanical manner deprive an employee of his legitimate reimbursement. The CGHS was propounded with a purpose of providing health facility scheme to the central government employees so that they are not left without medical care after retirement," it said.

The apex court, while directing the ministry to form the panel expeditiously, said there shall be a time-frame for finalisation and disbursement of the claim amounts of pensioners.

"In this view, we are of the opinion that after submitting the relevant papers for the claim by a pensioner, the same shall be reimbursed within a period of one month," it said.

The court was hearing the petition filed by Shiva Kant Jha, seeking reimbursement on account of his treatment done in November 2013 for Rs 9,86,343 for his cardiac ailment involving the implant of CRT-D device and two sets of the bill amounting to Rs 3,98,097 for his treatment at Mumbai for cerebral stroke and paralytic attack.

He had claimed that he was denied the amount of Rs 4.99 lakh out of the entire amount on the ground that he did not seek approval of authorities for the device implant.

The court, taking note of the facts, said: "the law does not require that prior permission has to be taken in such situation where the survival of the person is the prime consideration."

The bench said that the CGHS is responsible for taking care of healthcare needs and well-being of the central government employees and pensioners.

"In the facts and circumstances of the case, we are of opinion that the treatment of the petitioner in the non-empanelled hospital was genuine because there was no option left with him at the relevant time. We, therefore, direct the state to pay the balance amount of Rs 4,99,555 to the petitioner. We also make it clear that the said decision is confined to this case only," it said.