UNION OF INDIA vs MRS. IVY MILLER CHAHAL
- Court
- Karnataka High Court
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IN THE HIGH COURT OF KARNATAKA AT BENGALURU
TH
DATED THIS THE 15 DAY OF OCTOBER, 2026
PRESENT
THE HON'BLE MR. VIBHU BAKHRU, CHIEF JUSTICE
AND
THE HON'BLE MRS. JUSTICE K.S. HEMALEKHA
WRIT APPEAL NO.1781 OF 2026 (GM-RES)
BETWEEN:
1. UNION OF INDIA
REP. BY ITS SECRETARY
MINISTRY OF HEALTH AND FAMILY WELFARE,
NIRMAN BHAVAN,
MAULANA AZAD ROAD,
NEW DELHI – 110011.
2. ADDITIONAL SECRETARY
TO THE GOVERNMENT
AND DIRECTOR GENERAL
CENTRAL GOVERNMENT HEALTH SCHEME
NIRMAN BHAVAN,
MAULANA AZAD ROAD
NEW DELHI – 110011.
3. DIRECTOR
CENTRAL GOVERNMENT HEALTH SCHEME
CGHS BHAVAN, SECTOR-13
RK PURAM,
NEW DELHI – 110066.
4. ADDITIONAL DIRECTOR
CENTRAL GOVERNMENT HEALTH SCHEME
RD
3 FLOOR, E-WING, KENDRIYA BHAVAN
NEAR ST. JOHN HOSPITAL
KORMANGALA,
Digitally signed by
MAHALAKSHMI B M
Location: High Court
of Karnataka
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BENGALURU – 560034
REP. BY DR. H.S. PRASANNA. …APPELLANTS
(BY SMT. SADHANA S. DESAI, ADVOCATE)
AND:
MRS. IVY MILLER CHAHAL
W/O LATE GURMAIL SINGH CHAHAL
AGED ABOUT 75 YEARS,
RESIDING AT C-07
THE COUNTY, EAGLETON GOLF VILLAGE
BIDADI INDUSTRIAL AREA
RAMANAGARA DISTRICT – 562 109. …RESPONDENT
THIS WRIT APPEAL IS FILED UNDER SECTION 4 OF THE
KARNATAKA HIGH COURT ACT PRAYING TO ALLOW THE
PRESENT WRIT APPEAL AND SET ASIDE THE ORDER DATED
03.12.2025 PASSED BY THE LEARNED SINGLE JUDGE IN
W.P.NO.27013/2025 AND ETC.
THIS APPEAL, COMING ON FOR PRELIMINARY HEARING,
THIS DAY, JUDGMENT WAS DELIVERED THEREIN AS UNDER:
CORAM: HON'BLE MR. VIBHU BAKHRU, CHIEF JUSTICE
and
HON'BLE MRS. JUSTICE K.S. HEMALEKHA
ORAL JUDGMENT
(PER: HON'BLE MRS. JUSTICE K.S. HEMALEKHA)
1. This intra-court appeal is preferred by the Union of India and
the authorities of the Central Government Health Scheme [ CGHS ],
who were the respondents in W.P. No.27013/2025 (GM-RES)
impugning the order dated 03.12.2025 [ impugned order ] passed
by the learned Single Judge of this Court, whereby the writ petition
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filed by the respondent herein was allowed, the E-mail
communications dated 07.10.2024, 20.11.2024, and 04.03.2025
rejecting the respondent’s claim for full reimbursement of the
medical expenditure incurred towards implantation of a Cardiac
Resynchronization Therapy Defibrillator [CRT-D] undergone by her
late husband were quashed, and the appellants were directed to
reimburse the medical expenditure along with interest at the rate of
12% per annum.
Prefatory facts
2. The respondent herein, who was the petitioner before the
learned Single Judge, is a retired Indian Administrative Service
Officer [ IAS Officer ] of the Madhya Pradesh cadre and a
beneficiary under the CGHS. Her husband, late Sri Gurmail Singh
Chahal, had been suffering from serious cardiac ailments for a
considerable period and had undergone two bypass surgeries. The
respondent and her husband were residing in Bengaluru.
3. In April 2023, the respondent's husband experienced severe
chest discomfort and was admitted to Narayana Institute of Cardiac
Sciences, Bengaluru, where he was treated in the Cardiac Care
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Unit. Upon clinical examination, his left ventricular ejection fraction
was found to be only 20%, and he was placed under Heart Failure
Management Protocol.
4. Subsequently, in October 2023, his cardiac condition
deteriorated, necessitating further treatment at the said hospital.
Upon evaluation, the treating cardiologist advised implantation of a
CRT-D to protect him against the risk of sudden cardiac death.
Accordingly, the CRT-D implantation was undertaken on
31.10.2023.
