CGHS may not be able to deny claim for medical reimbursement now

Government employees who are Central Government Health Scheme (CGHS) beneficiaries are required to seek treatment in empanelled hospitals. CGHS guidelines say that “if the Central govt servant or a member of his family covered under CGHS falls ill at a place not covered under CGHS, the treatment shall be admissible under CS(MA) Rules. The reimbursement in such cases shall be restricted to the amount which would have been incurred had the treatment been taken in a Govt / State government hospital in that city” (http://www.pcdablr.gov.in/paymedicalguidelines.htm)

However, the CGHS now may not be able to deny claim for medical reimbursement to retired government employees, who have a CGHS card valid for whole life, for medical treatment taken by them in private hospitals or even a hospital which is not on the list of government empanelled hospitals following a ruling of the Supreme Court of India.

A Bench of Justice RK Aggarwal and Justice Ashok Bhushan in the matter titled as “Shiva Kant Jha versus Union of India, Writ Petition (Civil) No. 694/2015, vide judgment dated 13.04.2018” has allowed the petition filed by the petitioner against the alleged unfair treatment meted out to several retired government servants in their old age and their state of affairs pertaining to reimbursement of medical claims under the CGHS.

Accordingly, the Hon’ble Apex Court has allowed the medical reimbursement claim of the pensioners of Government of India for the treatment undertaken by him in a private or non-empanelled hospital stating that “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.”

In the same order, the Apex Court also directed the Ministry to form a grievance redressal committee for the retired pensioners “to ensure timely and hassle free disposal of the claims within a period of seven days”.

Dr KK Aggarwal

Padma Shri Awardee
Vice President CMAAO
Group Editor-in-Chief IJCP Publications

President Heart Care Foundation of India

Immediate Past National President IMA