Emergency medical reimbursement cannot be restricted by hospital empanelment status or technical procedural grounds.

The applicant, a 72-year-old retired Junior Engineer from Northern Railway, sought full reimbursement for medical expenses incurred during the emergency heart treatment of his late wife

His wife was treated at Max Hospital and Delhi Heart Hospital, eventually passing away on December 5, 2018, at Delhi Heart and Lung Institute, following a referral by the Railway Hospital due to an acute emergency

The applicant submitted a claim for ₹1,88,687, supported by emergency certificates and medical records; however, the respondents sanctioned only ₹75,399

The respondents justified the partial payment by citing policy guidelines under Railway Board letter No. 2005/H/6-4/policy-I dated January 31, 2007

After multiple rounds of litigation and contempt petitions (O.A. No. 1199/2023, CP No. 686/2023, and CP No. 366/2024), the applicant filed the present O.A. challenging the order dated October 21, 2024, which refused the balance reimbursement

1. Whether the respondents were legally justified in restricting the medical reimbursement to partial rates based on internal policy guidelines when the treatment was admittedly taken under emergency circumstances

2. Whether the applicant is entitled to the balance reimbursement of ₹1,13,288 in light of the judicial precedents regarding the medical rights of retired government employees

The Tribunal primarily applied the legal principles established by the Hon’ble Supreme Court in Shiva Kant Jha v. Union of India (2018) 16 SCC 187, which held that the right to medical reimbursement of a government employee or pensioner cannot be denied or curtailed on technical grounds, such as treatment in a non-empanelled hospital, provided the treatment was genuine and necessitated by an emergency

The court emphasized that the "real test" for a medical claim is the factum and genuineness of the treatment, and authorities must adopt a "humane and responsive approach" rather than a mechanical adherence to procedural technicalities

The Tribunal observed that the respondents did not dispute the emergent nature of the treatment received by the applicant’s wife

Applying the ratio in Shiva Kant Jha, the Tribunal reasoned that once the genuineness of the treatment and medical records is established, the respondents cannot restrict reimbursement based on internal rate policies or technicalities

The court noted that a patient or their relatives have little choice in the manner of treatment during an emergency, and the survival of the person is the primary consideration, overriding administrative sanctions

Consequently, the Tribunal found that the respondents’ action of curtailing the claim without adequate reasoning was inconsistent with the welfare-state objectives of the Central Government Health Scheme (CGHS) and Railway medical policies

It held that medical reimbursement cannot be denied or curtailed on technical grounds when treatment is taken in a genuine emergency

The respondents were directed to reimburse the balance amount of ₹1,13,288 to the applicant within six weeks from the date of receipt of the order

No order was made as to costs