CGHS is responsible for the healthcare needs of government employees and pensioners: Supreme Court of India

Shivani Bhardwaj

New Delhi: The Supreme Court of India has passed an order categorically stating that
Central Government Health Scheme (CGHS) is responsible for taking care of healthcare needs and well being of the central government employees and pensioners.

Going by the merit of a writ petition filed a retired Central Government pensioner, Shiv Kant Jha, a two Judge Bench of the Supreme Court of India comprising of Justice R.K. Agrawal and Justice Ashok Bhushan has passed an order on Friday (13 April 2018), which says that the treatment of the petitioner in non-empaneled hospital was genuine because there was no option left with him at the relevant time.

Therefore the apex court has directed the respondent, i.e., the State to pay the balance amount of Rs. 4,99,555 to the writ petitioner.

The Court has also made it clear that this decision is confined to this particular case.

Facts of the case:

(a) The petitioner, a CGHS beneficiary (retired pensioner) having a CGHS Card valid for whole life for medical treatment in Private Ward, submitted two sets of his Medical bills under the Central Government Health Scheme (CGHS) for reimbursement on account of his treatment done in November, 2013 in the Fortis Escorts Hospital, New Delhi for Rs. 9,86,343 for his cardiac ailments
involving the implant of CRT-D device and two sets of bill amounting to Rs. 3,98,097 for his treatment at Jaslok Hospital, Mumbai for cerebral stroke and paralytic attack.

(b) The petitioner submitted the first Bill on 2 January 2014 and the second Bill (two) on 19 July 2014 to the concerned authority. The first Bill was considered by the Technical Standing Committee (TSC) in May 2014 and the claim was rejected without informing him of the reasons for rejection.

The case was again considered by the Standing Committee on 10 July 2014 and was rejected on the ground that CRT-D implant was not required. Aggrieved of the above, the petitioner filed a representation before the Secretary, Ministry of Health & Family Welfare. This representation was again considered by the Standing Committee on 15 January 2015 and was rejected on the ground that “Prior approval for such device implant was not sought”. Again, the petitioner approached the Director General of the CGHS. After presenting the memorial to the Director General of the CGHS, the government credited an amount of Rs. 4,90,000 in the petitioner’s Bank Account, however, he was never heard on any point nor any speaking order was ever communicated to him.

(c) In the second set of Bills of the Jaslok Hospital, the petitioner’s claim was curtailed to the tune of Rs. 94,885, being just one-fourth of the claim and no opportunity of being heard was granted to the petitioner. Thus, the petitioner was denied an amount of Rs. 4,96,343 from the first claim and Rs. 3,03,212 from the second set of claim. Out of the total bills amounting to Rs. 13,84,440, the petitioner was paid Rs. 5,84,885, meaning thereby, the petitioner was denied Rs. 7,99,555. To both the hospitals, the petitioner had to pay out of his personal resources. However, the Supreme Court, through an order on 1 February 2016, had directed the State to pay a sum of Rs.3,00,000 to the petitioner as an interim relief.

(d) Aggrieved by the decision of the CGHS in not allowing the medical bills in full, the petitioner had filed a writ petition under Article 32 of the Constitution of India claiming that he being in late 70s of his age, needed money to meet the needs for his survival.

Taking into consideration the fact and circumstances of the case, the Supreme Court order places on record the opinion that the treatment of the petitioner in non-empanelled hospital was genuine because there was no option left with him at the relevant time. The Court has therefore directed the respondent-State to pay the balance amount of Rs. 4,99,555 to the writ petitioner. It has also been made clear by the court that this order is confined to this case only.

The petitioner in person contended before this Court that over several years, several retired government servants, in their old age, have suffered and even died due to unfair
treatment meted out to them by the CGHS and its controlling Ministry, the Ministry of Health and Family Welfare, in discharge of their duties. The petitioner contended that the impugned CAG’s Report with regard to “Reimbursement of Medical Claims to the Pensioners under CGHS” have also expressed the indifference against the pensioners. He further contended that every government employee during his life time or after his retirement is entitled to get the benefit of the medical facilities and no fetters can be placed on his rights.

The petitioner in-person contended that the Supreme Court may exercise its jurisdiction under Articles 32 and 142 of the Constitution so that the fundamental rights of the petitioner under Articles 14 and 21 are protected and promoted by reimbursing his medical expenditure already incurred by him
under genuine emergency and also to frame some guidelines for effective implementation of the claims of the pensioners under the CGHS.

The Counsel for the State while refuting the claim of the petitioner submitted that the case of the petitioner has been dealt with in accordance with the Circulars and Office Memorandums issued by the Ministry of Health & Family Welfare from time to time. Learned counsel further submitted that the petitioner cannot be given any special treatment beyond the terms of the circulars which would amount to violation thereof and would lead to arbitrariness and discrimination qua a large number of such like beneficiaries.

The counsel for the respondent further contended that the government has empanelled several hospitals under the CGHS and the petitioner did not approach the empanelled hospital during medical emergency and he was charged by the hospital as per their own rates whereas the rates charged for such facility shall be only at the CGHS rates and that too after following a proper procedure given in the Circulars issued on time to time by the concerned Ministry. Further, the CGHS has a complete set of rules and guidelines to be followed in each case and if the petitioner is compensated beyond the policy, it would have large scale ramifications. The counsel for the State also submitted that the petition is devoid of merits and is liable to be dismissed.

Union of India-the respondent, while complying with the order passed by the Supreme Court on 11 April 2016 filed an
affidavit describing the in-house procedure to be followed in dealing with the claims under CGHS, the remedy/appeal available in dealing with the claims and also the nature of claims pending in respect of card holders. The detailed procedure which is followed for the purpose of medical reimbursement claims of CGHS beneficiaries have been set out in a Circular of 14 November 2011 and further supplemented by the instructions on 11 December 2012.

