Medical Reimbursement Claims During COVID-19 Must Be Considered Pragmatically Rather Than Under Rigid Emergency Policies

The original petitioner, a retired Estate Officer of the Ahmedabad Municipal Corporation (AMC), underwent a proximal femoral nailing surgery on December 2, 2020, at a private hospital (K.D. Hospital) during the COVID-19 pandemic

The AMC rejected the claim on February 8, 2021, on the grounds that the surgery was not performed in an "emergent situation" and, per policy, private hospital treatment without emergency is not reimbursable

Following the petitioner's death during the proceedings, her son was substituted as the legal heir

Whether the Corporation's rejection of the medical reimbursement claim on the ground of a lack of an "emergency" was arbitrary given the prevailing COVID-19 pandemic conditions

Whether the petitioner is entitled to reimbursement as per the Corporation’s existing policy and resolutions

The court applied the principles of Article 226 and Article 12 of the Constitution of India, emphasizing that an instrumentality of the State must not take an inhumane or mechanical approach to its policies

The legal framework for reimbursement was governed by the AMC Standing Committee’s decision dated August 6, 2004, Resolution dated June 21, 2004, and Circular dated February 15, 2019, which outline the conditions for medical claims

The Court observed that at the time of surgery, the petitioner was 75 years old and the COVID-19 pandemic was at its peak

It noted that public hospitals were prioritized for COVID-19 patients, and the petitioner’s decision to seek private treatment to avoid infection was a prudent Choice, not a "fanciful" one

The Court reasoned that the Corporation, as a State authority, failed to consider the "unprecedented situation" and interpreted its "emergency" clause in a rigid, mechanical manner. While the petitioner was not entitled to full reimbursement of private hospital rates, the Court found the total rejection arbitrary and held that the COVID-19 period itself constituted an emergency setting for a high-risk elderly patient

The final payment is to be made to the substituted petitioner (the son) by June 30, 2026. The Court clarified that this order is based on peculiar facts and shall not serve as a precedent