Sh Rajinder Mani Dig Retd vs Union Of India & Ors.

Court
Delhi High Court

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* IN THE HIGH COURT OF DELHI AT NEW DELHI

st
% Reserved on: 31 August, 2026
th
Pronounced on: 15 October, 2026


# CNR No. DLHC010273642020
+ W.P.(C) 7596/2020
SH RAJINDER MANI DIG (RETD.)
FLAT NO. 905, TOWER-8
VALLEY VIEW ESTATE, GWAL PAHARI
GURUGRAM, HARYANA . ....PETITIONER

Through: Dr. S.S. Hooda, Mr. Aayushman
Aeron, Advs.
Ms. Aakanksha Kaul, Amicus
Curiae
Versus


1. UNION OF INDIA

THROUGH ITS SECRETARY
MINISTRY OF HEALTH & MEDICAL EDUCATION,
ROOM NO. 348 A-WING, NIRMAN BHAWAN, NEW DELHI-11

2. DIRECTOR, CGHS,
NIRMAN BHAVAN, NEW DELHI-11

3. ADDG (HQ), CGHS,
NIRMAN BHAVAN, NEW DELHI-11
.....RESPONDENTS

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Through: Ms. Amirta Prakash, CGSC with
Mr. Siddharth Srivastava, Adv. for
UOI.

CORAM:
HON’BLE THE ACTING CHIEF JUSTICE
HON’BLE MR. JUSTICE AMIT SHARMA

JUDGMENT

AMIT SHARMA, J.
1. The present writ petition filed under Article 226 of the Constitution
of India, 1950 seeks the following prayers: -
“1. Issue a Writ, order or direction in the nature of
Certiorari and quash the impugned opinion of the technical
standing committee dated 18.12.2019 on the basis of which
order dated 29.1.2019 has been issued by CMO (
R&H),CGHS (SZ) denying the full reimbursement to the
petitioner. And
2. Issue a Writ, order or direction in the nature of
Mandamus directing the respondents to reimburse the
balance of Rs. 5,80,361+ 1247 totaling to Rs. 5,81,608/- of
the medical expenses incurred by the petitioner on his
medical treatment with interest. And
3. Award the costs of filing of this writ petition to the
petitioner. And
4. Pass any other writ or order(S) as this Hon’ble court
may deem fit and proper to meet the ends of justice.”
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2. Relevant facts for adjudication of the present writ petition are as
follows:-
a) The petitioner is a retired DIG from Border Security Force
(hereinafter referred to as “ BSF ”) and a Central Government Health
Scheme (hereinafter referred to as “ CGHS ”) beneficiary.

b) The petitioner was suffering from heart ailment, thus, he was
undergoing treatment from Paras Hospital, Gurgaon. On 03.06.2019,
Senior Consultant of the said hospital opined that the petitioner should
undergo a Minimal Invasive Cardio-vascular Surgery (hereinafter referred
to as “ MICS ”). Subsequently on 27.06.2019, the petitioner approached
CGHS Dispensary, Sector 55, Gurgaon, where his case was referred to
cardiologist, Cardiothoracic and Vascular Surgery (hereinafter referred to
as “ CTVS ”) Surgeon at any CGHS approved Centre.

c) Allegedly, the best MICS was available in Apollo Hospital,
Bangalore. Thus, the petitioner went to the said Hospital to take opinion,
whether to go for open heart surgery or for MICS. Doctors at the said
Hospital opined that the petitioner should go for MICS. Accordingly, the
petitioner contacted CGHS authorities for obtaining prior permission.
However, the authorities informed that they have to approach CGHS
authorities in Delhi for the permission.

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d) On 06.07.2019, before the petitioner could obtain permission from
CGHS authorities at Delhi, he developed acute chest pain and on the
advice of the Doctors at the said Hospital, the petitioner got admitted in
the Apollo Hospital, Bangalore on ‘emergency basis’.

e) On 10.07.2019, the petitioner was operated for MICS after paying
in full for the said surgery and he was discharged on 16.07.2019. A total
of Rs. 7,81,698/- was spent on the petitioner’s treatment on account of not
submitting prior permission from the respondents/CGHS.

f) On 04.09.2019, petitioner submitted his Medical bills along with the
requisite documents to CMO, CGHS Dispensary, Sector-55, Gurgaon,
under CGHS, for reimbursement on account of his treatment done in the
Apollo Hospital, Bangalore of Rs. 7,81,698/-. On 21.10.2019, he was
reimbursed with Rs. 2,00,090/- being CGHS approved rates for Coronary
Artery Bypass Grafting (hereinafter referred to as “ CABG ”).
Subsequently, on 14.11.2019, petitioner preferred a representation for full
reimbursement of his medical claim to the Director General CGHS,
Director CGHS, Additional Director (South Zone) CGHS, CMO CGHS
Dispensary, Sector 56, Gurgaon.

g) On 29.01.2020, petitioner received a reply from the respondents
stating that a technical committee meeting convened on 18.12.2019 and
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the same opined that full reimbursement is not justified under any of the
clauses of OM dated 06.06.2018. Hence, the present petition.

