Medical reimbursement for urgent cancer treatment cannot be denied solely for want of Standing Medical Board referral.

The petitioner, a Group-C Work Assistant in the PWD(R&B) Department, sought reimbursement of ₹3,85,763 incurred for the treatment of his wife, Bina Rani Sutradhar, who was suffering from cancer.

She was initially treated at hospitals in Agartala, including the Regional Cancer Centre, IGM Hospital and GB Pant Hospital/AGMC, but the proposed surgery was postponed or not undertaken because of medical complications and the absence of high-risk consent.

She was thereafter taken to Apollo Gleneagles Hospital, Kolkata, where she underwent treatment, including an incisional biopsy, without obtaining a prior referral from the Standing Medical Board.

The petitioner submitted the medical reimbursement bill, which was returned and subsequently rejected by communication dated 28.11.2022 solely on the ground that the patient had not been referred outside the State by the Standing Medical Board.

The petitioner challenged that communication and sought a direction for sanction and release of the reimbursement amount.

Whether the petitioner’s medical reimbursement claim could be rejected solely because his wife had received cancer treatment outside Tripura without a prior referral from the Standing Medical Board.

Whether, in the circumstances of an urgent and serious medical condition, the requirement of prior referral was directory rather than an absolute condition precedent to reimbursement.

Whether the respondents were required to sanction and release the claimed medical reimbursement of ₹3,85,763.

The Court applied the Tripura Government’s medical reimbursement framework, particularly the Finance Department Memorandum dated 09.08.2005 concerning reimbursement for cancer treatment outside the State and the Health Department Memorandum dated 22.11.2019 permitting consideration of genuine cancer-treatment claims even where treatment was taken without prior referral, subject to examination and certification by the State Medical Board.

It also considered the Government notification dated 25.10.2013, under which reimbursement may be limited to the admissible rate of the approved/referred institution or the actual expenditure, whichever is lower.

Relying on Shiva Kant Jha v. Union of India, (2018) 16 SCC 187, the Court held that the real test is the factum and genuineness of treatment, and that a genuine claim should not be rejected on technical grounds once supported by medical records.

It further relied on Surjit Singh v. State of Punjab, (1996) 2 SCC 336, and earlier decisions of the High Court, including Uttam Pal v. State of Tripura, WP(C) No. 1479 of 2017, for the principle that the right to preserve life and the urgency of treatment may justify proceeding without first obtaining Medical Board approval.

At the same time, the Court recognised that reimbursement remains subject to the limitations and rates prescribed under the applicable Government scheme.

The Court found that the petitioner’s wife had a serious and undisputed cancer ailment and had already undergone treatment at several Government hospitals in Agartala, where the proposed operation was either postponed because of high blood pressure or not performed because high-risk consent was not furnished.

In those circumstances, shifting her to Kolkata for further and better treatment was not an arbitrary choice but a medically motivated decision taken in the context of a life-threatening disease.

Applying Shiva Kant Jha, Surjit Singh and the coordinate Bench decisions, the Court held that insisting upon prior referral in such circumstances would elevate a procedural requirement above the patient’s right to timely medical treatment.

The respondents did not dispute the cancer diagnosis, the treatment undertaken or the expenditure; their only objection was the absence of a prior referral order.

Accordingly, rejection solely on that technical ground was held unjustified, though reimbursement remained governed by the applicable scheme and admissible limits.

The Court quashed the respondents’ refusal to entertain the claim and directed them to allow and release the medical reimbursement bill for ₹3,85,763 incurred for the treatment of the petitioner’s wife.

The payment was directed to be made within three months from the date of the judgment and order.

No separate direction for interest was issued.

Pending applications, if any, were also disposed of.