5. Towards the aforesaid treatment the respondent incurred
medical expenditure amounting to ` 15,30,093/-, including
`
13,17,487.36/- towards the cost of the CRT-D implantation. The
respondent submitted a claim for medical reimbursement to the
CGHS authorities on 26.12.2023. During the pendency of the said
claim, the respondent's husband developed severe breathlessness
and nausea on 18.03.2024. Though he was rushed to Manipal
hospital, Panaji, he could not be revived and passed away on the
same day. Thereafter, the respondent submitted a representation
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dated 28.06.2024 seeking full reimbursement of the expenditure
incurred towards the CRT-D implantation.
6. The CGHS authorities, by communication dated 11.09.2024,
called upon the respondent to furnish her husband’s ECG report,
which was subsequently furnished. However, by communication
dated 07.10.2024, the respondent's claim for reimbursement was
rejected on the basis of the opinion of the concerned Medical
Committee that emergency CRT-D implantation was not justified.
The said decision was reiterated through subsequent
communications dated 20.11.2024 and 04.03.2025.
7. Aggrieved by the aforesaid communications, the respondent
approached this Court by filing the aforesaid writ petition, seeking
to quash the communications rejecting her claim and seeking a
direction to the CGHS authorities to reimburse the entire medical
expenditure incurred towards the CRT-D implantation.
Contention of the Writ Petitioner
8. It was contended on behalf of the respondent in the writ
petition that her husband had been suffering from severe cardiac
ailments for a considerable period and had undergone two bypass
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surgeries. It was further contended that the treatment was
undertaken on the advice of the specialists treating her husband
and the medical necessity of such intervention could not be
disregarded merely because the hospital was not empanelled
under the CGHS. Reliance was placed upon the judgment of the
1
Shiva Kant Jha Vs. Union of India
Supreme Court in , to contend
that the CGHS is a welfare measure intended to provide medical
protection to Government Employees, pensioners and their
beneficiaries, and that the genuine medical reimbursement claims
ought not to have been rejected mechanically on technical
grounds. It was contended that the contemporaneous medical
assessment made by the treating cardiologist was relevant in the
circumstances prevailing at the material time.
Impugned Order
9. The learned Single Judge took note of the serious cardiac
condition of the respondent's husband, his history of bypass
surgeries, the reduction of his left ventricular ejection fraction to
20% and the subsequent deterioration of his condition, which
necessitated CRT-D implantation on the advice of the treating
1
(2018) 16 SCC 187
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cardiologists. Relying on the judgment of the Supreme Court in
Shiva Kant Jha
( supra ), which dealt with the claim of a CGHS
beneficiary who had undergone CRT-D implantation at a non-
empanelled hospital, the learned Single Judge observed that the
medical necessity of the implantation, as assessed by the treating
doctors, could not be disregarded merely on the basis of a
subsequent opinion of the CGHS Authorities. The learned Single
Judge further observed that the CGHS authorities ought to have
considered the claims for medical reimbursement in a humane
manner, having regard to the object of the scheme, instead of
adopting a mechanical or overly technical approach and was of the
view that the circumstances in which the implantation was
undertaken justified reimbursement of the expenditure incurred by
the respondent.
10. By the impugned order, the learned Single Judge quashed
the communications and directed the CGHS authorities to
reimburse the entire medical expenditure incurred towards the
CRT-D implantation within the period stipulated in the order,
together with interest at the rate of 12% per annum calculated from
30.10.2023. The learned Single Judge also directed the authorities
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to examine and consider, at the appropriate administrative level,
the feasibility of implementation of a cashless medical treatment
mechanism under the CGHS, particularly for emergency and
critical care.
Contention of the appellants
11. The learned counsel appearing for the appellants would
contend that the reimbursement of medical expenditure is
governed by the prescribed CGHS rates and applicable guidelines
and a beneficiary cannot claim reimbursement of the entire
expenditure incurred at a non-empanelled hospital as a matter of
right. It is contended that the claim of full reimbursement was
examined by the competent medical authorities, who opined that
emergency CRT-D implantation was not justified. It is the principal
contention made by the learned counsel for the appellants that
permitting full reimbursement in circumstances where a Medical
Committee had not accepted the claim of emergency would create
an undesirable precedent, encourage similar claims, and
undermine the regulatory framework governing reimbursement
under the CGHS.
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12. We have bestowed our anxious consideration upon the
submission made by the learned counsel for the appellants and
perused the material on record, including the impugned order
passed by the learned Single Judge.
Reasons and conclusions
13. The principal contention urged by the learned counsel for the
appellants is that the CRT-D implantation undergone by the
respondent’s husband was not an emergency procedure and,
therefore, the respondent was not entitled to full reimbursement of
the medical expenditure incurred at a hospital that was not
empanelled under the CGHS. It is further contended that permitting
full reimbursement in such circumstances would create undesirable
precedent and encourage similar claims, thereby defeating the
object of the guidelines governing medical reimbursement under
the CGHS.
