Bombay High Court: In a case wherein, the petitioner, being a former Central Government employee, claimed for a heart transplant conducted at a private hospital, the Division Bench of G.S. Kulkarni* and Advait M. Sethna, JJ., opined that the petitioner, in a situation to save his life, was entitled to take a decision to have a heart transplant at a private hospital, in the absence of such facilities being readily/timely made available, in all the empanelled hospitals. The Court held that he was required to be granted full reimbursement of all the expenditure and patients like the petitioner, who was a pensioner, could not be deprived of benefits of medical reimbursement when he received treatment at private hospital, more particularly, when his case was accepted as a genuine case, which was certainly of an urgent nature.
Background
The petitioner voluntarily retired from Central Excise and Customs, Pune, as an Assistant Commissioner in March 2008 and was receiving pension. On 28-8-2011, the Government of India, Ministry of Health and Family Welfare (‘MOHFW’) notified a fresh empanelment of private hospitals and a corrected list of package rates applicable for empanelled hospitals under the Central Government Health Scheme (‘CGHS’), Mumbai. On 14-5-2021, the rates were updated and on 16-1-2013, MOHFW published guidelines and ceiling rates for liver transplant surgery for CGHS/Central Service (Medical Attendance) beneficiaries and by Office Memorandum dated 18-2-2015, rates of treatment procedures under CGHS were revised.
The petitioner had been suffering from Cardiomyopathy since 2009 and in 2019, upon a significant deterioration in the Left Ventricle Ejaculation Function, he was advised to undergo a heart transplant. It was stated that neither the Government Hospitals nor the CGHS-empanelled Super Speciality Hospital, namely Wockhardt Hospital, Mumbai Central, was performing heart transplant surgeries. Therefore, the petitioner availed treatment at Sir H.N. Reliance Foundation Hospital.
The petitioner addressed a letter to Respondent 5, Additional Director, CGHS Mumbai, stating that an estimate of Rs 25 lakhs was received by him towards the cost of heart transplant and requested due consideration for such medical reimbursement. The Chief Medical Officer Incharge, CGHS Mumbai, stated that the petitioner was permitted to undergo Indoor/OPD treatment and further, an endorsement was made on such letter that treatment at a non-empanelled hospital could only be reimbursed at CGHS rates and the difference in cost would have to be borne by the petitioner. The petitioner underwent surgery and the total expenses incurred by him were Rs. 29,96,020.35.
The petitioner stated that vide letter dated 8-3-2021, Respondent 4 directed Respondent 5 to grant reimbursement of the petitioner’s claim as per existing CGHS rates for Mumbai, in fulfillment of conditions of Heart Transplant Surgery. The Chief Medical Officer Incharge, CGHS Mumbai informed the petitioner of sanction of Rs 1,60,805 being approved towards his claim. Thereafter, the petitioner submitted a letter to Respondent 4 referring to his revised claim amount of Rs 22,08,440. Respondent 5 addressed a letter dated 13-4-2022 to the petitioner conveying the decision of Respondent 7, the High-Power Committee that grant of full reimbursement was not recommended as the treatment was undertaken by the petitioner at non-CGHS rates and the procedure was a planned, non-emergency surgery. Thus, the petitioner being aggrieved by the rejection of his application by the High-Power Committee, of his claim for full reimbursement of expenses, incurred by him towards his heart transplant surgery, he filed the present petition praying for the reliefs.
Analysis, Law, and Decision
The Court referred to the facts and after considering the applicability of Office Memorandum dated 28-8-2011 and the impugned decision dated 13-4-2, opined that the decision taken by the High-Power Committee denying the petitioner full reimbursement of the medical expenses incurred by him for the heart transplant on the ground that CGHS permitted rates were required to be followed, was not the correct and a legal stand of the respondents.
The Court noted that the the High-Power Committee’s observation that the procedure of heart transplantation was a planned surgery and not an emergency, hence, the reimbursement was done as per CGHS extant rules and guidelines, were the only reasons on which full reimbursement under relaxation of rules were rejected.
