Optional contributory medical scheme benefits cannot be claimed retrospectively for treatments undertaken prior to enrolment.

The applicant, a 76-year-old retired Head Mistress of the MCD who superannuated in 2007, underwent emergency treatment at Holy Family Hospital from 26.01.2024 to 09.02.2024

Following the treatment, on 18.03.2024, she applied for a medical card under the MCD Medical Scheme for Pensioners and paid the requisite contribution

She subsequently filed a claim for reimbursement of ₹3,35,967

The respondents rejected the claim via an order dated 12.03.2025, stating that the treatment was availed prior to her admission into the scheme

Notably, as part of her application for the medical card, the applicant had submitted an affidavit dated 12.03.2024, specifically undertaking that she would not claim reimbursement for expenses incurred prior to joining the scheme

1. Whether a pensioner is entitled to medical reimbursement for emergency treatment undergone prior to enrolling in a contributory and optional medical scheme

2. Whether an express undertaking by the applicant not to claim pre-enrollment expenses estops them from seeking such reimbursement under Article 21 of the Constitution

The Tribunal considered the "Right to Health" as an integral part of the "Right to Life" under Article 21 of the Constitution of India

It noted the precedent in Narendra Pal Singh v. Union of India, which held that the government must grant ex-post facto sanction for emergency treatment and not deny claims on technical grounds

However, the court primarily applied the principles laid down by the Division Bench of the Hon’ble High Court in Dal Chand Vashisht v. GNCTD and Ors., which established that contributory health schemes are structured like insurance; they are optional, require a positive exercise of choice through subscription, and cannot be applied retrospectively to cover expenses incurred before membership was sought

The Tribunal analyzed the tension between the constitutional right to health and the contractual/procedural requirements of contributory schemes.

While acknowledging the emergency nature of the treatment, the Tribunal found that the applicant was bound by the specific undertaking she provided in her affidavit dated 12.03.2024, wherein she waived claims for pre-enrollment treatment as a condition for joining the scheme

Furthermore, the Tribunal held that the Division Bench decision in Dal Chand Vashisht carries higher precedential value than the Single Bench decision in Narendra Pal Singh

The court reasoned that allowing retrospective claims would undermine the financial structure of contributory schemes, which rely on a common pool of funds created by prior contributions

Thus, because the applicant was not a member at the time of treatment and had explicitly waived her right to such a claim, the respondents' rejection was deemed legal

The court concluded that the balance of convenience favoured the respondents and that no relief could be granted for expenses incurred prior to joining the scheme. All pending MAs were disposed of with no order as to costs