Court affirms reimbursement under CGHS for life-saving surgery conducted in emergency despite the hospital's non-empanelled status.
In a significant ruling, the Kerala High Court has reinforced the rights of Central Government Health Scheme (CGHS) beneficiaries to claim reimbursement for emergency medical treatments conducted in non-empanelled hospitals. The Division Bench, comprising Justices Devan Ramachandran and Basant Balaji, dismissed the appeal filed by the Union of India against the order of the Central Administrative Tribunal (CAT), Ernakulam Bench, which had granted medical reimbursement to K.J. Joseph for his wife's emergency surgery.
The case centered around the denial of reimbursement claims by the Union of India on the grounds that the surgery was performed in a non-empanelled hospital, "Aster Medcity" in Kochi. The government contended that the medical condition of the patient did not warrant an emergency intervention and that the procedure was elective, citing the inability to meet CGHS guidelines.
However, the High Court upheld the Tribunal's decision, emphasizing the critical nature of the treatment. The judgment relied heavily on the precedent set by the Supreme Court in "Shiva Kant Jha v. Union of India," which asserts that the ultimate decision regarding a patient's treatment lies with the attending medical professionals. The court observed that the patient was in a precarious condition, requiring immediate surgical intervention, as corroborated by the medical records and certificates from the treating hospital.
Justice Ramachandran noted, "The fact that the surgery was performed under emergency circumstances, as confirmed by the certified medical records, negates the arguments presented by the Union. The right to medical reimbursement cannot be denied solely because the hospital is not on the CGHS empanelled list."
The court further referenced the Office Memorandum dated 22nd May 2018, which clarifies that treatments obtained in non-recognized hospitals under emergency conditions for advanced ailments like malignancy do not disqualify patients from CGHS benefits.
This judgment reinforces the legal position that in cases of medical emergencies, the necessity of treatment as determined by qualified healthcare professionals supersedes administrative guidelines regarding hospital empanelment. It serves as a crucial affirmation of patients' rights to access necessary medical care and seek reimbursement without being constrained by bureaucratic limitations.
Bottom line:-
Central Government Health Scheme (CGHS) - Emergency medical treatment in non-empanelled hospital - Reimbursement cannot be denied solely on the ground that the hospital is not empanelled under CGHS if the treatment is deemed necessary and urgent by medical experts.
Statutory provision(s): Central Government Health Scheme (CGHS), Shiva Kant Jha v. Union of India (2018) 16 SCC 187, Office Memorandum dated 22.05.2018
Union of India v. K.J. Joseph, (Kerala)(DB) : Law Finder Doc id # 2943015