The Court also noted that vide Office Memorandum dated 15-7-2014, the Government of India had provided for relaxation of procedures to be followed in considering requests for medical reimbursement claims in respect of CS(MA) beneficiaries. The relaxation was made in reimbursement of the medical expenses incurred in special cases, peculiar circumstances, and in cases of emergency and other special circumstances.
The Court opined that how a requirement of heart transplant was not considered to be an extraordinary and not an emergent and inevitable surgery, as a heart transplant was required only when the heart was failing, the consequences of which were just to be imagined. The Court stated that the petitioner’s case should have been considered by the High-Power Committee, and opined that a narrow, pedantic and/or too technical view was taken by the High-Power Committee in rejecting the full medical reimbursement to the petitioner.
The Court opined that it could not be said that the respondents were powerless or would lack authority to consider special cases of reimbursements of medical expenses when the treatment received was of such serious nature, in considering applications for reimbursement in such category. The Court further opined that these were all executive powers conferred on the Central Government under Article 73 of the Constitution, which were coterminous with the power to legislate and in the absence of any specific legislation, exercise of such power and more particularly for preservation of fundamental rights necessarily had a legitimate constitutional recognition.
The Court opined that a case-to-case legitimate decision protecting the fundamental rights was expected to be taken by the officers concerned and such powers were conferred only to be utilized and more particularly when there was a need to exercise such powers not only to protect the fundamental rights but right to life and right to livelihood. Thus, apart from the Office Memorandum dated 15-7-2014 providing for relaxation, the High-Power Committee could even exercise such powers of relaxation and in such deserving case, exercise its discretion to award full medical reimbursement.
The Court stated that the present case was a case of heart transplant which was a serious ailment, and its surgery was critically important, and could not have been postponed, thus, being a special circumstance. Such surgeries were expedited in the interest of human life without an embargo of an expenditure which was secondary to human life.
The Court opined that the petitioner, in a situation to save his life, was entitled to take a decision to have a heart transplant at a private hospital, in the absence of such facilities being readily/timely made available, in all the empanelled hospitals. Thus, the Court held that he had to be granted full reimbursement of all the expenditure when such expenditure was not in dispute.
The Court opined that not granting full reimbursement, in these circumstances was not only violative of the fundamental rights but strikes at the very root, purpose, and essence of the basic human rights as guaranteed by the Constitution, i.e., Right to Life under Article 21.
The Court stated that the High-Power Committee in its usual, routine, and mundane method took the decision without hearing the petitioner, despite the clear orders of this Court in the prior proceedings filed by the petitioner. The Court observed that although some medical facilities were available in CGHS hospitals, it was not possible that such specialized medical facilities were available and so necessarily treatment had to be availed by such patients from private hospitals, for which reimbursement was sought from the Central Government. Thus, in such a situation, the Central Government must grant reimbursement on a case-to-case basis.
The Court opined that any employee, merely because he had retired, must not to be differently treated when it comes to genuine and realistic health expenditure and moreover, the reimbursement rates were not revised from time to time in the absence of which, they were rendered unrealistic. Thus, patients like the petitioner, who was a pensioner, could not be deprived of benefits of medical reimbursement when he received treatment at private hospital, more particularly, when his case was accepted as a genuine case, which was certainly of an urgent nature.
The Court stated that to make the petitioner suffer for reimbursement amounted to travesty of justice and a glaring violation of the fundamental rights guaranteed to a citizen who was the former employee of the Central Government. Thus, the High-Power Committee should have been humanely sensitive in dealing with the petitioner’s case and should not to have adopted a mechanical and narrow-minded approach. The Court allowed the petition and held that the needful reimbursement should be done to the petitioner within four weeks from the date of the present order.
[Anirudh Prataprai Nansi v. State of Maharashtra, Writ Petition No. 7546 of 2022, decided on 6-6-2025]
*Judgment authored by: Justice G.S. Kulkarni
Advocates who appeared in this case :
For the Petitioner: Prakash Shah, Senior Advocate a/w. Anil Balani, Durgaprasad Poojari, Jas Sanghavi, Priyasha Pawar, Vikas Poojary i/b. PDS Legal for the petitioner.
For the Respondents: Y.R. Sharma a/w. Vinit Jain, Ashok Varma for the respondents.
Buy Constitution of India HERE
