CGHS- Central Govt Employees Can Seek Reimbursement Of Medical Expenses At Non-Empanelled Hospital If Patient Is Referred By Recognized Govt Hospital: Karnataka HC
The Karnataka High Court held that a government servant is entitled to reimbursement of medical expenses at the Central Government Health Scheme (CGHS) rate for treatment provided at a non-empanelled private hospital if the patient is referred by a recognised government hospital.
The Court allowed a writ petition filed under Articles 226 and 227 of the Constitution praying to quash the order issued by the executive director of Suvarna Arogya Suraksha Trust (Trust), which dismissed the petitioner’s claim to reimburse the medical claim.
A Single Bench of Justice Hemant Chandangoudar observed, “The petitioner is entitled to reimbursement of medical expenses under Clause 5 of Paragraph 3 of the Government Order dated 05.11.2014, which allows government servants to seek reimbursement of medical expenses at CGHS rates, even if the treatment was provided at a private hospital, provided that a recognized government hospital referred the patient to a specialist.”
Advocate Shridhar Prabhu appeared for the petitioner, while Advocate TP Vivekananda represented the respondents.
The petitioner challenged the decision of the Trust that rejected the petitioner's request to quantify the admissible amount of the medical claim, citing that the claim was not covered under emergency circumstances as defined in a Government Order (GO).
The GO pertained to the reimbursement of medical claims for government servants who had received treatment at recognised hospitals. However, under exceptional circumstances, government servants were entitled to reimbursement of medical expenses incurred at non-empanelled private hospitals, especially when a recognised government hospital referred the patient to a non-empanelled private hospital for any reason.
The petitioner was working as an Assistant Court Officer in the Karnataka High Court and sought treatment for CTD with ILD and pulmonary hypertension. The petitioner submitted a medical claim application for reimbursement. He also submitted a representation explaining the emergency circumstances that necessitated treatment at an unrecognised hospital.
However, the claim was rejected for not being covered under the emergency circumstances as per the aforementioned GO.
The High Court noted, “In this instance, the petitioner initially sought treatment at the Sri. Jayadeva Institute of Cardiovascular Sciences & Research, which is a government hospital, and was subsequently referred to a multispecialty pulmonologist. Thereafter, the petitioner received treatment at Mazumdar Shaw Medical Centre (a unit of Narayana Hrudayalaya), which is a private and non-empanelled hospital according to the Government Order.”
Consequently, the Court directed, “Respondent No. 3 is directed to consider the petitioner's claim for reimbursement of medical expenses at CGHS rates, subject to the petitioner providing a complete set of documents, and to pass an appropriate order in accordance with the law.”
Accordingly, the High Court allowed the petition.
Cause Title: Nagabhushana B v. The Registrar General & Ors. (Neutral Citation: 2024:KHC:39664)
Appearance:
Petitioner: Advocate Shridhar Prabhu
Respondents: Advocates TP Vivekananda and SH Prashanth; AGA Navya Shekhar