Case Note & Summary
The petitioner, a retired Central Government employee from Pune, was a pensioner residing in Mumbai. He voluntarily retired in March 2008 as Assistant Commissioner, Central Excise and Customs. Since 2009, he suffered from cardiomyopathy, and by October 2019 his LVEF deteriorated to 12–15%, requiring a heart transplant. At that time, no CGHS-empanelled hospital in Mumbai, including the super-speciality Wockhardt Hospital, performed heart transplants. On 26 November 2020, a doctor at Lokmanya Tilak Municipal Medical College recommended cardiac transplantation. The petitioner approached Sir H. N. Reliance Foundation Hospital, a non-empanelled private facility, and was admitted for pre-transplant work-up. On 3 December 2020, he informed the Additional Director, CGHS Mumbai, about the estimated cost of Rs. 25,00,000 and sought due consideration for reimbursement. The CGHS issued a letter permitting indoor/OPD treatment but endorsed that reimbursement for non-empanelled hospitals would be at CGHS rates, with the patient bearing the excess. On 8 December 2020, the petitioner successfully underwent a heart transplant and was discharged on 29 December 2020, incurring a total expenditure of Rs. 29,96,020.35. He submitted a medical reimbursement claim to the Wellness Centre on 7 January 2021, accompanied by a request to apply higher CGHS rates fixed for other metropolitan cities (Rs. 3,17,400) instead of the Mumbai rate of Rs. 79,000 (as per 2010 CGHS notification). Correspondence ensued between CGHS Mumbai and Delhi regarding applicable rates. Respondent No. 5 by letter dated 13 April 2022 rejected the claim for full reimbursement, prompting the petitioner to file the present writ petition. The petition sought a writ of mandamus for reimbursement of Rs. 22,08,440 with interest at 9% per annum, and a writ of certiorari to quash the rejection letter and the Office Memorandum dated 28 August 2011 read with the 2010 Mumbai rates. The petitioner contended that the life-saving nature of the surgery, unavailability in CGHS network, and the constitutional right to health entitled him to full reimbursement. The court noted the peculiar nature of the case and framed the issue whether the normal reimbursement rules should be relaxed in such a pressing, life-threatening situation. The matter was heard and judgment reserved on 24 January 2025, and pronounced on 6 June 2025, but the provided text does not include the final decision or ratio.
Issue of Consideration
Whether in the inescapable and pressing situation the petitioner, having undergone a heart transplant at a private hospital, could be denied full reimbursement of the medical expenses; and whether the rigors of normal medical reimbursement rules should give way to a special case for full reimbursement, considering the constitutional right to health.
Final Decision
Decision not clearly stated
Law Points
- Legal points not extracted
- Right to health under Article 21
- Medical reimbursement for life-saving treatment
- Special case for full reimbursement despite non-empanelment
- Rigors of normal rule of medical reimbursement should yield for special case
- Constitutional guarantee of right to life
- Access to life-saving medical treatment
- Reimbursement not to be denied for non-empanelled hospitals when procedure unavailable in empanelled ones
Case Details
2025 LawText (BOM) (06) 99
WRIT PETITION NO. 7546 OF 2022
G. S. Kulkarni, J. and Advait M. Sethna, J.
Citation not available, 2025:BHC-AS:22550-DB
Mr. Prakash Shah, Senior Advocate a/w. Mr. Anil Balani, Mr. Durgaprasad Poojari, Mr. Jas Sanghavi, Mr. Priyasha Pawar. Mr. Vikas Poojary i/b. PDS Legal for the petitioner; Mr. Y.R. Sharma a/w. Mr. Vinit Jain, Mr. Ashok Varma for the respondents.
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Nature of Litigation
Writ Petition under Article 226 of the Constitution of India seeking mandamus for full medical reimbursement and certiorari to quash rejection order and Office Memorandum.
Remedy Sought
Petitioner sought reimbursement of Rs. 22,08,440/- with interest at 9% per annum from respondents, and quashing of rejection letter dated 13.04.2022 and Office Memorandum No. S.110011/23/2009-CGHS D.II/Hospital Cell (Part I) dated 28.08.2011 read with CGHS Mumbai Rates for Hospitals - 2010.
Filing Reason
The petitioner, a retired Central Government employee, underwent a heart transplant at a non-empanelled private hospital as the procedure was not available in CGHS empanelled hospitals in Mumbai. He incurred expenses of Rs. 29,96,020.35 but was only offered reimbursement at CGHS rates (Rs. 69,000 to 79,000), leading to a substantial shortfall. He challenged the rejection and the rate fixation as arbitrary and violative of the right to health.
Previous Decisions
The petitioner had previously approached this Court on the same cause of action; this was the second occasion. The claim was rejected by Respondent No. 5 via letter dated 13.04.2022.
Issues
Whether in the inescapable and pressing situation, the petitioner, having undergone a heart transplant at a private hospital, could be denied or not given full reimbursement of the medical expenses incurred.
Whether the rigors of normal rule of medical reimbursement should make way for the case to be considered as a special case for grant of full reimbursement.
Submissions/Arguments
Ratio Decidendi
Ratio not explicitly mentioned
Judgment Excerpts
The case is a peculiar case, namely, of a dispute arising from the reimbursement of expenditure incurred by the petitioner on a serious medical treatment of a “heart transplant”.
The issue which arises for consideration is whether in the inescapable and pressing situation the petitioner, having undergone a heart transplant at a private hospital, could the petitioner be denied and/or not given full reimbursement of the medical expenses incurred by him for such major treatment.
The question is also as to whether the rigors of normal rule of medical reimbursement should make a way for the case to be considered as a special case, for grant of full reimbursement.
More particularly considering such situations on the touchstone of the Constitutional guarantee of right to life, which includes right to health and certainly right to avail of treatment, necessary to save one’s life.
if treatment availed from Non-Empanelled hospital, reimbursement will be at CGHS rates and excess amount will be borne by the patient.
on availability of a donor with a compatible heart, the petitioner successfully underwent heart transplant surgery at Sir H. N. Reliance Hospital on 8 December 2020.
Procedural History
The petitioner voluntarily retired in March 2008. He was diagnosed with cardiomyopathy since 2009; in October 2019 his condition deteriorated, requiring heart transplant. On 26.11.2020, a doctor recommended transplantation. On 03.12.2020, he sought CGHS permission and was granted with an endorsement that non-empanelled treatment would be reimbursed at CGHS rates only. On 08.12.2020, heart transplant surgery was performed; he was discharged on 29.12.2020. On 06.01.2021, he requested higher rates; on 07.01.2021, he submitted a medical reimbursement claim. Correspondence between CGHS Mumbai and Delhi ensued regarding applicable rates. On 13.04.2022, Respondent No. 5 rejected the full reimbursement claim. The writ petition was filed thereafter. The matter was heard on 24.01.2025 and judgment reserved; pronounced on 06.06.2025.
Acts & Sections
- Constitution of India: Article 21, Article 226
