Retrospective CGHS coverage is permissible for interim periods of non-coverage upon payment of subscription arrears.

The applicant, a retired Senior Superintendent of Railway Mails (retired 2007), initially opted for Fixed Medical Allowance (FMA) upon retirement.

In 2011, he joined the Central Government Health Scheme (CGHS).

After being diagnosed with cancer requiring treatment at Vellore, he decided to opt out of CGHS to restore his FMA and surrendered his CGHS card on 10.12.2019.

His request to restore FMA was declined by the respondents on the grounds that a pensioner cannot change their option once exercised.

During the pendency of this application, the respondents restored the applicant’s CGHS card effective from 04.09.2024.

Consequently, the dispute narrowed to the "gap period" from 17.04.2019 to 04.09.2024, during which the applicant received neither FMA nor CGHS benefits.

1. Whether the applicant is entitled to the restoration of Fixed Medical Allowance (FMA) or retrospective CGHS coverage for the period between 17.04.2019 and 04.09.2024.

2. Whether the technical requirement of "prior permission" for medical treatment can be waived for reimbursement claims during the gap period.

The Tribunal primarily considered the administrative rules governing medical options for pensioners, noting that once an option for FMA or CGHS is exercised, it is generally considered final, precluding a shift back to FMA.

However, it applied the principle of equitable relief and "natural consequence" following the restoration of a surrendered facility, emphasizing that technical objections (such as lack of prior permission for treatment) should not defeat substantive claims for medical benefits.

The Tribunal declined to grant FMA for the gap period, stating such a relief would not be in accordance with the established rules.

However, it observed that since the respondents had already restored the applicant’s CGHS card, the logical and "natural consequence" was to treat the applicant as being covered under the CGHS scheme retrospectively from the date his previous coverage effectively ceased (17.04.2019).

To bridge this gap, the Tribunal reasoned that the applicant must remit the requisite annual or monthly subscriptions for the intervening period.

By regularizing the membership through back-payment, the applicant becomes eligible to submit medical bills for treatment undergone during that period.

The Tribunal specifically directed the respondents to waive technical objections regarding "prior permission" for treatments during this gap, ensuring the focus remains on the admissibility of rates and the authenticity of treatment records.

The 4th Respondent was directed to quantify the subscription arrears due from the applicant within one month, and the applicant was directed to remit the same within one month thereafter.

Upon such payment, the authorities must process the applicant’s medical claims for the period of 17.04.2019 to 04.09.2024 at admissible rates, without rejecting them on the technical ground of lack of prior permission.

No costs were awarded.