Case Note & Summary
The petitioner, Bina Saxena, is the widow of a Central Government pensioner who was a beneficiary of the Central Government Health Scheme (CGHS). Her husband suffered from chronic kidney disorder and was admitted to Ruby Hall Clinic, a CGHS empanelled hospital, on three occasions in early 2016. For the first two admissions, he did not claim reimbursement but used a mediclaim policy. On 24 February 2016, he developed acute pain in the urinary bladder in the evening and was rushed to Ruby Hall Clinic in an emergency. The CGHS Wellness Centre was closed at that time, making it impossible to obtain a prior referral. He was diagnosed with urinary bladder cancer and died on 9 April 2016 due to multiple organ failure. The total medical expenses for the third admission were Rs.13,47,879/-. The CGHS authorities reimbursed only Rs.9,68,893/-, disallowing Rs.3,78,986/- on the ground that the petitioner had not obtained prior referral from the CGHS Wellness Centre before admission. The petitioner filed Original Application No.176 of 2018 before the Central Administrative Tribunal, Mumbai, which was dismissed on 5 April 2019. Aggrieved, she filed the present writ petition. The High Court examined the CGHS guidelines and noted that while prior referral is generally required, exceptions exist for emergencies. The court found that the petitioner's husband was admitted in a genuine emergency, and the CGHS Wellness Centre was closed at the time. The court held that strict adherence to referral procedure cannot be insisted upon in such circumstances, and the denial of reimbursement was unjustified. The court allowed the petition, set aside the Tribunal's order, and directed the respondents to reimburse the balance amount of Rs.3,78,986/- within four weeks.
Headnote
A) Central Government Health Scheme - Medical Reimbursement - Emergency Treatment - Prior Referral - CGHS Guidelines - Petitioner's husband, a CGHS beneficiary, was admitted in emergency to Ruby Hall Clinic (empanelled hospital) without prior referral from CGHS Wellness Centre due to acute pain in the evening when the centre was closed - The Tribunal denied balance reimbursement on ground of non-compliance with referral procedure - The High Court held that in genuine emergencies, strict adherence to referral procedure cannot be insisted upon, and reimbursement must be made at CGHS rates - Held that the denial of balance amount was unjustified and directed reimbursement of Rs.3,78,986/- (Paras 6-14).
Issue of Consideration
Whether a CGHS beneficiary is entitled to full reimbursement of medical expenses incurred for emergency treatment at a non-empanelled hospital without obtaining prior referral from a CGHS Wellness Centre.
Final Decision
The High Court allowed the writ petition, set aside the order of the Central Administrative Tribunal dated 5 April 2019, and directed the respondents to reimburse the balance amount of Rs.3,78,986/- to the petitioner within four weeks.
Law Points
- Medical reimbursement
- emergency treatment
- CGHS
- prior referral
- empanelled hospital
- Central Government Health Scheme
- pensioner benefits
