LEGAL ISSUE: Whether a retired government servant is entitled to full reimbursement of medical expenses incurred at a non-empanelled hospital during a medical emergency under the Central Government Health Scheme (CGHS).
CASE TYPE: Service Law/Medical Reimbursement
Case Name: Shiva Kant Jha vs. Union of India
[Judgment Date]: April 13, 2018
Introduction
Date of the Judgment: April 13, 2018
Citation: 2018 INSC 308
Judges: R.K. Agrawal, J. and Ashok Bhushan, J.
Can a retired government servant be denied full medical reimbursement for treatment at a non-empanelled hospital during a medical emergency? The Supreme Court of India recently addressed this critical question, highlighting the importance of timely medical care for pensioners under the Central Government Health Scheme (CGHS). This case underscores the responsibility of the state to ensure that its retired employees receive adequate medical attention, particularly during emergencies, and that the procedures for medical reimbursement are not unduly burdensome.
Case Background
The petitioner, a retired government servant and CGHS beneficiary, sought reimbursement for medical expenses incurred at Fortis Escorts Hospital, New Delhi, and Jaslok Hospital, Mumbai. He had undergone treatment for cardiac ailments, including the implant of a CRT-D device, and for a cerebral stroke. The petitioner submitted his medical bills to the CGHS for reimbursement. The CGHS initially rejected the claims, stating that the CRT-D implant was not required and that prior approval was not sought. The petitioner had to pay out of his personal resources.
Timeline:
| Date | Event |
|---|---|
| November 2013 | Petitioner receives treatment at Fortis Escorts Hospital, New Delhi, for cardiac ailments, including CRT-D device implant. |
| November 2013 | Petitioner receives treatment at Jaslok Hospital, Mumbai for cerebral stroke and paralytic attack. |
| 02.01.2014 | Petitioner submits first set of medical bills to CGHS for treatment at Fortis Escorts Hospital. |
| 19.07.2014 | Petitioner submits second set of medical bills to CGHS for treatment at Jaslok Hospital. |
| May 2014 | Technical Standing Committee rejects the first bill without informing the petitioner of the reasons for rejection. |
| 10.07.2014 | Standing Committee rejects first bill again, stating CRT-D implant was not required. |
| 15.01.2015 | Standing Committee rejects first bill for the third time stating prior approval for the device implant was not sought. |
| After Memorial to Director General of CGHS | Government credited Rs. 4,90,000 in the petitioner’s bank account. |
| Petitioner’s second claim from Jaslok Hospital was curtailed to Rs. 94,885. | |
| 01.02.2016 | Supreme Court directs the State to pay Rs. 3,00,000 to the petitioner as interim relief. |
| 11.04.2016 | Union of India files an affidavit describing the in-house procedure to be followed in dealing with the claims under CGHS. |
| 13.04.2018 | Supreme Court directs the State to pay the balance amount of Rs. 4,99,555 to the petitioner. |
Arguments
Petitioner’s Arguments:
- The petitioner argued that retired government servants are facing unfair treatment from CGHS, causing them suffering in their old age.
- He contended that every government employee, during their service or after retirement, is entitled to medical benefits without restrictions.
- The petitioner invoked Articles 32 and 142 of the Constitution, seeking protection of his fundamental rights under Articles 14 and 21.
- He requested reimbursement for his medical expenses incurred during an emergency and asked for guidelines for effective implementation of CGHS claims for pensioners.
Respondent’s Arguments:
- The respondent argued that the petitioner’s case was handled according to the circulars and office memorandums issued by the Ministry of Health & Family Welfare.
- They stated that providing special treatment beyond the terms of the circulars would lead to arbitrariness and discrimination.
- The respondent contended that the petitioner did not approach an empanelled hospital during the emergency and was charged at higher rates.
- The respondent argued that CGHS has rules and guidelines, and compensating the petitioner beyond those would have large-scale ramifications.
Submissions Table
| Main Submission | Sub-Submissions (Petitioner) | Sub-Submissions (Respondent) |
|---|---|---|
| Fair Treatment of Pensioners |
|
|
| Entitlement to Medical Benefits |
|
|
| Constitutional Rights |
|
|
| Reimbursement and Guidelines |
|
|
Issues Framed by the Supreme Court
The Supreme Court did not explicitly frame issues in a separate section. However, the core issue addressed by the court was:
- Whether the petitioner is entitled to full reimbursement of medical expenses incurred at a non-empanelled hospital during a medical emergency under the CGHS.
