Full medical reimbursement for treatment at AIIMS cannot be denied based on technical CGHS rate restrictions.

The applicant, a 74-year-old retired Secretary of the University Grants Commission (UGC), underwent bilateral cataract surgeries in May and June 2023 at the Dr. Rajendra Prasad Centre for Ophthalmic Science, AIIMS, New Delhi

He submitted a medical reimbursement claim of Rs. 1,51,259/-, but the respondent (UGC) reimbursed only Rs. 40,616/- (later adjusted to a total of Rs. 48,830/-)

The reimbursement for the balance of Rs. 1,10,643/- was denied on the grounds that "Laser Surgery" (LASIK) is not admissible under CGHS rules and that cataract surgery rates at AIIMS are restricted to CGHS approved rates

The applicant challenged the impugned communications dated 31.10.2023 and 15.01.2024, contending that as a senior citizen treated at a premier government institution, he is entitled to full reimbursement

Whether the respondents are justified in denying full medical reimbursement for cataract surgery performed at a premier government hospital (AIIMS) based on restrictive CGHS rate norms and the non-admissibility of LASIK methodology

The court primarily relied on the constitutional principle that the "right to health" is integral to the "right to life" under Article 21, as established in State of Punjab v. Mohinder Singh Chawla

It applied the "factum of treatment" test from Shivakant Jha v. Union of India, which mandates that once treatment in a genuine case is established, claims cannot be denied on technical grounds

Ministry of Health and Family Welfare OM dated 27.04.2015 regarding the extension of CGHS facilities to retired UGC employees

The Tribunal noted that the genuineness of the medical treatment at AIIMS and the resulting bills were undisputed

It rejected the respondents' contention that reimbursement should be capped at CGHS rates or denied for LASIK components, observing that the methodology of treatment is decided by the treating surgeon in the patient's best interest and is not within the patient's control

The Tribunal reasoned that since AIIMS is a premier medical institution fully owned by the Central Government, and the concept of CGHS approved rates was originally based on AIIMS rates, the state has a constitutional obligation to bear the actual expenses incurred by a pensioner

Relying on settled precedents, the Tribunal concluded that technical CGHS norms cannot override the right to reimbursement for actual treatment undergone at a specialized government-approved hospital

It held that the balance of convenience lay with the applicant and directed the respondents to reimburse the remaining amount of Rs. 1,10,643/- to the applicant within eight weeks from the receipt of the order

No interest or litigation costs were awarded