14. Before considering the aforesaid contention, it is necessary
to advert to the medical condition of the respondent's husband and
the circumstances in which the treatment was undertaken.
Admittedly, the respondent's husband had been suffering from
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serious cardiac ailments for a considerable period and had
undergone two bypass surgeries. In April 2023, he experienced
severe chest discomfort and was admitted to Narayana Institute of
Cardiac Sciences, Bengaluru, where, upon clinical examination, his
ventricular ejection fraction was found to have reduced to 20%. He
was thereafter placed under a Heart Failure Management Protocol.
Subsequently, in October 2023, his cardiac condition deteriorated
further, necessitating treatment once again at the said hospital.
Upon evaluation, the treating cardiologist advised implantation of a
CRT-D to protect him against the risk of sudden cardiac death.
Accordingly, the implantation was undertaken on 31.10.2023.
15. It is also relevant to note that, notwithstanding the treatment
undergone by him, the respondent's husband subsequently
developed severe breathlessness and nausea and on 18.03.2024.
Though he was immediately rushed to the hospital, he could not be
revived and passed away on the same day, while his medical
reimbursement claim submitted on 26.12.2023 was still pending.
Though his subsequent death cannot, by itself, determine whether
the earlier implantation constituted an emergency procedure, it is a
circumstance which cannot be overlooked while appreciating the
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serious nature of cardiac ailments from which he had been
suffering. It is against this factual background that the contention of
the appellants that the CRT-D implantation was not undertaken in
an emergency requires consideration.
16. The seriousness of a medical condition of a patient cannot
be determined merely by reference to whether procedure was
undertaken immediately upon admission. The patient's medical
history, the deterioration of his cardiac condition and the advice of
the treating specialist are relevant considerations. In the present
case, the patient's ventricular ejection fraction had fallen to 20% as
early as April 2023, and his condition subsequently deteriorated in
October 2023. It was upon such deterioration that the treating
cardiologist advised CRT-D implantation to avoid the risk of sudden
cardiac death.
17. The further question that arises is whether, in such
circumstances, the respondent's husband could reasonably have
been expected to approach another hospital empanelled under the
CGHS to undergo the said procedure. The patient had already
been undergoing treatment at Narayana Institute of Cardiac
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Sciences, where his cardiac condition had been assessed and
monitored by the treating specialists. When his condition
deteriorated and CRT-D implantation was advised, the
circumstances prevailing at the relevant point of time assumed
significance. Any such assessment must necessarily take into
consideration the condition of the patient and medical advice
received by him.
18. At this juncture, it is necessary to examine the relevant
provisions of CGHS guidelines. The Office Memorandum dated
06.06.2018, issued by the Ministry of Health and Family Welfare
pursuant to the judgment of the Hon'ble Supreme Court in Shiva
Kant Jha ( supra ), prescribes the procedure for settlement of
medical reimbursement claims of pensioners and other
beneficiaries. Clause 2 thereof contemplates two categories of
claims seeking full reimbursement, namely, full reimbursement-
Non-High Power Committee [ Non-HPC ] cases under clause 2(a)
and full reimbursement- High Power Committee [ HPC ] cases under
clause 2(b).
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19. While clause 2(a) enumerates specific circumstances in
which claims for full reimbursement may be processed without
reference to the HPC, clause 2(b) provides for consideration by the
HPC of representations seeking full reimbursement under special
circumstances, including requests for relaxation of the rules. The
guidelines thus recognize that, apart from the specified categories,
exceptional circumstances may arise warranting consideration of
claims for reimbursement beyond the prescribed CGHS rate.
20. In the present case, the respondent submitted a medical
reimbursement claim on 26.12.2023, subsequent to the
implantation undertaken on 31.10.2023. The claim was thereafter
pursued through a representation seeking full reimbursement. The
authorities subsequently rejected the claim for full reimbursement
on the ground that CRT-D implantation was not justified as an
emergency procedure. However, the question as to whether the
respondent's claim warranted exceptional consideration under
CGHS guidelines required examination with reference to the
serious medical condition of the patient, the contemporaneous
advice of the treating cardiologist and the circumstances in which
the implantation was undertaken.
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21. At this stage, it is apposite to refer to the judgment of the
Supreme Court in Shiva Kant Jha ( supra ). The said case also
concerned a CGHS beneficiary, who had undergone CRT-D
implantation at a non-empanelled hospital and whose claim for full
reimbursement had been declined by the authorities.
