REIMBURSEMENT OF MEDICAL CLAIMS UNDER THE CENTRAL GOVERNMENT HEALTH SCHEME (CGHS) : SUPREME COURT JUDGEMENT.

Central Govt Employees





REPORTABLE
IN THE SUPREME COURT OF INDIA
CIVIL ORIGINAL JURISDICTION
WRIT PETITION (CIVIL) NO. 694 OF 2015
Shiva Kant Jha …. Petitioner(s)
Versus
Union of India …. Respondent(s)
J U D G M E N T
R.K. Agrawal, J.
1) The jurisdiction of this Court has been invoked by the
petitioner herein by filing this writ petition against the alleged
unfair treatment meted out to several retired government
servants in their old age and their state of affairs pertaining to
reimbursement of medical claims under the Central
Government Health Scheme (CGHS).
2) Brief facts:
(a) The petitioner herein is a CGHS beneficiary (retired
pensioner) having a CGHS Card valid for whole life for medical

treatment in Private Ward. The petitioner herein submitted
two sets of his Medical bills under the Central Government
Health Scheme (CGHS) for reimbursement on account of his
treatment done in November, 2013 in the Fortis Escorts
Hospital, New Delhi for Rs. 9,86,343/- for his cardiac ailments
involving the implant of CRT-D device and two sets of bill
amounting to Rs. 3,98,097/- for his treatment at Jaslok
Hospital, Mumbai for cerebral stroke and paralytic attack.
(b) The petitioner herein submitted the first Bill on
02.01.2014 and the second Bill (two) on 19.07.2014 to the
authority concerned. The first Bill was considered by the
Technical Standing Committee in May 2014 and the claim was
rejected without informing him of the reasons for rejection.
The case was again considered by the Standing Committee on
10.07.2014 and was rejected on the ground that CRT-D
implant was not required. Aggrieved of the above, the
petitioner herein filed a representation before the Secretary,
Ministry of Health & Family Welfare. The said representation
was again considered by the Standing Committee on
15.01.2015 and was rejected for the reason that “Prior



approval for such device implant was not sought”. Again, in
fourth attempt, the petitioner herein approached the Director
General of the CGHS. After presenting the memorial to the
Director General of the CGHS, the government credited an
amount of Rs. 4,90,000/- in the petitioner’s Bank Account,
however, he was never heard on any point nor any speaking
order was ever communicated to him.
(c) In the second set of Bills of the Jaslok Hospital, the
petitioner’s claim was curtailed to the tune of Rs. 94,885/-,
being just one-fourth of the claim and no opportunity of being
heard was granted to the petitioner. Thus, the petitioner
herein was denied an amount of Rs. 4,96,343/- from the first
claim and Rs. 3,03,212/- from the second set of claim. In
other way, out of the total bills amounting to Rs. 13,84,440/-,
the petitioner herein was paid Rs. 5,84,885/-, meaning
thereby, the petitioner herein was denied Rs. 7,99,555/-. To
both the hospitals, the petitioner had to pay out of his
personal resources. However, this Court, vide order dated
01.02.2016, directed the respondent-State to pay a sum of Rs.
3,00,000/- to the petitioner as an interim relief.

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