Treatment of the Issue by the Court
| Issue | Court’s Decision | Brief Reasons |
|---|---|---|
| Whether the petitioner is entitled to full reimbursement of medical expenses incurred at a non-empanelled hospital during a medical emergency under the CGHS. | The Court directed the respondent-State to pay the balance amount of Rs. 4,99,555 to the petitioner. | The Court held that the treatment in a non-empanelled hospital was genuine due to the emergency, and the petitioner had no other option at the time. The Court emphasized that the right to medical claim cannot be denied merely because the name of the hospital is not included in the Government Order. |
Authorities
The Court did not cite any specific cases or books in the judgment. However, the following legal provisions were considered:
- Article 32 of the Constitution of India: This article grants the Supreme Court the power to issue writs for the enforcement of fundamental rights.
- Article 14 of the Constitution of India: This article guarantees equality before the law and equal protection of the laws.
- Article 21 of the Constitution of India: This article protects the right to life and personal liberty.
Authorities Considered by the Court
| Authority | How the Court Viewed It |
|---|---|
| Article 32 of the Constitution of India | Considered as the basis for invoking the Court’s jurisdiction. |
| Article 14 of the Constitution of India | Considered in the context of ensuring equal treatment and non-discrimination in medical reimbursement. |
| Article 21 of the Constitution of India | Considered as the basis for the right to health and timely medical care. |
Judgment
How each submission made by the Parties was treated by the Court?
| Party | Submission | Court’s Treatment |
|---|---|---|
| Petitioner | CGHS unfairly treats pensioners, denying them medical benefits. | The Court agreed that the CGHS had not been responsive and had taken an inhuman approach in denying full reimbursement. |
| Petitioner | Every government employee is entitled to medical benefits without restrictions. | The Court affirmed the right of government employees to medical benefits and stated that no fetters can be placed on these rights. |
| Petitioner | Invoked Articles 32 and 142 to protect fundamental rights. | The Court exercised its jurisdiction under Article 32 to direct full reimbursement. |
| Petitioner | Requested reimbursement for emergency expenses and guidelines for CGHS claims. | The Court directed the respondent to pay the balance amount and ordered the formation of a grievance redressal committee. |
| Respondent | Case handled as per Ministry guidelines. | The Court acknowledged the guidelines but emphasized that they cannot override the need for timely medical care in emergencies. |
| Respondent | Special treatment would lead to arbitrariness. | The Court clarified that the decision was confined to the specific facts of the case and did not set a precedent for all cases. |
| Respondent | Petitioner did not approach an empanelled hospital. | The Court recognized the emergency situation and held that the petitioner had no other option. |
| Respondent | CGHS has rules and guidelines, and compensating beyond those would have large-scale ramifications. | The Court stated that the rules and guidelines could not be applied mechanically and must consider the welfare of pensioners. |
How each authority was viewed by the Court?
- Article 32 of the Constitution of India: The Court invoked this article to exercise its jurisdiction to protect the petitioner’s fundamental rights.
- Article 14 of the Constitution of India: The Court emphasized that the right to medical claim cannot be denied on technical grounds, ensuring equality.
- Article 21 of the Constitution of India: The Court recognized the right to life and timely medical care as paramount, especially in emergencies.
What weighed in the mind of the Court?
The Supreme Court’s decision was primarily influenced by the following:
- The emergency nature of the petitioner’s medical condition and the lack of other options at the time.
- The need to protect the fundamental rights of pensioners, especially their right to life and health.
- The responsibility of the state to ensure that its retired employees receive adequate medical care.
- The inhuman approach of CGHS officials in denying the medical reimbursement.
- The importance of timely medical care and the fact that the ultimate decision on treatment rests with the doctor.
| Reason | Percentage |
|---|---|
| Emergency medical condition | 30% |
| Protection of fundamental rights | 25% |
| State’s responsibility for retired employees’ medical care | 20% |
| Inhuman approach of CGHS | 15% |
| Importance of timely medical care | 10% |
Fact:Law Ratio
| Category | Percentage |
|---|---|
| Fact (Consideration of factual aspects of the case) | 60% |
| Law (Consideration of legal provisions) | 40% |
The Court’s reasoning was heavily influenced by the specific facts of the case, particularly the emergency situation and the petitioner’s lack of options. However, the Court also emphasized the legal principles of fundamental rights and the state’s responsibility to provide medical care.