22. The Hon'ble Supreme Court, while considering the
circumstances in which treatment was undertaken, emphasized
that CGHS authorities are required to examine genuine medical
reimbursement claims in a reasonable and humane manner and
that legitimate claims ought not to be rejected mechanically on
technical grounds. In paragraph Nos.16 to 19, the Hon'ble
Supreme Court held as under:
“ 16. 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 CGHS rates and, hence, the same are paid as per
the procedure. Though the respondent State has pleaded
that 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 that such private
hospitals raise exorbitant bills subjecting the patient to
various tests, procedures and treatment which may not be
necessary at all times.
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17. It is a settled legal position that the
government employee during his lifetime 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 specialised 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 CGHS have denied the grant of medical
reimbursement in full to the petitioner forcing him to
approach this Court.
18. 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 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 abovesaid hospitals in emergency
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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 CGHS rates and that too after following a proper
procedure given in the circulars issued on time to time by
the Ministry concerned, 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.
19. In the present view of the matter, we are of the
considered opinion that 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 the 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. ”
23. The Supreme Court emphasized the welfare objective
underlying the CGHS, observing that the scheme was introduced to
ensure government employees and pensioners are not deprived of
medical care. The Supreme Court also observed that where a
treatment is undertaken in emergency circumstances and the
survival of the patient assumes paramount importance, the
requirement of obtaining prior permission cannot be insisted upon
without regard to the medical exigency. The Court also took
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note of the fact that the treating doctors had considered CRT-D
implantation essential and timely, notwithstanding the objections of
the authorities regarding the rates charged and the fact that the
treatment had been undertaken at a non-empanelled hospital. The
Supreme Court reiterated the responsibility of the CGHS to
safeguard the healthcare needs and well-being of government
employees and pensioners. Having regard to the circumstances
prevailing in that case, the Supreme Court held that the treatment
obtained at a non-empanelled hospital was genuine, as the patient
had no other option at the relevant point of time. Accordingly, the
balance amount was directed to be reimbursed.
24. The principles emerging from the aforesaid judgment are that
the object of the CGHS is to secure medical protection to its
beneficiaries and that claims arising out of serious medical
circumstances must receive meaningful consideration. The opinion
of the treating specialist, the medical condition of the patient, and
the circumstances in which the treatment was undertaken are
material considerations. Equally, the judgment does not dispense
with the applicable CGHS guidelines or recognize an absolute right
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to full reimbursement in every case involving treatment at a non-
empanelled hospital.
25. Applying the aforesaid principles to the facts of the present
case, it is evident that the respondent's husband was suffering from
serious cardiac ailments, had undergone two bypass surgeries,
had a ventricular ejection fraction of only 20%. His condition
subsequently deteriorated, whereupon the treating cardiologist
advised CRT-D implantation to protect him against the risk of
sudden cardiac death. The medical necessity of the intervention, as
assessed by the treating specialists and circumstances prevailing
at that point of time, could not have been disregarded merely on
the basis of a subsequent conclusion that the procedure was not
an emergency.
26. It is no doubt true that the authorities administering CGHS
are entitled to scrutinize medical reimbursement claims and
determine entitlement in accordance with the prescribed guidelines.
However, such scrutiny must be meaningful and must take into
consideration the contemporaneous medical records and the
circumstances in which the treatment was undertaken.
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27. It is also relevant that the respondent's husband passed
away on 18.03.2024. The respondent having incurred substantial
expenditure towards the treatment of her husband, was thereafter
required to pursue the claim through repeated representations and
correspondence. The circumstances of the case required the
authorities to consider the claim with due sensitivity, particularly
having regard to the welfare objective underlying the CGHS and
the requirement for timely disposal of medical reimbursement
claims.
28. Insofar as the contention that permitting full reimbursement
would create an undesirable precedent is concerned, we are
unable to accept the same as a sufficient ground to interfere with
the impugned order. Every claim for medical reimbursement must
necessarily be examined on its own facts. The conclusion reached
in the present appeal rests upon the peculiar facts and
circumstances of this case. It cannot be construed as laying down
a general proposition that every medical procedure undertaken at a
non-empanelled hospital under the CGHS would entitle a
beneficiary to the reimbursement of the entire expenditure,
irrespective of the conditions prescribed under the scheme.
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29. Having regard to the serious medical condition of the
respondent's husband, the circumstances in which the CRT-D
implantation was advised by the treating cardiologist, the welfare
objective underlying the CGHS, and the principles enunciated in
Shiva Kant Jha
the decision in (supra) , we are of the considered
view that the learned Single Judge was justified in granting the
relief to the respondent.
30. The contentions urged by the appellants do not furnish
sufficient grounds to interfere with the impugned order.
Accordingly, we find no merit in the writ appeal. Accordingly, the
writ appeal is dismissed.
31. The pending interlocutory applications also stand disposed
of.
Sd/-
(VIBHU BAKHRU)
CHIEF JUSTICE
Sd/-
(K.S. HEMALEKHA)
JUDGE
MBM
List No.: 2 Sl No.: 11