Procedure for Medical Reimbursement Claim (MRC) in Central Government Health Scheme (CGHS)

(a) The patient or beneficiary has to approach the in-charge of the wellness centre where he/she is registered.
(b) That after getting all the documents required for MRC from the beneficiary, CMO in-charge submits the same online to CMO (R&H) of the respective Zonal Office and also send one hard copy through
official dak to the respective Zonal Office CMO (R&H) who process the MRC as per CGHS rates.
(c) The CMO (R&H) processes the MRC as per CGHS Rates. If CGHS rates are not available, reimbursement is considered at AIIMS rates. And if AIIMS rates are also not available, the reimbursement is made as per actual rates.
(d) The CMO (R&H) gets the approval of Additional Director (AD) of the respective Zonal Office for the MRC. Then approved amount of MRC is sent as bill to the Pay & Accounts Office (PAO) CGHS Rajinder Nagar.
(e) Pay & Accounts Office credits the approved amount of MRC in the account of beneficiary through Electronic Clearing System (ECS).

The procedure of appeal/remedy in CGHS regarding MRC is given hereunder:-

(a) If the beneficiary is not satisfied with the claim, he can request in writing to the Competent Authority in CGHS. The request is then forwarded to the higher authority by the respective Zonal Office for consideration.
(b) If the higher authority considers it necessary to have the opinion of the specialist of concerned speciality, a Special Technical Committee (STC) meeting is held.
(c) On the basis of the recommendation of the Special Technical Committee, the approval of the competent authority is taken and the approved amount is paid to the beneficiary by PAO.

Union of India, by filing an affidavit before the Supreme Court, submitted that most of the claims were reimbursed only through the CGHS sources as per the package rates of CGHS.

However, there are few cases received occasionally where reimbursement was being done from two sources i.e. from CGHS and from the insurance companies. Such claims are first processed by insurance companies and then by the CGHS.

The claim of CGHS is reimbursed as per the Office Memorandum of 19 February 2009. It was further submitted that no such cases involving reimbursement from two sources was pending in CGHS.

Further, the writ petitioner was admitted in emergency condition with complaint of breathlessness on 11 November 2013 in Fortis Escorts Health Institute, which was a non-empanelled hospital at the relevant time. He underwent angiography on 12 November 2013 which revealed diffused disease in left anterior descending coronary artery 50-60%. He had been implanted the CRT-D device (Combo) as part of cardiac resynchronization therapy (CRT) on 12 November 2013. The hospital charged an amount of Rs. 11,56,293 for this treatment, out of which, an amount of Rs. 10,70,000 was for the cost of the unlisted cardiac implant (CRT-D) and an amount of Rs. 3,19,950 was paid by the Insurance company directly to the hospital.

A Special Technical Committee meeting was held on 29 April 2014 to consider the case of the petitioner. However, on examining it, the Committee did not find any justification for the implant of CRT-D device of the petitioner. On a further request by the petitioner, the Special Technical Committee again did not find any justification for the implant of CRT-D device on 10 July 2014. On a request for reconsideration by the petitioner, on 15 January 2015, the case of the petitioner was again reconsidered by the Special Technical Committee which denied the claim of CRT-D.

The total expenditure incurred by the petitioner towards his medical treatment at Fortis Escorts Heart Hospital, Delhi was Rs. 9,86,343 and at Jaslok Hospital, Mumbai was Rs. 3,98,097/-, hence, the total amount claimed by the petitioner was Rs. 13,84,440. Though the Special Technical Committee did not find the implant justified, the competent
authority, keeping in view the emergency nature of the case of the petitioner, approved the reimbursement of implant as per AIIMs rate. Therefore, out of the total amount i.e., Rs. 13,84,440, an amount of Rs. 4,90,000 was paid to the petitioner on the direction of the authority and Rs. 94,885 for the treatment at Jaslok Hospital. Following the Supreme Court’s direction on 1 February 2016, a sum of Rs. 3,00,000 was also paid by the State. Hence, a sum of Rs. 4,99,555 was the claim of the petitioner in the writ petition.

To provide the medical facility to the retired/serving CGHS beneficiaries, the government has empanelled a large number of hospitals on CGHS panel, however, the rates charged for such facility shall be only at the CGHS rates and, hence, these are paid as per the procedure. Though the respondent-State pleaded that the CGHS has to deal with large number of such retired beneficiaries and if the petitioner is compensated beyond the policy, it would have large scale ramification as none would follow the procedure to approach the empanelled hospitals and would rather choose private hospital as per their own free will, and it cannot be ignored that such private hospitals raise exorbitant bills subjecting the patient to various tests, procedures and treatment which may not be necessary at all times.

The Supreme Court order says it is a settled legal position that the Government employee during his life time or after his retirement is entitled to get the benefit of the medical facilities and no fetters can be placed on his rights. 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. Very little scope is left to the patient or his relative to decide as to the manner in which the ailment should be treated. Speciality Hospitals are established for treatment of specified ailments and services of Doctors specialized in a discipline are availed by patients only to ensure proper, required and safe treatment. Can it be said that taking treatment in Speciality
Hospital by itself would deprive a person to claim reimbursement solely on the ground that the said Hospital is not included in the Government Order. 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. Before any medical claim is honoured, the authorities are bound to ensure as to whether the claimant had actually taken treatment and the factum of treatment is supported by records duly certified by Doctors/Hospitals concerned. Once, it is established, the claim cannot be denied on technical grounds. 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 the Supreme Court.


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