3. Learned Counsel for the petitioner, in support of the present petition
made the following submissions:-
i) The factum of petitioner’s treatment is undisputed and the re-
imbursement of the medical bills has been denied on technical grounds
which is against the law laid down by the Hon’ble Supreme Court on
13.04.2018 in W.P.(C) 694/2015 titled as “ Shiva Kant Jha v. UOI ”.

ii) The treatment availed by the petitioner from Apollo Hospital,
Bangalore is a duly empaneled hospital with CGHS and the petitioner has
got himself treated from it as per the advice of the specialist doctors.

iii) The Petitioner was in Bengaluru while he was admitted on
‘emergency basis’ for MICS and the required permission was to be
obtained from Delhi. Further, the Petitioner being aged about 70 years and
of ill health, prevented him from obtaining such permissions. Even
otherwise, the policy allows the CGHS holder to get treatment/ surgery in
cases of emergency without completing prior documentary requisitions, as
in the cases of cardiac ailment the patient must rush for immediate
treatment.

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iv) In response to the petitioner’s letter seeking reimbursement of his
medical claims, the respondents did not assign a single reason for not
reimbursing the said claims.

v) The guidelines laid down in OM dated 06.06.2018 are merely
indicative and not exhaustive in nature. Further, doctors have given
emergency certificate which presupposes that the petitioner was severely
incapacitated and he was hospitalized for a prolonged period. Under such
conditions the case of the petitioner shall be covered for full
reimbursement as in terms of para 2(a)(i) of the OM dated 06.06.2018, as
even a treatment from a non-empanelled hospital under emergency is
covered.

4. Refuting the submissions made on behalf of the petitioner, learned
counsel for the respondents made the following submissions: -

i) Petitioner’s treatment was going on in the CGHS empanelled- Paras
Hospital. In the said Hospital, he was advised for CABG, a CGHS listed
procedure, however subsequently, he was suggested MICS as it was a
better option, though it was not a CGHS listed procedure. Permission in
such unlisted cases is considered by CGHS in Technical consultation with
expert Committee for justification of the use of said treatment. Petitioner,
without following the due process for such permission, voluntarily decided
to undergo MICS in the Apollo Hospital, Bangalore.
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ii) MICS being a novel technique and an unlisted procedure in CGHS,
petitioner’s case was sent to the technical committee and the said
committee opined that " Mr. Rajinder Mani 68/M, s/p PTCA + S (2019) to
RCA underwent MICS CABG on 10.7.2019. After going through records,
we do not find any justification favouring the MICS approach over median
sternotomy. And hence patient may be reimbursed in line of existing CGHS
codes of open/conventional CABG ". Hence, the Medical Reimbursement
Claim (hereinafter referred to as “ MRC ”) was calculated at CGHS
package rate for coronary artery bypass grafting as per rate for a NABH
accredited centre with 15% added as per the patient's entitlement for
private ward.

iii) After petitioner’s representation dated 14.11.2019, the matter was
put before the technical committee on 18.12.2019 for examination and the
said committee consisting of experienced doctors opined that the
petitioner's case does not fall under any of the clauses for full
reimbursement in terms of OM dated 06.06.2018 and vide letter dated
29.01.2020, same was communicated to the petitioner. As per the said OM,
for a case to be considered for full reimbursement, it must fall under any
of the following category:-
“i) Treatment was obtained in a private unrecognized hospital
under emergency and the patient was admitted by others when the
beneficiary was unconscious or severely incapacitated and was
hospitalized for a prolonged period.
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ii) Treatment was obtained 1n a private unrecognized hospital
under emergency arid. was admitted for prolonged period for
treatment of Head Injury, Coma, Septicemia, Multi-organ failure,
etc.
iii) Treatment was obtained in a private unrecognized hospital
under emergency for treatment of advanced malignancy.
iv) Treatment was taken under emergency in higher type of
accommodation. as. rooms as per his/her entitlement are not
available during that period.
v) Treatment was taken in higher type of accommodation under
specific conditions for isolation of patients to avoid contacting
infections.
vi) Treatment was obtained in a private unrecognized hospital
under emergency when there is a strike in Govt. hospitals.
vii) Treatment was obtained in a private unrecognized hospital
under emergency while on official tour to non-CGHS covered
area” .

