Himachal Pradesh High Court: In a petition seeking full medical reimbursement for the treatment of the petitioner’s wife at the Post Graduate Institute of Medical Education and Research, Chandigarh (‘PGIMER’), the petitioner had claimed an amount of ₹2,93,295. However, the respondents disbursed only ₹2,08,495, deducting ₹84,800 on the ground that a ceiling limit applied to knee and hip implants under the Central Government Health Scheme (CGHS) and Central Services (Medical Attendance) Rules, as per an Office Memorandum issued in 1995, the Division Bench of Vivek Singh Thakur* and Ranjan Sharma, JJ. observed that no such ceiling was in force at the time of the treatment. The Court held that once a medical claim is otherwise admissible under a beneficial policy of the State, it should not be denied on flimsy grounds or irrelevant considerations. Accordingly, the Bench directed the authorities to release the withheld amount of ₹84,800 to the petitioner.
Background:
The petitioner was a retired government school teacher. His wife underwent knee replacement surgery at Post Graduate Institute of Medical Education and Research, Chandigarh (‘PGIMER’) on 29-8-2016, of which he submitted a duly verified claim for reimbursement on 22-10-2016 to the Block Elementary Education Officer, District Kangra who in turn sent the medical bills of worth Rs 2,93,295 to Deputy Director, Elementary Education Kangra. The Deputy Director sent them back with certain objections after which the Block Elementary Education Officer restricted the claim to Rs 2,08,495. The bills were again referred back after which the claim was reduced to Rs 1,43,495. But they were again sent back with the objection that the medical claim was time barred. The Block Elementary Education Officer again sent the bills to Deputy Director after completing all the formalities. When nothing was heard about the claim, the petitioner approached the Himachal Pradesh State Administrative Tribunal which was later abolished leading the petition to be transmitted to this Court.
The petitioner stated that against the claim of medical reimbursement of Rs 2,93,295, only Rs 2,08,495 had been disbursed and Rs 84,800 was yet to be paid. He contended that the respondent had no authority or reason to make the deduction. The respondents submitted that the remaining amount was not admissible due to restriction of the claim as per Government approved rates, as contained in the Office Memorandum of 1995.
Analysis and Decision:
The Court pointed out that no policy decision of the State had been placed on record except the Office Memorandum of 1995, which imposed restriction of medical claim with respect to Knee replacement as was done in the present case. The Court opined that once a medical claim was admissible in terms of beneficial policy of the State, the same should not be denied on flimsy grounds or irrelevant factors.
The Court also considered the updated Office Memorandum of 2017, as issued by the Government of India with reference to the ceiling rates for Knees replacement/implant and Hip implant under the Central Government Health Scheme and Central Service (Medical Attendance) Rules, even though they were not referred to by both the parties. The Court observed that nothing was placed on record indicating that the aforesaid Office Memorandums of 1995 or 2017 were ever adopted by the State of Himachal Pradesh.
The Court held that the Office Memorandum of 2017 was not applicable, as the wife had undergone knee replacement on 29-8-2016 and medical bills were also submitted on 22-10-2016 i.e. prior to issuance of office memorandum of 2017. The Court further said that Clause 3 of the Office Memorandum of 1995 provided that it will remain effective from 1-4-1995 till a period of five years, i.e. 30-3-2000. Thus, at the time of treatment of the wife of petitioner for knee replacement and submission of medical reimbursement bills, there was no ceiling in force for reimbursement of knee replacement. Therefore, the petitioner was entitled for the entire amount of medical reimbursement of the cost of knee replacement for his wife.
Consequently, the Court ordered the respondents to reimburse the balance amount of Rs 84,800 to the petitioner on or before 30-7-2025, failing which the petitioner would be entitled to interest thereon at the rate of 6 per cent per annum from the date of submitting the medical bill till the payment is made.
[Ishwar Dass v. State of H.P., CWPOA No. 6723 of 2020, decided on 18-6-2025]
*Judgment authored by: Justice Vivek Singh Thakur
Advocates who appeared in this case:
For the Petitioner: Sangeeta Vasudeva, Advocate.
For the Respondents: Seema Sharma, Deputy Advocate General.
