CGHS Must Fully Reimburse Treatment at Referred Government Hospitals.

The applicant, Ramesh Chandra Verma, sought reimbursement for medical expenses incurred for his wife's surgery at AIIMS, New Delhi, from August 12, 2019, to August 23, 2019.

His wife was referred to AIIMS, New Delhi, by CGHS for further treatment.

The total claim submitted was Rs. 5,24,132/-.

The respondents restricted the reimbursement to Rs. 86,046/-, stating it was as per prescribed CGHS rates and that the implant selected was priced above the CGHS ceiling by the applicant's choice.

The applicant's representation was rejected on August 13, 2024.

The bills amounting to Rs. 5,15,847/- were issued by private agencies (Ahujasons Surgical and Cure Surgical) and countersigned by an AIIMS surgeon.

The respondents relied on CGHS rules, an OM dated September 26, 2017 (Annexure R-1), and guidelines issued vide OM dated June 6, 2018 (Annexure R-2) following the *Shiva Kant Jha* judgment, affirming that reimbursement was as per rules and CGHS rates.

The applicant argued that as treatment was in a government hospital after CGHS referral, full reimbursement was due, citing *Shiva Kant Jha v. UOI & Ors.*

Whether the applicant is entitled to full medical reimbursement for treatment undertaken at AIIMS, New Delhi, a government hospital, despite the amount exceeding CGHS prescribed rates, when the patient was duly referred by CGHS and the bills were countersigned by the hospital?

Whether the restriction of reimbursement to CGHS rates for treatment at a government hospital, after due referral, is illegal, arbitrary, or unjustified?

The court recognized the right of a government employee to medical facilities during and after retirement.

It emphasized that the decision on how a patient is treated vests with the doctor.

The court considered the principle that once treatment is established, a claim should not be denied on technical grounds.

It also acknowledged the judgment in *Shiva Kant Jha v. UOI & Ors.* (Writ Petition (Civil) No. 694/2015), which, though noted by the respondents to be confined to that specific case, generally underscored issues of medical reimbursement.

The respondents referred to CGHS rules, OM dated September 26, 2017, and guidelines vide OM dated June 6, 2018, for settlement of medical claims as per CGHS rates and ceilings.

The court found that the applicant's wife was undeniably referred by CGHS to AIIMS, New Delhi, a government hospital, and received treatment there.

While the respondents argued that reimbursement was restricted to CGHS rates due to the applicant's choice of an implant above the CGHS ceiling and that the *Shiva Kant Jha* judgment was case-specific, the court reasoned that denying full reimbursement on technical grounds, particularly when treatment was taken in a government hospital after prior CGHS permission, was improper.

The court highlighted that responsibility for treatment decisions rests with specialized doctors, and limiting reimbursement solely based on CGHS ceiling rates for referred government hospital treatment, where bills are countersigned by the doctor, is not justified.

The court concluded that authorities must be responsive and cannot mechanically deny legitimate reimbursement.

The respondents were directed to consider the applicant's claim for full reimbursement as per Annexure A-7 of the OA and pay the remaining amount within 45 days from the date of receipt of the certified copy of the order.

No order as to costs was made.