Medical Reimbursement Cannot Be Denied on Technical Grounds in Life-Threatening Diseases Despite Lack of Prior Permission

The applicant, a retired Junior Engineer of the North Central Railway, sought reimbursement for medical expenses totaling Rs. 5,22,235 incurred for his wife’s cancer treatment at Dharmshila Hospital, New Delhi, between 2014 and 2016

His wife was initially referred to the said private hospital by Railway medical authorities on June 10, 2014, but continued subsequent treatment there without obtaining fresh prior permission for every instance

The respondents rejected the bulk of the claim via an order dated March 8, 2017, arguing that the treatment was for a chronic illness rather than an emergency, and was undertaken without following the prescribed procedure under the Indian Railway Medical Manual (IRMM)

The respondents had only reimbursed a partial amount of Rs. 24,510 for the initial referral period

1. Whether the denial of full medical reimbursement on the grounds of lack of prior permission and the non-emergency nature of the ailment was legally sustainable

2. Whether continuous treatment for a life-threatening disease like cancer constitutes a "medical emergency" justifying treatment at a private specialty hospital

The Tribunal primarily applied the principles governing medical reimbursement for government employees as established by the Supreme Court in Shiva Kant Jha v. Union of India (2018), which held that the right to health is fundamental and technicalities like a hospital not being empanelled or lack of prior permission cannot override the factum of treatment in life-threatening situations

It further relied on the Indian Railway Establishment Code Vol-1 and the Indian Railway Medical Manual (IRMM), interpreting the provisions regarding emergency care and specialized treatment in a manner consistent with a welfare state's obligations

The Tribunal reasoned that cancer is inherently a serious and life-threatening disease that requires continuous, specialized, and timely intervention; therefore, such a condition itself constitutes a "medical emergency"

The court noted that because the patient was initially referred to Dharmshila Hospital by the Railways, the treatment could not be labeled "unauthorized"

The Tribunal observed that insisting on repeated formal permissions during a continuous course of specialized treatment is impractical and potentially detrimental to the patient's life

By partially reimbursing the initial bills, the respondents had already admitted the genuineness of the illness; thus, denying the remainder of the claim on technical procedural grounds was deemed arbitrary and "inhuman"

The court emphasized that the real test for reimbursement is the factum of treatment supported by records, not the strict adherence to administrative formalities

It held that the applicant is entitled to full medical reimbursement for the actual expenses incurred for his wife's treatment

The respondents were directed to verify the remaining medical bills and reimburse the amount within three months, failing which a simple interest of 6% per annum would apply from the date the amount became due until the date of payment