iv) After filing of the present petition, Technical Committee again met
on 15.12.2020 to reconsider the petitioner’s case and the said committee
concluded that MICS was a procedure, which is not listed with CGHS and
there was neither any justification provided for not choosing the
conventional mode i.e. CABG nor did the Petitioner took any prior
permission for undergoing MICS and therefore, he was reimbursed with
the amount which is admissible for CABG, as per the guidelines of CGHS.
Further, petitioner’s discharge summary clearly states that he was admitted
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in a stable condition and not in emergency for MICS. Moreover, as per
records, petitioner was admitted on 08.07.2019, operated on 10.07.2019
and discharged on 16.07.2019, thus, an admission for 9 days cannot be
termed as “prolonged period”, in terms of para 2(a)(i) of the OM dated
06.06.2018.

v) Shiva Kant Jha (Supra) case cannot be equated with the present
case, as Hon’ble Supreme Court in said Judgment confined the order for
payment of balance amount only in that particular case.

5. Refuting the stand taken by the respondents, learned counsel for the
petitioner submitted that:-
i) Respondents, as a result of an afterthought, cannot justify their acts
by subsequently obtaining a desired opinion dated 15.12.2020 from the
body of experts as the same has been obtained after filing of the instant
Writ petition and Notice being issued. Further, respondent’s Justification
vide additional affidavit dated 16.12.2022 that a sum of Rs. 2,00,090 was
reimbursed at the rate of conventional CABG package rates since that was
the only approved procedure, has also come after filing of the instant writ
1
petition. In Mohinder Singh Gill v. Chief Election Commr. , Hon’ble
Supreme Court held that the respondents therein cannot justify any action
by way of an Counter Affidavit which is not borne out from the records as
existed on the date of filing of the petition.

1
(1978) 1 SCC 405
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ii) As far as the respondent’s contention of not taking prior approval
and being admitted in stable condition is concerned, it is a matter of record
that the procedure undergone was in emergency circumstances. The same
is also attested by the Apollo Hospital, Bangalore vide its emergency
certificate dated 16.07.2019. Thus, once the petitioner was admitted on
emergency basis, there cannot be any question of prior approval.

iii) Further, the argument that there is no justification for not choosing
CABG is concerned, it needs to be kept in mind that any patient has a little
scope to decide the nature of treatment to be undergone. This Court on
10.05.2023 in Union of India v. Joginder Singh , WP(C) No. 10684 of
2022, held that:

“13. It needs to be kept in perspective that patient has a little
scope to decide the nature of treatment and merely looks
forward to an expert guidance/treatment for relieving him
from immense pain and suffering. The patient in distress is not
in a position to go against the specialist medical advice for
surgery in emergency.”

iv) In the aforesaid case, this Court reiterated that the test remains
whether the claimant had actually undertaken the treatment in emergent
condition as advised and if the same is supported by records, as
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preservation of human life is of paramount importance. In the said case,
Union of India had contended that the claimant therein underwent
procedure at a non-empanelled hospital and therefore not entitled for full
reimbursement. However, applying the aforesaid test, this Court upheld
the decision of the Central Administrative Tribunal in allowing full
reimbursement to the claimant therein. Instant case of the petitioner is even
better as he underwent treatment at an empanelled hospital.

6. Keeping in view the nature of dispute, this Court vide order dated
26.07.2023 appointed Ms. Aakanksha Kaul, Advocate as an Amicus
Curiae in the present case . She submits that:-
i) Rates specified under CGHS are on the basis of the cost for a
conventional CABG. However, the petitioner on medical advice
underwent MICS at an empanelled hospital, which is substantially more
expensive than a conventional CABG. The Respondents do not dispute the
fact that the petitioner was required to undergo treatment. In these
circumstances, an expert committee could have considered the issue of
whether the approved rates for CABG ought to be revised in view of
medical advancement as Para 3 of the OM dated 06.06.2018 itself refers
to existence of several expert committees.

ii) The two categories referred in OM dated 06.06.2018 i.e. High
Powered Committee (hereinafter referred to as “ HPC ”) and Non-HPC
apply only where a relaxation in the rules is required. Assuming that the
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case of the petitioner required a relaxation of the rules, then his case would
fall in the HPC category. Admittedly, the Apollo Hospital, Bangalore is an
empanelled hospital. Thus, the questions of whether the petitioner was
admitted into the hospital under emergency and for a prolonged period are
not relevant. Such a question would have arisen only if the hospital in
question was not empanelled and thus, the case of the petitioner may have
fallen within Para 2 (a)(ii) of the said OM, being a Non-HPC case.