Logical Reasoning:
Petitioner admitted in emergency to non-empanelled hospital
CGHS denies full reimbursement citing non-empanelled hospital and lack of prior approval
Supreme Court considers emergency nature of treatment and fundamental rights
Court directs full reimbursement, emphasizing the right to life and health
The Court considered the emergency situation, the lack of options for the petitioner, and the importance of timely medical care. It emphasized that the right to medical claim cannot be denied merely because the name of the hospital is not included in the Government Order. The Court also noted that the ultimate decision as to how a patient should be treated vests only with the Doctor. The Court rejected the CGHS’s mechanical application of rules and guidelines, holding that they could not override the welfare of pensioners.
The Court stated, “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.”
The Court further observed, “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.”
Finally, the Court noted, “Clearly, in the present case, by taking a very inhuman approach, the officials of the CGHS have denied the grant of medical reimbursement in full to the petitioner forcing him to approach this Court.”
Key Takeaways
- Government employees and pensioners are entitled to medical benefits, and no restrictions should be placed on these rights.
- In emergency situations, treatment at non-empanelled hospitals is justified, and medical claims cannot be denied on technical grounds.
- The ultimate decision on treatment rests with the doctor, and the welfare of the patient is paramount.
- The CGHS must be more responsive and cannot mechanically deprive employees of their legitimate reimbursements.
- A High Powered Committee should be formed to ensure timely disposal of medical claims for pensioners.
Directions
The Supreme Court directed the following:
- The respondent-State to pay the balance amount of Rs. 4,99,555 to the writ petitioner.
- The concerned Ministry to form a Secretary level High Powered Committee for quick disposal of medical claims of pensioners, which should meet every month.
- The concerned Ministry to device a Committee for grievance redressal of the retired pensioners consisting of Special Directorate General, Directorate General, 2 (two) Additional Directors and 1 (one) Specialist in the field which shall ensure timely and hassle free disposal of the claims within a period of 7 (seven) days.
- The relevant papers for claim by a pensioner shall be reimbursed within a period of 1 (one) month.
Specific Amendments Analysis
There was no specific amendment discussed in this judgment.
Development of Law
The ratio decidendi of this case is that in emergency situations, government employees and pensioners are entitled to medical reimbursement for treatment at non-empanelled hospitals. The Court clarified that the right to medical claim cannot be denied merely because the name of the hospital is not included in the Government Order and that the ultimate decision as to how a patient should be treated vests only with the Doctor. This judgment reinforces the principle that the welfare of the patient is paramount, and the state has a responsibility to ensure timely and adequate medical care for its retired employees. There is no change in the previous position of law, but it clarifies the application of existing principles in the context of medical emergencies.
Conclusion
The Supreme Court’s judgment in Shiva Kant Jha vs. Union of India is a significant ruling that protects the rights of retired government servants to receive full medical reimbursement, especially during emergencies. The Court emphasized that the right to life and health is paramount and that the state has a responsibility to ensure that its retired employees receive adequate medical care. The judgment also directs the formation of a grievance redressal committee to ensure timely disposal of medical claims for pensioners, highlighting the need for a more humane and responsive approach from the CGHS.
Category
Parent Category: Service Law
Child Category: Medical Reimbursement
Child Category: Central Government Health Scheme (CGHS)
Child Category: Article 32, Constitution of India
Child Category: Article 14, Constitution of India
Child Category: Article 21, Constitution of India
FAQ
Q: What is the Central Government Health Scheme (CGHS)?
A: The CGHS is a health facility scheme for central government employees and pensioners, providing medical care.
Q: Can a pensioner claim medical reimbursement for treatment in a non-empanelled hospital?
A: Yes, especially in emergency situations, the Supreme Court has held that medical claims cannot be denied solely because the hospital is not empanelled.
Q: What should I do if my medical claim is denied by CGHS?
A: You can request a review by the competent authority in CGHS, and if needed, the case will be referred to a Special Technical Committee.
Q: How long should it take for medical claims to be reimbursed?
A: The Supreme Court has directed that medical claims of pensioners should be reimbursed within one month of submitting the relevant documents.
Q: What if I have to go to a non-empanelled hospital in an emergency?
A: In emergency situations, treatment at non-empanelled hospitals is justified, and medical claims cannot be denied on technical grounds. The factum of treatment is the real test.
Q: What is the role of the doctor in deciding treatment?
A: The ultimate decision on how a patient should be treated rests with the doctor, who is well-versed and expert in their field.