Established emergency treatment at a non-empanelled hospital warrants full medical reimbursement without prior approval.

The applicant, a retired Railway employee, sought reimbursement of ₹11,62,430 for treatment at the Indian Spinal Injuries Centre, a non-empanelled hospital.

He had first been treated at Railway Hospital, Agra, and referred to Medanta and then Pushpanjali Hospital, both empanelled hospitals.

Pushpanjali referred him to a higher medical institute; the applicant’s family arranged treatment at the Indian Spinal Injuries Centre as his condition deteriorated.

The respondents rejected the claim, citing the absence of prior permission and treatment at a non-empanelled hospital.

The applicant challenged that decision before the Tribunal.

The Tribunal also noted an emergency certificate issued by the treating hospital and that the applicant remained bedridden after discharge.

1. Whether reimbursement could be denied because treatment was taken at a non-empanelled hospital without prior permission, where the circumstances indicated a medical emergency.

2. Whether the rejection order was sustainable despite being brief and not identifying the specific conditions the applicant had failed to meet.

The Tribunal applied paragraph 648(2) of the Indian Railway Medical Manual, Vol. I, as invoked by the applicant, concerning reimbursement where an emergency is established.

It relied principally on Shiva Kant Jha v. Union of India, W.P. (C) No. 694 of 2015, decided 13 April 2018, for the principles that a genuine medical claim should not be denied solely on technical grounds such as the hospital’s non-empanelled status, that the fact of treatment should be verified through medical records, and that prior permission is not required where survival is the immediate concern.

The Tribunal also noted the applicant’s reliance on State of Punjab v. Mohinder Singh Chawla, Pt. Parmanand Katara v. Union of India and Surjit Singh v. State of Punjab concerning the importance of health and preservation of human life.

The respondents relied on the Railway Board’s policy letter dated 31 January 2007, governing referrals to empanelled hospitals and post-facto permission in exceptional, life-threatening cases.

The Tribunal found that the applicant had followed referrals through Railway Hospital, Medanta and Pushpanjali, and that Pushpanjali had referred him to a higher medical institute without naming a particular facility.

Given the deterioration in his condition, the emergency certificate and the circumstances surrounding his treatment, the Tribunal considered it unreasonable to expect him to return to the Railway authorities for further directions before obtaining care.

It also accepted that his post-treatment condition impeded communication with the respondents.

Applying Shiva Kant Jha, the Tribunal held that the emergency and actual treatment supported reimbursement and that the absence of prior permission or treatment at a non-empanelled hospital did not justify rejecting the claim on technical grounds.

It further found the rejection order cryptic because it did not specify which conditions had not been met.

It directed the competent authority to reimburse the full claimed medical amount within three months of receiving a certified copy of the order.

If payment was not made within that period, interest at the GPF rate would be payable.

The Tribunal made no order as to costs.