Back
HIGH COURT OF MEGHALAYA AT SHILLONG
W. Diengdoh, J.
Mohan Lal Goswami - Appellant
Versus
Union of India & Ors. - Respondents
WP(C) No. 401 of 2018
Decided On : 12-08-2022
Medical Reimbursement - Central Government Health Scheme - Office Memorandum dated 28.05.2018 - Shiva Kanta Jha v. Union of India - Emergency Medical Treatment - Rejection of Claim
Fact of the Case:
The petitioner, a retired Central Government employee covered by the Central Government Health Scheme, sought reimbursement for medical treatment received at a non-empaneled hospital. The respondent authorities settled the claim for a lesser amount, leading to the petitioner's plea for full reimbursement.
Finding of the Court:
The court found that the petitioner's case did not qualify as an emergency under the relevant rules, as the treatment did not meet the criteria for emergency medical procedures. The court also noted the petitioner's admission that his case did not fall under the specified categories for full reimbursement.
Issues: The main issue was whether the petitioner's medical treatment qualified as an emergency under the Central Government Health Scheme, entitling him to full reimbursement.
Ratio Decidendi: The court held that the petitioner's case did not meet the criteria for emergency medical treatment as per the relevant rules and Office Memorandum. The court also emphasized the petitioner's admission that his case did not fall under the specified categories for full reimbursement.
Final Decision: The petition was dismissed, and the court found no merit in the petitioner's claim for full reimbursement.
JUDGMENT
1. The petitioner herein was a retired Junior Engineer in the Department of Military Engineering Service. As a retired Central Government employee, the petitioner is also covered by the Central Government Health Scheme (CGHS) which entitles him to be reimbursed for any medical treatment that he undergoes.
2. In the month of February 2018, the petitioner along with his son went on a personal trip to Chennai. However, while in Chennai, he developed serious urinary problem and was required to urgently go for medical check-up. Being in great pain and discomfort, on 09.02.2018, he was taken to the Apollo Hospital which is the nearest hospital from the hotel where he was staying. In the out-patient department (OPD), the attending doctor advised the petitioner to get all the necessary tests and investigations done urgently which was done so on the next day, that is, on 10.02.2018. On the basis of the results of the tests, he was diagnosed to have left Renal Tumor with Renal Calculi and was advised for immediate surgery. Accordingly, the petitioner was admitted to the hospital on 12.02.2018 in the Urology Department and underwent surgery procedure Laparoscopic left Radical Nephrectomy on 13.02.2018 and was discharged on 15.02.2018.
3. According to the petitioner, the whole treatment process costs him Rs. 2,63,294/- (Rupees two lakhs, sixty-three thousand, two hundred and ninety-four) only. Being a holder of a valid Central Government Health Scheme (CGHS) card, the petitioner had duly submitted his medical reimbursement claim (MRC) in the prescribed form to the appropriate authority on 09.03.2018 vide his letter dated 07.03.2018.
4. It is also the case of the petitioner that the respondent authorities most illegally and arbitrarily by being hyper technical had settled the medical reimbursement claim and paid the petitioner only a sum of Rs. 33,384/- (Rupees thirty-three thousand three hundred and eighty-four) only towards his claim as aforesaid.
5. The petitioner not being satisfied with the action of the respondent authorities has caused issuance of a pleader's notice dated 30.06.2018 requesting the authorities to reimburse the full and actual expenditure incurred for the actual treatment.
6. The respondents vide letter No. CGHS/ESH/HOSP/43/6261-62 dated 27.07. 2018 in reply to the said pleader's notice had informed the petitioner that his medical claim was not entertained on the grounds stated therein. It transpired that the case of the petitioner was re-scrutinized by a Committee with the Additional Director as Chairman and three other members and the Committee in its meeting held on 06.07.2018 had rejected the claim of the petitioner mainly on the ground, inter alia, that the treatment of the petitioner was not in the emergency life threatening condition.
7. Again, the said Committee met on 13.07.2018 wherein the petitioner was also present. The minutes of the meeting was circulated vide letter dated 16.07.2018. Copy of the above-mentioned minutes along with the Report of the re-scrutinizing meeting of 06.07.2018 were all enclosed with the reply to the said pleader's notice.
8. The petitioner in his quest for justice which was allegedly denied to him, has accordingly approached this Court seeking invocation of the extraordinary writ jurisdiction for redressal of his grievances. Hence this petition.
9. Ms. P.D. Bujarbaruah, learned Sr. counsel appearing for the petitioner has submitted that the fact that the petitioner has been admitted at the Apollo Hospital, Chennai on 13.02.2018 to undergo surgery has not been denied. That the petitioner has to spend a sum of Rs. 2,63,294/- (Rupees two lakhs sixty-three thousand, two hundred and ninety-four) only has also not been challenged by the respondents.
10. The only dispute according to the petitioner is the non- acceptance of the respondent authorities that the case of the petitioner is an emergency one. The fact that the attending Physician who had examined the petitioner at the hospital
The judgment establishes the importance of meeting specific criteria for emergency medical treatment under the Central Government Health Scheme, and the significance of the petitioner's admission reg....
In emergency medical situations, full reimbursement of medical expenses is mandated regardless of any imposed ceiling limits, emphasizing the right to timely medical treatment.
Full medical reimbursement mandatory for genuine emergency treatment in empanelled hospitals, regardless of CGHS rates.
The central legal point established in the judgment is the obligation of the State to ensure timely medical treatment, the authority of the treating physician in deciding the course of treatment in a....
The main legal point established in the judgment is that the entitlement to medical claim cannot be denied solely on the ground that the hospital is not included in the Government Order. The real tes....
The main legal point established in the judgment is the obligation of the state to ensure timely medical treatment and the need for a compassionate and sympathetic consideration of medical reimbursem....
An indispensable Tool for Legal Professionals, Endorsed by Various High Court and Judicial Officers
Please visit our Training & Support
Center or Contact Us for assistance
Scan Me!
India’s Legal research and Law Firm App, Download now!
For Daily Legal Updates, Join us on :
Back to top
