Absence of Medical Emergency Prevails Over Cashless Treatment Scheme Policy for Reimbursement Entitlement.

The Petitioner, a retired Railway employee, was admitted to Moolchand Kharaiti Ram Hospital (Respondent No. 5), an empanelled hospital, from January 29, 2020, to February 11, 2020, presenting with cough, expectoration, and fever.

Upon discharge, the Petitioner was initially charged Rs. 1,70,267/-, which was later revised to Rs. 64,446/- as per CGHS cash rates after the hospital refunded a portion of the deposit.

The Petitioner sought full reimbursement under the Cashless Treatment Scheme in Emergency (CTSE) Policy.

The Railway authorities rejected the claim on October 13, 2020, and subsequently rejected the appeal on February 12, 2021, on the grounds that the medical condition did not constitute an "emergency" as defined by the policy.

Whether the Petitioner’s medical condition qualified as an "emergency" under the Cashless Treatment Scheme in Emergency (CTSE) Policy dated July 14, 2016.

Whether the Petitioner was entitled to a refund/reimbursement of the balance treatment cost from the Respondents.

The Court primarily applied the Railways' Policy on Cashless Treatment Scheme in Emergency (CTSE) dated July 14, 2016, and January 24, 2017.

Under this policy, empanelled hospitals are required to inform the Railways of an admission, following which the Railways must determine if the case qualifies as a clinical emergency.

The policy specifies a restricted category of ailments that qualify for cashless treatment without prior referral from an Authorized Medical Officer.

The Court examined the discharge certificate issued by Respondent No. 5, which noted symptoms of "cough with expectoration and fever" and a history of fever with chills.

The Court observed that the Petitioner’s clinical findings—absence of shortness of breath, stable history regarding diabetes and hypertension, and the specific nature of medications administered (antibiotics and supportive measures)—did not align with the list of emergency ailments defined in the CTSE Policy.

Furthermore, the Court noted that the Railway Authorities had re-examined the claim via a Reimbursement Committee and concluded that the treatment was not justified in a non-railway hospital without a referral, as the condition was not an acute emergency.

Since the Petitioner failed to demonstrate that the ailment fell within the protected scope of the CTSE scheme, the hospital’s application of CGHS cash rates (as opposed to full cashless coverage) was deemed appropriate.

Consequently, the Petitioner was not entitled to the reimbursement of the sum of Rs. 64,446/-.

The writ petition was dismissed.