iii) The respondents while submitting that the OM dated 06.06.2018
does not apply to the petitioner have referred to Non-HPC cases only and
not HPC cases. An HPC in terms of Para 2(b) of the said OM could have
considered whether the petitioner is entitled for relaxation of rules or
whether the present circumstances amount to special circumstances
entitling the petitioner to full reimbursement. However, despite the
respondents having found that the case of the petitioner does not fall within
the category of non-HPC cases, the case of the petitioner appears to have
been considered by two Technical Committees which cannot be described
as ‘HPC’ in terms of the said OM.

iv) Pertinently, as per OM dated 28.06.2024, 27.12.2023 and
05.10.2016, the CGHS has provisions to grant ex-post facto approval and
reimbursement related to unlisted treatment procedures/ investigations/
implants.
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v) Further, with respect to question of whether the petitioner was
admitted under emergency, this Court in Joginder Singh ( Supra) and
2
Basant Dabas v. Govt. Of India & Ors. , has deemed an emergency
certificate issued by the relevant hospital to be enough evidence to show
that the claimant was admitted in emergency. Further, this Court in
Joginder Singh ( Supra) has stated that merely because the patient was
conscious, awake, and oriented at time of admission, it cannot lead to an
inference that his claim of being admitted in emergency is false.

vi) Moreover, with respect to respondent’s submission that the
petitioner was not admitted for ‘prolonged period’, it relevant to note that
what amounts to a ‘prolonged period’ has not been explained in the OM
dated 06.06.2018. However, from the records, it appears that the petitioner
was admitted for 11-12 days.

7. Heard respective counsels for the parties and perused the records.

8. Before proceeding further, reference should be made to the
judgment of the Hon’ble Supreme Court in Shiva Kant Jha ( supra ) . In
the said case, the petitioner therein was a CGHS beneficiary (retired
pensioner) having a valid CGHS card. He had submitted his medical bills
under CGHS for reimbursement on account of his treatment done in Fortis
Escorts Hospital for a sum of Rs. 9,86,343/- for his cardiac ailment

2
2019 SCC OnLine Del 9545
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involving implant of CRT-D device and another bill amounting to Rs.
3,98,097/- for his treatment at Jaslok Hospital, Mumbai for cerebral stroke
and paralytic attack. The petitioner’s first bill with regard to Fortis Escorts
Hospital was considered by the Technical Standing Committee and the
same was rejected without assigning him any reason. The case was again
considered by the Standing Committee and the same was again rejected on
the ground that CRT-D implant was not required. Aggrieved with the
same, the said petitioner filed a representation before the Secretary,
Ministry of Health & Family Welfare and the same was again considered
by the Standing Committee only to be rejected for the reason that “Prior
approval for such device implant was not sought” . Finally, in his fourth
attempt, the said petitioner approached the Director General, CGHS and
subsequently, the Government credited an amount of Rs. 4,90,000/- out of
Rs. 9,86,343/- in the petitioner’s bank account. With respect to second set
of bill of the Jaslok Hospital, the amount was curtailed to Rs. 94,885/- for
his claim of Rs. 3,98,097/-. The Hon’ble Supreme Court after analysing
the reciprocal arguments of the parties, observed and held as under:
“9) Further, the writ petitioner was admitted in emergency
condition with complaint of breathlessness on 11.11.2013 in
Fortis Escorts Health Institute, which was a non-empanelled
hospital at the relevant time. He underwent angiography on
12.11.2013 which revealed diffused disease in left anterior
descending coronary artery 50-60%. He had been implanted the
CRT-D device (Combo) as part of cardiac resynchronization
therapy (CRT) on 12.11.2013. The hospital charged an amount
of Rs. 11,56,293/- for the said treatment, out of which, an
amount of Rs. 10,70,000/- was for the cost of the unlisted
cardiac implant (CRT-D) and an amount of Rs. 3,19,950/- was
paid by the Insurance company directly to the hospital.
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10) A Special Technical Committee meeting was held on
29.04.2014 to consider the case of the petitioner. However, on
examining the same, the Committee did not find any
justification for the implant of CRT-D device of the petitioner.
On a further request by the petitioner, the Special Technical
Committee again did not find any justification for the implant
of CRT-D device on 10.07.2014. On a request for
reconsideration by the petitioner, on 15.01.2015, the case of the
petitioner was again reconsidered by the Special Technical
Committee which denied the claim of CRT-D.

