Genuine emergency medical treatment at non-empanelled hospitals warrants full reimbursement regardless of administrative rate-capping.

The Petitioner, a 90-year-old retired IPS officer and life beneficiary of the Central Government Health Services (CGHS), sought full reimbursement for his late wife’s cancer treatment

His wife suffered from advanced oral cancer that escalated into an emergency involving airway obstruction

On the advice of specialists, she underwent Dendritic Cell Immunotherapy (DCT) at a private clinic and laser surgery at a non-empanelled hospital because these treatments were unavailable at CGHS empanelled facilities

The Petitioner filed two claims: MRC-1 (Rs. 5,27,508/-) and MRC-2 (Rs. 5,04,362/-). The Department partially reimbursed these, leaving a balance of Rs. 3,14,348/-

The High-Powered Committee (HPC) rejected the remainder, classifying DCT as an "unapproved/experimental" therapy despite the Ministry of Defence (ECHS) having sanctioned it for other patients

1. Whether the Respondents are justified in denying full medical reimbursement on the grounds that the treatment was "experimental/unapproved" or obtained at a non-empanelled facility during a medical emergency

2. Whether the technical opinion of a committee can override the clinical judgment of treating physicians in life-threatening situations

The Court primarily relied on the Supreme Court’s decision in Shiva Kant Jha v. Union of India, which established that the right to medical claim cannot be denied on technical grounds or because a hospital is not empanelled, provided the treatment is genuine

It applied the principle that the ultimate decision on treatment vests with the doctor, not administrative committees

The Court also cited the Office Memorandum dated 20.02.2009 (Ministry of Health and Family Welfare), which allows reimbursement in excess of approved rates for emergencies involving advanced malignancy

Further precedents included Basant Dabas v. Govt of India and Jagir Kaur v. Union of India, affirming that genuine emergency treatment at private facilities merits full reimbursement

The Court reasoned that the Petitioner’s wife faced an "imminent risk of asphyxiation," making the treatment choice a specialized medical decision rather than an elective one

It rejected the Respondents' argument that DCT was "experimental," noting that the Government's own circular (OM dated 20.02.2009) specifically provides for reimbursement in cases of advanced malignancy

The Court observed an "institutional tendency" of committees to place procedural barriers before bonafide medical decisions, citing a previous instance where the Petitioner had to seek the Secretary's intervention to override a similar rejection of approved drugs

Crucially, the Court clarified that the restrictive phraseology in Shiva Kant Jha (limiting the decision to the facts of that case) does not efface the legal ratio that health schemes must be responsive and humane under a welfare state

It quashed the decisions of the High-Powered Committee dated 11.01.2019 and 11.02.2019

The Court directed the appropriate Committee to consider the claims in light of this judgment and ensure reimbursement within three months

The petition was disposed of with the finding that technical and administrative objections cannot penalize a beneficiary for seeking life-saving treatment recommended by qualified doctors