Karnataka HC Upholds ₹15.3 Lakh CGHS Reimbursement With 12% Interest To Widow For Husband’s CRT-D Implant At Non-Panel Hospital After His Heart Condition Worsened

The respondent, a retired IAS officer and CGHS beneficiary, sought reimbursement for the CRT-D implantation performed on her late husband at Narayana Institute of Cardiac Sciences, a non-empanelled hospital.

His ejection fraction was 20%, and his treating cardiologist advised the procedure after his cardiac condition deteriorated; implantation took place on 31 October 2023.

The respondent claimed ₹15,30,093 in medical expenses. CGHS rejected full reimbursement, relying on a Medical Committee’s view that emergency implantation was not justified.

The respondent’s writ petition was allowed: the rejection communications were quashed, full reimbursement with 12% annual interest was ordered, and CGHS was directed to consider the feasibility of a cashless treatment mechanism. The Union of India and CGHS authorities appealed.

The Court considered the Ministry of Health and Family Welfare Office Memorandum dated 6 June 2018, particularly clause 2, which provides for full-reimbursement claims through non-HPC and HPC processes, including consideration of exceptional circumstances and requests for relaxation of rules.

Applying Shiva Kant Jha v. Union of India, (2018) 16 SCC 187, the Court held that CGHS authorities must assess genuine claims reasonably and humanely, considering the fact of treatment, medical records, the treating doctor’s opinion, and the circumstances in which treatment was obtained; claims should not be rejected mechanically on technical grounds.

The judgment does not, however, establish an automatic right to full reimbursement for every procedure undertaken at a non-empanelled hospital; claims remain subject to the applicable guidelines and their individual facts.

The patient’s history of serious cardiac disease and bypass surgeries, his ejection fraction of 20%, and the subsequent deterioration that led his cardiologist to recommend CRT-D implantation were material to assessing the claim.

The Court held that the medical necessity of the procedure, as assessed by the treating specialists at the relevant time, could not be disregarded merely because a later review concluded that it was not an emergency.

The claim therefore required meaningful consideration under the CGHS guidelines, having regard to the contemporaneous medical records and circumstances of treatment.

The appellants’ concern about creating a precedent did not justify interference, since the decision rested on the particular facts and did not confer a general entitlement to full reimbursement in all such cases.

The directions for full reimbursement of the medical expenditure with interest at 12% per annum, and for administrative consideration of the feasibility of a cashless CGHS treatment mechanism, accordingly remained in force.