11) The total expenditure incurred by the petitioner towards
his medical treatment at Fortis Escorts Heart Hospital, Delhi
was Rs. 9,86,343/- and at Jaslok Hospital, Mumbai was Rs.
3,98,097/-, hence, the total amount claimed by the petitioner
was Rs. 13,84,440/-. Though the Special Technical Committee
did not find the implant justified, the competent authority,
keeping in view the emergency nature of the case of the
petitioner, approved the reimbursement of implant as per AIIMs
rate. Therefore, out of the total amount i.e., Rs. 13,84,440/-, an
amount of Rs. 4,90,000/- was paid to the petitioner on the
direction of the authority and Rs. 94,885/- for the treatment at
Jaslok Hospital. As per this Court’s direction dated 01.02.2016,
a sum of Rs. 3,00,000/- has also been paid by the respondent.
Hence, a sum of Rs. 4,99,555/- is the claim of the petitioner in
the present writ petition.

12) With a view to provide the medical facility to the
retired/serving CGHS beneficiaries, the government has
empanelled a large number of hospitals on CGHS panel,
however, the rates charged for such facility shall be only at the
CGHS rates and, hence, the same are paid as per the procedure.
Though the respondent-State has pleaded that the CGHS has to
deal with large number of such retired beneficiaries and if the
petitioner is compensated beyond the policy, it would have
large scale ramification as none would follow the procedure to
approach the empanelled hospitals and would rather choose
private hospital as per their own free will. It cannot be ignored
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that such private hospitals raise exorbitant bills subjecting the
patient to various tests, procedures and treatment which may
not be necessary at all times.

13) It is a settled legal position that the Government
employee during his life time or after his retirement is entitled
to get the benefit of the medical facilities and no fetters can be
placed on his rights. It is acceptable to common sense, that
ultimate decision as to how a patient should be treated vests
only with the Doctor, who is well versed and expert both on
academic qualification and experience gained. Very little
scope is left to the patient or his relative to decide as to the
manner in which the ailment should be treated. Speciality
Hospitals are established for treatment of specified ailments
and services of Doctors specialized in a discipline are availed
by patients only to ensure proper, required and safe treatment.
Can it be said that taking treatment in Speciality Hospital by
itself would deprive a person to claim reimbursement solely
on the ground that the said Hospital is not included in the
Government Order. 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. Clearly, in the present case, by taking a
very inhuman approach, the officials of the CGHS have
denied the grant of medical reimbursement in full to the
petitioner forcing him to approach this Court.

14) This is hardly a satisfactory state of affairs. The relevant
authorities are required to be more responsive and cannot in
a mechanical manner deprive an employee of his legitimate
reimbursement. The Central Government Health Scheme
(CGHS) was propounded with a purpose of providing health
facility scheme to the central government employees so that
they are not left without medical care after retirement. It was
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in furtherance of the object of a welfare State, which must
provide for such medical care that the scheme was brought in
force. In the facts of the present case, it cannot be denied that
the writ petitioner was admitted in the above said hospitals in
emergency conditions. Moreover, the law does not require
that prior permission has to be taken in such situation where
the survival of the person is the prime consideration. The
doctors did his operation and had implanted CRT-D device
and have done so as one essential and timely. Though it is the
claim of the respondent-State that the rates were exorbitant
whereas the rates charged for such facility shall be only at the
CGHS rates and that too after following a proper procedure
given in the Circulars issued on time to time by the concerned
Ministry, it also cannot be denied that the petitioner was taken
to hospital under emergency conditions for survival of his life
which requirement was above the sanctions and treatment in
empanelled hospitals.

15) In the present view of the matter, we are of the considered
opinion that the CGHS is responsible for taking care of
healthcare needs and well being of the central government
employees and pensioners. In the facts and circumstances of the
case, we are of opinion that the treatment of the petitioner in
non-empanelled hospital was genuine because there was no
option left with him at the relevant time. We, therefore, direct
the respondent-State to pay the balance amount of Rs.
4,99,555/- to the writ petitioner. We also make it clear that the
said decision is confined to this case only.

