Medical reimbursement claims cannot be restricted to package rates without High-Powered Committee consideration.

The applicant, a 78-year-old retired Superintendent of the Employees’ State Insurance Corporation and member of the ESIC Pensioners’ Medical Scheme, underwent emergency inpatient treatment for Guillain-Barré Syndrome and related conditions at Amala Institute of Medical Sciences from 21 July 2023 to 29 July 2023, followed by treatment at Aster Medcity, Kochi, from 29 July 2023 to 12 October 2023.

Aster Medcity was an ESIC-empanelled hospital, and cashless treatment was provided until 21 August 2023 at 19:45 hours.

Cashless treatment was thereafter denied when the applicant was shifted within the same hospital to the Department of Physical Medicine and Rehabilitation, although the treatment was claimed to be a continuation of her existing inpatient care.

The applicant incurred expenses of Rs. 12,76,458 after hospital discount and sought full reimbursement under the applicable ESIC guidelines and the special-circumstances procedure.

The claim was eventually processed by the Regional Office, which sanctioned only Rs. 5,08,854 and disallowed Rs. 7,67,604.

The applicant challenged the partial disallowance, contending that her claim ought to have been referred to the High-Powered Committee constituted for considering relaxation of reimbursement rules.

The respondents maintained that the Physical Medicine and Rehabilitation Department was not separately empanelled for cashless treatment and that reimbursement was subject to applicable CGHS/package rates.

Whether the applicant was entitled to consideration of her claim for full reimbursement of the medical expenses incurred during her continued inpatient treatment at Aster Medcity, notwithstanding the denial of cashless treatment after her transfer to the Physical Medicine and Rehabilitation Department?

Whether the Regional Office acted unlawfully by deciding the applicant’s claim directly, without referring it to the High-Powered Committee constituted to consider relaxation of reimbursement rules in special circumstances?

Whether reimbursement could be restricted solely on the basis of package or prescribed rates when the genuineness of the treatment and the actual expenditure were not disputed?

The Tribunal applied the ESIC Pensioners’ Medical Scheme and the revised ESIC guidelines dated 25 May 2021, particularly clause (c)(2)(iii), under which treatment taken in a tie-up or non-tie-up hospital without prior permission or referral may be considered for ex-post facto approval, with reimbursement subject to the applicable rules and rates.

It relied on the Office Memorandum dated 11 October 2018 constituting the High-Powered Committee for considering relaxation of rules in medical reimbursement claims.

The Tribunal further relied on Shiv Kant Jha v. Union of India, AIR 2018 SC 1975, where the Supreme Court held that the right to medical reimbursement cannot be denied on purely technical grounds once the factum of treatment is established through authenticated medical records; the primary test is the actual treatment received.

The Tribunal also considered the principle that genuine medical expenditure incurred by an eligible beneficiary should not be unjustifiably curtailed merely by applying package rates where the claim is otherwise admissible.

The Tribunal found that the applicant had remained continuously admitted in the same empanelled hospital and that her transfer to the Physical Medicine and Rehabilitation Department was made on medical advice, not by voluntary choice or for an unrelated elective treatment.

The treatment and expenditure were supported by discharge summaries, inpatient bills and other medical records, and their genuineness was not disputed.

In these circumstances, the Regional Office could not conclusively dispose of the claim by treating the subsequent treatment as an independent non-cashless episode and limiting reimbursement through package rates.

Since the applicant had specifically invoked the special-circumstances procedure, the claim ought to have been placed before the High-Powered Committee, which was the competent body to consider relaxation and full reimbursement in appropriate cases.

The Tribunal therefore held that the direct rejection or partial disallowance by the Regional Office was procedurally defective and that the restriction based merely on package rates could not be sustained at that stage.

The Tribunal did not itself award the balance amount but directed that, if the Committee found full reimbursement admissible, the amount should be granted within one month from receipt of a copy of the order.

No order as to costs was made.