Mere non-empanellment with CGHS, no ground to deny reimbursement: SC

Source: The Hitavada      Date: 16 Apr 2018 10:13:13


Staff Reporter,

SC raps CGHS for delay in clearing of medical reimbursement claims

Warns CGHS stating that it can not deny medical claim merely because treatment was in non-empanelled hospital when survival of pensioner or staffer is at stake

Directs Ministry to constitute special panels to decide reimbursement claims within one month

Deprecating the “inhuman approach” taken by Central Government Health Scheme (CGHS) in denying a genuine medical reimbursement claim made by a very senior pensioner, the Supreme Court of India has made it clear that claim can not be denied merely on the ground that the said specialty hospital is not empanelled with CGHS.

A bench of Justice RK Agrawal and Justice Ashok Bhushan while allowing a writ petition filed by Shiv Kant Jha, former Income Tax Commissioner who was posted in Nagpur, took a serious note of slow and tardy pace by CGHS in disposing of medical reimbursement claims in case of pensioner beneficiaries and said after submitting the relevant papers for claim by a pensioners, the same shall be reimbursed within a period of one month.

S k Jha, who argued his matter in person before the Apex Court, pointed out the utterly mechanical manner in which CGHS rejected his claim on the ground CRT-D implant was not required and that Fortis was not empanelled with CGHS at that time. The petitioner highlighted sufferings of several retired government servants due to unfair treatment meted out to them by the CGHS and its controlling Ministry, the Ministry of Health and Family Welfare, in discharge of their duties.

The petitioner also placed on record CAG’s Report with regard to “Reimbursement of Medical Claims to the Pensioners under CGHS” which also expressed the indifference against the pensioners. He further contended that every government employee during his life time or after his retirement is entitled to get the benefit of the medical facilities and no fetters can be placed on his rights. He urged the Supreme Court to for effective implementation of the claims of the pensioners under the CGHS.

The government stated before the court that, CGHS has to deal with large number of such retired beneficiaries and if the petitioner is compensated beyond the policy, it would have large-scale ramification as none would follow the procedure to approach the empanelled hospitals and would rather choose a private hospital as per their own free will.

The Supreme Court noted that the Government employee during his life time or after his retirement is entitled to get the benefit of the medical facilities and no fetters can be placed on his rights. “It is acceptable to common sense, that ultimate decision as to how a patient should be treated vests only with the Doctor, who is well versed and expert both on academic qualification and experience gained. Very little scope is left to the patient or his relative to decide as to the manner in which the ailment should be treated. Specialty Hospitals are established for treatment of specified ailments and services of Doctors specialized in a discipline are availed by patients only to ensure proper, required and safe treatment.”

Can it be said that taking treatment in Specialty 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, the Supreme Court noted.

Laying down the important guideline before any medical claim is honoured, the Apex Court stated “the authorities are bound to ensure as to whether the claimant had actually taken treatment and the factum of treatment is supported by records duly certified by Doctors/Hospitals concerned. Once, it is established, the claim cannot be denied on technical grounds,” while holding that denial of claim to Jha was utterly inhuman and unjustified.

The Supreme Court also observed that one of the reasons for rejection was that “Prior approval for such device implant was not sought”. In this regard, the Apex Court 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 Supreme Court directed the ministry to constitute a secretary-level high power committee for grievance redressal of the retired pensioners, for ensuring timely and hassle-free disposal of the claims within seven days and directed them to meet once in a month and ensure that claims should be settled preferably within a months time.