Genuine emergency treatment at a non-empanelled hospital cannot be restricted to package rates.

The applicant, a retired BSNL Sub-Divisional Engineer, sought reimbursement of ₹11,56,459 for his wife’s treatment for brain haemorrhage/aneurysm at Bhailal Amin General Hospital, Vadodara, from 2 to 20 October 2019.

The hospital was not empanelled under BSNL’s medical scheme, but the applicant relied on hospital records certifying the emergency and on a departmental communication, sent during the hospitalisation, requesting an officer to visit the hospital.

After the claim was submitted, the respondents raised documentary objections and, in March 2024, approved reimbursement of only ₹1,28,772 at CGHS package rates.

The claim remained unresolved despite the applicant’s repeated representations and the matter being placed before a Medical Adalat.

1. Whether the treatment of the applicant’s wife was taken in circumstances constituting a genuine medical emergency.

2. Whether treatment at a non-empanelled hospital justified denying full reimbursement in the circumstances of the case.

3. Whether alleged deficiencies in certificates, the medical-card renewal, and other formalities could be relied on against the applicant.

4. Whether reimbursement could be restricted to ₹1,28,772 under CGHS package rates, and whether the applicant was entitled to the amount claimed with interest.

The application was brought under Section 19 of the Administrative Tribunals Act, 1985.

The Tribunal applied the principle in Shiva Kant Jha v. Union of India, 2018 (3) SLR 328 (SC), that a medical claim should not be denied solely because treatment was taken at a hospital not included in the relevant government order, where the fact of treatment is established by duly certified records.

It also considered the respondents’ 20 December 2012 instruction, which recognised life-saving treatment requiring immediate hospitalisation as a genuine emergency category.

The governing principle was that non-empanelment and procedural requirements should not defeat reimbursement for established emergency treatment on technical grounds.

The hospital records supported the applicant’s account that his wife had a serious neurological condition requiring urgent treatment, and the respondents did not dispute her admission or the treatment period.

The contemporaneous departmental request for a hospital visit showed that the authorities had been notified; any failure to conduct or document that visit could not fairly be attributed to the applicant.

The treatment and expenditure were supported by medical records and payment receipts, and the respondents produced no evidence that the treatment was fictitious, unnecessary, or fabricated.

The Tribunal therefore found no sustainable basis to deny the claim merely because the hospital was non-empanelled or to restrict reimbursement to CGHS package rates.

It also noted the prolonged delay in processing the claim.

The respondents were directed to complete the exercise within 90 days of receiving a certified copy of the order.

No interest was expressly awarded, and there was no order as to costs.