Absence of hospital-to-authority communication precludes deemed emergency approval for reimbursement under CTSE Policy.

The Appellant, a retired Railway employee and beneficiary of the Cashless Treatment Scheme in Emergency (CTSE), was admitted to Respondent No. 5 (a private empanelled hospital) on 29.01.2020 for severe cough, breathlessness, and fever

Upon discharge, he was billed ₹1,70,267/-, out of which the hospital eventually withheld ₹64,446/- despite the Appellant’s claim that he was entitled to full cashless treatment under the CTSE Policy

The Railway authorities (Respondents 1-4) rejected his reimbursement claims in October 2020 and February 2021, asserting the condition did not qualify as an "emergency" under the policy guidelines

A Single Judge of the Delhi High Court dismissed the subsequent Writ Petition

The legal heirs of the deceased Appellant filed this intra-court appeal challenging that dismissal

1. Whether the Appellant’s medical condition qualified as an "emergency" as defined under the CTSE Policy to entitle him to a full refund/reimbursement

2. Whether the failure of the empanelled hospital to seek authorization from the Railway Medical Authority (RMA) within 24 hours triggered a "deemed approval" of the emergency under the policy

The court applied the Cashless Treatment Scheme in Emergency (CTSE) Policy and the Indian Railway Medical Manual (3rd Edition), 2000

These rules stipulate that cashless treatment in private empanelled hospitals is restricted to specific emergency ailments certified by a designated Railway Medical Authority (RMA)

The "deemed emergency" clause provides that if the RMA fails to respond to a hospital's authorization request within 48 hours, the case is treated as an emergency

The Court observed that while the Appellant was a CTSE cardholder, the discharge certificate from Respondent No. 5 did not reflect any of the specific emergency ailments listed in the CTSE Policy

The Reimbursement Committee and the appellate authority investigated the medical documents and found the treatment for cough and fever did not meet the "emergency" threshold requiring private hospitalization without a prior referral

Regarding the "deemed approval" argument, the Court reasoned that the 48-hour clock for deemed emergency status only begins once the RMA receives a request from the hospital; since no such request was proved to have been sent, the provision could not be invoked to penalize the Railways

The court deferred to the specialized expertise of the Railway Medical Authorities in interpreting policy-defined ailments

The court found no perversity or arbitrariness in the findings of the Railway authorities or the Single Judge. All pending applications were dismissed without costs