Central Government Pensioner Not Entitled To Medical Reimbursement Beyond CGHS Rates When No Referral Memo Obtained: Bombay High Court

A division bench of Acting Chief Justice Nitin Jamdar and Justice Sandeep V Marne dismissed a widow’s writ petition seeking reimbursement for the entire medical expenses incurred in her pensioner husband’s treatment.

“…no fault can be found in the action of the Respondents (Central Government) who have taken sympathetic view of the matter and have reimbursed the entire costs of medical treatment (at CGHS rates) by ignoring the fact that Referral Memo was not obtained from CGHS Wellness Centre and Petitioner’s husband was not admitted in emergency situation. In this manner, substantial amount of Rs.9,68,893/- (as per CGHS rates) has been reimbursed to the Petitioner. Petitioner’s claim for reimbursement of additional amount over and above Rs.9,68,893/- is not supported by any rule or administrative instructions”, the court held.

The petitioner, one Bina Saxena, had to pay the hospital bills at the actual rate and not the subsidized CGHS rates, as she did not obtain a CGHS Referral Memo before or during her husband’s hospitalization.

Saxena’s husband retired in 2001 and was enrolled as a CGHS beneficiary. He was suffering from chronic kidney disorder. In the month of January and February 2016, he was admitted twice in Ruby Hall Clinic, a CGHS empaneled hospital, due to pain in urinary bladder. He was discharged after the second hospitalisation on February 19, 2016.

On February 24, 2016, he again complained of acute pain and was rushed to Ruby Hall Clinic in an emergency. Saxena contended that since the pain was experienced in the evening, and the CGHS Wellness Centre closes at 2:00 PM, it was impossible to take him there. On February 25, 2016, her husband was diagnosed with urinary bladder cancer and passed away on April 9, 2016.

Between February 24, 2016 and April 9, 2016, the petitioner incurred an expense of Rs.13,47,879/- and claimed reimbursement for the same. Additional Director, CGHS, Pune sanctioned Rs. 9,68,893/- to be reimbursed to her.

She filed an original application before the Central Administrative Tribunal, Mumbai claiming balance reimbursement of Rs. 3,78,986/-. The tribunal dismissed the application and hence she approached the High Court.

The petitioner contended that her husband was required to be admitted to Ruby Hall Clinic in an emergency and it was impossible to collect a Referral Memo from CGHS Wellness Centre. She relied on a Certificate issued by Ruby Hall Clinic certifying that the admission was done in an emergency.

The tribunal in its decision had relied on an email written by the hospital to the petitioner in response to a query regarding reimbursement of medical expenses. According to the email, the patient did not bring any CGHS Memo at the time of admission or at any time during the treatment. Further, the admission was not an emergency case and the patient took regular admission.

The court did not find any perversity in the tribunal’s finding that the patient was not admitted in an emergency situation. “…‘emergency’ within the context of reimbursement of medical expenses was required to be certified by the hospital and has been so certified by way of Email dated 25 July 2017. As against this, the Certificate dated 17 May 2016 is in a standard format and is not issued in the context of reimbursement of medical expenses”, the court observed.

The court noted that about 70% of the claim has already been sanctioned and reimbursed. Further, question of emergency has become academic as the central government reimbursed the entire cost of treatment, albeit at CGHS rates, the court said.

The court relied on office memorandum dated October 5, 2016 issued by the Central Ministry of Health and Family Welfare regarding the reimbursement/permissions/ex-post facto approval in respect of pensioner CGHS beneficiaries. Clause (ii) of the memorandum provides that the of reimbursement for treatment without prior approval will be restricted to CGHS rates or actual expenditure, whichever is lower.

The court noted that the petitioner did not show any administrative instruction or rule providing that any amount over CGHS rates can be reimbursed and upheld the tribunal’s order.

Case no. – Writ Petition No. 628 of 2020

Case Title – Bina Saxena w/o Late Ravendra Kumar Saxena v. Union of India