Denial of reimbursement for emergency medical treatment under CGHS violates constitutional rights and undermines the scheme's welfare purpose.

ORDER :

SURAJ GOVINDARAJ, J.

1. The Petitioner is before this Court seeking for the following reliefs:

WHEREFORE it is most respectfully prayed that this Hon'ble Court be pleased to issue a writ of certiorari or any other appropriate writ order or direction quashing the impugned email communications dated 07/10/2024, 20/11/2024, and 04/03/2025 sent by Respondent No. 3 produced at Annexures- M, P, and T, respectively, and further issue a writ of mandamus directing the Respondents to make full reimbursement of the medical reimbursement claim of the Petitioner dated 26/12/2023 in respect of the CRT-D implantation of the late husband of the Petitioner as acknowledged by Respondent No. 3, as per their receipt/acknowledgement bearing MRC No. 3559/2023/BNGLR/BA04 as per Annexure- G, and allow this writ petition with costs, and grant such other reliefs as this Hon'ble Court deems fit to grant in the circumstances of the case, in the interest of justice and equity.

2. The Petitioner is a retired officer from the Indian Administrative Service from the Madhya Pradesh cadre, having retired in the year 2010. Her husband was working in the Madhya Pradesh Tourism Development Corporation as an Executive Director. After her retirement, the Petitioner and her husband were residing in Bangalore.

3. The petitioner, being a retired IAS officer, is covered under the Central Government Health Scheme (CGHS), and as such, she is entitled to all the benefits thereunder.

4. The husband of the Petitioner, being a cardiac patient, underwent two major bypass surgeries, and ever since then, he has been under cardiac supervision. In the month of April 2023, the Petitioner's husband experienced severe chest discomfort and, in an emergency, was shifted to Narayana Institute of Cardiac Sciences for treatment, where he was admitted to the Cardiac Care Unit (CCU), where his ventricular ejection fraction had been reduced to 20%. Hence, he was put on Heart Failure Management Protocol. In the month of October, 2023, the condition of the husband of the Petitioner worsened when again he was treated at Narayana Institute of Cardiac Sciences due to an emergency, and at the diagnosis and prognosis of the Doctors was given a CRT-D implant to protect against sudden death on account of ectopic beats in the heart, which was implanted on 31.10.2023. As regards which the Petitioner had incurred an expense of Rs.15,30,093/- including the cost of the implant CRT-D implant being Rs.13,17,487.36/- as regards which an invoice has been issued. The Petitioner submitted a medical reimbursement claim with Respondent No.3 for a sum of Rs.15,30,093/- on 26.12.2023, which claim was confirmed by way of SMS by Respondent No.3. Unfortunately, the Petitioner's husband on 18.03.2024 suffered from severe breathlessness and nausea and though he was rushed to the hospital, he could not be revived. Until then the claim of the Petitioner had not been satisfied.

5. The Petitioner had submitted a representation on 28.06.2024 requesting for full reimbursement and disbursement of the amounts due. Finally, on 11.09.2024, Respondent No.3 sent an email to the Petitioner requesting the Petitioner to submit the ECG report, which was submitted with great difficulty since the implantation had been done a year earlier on 31.10.2023, and a claim had been submitted on 26.12.2023. Despite the said submission, Respondent No.3 did not pr