Pensioners residing in non-CGHS areas cannot claim reimbursement under CS (MA) Rules without CGHS coverage.

The applicant, a retired Central Government employee residing in Gwalior, a non-CGHS-covered area, sought reimbursement of ₹6,04,718.23 incurred towards the indoor treatment of his wife at Max Institute, Saket Nagar, New Delhi, from 26 October 2008 to 11 November 2008.

His reimbursement claim was rejected by the respondents by order dated 26 July 2017.

During the pendency of the Original Application, the applicant died and was substituted by his daughter, Ms. Sangeeta Gupta.

The applicant relied upon the Office Memorandum dated 5 June 1998, contending that the Central Services (Medical Attendance) Rules, 1944 (“CS (MA) Rules”) applied to pensioners residing in non-CGHS areas.

The respondents contended that the CS (MA) Rules were not applicable to pensioners and that such pensioners could instead choose between Fixed Medical Allowance (“FMA”), CGHS coverage after registration and payment of subscription, or FMA for OPD treatment with CGHS facilities for IPD treatment.

It was undisputed that the applicant had neither registered under CGHS nor paid the requisite subscription.

1. Whether a Central Government pensioner residing in a non-CGHS area, who had not registered under CGHS or paid the prescribed subscription, could claim reimbursement for indoor medical treatment under the CS (MA) Rules, 1944.

2. Whether the Office Memorandum dated 5 June 1998 conferred an operative entitlement upon such pensioners to reimbursement of indoor treatment expenses.

3. Whether the applicant was entitled to reimbursement or any consequential relief on the basis of the increase in FMA.

The Tribunal applied the CS (MA) Rules, 1944, together with the relevant Ministry of Health and Family Welfare Office Memoranda.

The governing principle, as clarified by the O.M. dated 20 August 2004, is that the CS (MA) Rules are not extended to Central Government pensioners because of the financial implications involved.

The O.M. dated 29 September 2016 reiterates that the CS (MA) Rules do not apply to pensioners and provides three alternatives for pensioners residing in non-CGHS areas: claiming FMA in lieu of OPD facilities; obtaining CGHS OPD and IPD facilities by registering in the nearest CGHS-covered city and paying the prescribed subscription; or claiming FMA for OPD treatment while using CGHS facilities for IPD treatment after registration and payment of subscription.

CGHS beneficiaries residing in non-CGHS areas may obtain treatment in specified Government or approved hospitals and seek reimbursement under applicable CGHS rules, but that facility depends upon subsisting CGHS coverage.

The Tribunal held that the applicant’s residence in a non-CGHS area did not, by itself, make the CS (MA) Rules applicable to him.

The O.M. dated 5 June 1998 could not be treated as an operative statutory extension of those Rules, particularly in view of the subsequent clarification dated 20 August 2004 and the reiteration contained in the O.M. dated 29 September 2016.

Since the applicant had never registered under CGHS or paid the requisite subscription, he was not a CGHS beneficiary when the treatment was undertaken and could not claim reimbursement available to existing CGHS beneficiaries.

The alternative facilities of FMA or CGHS coverage upon registration and payment of subscription did not create a retrospective right to reimbursement under the CS (MA) Rules.

It held that the CS (MA) Rules, 1944, did not apply to the applicant as a pensioner; that the O.M. dated 5 June 1998 did not create an enforceable entitlement to reimbursement; and that the applicant, having neither registered under CGHS nor paid the prescribed subscription, was not entitled to reimbursement of his wife’s indoor treatment expenses.

The Original Application was dismissed as devoid of merit, with no order as to costs.