16) Further, with regard to the slow and tardy pace of disposal
of MRC by the CGHS in case of pensioner beneficiaries and the
unnecessary harassment meted out to pensioners who are senior
citizens, affecting them mentally, physically and financially, we
are of the opinion that all such claims shall be attended by a
Secretary level High Powered Committee in the concerned
Ministry which shall meet every month for quick disposal of
such cases. We, hereby, direct the concerned Ministry to device
a Committee for grievance redressal of the retired pensioners
consisting of Special Directorate General, Directorate General,
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2 (two) Additional Directors and 1 (one) Specialist in the field
which shall ensure timely and hassle free disposal of the claims
within a period of 7 (seven) days. We further direct the
concerned Ministry to take steps to form the Committee as
expeditiously as possible. Further, the above exercise would be
futile if the delay occasioned at the very initial stage, i.e., after
submitting the relevant claim papers to the CMO-I/C, therefore,
we are of the opinion that there shall be a timeframe for
finalization and disbursement of the claim amounts of
pensioners. In this view, we are of the opinion that after
submitting the relevant papers for claim by a pensioner, the
same shall be reimbursed within a period of 1 (one) month.”
(emphasis supplied)

9. Following the aforesaid ratio , learned Co-ordinate Division Bench
3
of this Court in Union of India v. Shri. Joginder Singh , observed and
held as under:-

“12. The medical claim for treatment undertaken in emergency
should not be denied for reimbursement merely because the
hospital is not empanelled. The test remains whether the
claimant had actually undertaken the treatment in emergent
condition as advised and if the same is supported by record.
Preservation of human life is of paramount importance. The
State is under an obligation to ensure timely medical treatment
to a person in need of such treatment and a negation of the same
would be a violation of Article 21 of the Constitution of India.
Administrative action should be just on test of fair play and
reasonableness. Accordingly, keeping into consideration the
constitutional values, the executive instructions need to be
applied than rejecting the claim on technical ground of
undertaking treatment in a nonempanelled hospital, since the
CGHS/State is responsible to ensure proper medical treatment
in an emergent condition and further cannot escape the liability,

3
2023:DHC:3138-DB
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if the treatment undertaken is genuine. Any denial of claim by
the authorities in such cases only adds to the misery of the
Government servant by further forcing him to resort to Court of
law.”


10. It is further pertinent to note that in pursuance to the judgment
rendered by the Hon’ble Supreme Court in Shiva Kant Jha ( supra ) ,
Government of India, Ministry of Health and Welfare came out with an
th
OM dated 6 June, 2018. The said O.M. has been relied upon by the
respondents in the present case to submit that the case for consideration of
full reimbursement should fall in the categories mentioned therein.
However, it is the contention of learned Amicus Curiae that the categories
which have been relied upon by the respondents would fall with respect to
the cases mentioned in para-2(a) of the said OM i.e. titled as “ Full
reimbursement-Non-HPC ” cases. A closer look at para-2(b) of the said
OM would reflect that the case of the petitioner would fall in the said
category, relevant portion of the same reads as under:

“2. Full reimbursement case /Cases for relaxation of Rules
As per the new guidelines they fall into two categories
(a) Full reimbursement - Non-HPC (Non- High Power
Committee) cases
(b) Full reimbursement - HPC (High Power Committee) cases

a) Full reimbursement - Non-HPC cases
The following cases fall under this category;
i) Treatment was obtained in a private unrecognized hospital
under emergency and the patient was admitted by others when
the beneficiary was unconscious or severely incapacitated and
was hospitalized for a prolonged period.
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ii) Treatment was obtained 1n a private unrecognized hospital
under emergency arid. was admitted for prolonged period for
treatment of Head Injury, Coma, Septicemia, Multi-organ
failure, etc.
iii) Treatment was obtained in a private unrecognized hospital
under emergency for treatment of advanced malignancy.
iv) Treatment was taken under emergency in higher type of
accommodation. as. rooms as per his/her entitlement are not
available during that period.
v) Treatment was taken in higher type of accommodation under
specific conditions for isolation of patients to avoid contacting
infections.
vi) Treatment was obtained in a private unrecognized hospital
under emergency when there is a strike in Govt. hospitals.
vii) Treatment was obtained in a private unrecognized hospital
under emergency while on official tour to non-CGHS covered
area.
Although the new OM has not mentioned about STC
recommendation, it is advisable to have expert Committee
meetings under the Chairperson of Addl. DGHS (as in the case'
of. earlier STC meetings) in respect of item Nos. i), ii),ii) and
v) before arriving at a decision. The conditions mentioned at
Nos. iv),vi) and vii) are administrative in nature and do not
required meeting of expert committees and may be
recommended by Addl. Director, if conditions are satisfied.

In Delhi the expert committee meetings shall be organized by
respective CMO(R&H) and by AD(R&H) in case of claims of
serving employees of Delhi. Such meetings in respect of other
cities shall be organized by Sr. CMO in the office of Addl.
DDG(HQ).

