Reimbursement for non-empanelled private hospital treatment requires proof of a genuine medical emergency.

The applicant, a retired Stock Verifier of East Central Railway, claimed reimbursement of medical expenses incurred for the treatment of his wife, Chinta Devi, at Paras HMRI Hospital, Patna.

The claims comprised ₹37,220 for treatment from 06.12.2013 to 09.12.2013, ₹24,220 for subsequent OPD treatment, and ₹25,898 for hospitalisation from 28.04.2014 to 01.05.2014, totalling ₹87,318.

The applicant contended that his wife suffered from Hepatitis C and liver cancer and that he had taken her to Paras Hospital in an emergency when her condition deteriorated while he was travelling to IGIMS, Patna.

The Railway authorities rejected the claims on the grounds that the treatment was not emergent, the OPD treatment was inadmissible under Railway instructions, and the final claim was incomplete and unsupported by requisite documents.

Pursuant to directions in an earlier OA, the applicant’s representation was rejected by order dated 19.04.2017, leading to the present proceedings seeking quashing of that order and reimbursement of ₹87,318.

Whether the treatment obtained by the applicant’s wife at the non-empanelled Paras HMRI Hospital on 06.12.2013 and 28.04.2014 was undertaken in a medical emergency so as to qualify for reimbursement under Para 617 of the Indian Railway Medical Manual (IRMM).

Whether the applicant was entitled to reimbursement of ₹24,220 incurred for OPD treatment at Paras Hospital in the absence of empanelment or prior authorisation.

Whether the claim of ₹25,898 could be allowed when the applicant had not furnished the requisite documents despite being called upon to do so.

The Tribunal applied Para 617 of the Indian Railway Medical Manual, under which treatment at a non-recognised or non-empanelled hospital may be reimbursed only where a genuine medical emergency necessitated immediate treatment, subject to ex-post facto approval by the competent medical authority and production of the prescribed medical certification.

It also relied on Railway Board Circular No. 2005/H/6-4/Policy-II dated 31.01.2007, which defines an emergency as a sudden condition where delay in treatment would be detrimental to the patient’s health or would jeopardise life, and requires examination of admission particulars, clinical findings, and immediate treatment administered.

OPD treatment at a private or non-empanelled hospital is generally not reimbursable absent specific empanelment or prior approval.

A reimbursement claim must also be supported by the documents necessary for verification.

The Tribunal found that the medical records did not establish a genuine emergency.

The referral from the Railway Hospital merely recorded that the patient was HCV-positive and referred her to the Gastroenterology Department at IGIMS; it did not certify an emergent or life-threatening condition.

The discharge summary for the admission beginning 06.12.2013 recorded fever, weakness, poor food intake and incontinence, but did not demonstrate that any delay would have endangered the patient’s life.

Since IGIMS and Paras Hospital were situated within approximately one kilometre of each other, the applicant could have taken his wife to the Government hospital to which she had been referred.

The later admission from 28.04.2014 to 01.05.2014 showed that the patient was conscious, oriented, afebrile and haemodynamically stable, which was inconsistent with an emergency admission.

The ₹24,220 claim related to OPD visits and was inadmissible because Paras Hospital was not shown to be empanelled and no prior referral or approval had been obtained.

The ₹25,898 claim was also not maintainable for adjudication because the applicant failed to submit the documents required for verification despite notice from the authorities.

The treatment on 06.12.2013 and 28.04.2014 was not shown to have been undertaken in a genuine medical emergency; the OPD expenses were inadmissible in the absence of empanelment or prior approval; and the final claim remained incomplete for want of supporting documents.

Accordingly, the Tribunal found no illegality in the rejection order dated 19.04.2017, dismissed OA No. 050/00863/2018, and made no order as to costs.