The Karnataka High Court ruled that government employees are entitled to reimbursement of medical expenses for treatment at non-empanelled private hospitals, provided they are referred by a recognized government hospital. This decision came after a petition challenging the rejection of a medical claim under the Central Government Health Scheme (CGHS).
Constitutional Petition for Reimbursement
The petitioner filed a writ petition under Articles 226 and 227 of the Constitution, seeking to overturn an order issued by the Suvarna Arogya Suraksha Trust. The Trust had denied the petitioner’s request for reimbursement of medical expenses. Justice Hemant Chandangoudar presided over the case, hearing arguments from both sides.
The court referred to Clause 5 of Paragraph 3 of the Government Order (GO) dated 5th November 2014. This GO allows government employees to seek reimbursement at CGHS rates, even when treatment is provided by a private, non-empanelled hospital, if a recognized government hospital refers the patient to a specialist. The petitioner’s legal claim was based on this provision, which the court upheld in its ruling.
Petitioner’s Medical Treatment and Claim Rejection
The petitioner, who worked as an Assistant Court Officer in the Karnataka High Court, sought medical treatment for CTD with ILD and pulmonary hypertension. Initially treated at Sri. Jayadeva Institute of Cardiovascular Sciences & Research, a recognized government hospital, the petitioner was referred to a specialist at Mazumdar Shaw Medical Centre, a non-empanelled private hospital.
Despite submitting a medical claim application, the Trust rejected it, stating that the claim did not meet the emergency conditions outlined in the GO for treatment at non-empanelled hospitals. The petitioner had explained the emergency circumstances, but the Trust denied reimbursement, citing a lack of coverage under the emergency criteria.
Court’s Interpretation of Reimbursement Criteria
The High Court ruled in favor of the petitioner, stating that the referral from a recognized government hospital to a non-empanelled private hospital met the conditions set out in the Government Order. The court clarified that government employees are entitled to reimbursement not only in emergencies but also in exceptional situations where referral by a recognized hospital occurs.
The court directed the Trust (Respondent No. 3) to reconsider the petitioner’s reimbursement claim at CGHS rates, subject to the submission of all necessary documents. The Trust was ordered to pass an appropriate decision in line with legal requirements. The petition was ultimately allowed.
Case Title: Nagabhushana B v. The Registrar General & Ors.