The requests for full reimbursement as examined by Additional
Director (HQ)/ Addl. DDG(HQ), in consultation with· expert
committee meetings, wherever deemed necessary and
recommended for full reimbursement shall be submitted to
Director, CGHS and concurrence of IFD may be obtained after
approval of AS&DG, CGHS before the seeking the approval of
Secretary for reimbursement in excess of CGHS rates.
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If the above criteria are not satisfied (including the regrets by
expert committees) the requests may be regretted by Addl.
Director of concerned City, with a covering letter explaining the
reasons and referring to the concerned OM.

In case there is a representation to consider as a special case
then only it may be placed before the High Power Committee.

Addl. Directors shall prepare a self-contained note giving
details of case and submit the files with relevant documents to
Director, CGHS though AD(HQ) /Addl. DDG(HQ)

If the proposal is approved by AS & DG, CGHS, concurrence
of IFD and approval· of Secretary, Health &: Family Welfare
are solicited for reimbursement in excess of approved rates.

Full reimbursement- HPC cases
The Composition of High Power Committee, shall be as under:
1. Special Director General .... Chairperson
2. Directorate General, CGHS or his Nominee... . ..... Member
3. Additional Director, CGHS(HQ) I Addl. DDG(HO} CGHS
…Member
4. Addl. Director, CGHS(R&H) ...Member Secretary
5. One Government Specialist (of concerned Specialty)
…Member

The High Powered Committee shall consider the
representations of only those CGHS beneficiaries having a
valid CGHS Card.

The High Powered Committee shall consider representations
received from CGHS beneficiaries holding valid CGHS cards
only at the time treatment, in respect of the following
conditions.
1. Approval for air-fare with or without attendant on the advice
of treating doctor for treatment in another city even though he
is not eligible for air travel / treatment facilities are available in
city of residence.
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2. Representations from CGHS beneficiaries seeking full
reimbursements under special Circumstances.
3. Relaxation of Rules

High Powered Committee shall meet once in a month and
action on the decisions taken shall be completed within seven
days of meeting, with the concurrence of the IFD, wherever, it
is deemed necessary.

Addl. Directors shall submit the files with relevant documents
to the AD(HQ) / Addl. DDG(HQ) for placing the
representations before High Power Committee.

AD(R&H) shall be Member Secretary, who shall with the help
of Sr. CMO of the Office of Addl. DDG(HQ) shall issue
meeting notices including notices to concerned Govt.
Specialists and organize meting for the Meetings of High Power
Committee.

The requests received upto the 15 of the month shall be placed
before the Committee. If the High Power Committee does not
recommend the regret letters shall be issued explaining the
reasons.

If the high Power Committee recommends full
reimbursement/relaxation of rules, Concurrence of IFD and
approval of Secretary (H&FW) shall be obtained with 7 days.

3. In Addition there are expert committees to consider several
cases.

Expert Committee meetings for Consideration of Liver
Transplant cases, Bariatric Surgery,

Bone-marrow / Stem Cell Transplant, Justification of treatment
/Implants in selected cases shall continue as before.

Standing Committee meetings for Cochlear Implant shall
continue as before.
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Expert Committee meeting for approval of Drugs, etc., shall
continue.”

11. In the present case, admittedly the Apollo Hospital, Bangalore, is an
empanelled hospital. The only ground taken for non-full reimbursement of
the expenses incurred by the petitioner is that the procedure which was
followed was not listed with the CGHS and there was no justification for
not choosing the conventional mode, i.e. , CABG. It is also contended that
the petitioner did not take any prior permission for undergoing MICS. The
respondents are relying on the opinion of the Technical Committee which
opined that there was no justification to favour the MICS approach over
Median Sternotomy.

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12. The representation of the petitioner dated 14 November, 2019 was
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rejected by communication dated 29 January, 2020 by the Office of the
Additional Director, CGHS, South Zone, Sector-8, R.K. Puram, New
Delhi-110022, which reads as under:
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13. The minutes of meeting dated 18 December, 2019 referred above
further reads as under:
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14. The respondents have also placed on record another set of minutes
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of meetings dated 15 December, 2020, which is reproduced as under:

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15. It is pertinent to note that the aforesaid meeting was held post filing
of the present petition on 06.10.2020.

16. The perusal of the aforesaid minutes of meetings would reflect that
initially the only reason for denial of the claim of reimbursement was on
the ground that the petitioner is not covered by the aforesaid O.M. dated
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6 June, 2018 and it was observed that the Apollo hospital is a non-
empanelled hospital. The ground that treatment through MICS was not
justified was only given post filing of the present petition.

