Medical reimbursement claims cannot be denied on technical grounds when factum of treatment in emergency is established.

The applicant, a Senior Accountant in the Postal Department, was diagnosed with 3rd-stage kidney cancer in March 2018

Acting on a CGHS doctor's advice for immediate surgery, the applicant underwent a radical nephrectomy at Manipal Hospital, Bangalore, a private facility, in an emergent state on April 4, 2018

He incurred expenses totaling ₹3,04,118

While the respondents granted post-facto permission for the treatment, they categorized the case as "not emergent" via an order dated May 18, 2018, and restricted the reimbursement to CGHS package rates, paying only ₹22,325

The applicant challenged this restricted reimbursement, seeking the balance amount based on the emergency nature of the life-threatening illness

1. Whether the respondents were legally justified in restricting the medical reimbursement to CGHS package rates for a life-threatening 3rd-stage cancer surgery performed in an emergency

2. Whether the "right to health" under Article 21 of the Constitution precludes the denial of full medical claims on technical grounds such as the non-recognition of a hospital or absence of a pre-approved emergency status

The court primarily applied the constitutional "Right to Health" embodied in Article 21 of the Constitution of India

It relied heavily on the precedent set by the Hon’ble Supreme Court in Shiva Kant Jha v. Union of India (2018), which held that medical claims cannot be denied on technical grounds if the factum of treatment is established

It further cited Suman Rakheja v. State of Haryana (2006), supporting the principle that in emergency cases involving private hospitals, the claimant is entitled to 100% of AIIMS rates and a significant portion of the excess expenditure

The Tribunal reasoned that 3rd-stage kidney cancer is inherently serious and that the respondents, being administrative officials and not medical experts, lacked the authority to unilaterally declare the case as "not emergent"

The court observed that the respondents’ decision to restrict the claim to ₹22,325 against an expenditure of over ₹3 Lakh was a "typical bureaucratic and clerical response" that ignored the reality of the treatment

Following the Shiva Kant Jha ruling, the Tribunal emphasized that once the factum of treatment is verified and supported by hospital records, the government is duty-bound to honor the claim regardless of whether the hospital is included in a specific government list or if technical permissions were limited

The Tribunal found that the applicant’s right to health would be violated if he were forced to bear the massive financial burden of life-saving surgery due to rigid adherence to package rates

The court held that the respondents cannot deny genuine medical claims on technicalities or arbitrary assessments of emergency

The respondents were directed to refer the applicant’s claim to a Medical Experts Committee to re-examine the emergency nature and the justification of expenses

Upon such examination, the competent authority is ordered to take necessary action for reimbursement in light of the settled law discussed. No interest or costs were awarded