CGHS Must Fully Reimburse Genuine Emergency Treatment Despite Unlisted Procedures or Lack of Prior Approval.

The petitioner, a retired BSF officer and CGHS beneficiary, was advised to undergo minimally invasive cardiovascular surgery (MICS).

After developing acute chest pain while in Bengaluru, he was admitted to CGHS-empanelled Apollo Hospital and underwent MICS.

He paid ₹7,81,698 and was reimbursed ₹2,00,090 at the CGHS package rate for conventional CABG.

His request for full reimbursement was rejected on the basis of a technical committee’s opinion and the CGHS Office Memorandum (OM) dated 6 June 2018.

After filing the writ petition, a further committee reviewed the case and questioned the justification for MICS and the absence of prior permission.

The petitioner sought reimbursement of the balance amount.

1. Whether the petitioner’s request for full reimbursement was required to be considered under the High Powered Committee (HPC) category for special circumstances under the OM dated 6 June 2018, rather than the Non-HPC categories.

2. Whether reimbursement could be denied because MICS was an unlisted procedure, prior permission had not been obtained, or the petitioner’s emergency admission and period of hospitalisation were disputed.

In Shiva Kant Jha v. Union of India, the Supreme Court held that a medical reimbursement claim cannot be denied on technical grounds once the fact of treatment is established by records certified by the treating doctors or hospital; in an emergency, prior permission cannot be insisted upon where survival is the primary consideration.

The OM dated 6 June 2018 provides for consideration by an HPC of CGHS beneficiaries’ requests for full reimbursement under special circumstances and for relaxation of rules.

Under Mohinder Singh Gill v. Chief Election Commissioner, the validity of an administrative order must be assessed on the reasons stated when it was made; fresh reasons cannot subsequently be added to sustain it.

The Court also relied on Union of India v. Joginder Singh, which emphasised that genuine emergency treatment should not be denied reimbursement on technical grounds and that preservation of human life is paramount.

Apollo Hospital was CGHS-empanelled, and the petitioner had a hospital-issued emergency certificate.

The Court held that the circumstances, including the treating surgeon’s choice of procedure, warranted consideration as a request for full reimbursement under the HPC’s special-circumstances category—not rejection under the Non-HPC criteria concerning treatment at a private unrecognised hospital.

The disputed length of hospitalisation and the petitioner’s stable or conscious condition did not displace the hospital’s emergency certificate; moreover, the OM did not define “prolonged period”.

The Court further observed that the initial rejection relied on the OM’s Non-HPC category, while the objection to MICS was raised after the petition was filed. That subsequent justification could not cure the original decision under Mohinder Singh Gill.

It directed the respondents to pay the balance amount of ₹5,80,361 within four weeks.