The Delhi High Court has directed the Central Government Health Scheme (CGHS) to reimburse the balance amount of ₹5.80 lakh to a retired Border Security Force (BSF) officer for cardiac surgery performed using a procedure not listed under CGHS rates. The Court held that the claim qualified for full reimbursement under the special-circumstances category and could not be rejected merely because the procedure was unlisted or prior permission had not been obtained.
A Division Bench of Acting Chief Justice and Justice Amit Sharma allowed the petition filed by the retired officer, who had undergone minimally invasive coronary artery bypass surgery (MICS CABG) at Apollo Hospital, Bengaluru, in July 2019. The officer had incurred medical expenses of ₹7.81 lakh, of which CGHS had reimbursed ₹2 lakh at the prescribed rates for conventional coronary artery bypass grafting (CABG).
The CGHS authorities had denied further reimbursement on the ground that MICS was an unlisted procedure and the technical committee had found no justification for choosing it over conventional surgery. The officer, however, contended that he had been admitted in an emergency after developing acute chest pain and that the treatment was undertaken on specialist medical advice.
The Court observed that the hospital had issued an emergency certificate and that the procedure’s justification was questioned by the authorities only after the writ petition was filed. It held that the case fell within the provisions for full reimbursement under the Ministry of Health and Family Welfare’s Office Memorandum dated June 6, 2018, which permits consideration of claims under special circumstances by a High-Powered Committee.
Relying on the Supreme Court’s decision in Shiva Kant Jha v. Union of India, (2018) 16 SCC 187, the Court reiterated that once the treatment is established through certified medical records, a claim cannot be denied on technical grounds. It also noted that subsequent reasons cannot be used to supplement an administrative order whose validity must be judged by the grounds originally stated.
Accordingly, the Court directed the respondents to pay the balance amount of ₹5,80,361 to the petitioner within four weeks.
The Court also acknowledged the assistance rendered by Advocate Aakanksha Kaul, who had been appointed as amicus curiae in the matter.