17. Be that as it may, in the considered opinion of this Court, the case
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of the petitioner is fully covered by O.M. dated 6 June, 2018 particularly
under para-2(b) as reproduced hereinabove. The said OM which was
formulated in pursuance of Judgment of the Hon’ble Supreme Court in
Shiva Kant Jha ( supra ) , clearly contemplates the representation from
CGHS Beneficiaries seeking full reimbursement under special
circumstances. The petitioner has already placed on record an emergency
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certificate issued by the Apollo Hospital dated 16 July, 2019, which is
reproduced as under:
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18. The objection of the respondents that the petitioner was not admitted
in an emergency and was not there for ‘prolonged period’ is misplaced.
The respondents further relied upon the discharge summary and
information records to submit that the petitioner was in a stable condition
and that he was conscious and oriented at that time. It is submitted that as
per the Judgment of Hon’ble Supreme Court in Shiva Kant Jha ( supra ) ,
it is for the hospital to certify whether the patient was admitted in an
emergency condition or not and the respondents will not be in a position
to deny the same once a certificate from the said hospital is on record.
Even as to what would be “ prolonged period ” is not clearly defined in any
of the OMs. As per records, the petitioner was admitted in the hospital for
11-12 days. The line of treatment was decided by the Surgeon, who was
treating the petitioner at the relevant point of time, these circumstances
would definitely come under the category of “ Special circumstances ” and
thus, he would be entitled for full reimbursement.

19. Despite following the mandate of the Hon’ble Supreme Court in
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Shiva Kant Jha ( supra ) and formulating the O.M. dated 6 June, 2018,
the respondents did not follow the same and chose to categorise the
petitioner in non-HPC cases, while, as per records, he was to be considered
for full reimbursement in HPC cases.

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20. It is also a matter of record that the petitioner was referred by CGHS
to a specialist, i.e. , Cardiologist, CTVS Surgeon at any other CGHS
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approved Centre on 27 June, 2019, by way of following referral:

21. In Shiva Kant Jha ( supra ) , the Hon’ble Supreme Court has held
that the real test would be factum of treatment and that before any medical
claim is honoured, the authorities are to ensure as to whether the claimant
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had actually taken the treatment and the said treatment is supported by the
records certified by Doctors/Hospital concerned and once the same is
established the claim cannot be denied on technical grounds. In the present
case, the only reason for disallowing the reimbursement is that the
procedure adopted was unlisted in CGHS and thus, the same cannot be
recognised. In Shiva Kant Jha ( supra ) , it was the case of the respondents
therein that implant of CRT-D device was not required and no prior
approval for such implant was taken and the same was done from a non-
empanelled hospital. The case of the present petitioner is on a better
footing inasmuch as the Apollo hospital, Bangalore was CGHS
empanelled hospital and reading of the aforesaid O.M. in pursuance of the
Shiva Kant Jha ( supra ) judgment makes it clear that now there is a
provision for full re-imbursement under special circumstances. Moreover,
as noted above, this aspect that the present procedure was not justified is
an after thought inasmuch as the same opinion has been given by the
Doctors post filing of the present petition. The initial rejection of the
petitioner’s representation was only on the basis of para-2(a) covering non-
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HPC cases under O.M. dated 6 June, 2018, which was not applicable to
the petitioner. Further, any other subsequent justification given by way of
an affidavit in the present case would not be valid, in view of Mohinder
Singh Gill ( supra ) judgment wherein, it is held as under:
“ 8. The second equally relevant matter is that when a statutory
functionary makes an order based on certain grounds, its
validity must be judged by the reasons so mentioned and cannot
be supplemented by fresh reasons in the shape of affidavit or
otherwise. Otherwise, an order bad in the beginning may, by the
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time it comes to court on account of a challenge, get validated
by additional grounds later brought out. We may here draw
attention to the observations of Bose, J. in Gordhandas Bhanji
[ Commr. of Police, Bombay v. Gordhandas Bhanji , 1951 SCC
1088 : AIR 1952 SC 16]”

22. In view of the above, present petition stands allowed and disposed
of. Respondents are directed to pay the balance amount of Rs. 5,80,361/-
to the petitioner, within a period of 4 weeks.

23. We place on record our appreciation for the assistance rendered by
Ms. Aakanksha Kaul, learned amicus curiae .

24. Pending applications, if any, stands disposed of.

25. Order be uploaded on the website of this Court, forthwith.



NITIN WASUDEO SAMBRE
(ACTING CHIEF JUSTICE)



AMIT SHARMA
(JUDGE)


OCTOBER 15, 2026 /bsr/sg
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