CGHS cover applies even to hospitals not on govt list: SC

NEW DELHI: In a relief to over 44 lakh current and retired government employees and their families covered under the Central Government Health Scheme, the Supreme Court said on Friday that reimbursement cannot be denied to them even if they received treatment in a hospital not empanelled under the plan.

The SC bench said “no fetters” could be placed on the rights of a government employee during his lifetime to get the best medical treatment and it was wrong to reimburse bills on the basis of rates fixed under CGHS in case the employee got treatment from a hospital which is not empanelled.

“The right to medical claim cannot be denied merely because the name of the hospital is not included in the government order,” the bench said.

“The real test must be the factum of treatment. Before any medical claim is honoured, the authorities are bound to ensure as to whether the claimant had actually taken treatment. Once it is established, the claim cannot be denied on technical grounds,” the bench said.

The court passed the order on a PIL filed by former Indian Revenue Service officer and advocate Shiva Kant Jha who was treated for a heart ailment at Fortis Escorts Hospital in Delhi and Jaslok Hospital in Mumbai in 2003. The total expenditure in the treatment was around Rs 13.8 lakh. The government initially refused to reimburse the bill on the ground that the hospitals were not empanelled and there was no need to implant CRT-D device

After repeated representations made to the government, an amount of Rs 5.84 lakh was reimbursed to Jha on the basis of rates fixed under CGHS. He thereafter approached the Supreme Court for reimbursement of the rest of the amount.

Opposing his plea, the Centre said reimbursement must be done on the basis of fixed rates since private hospitals, not empanelled under the scheme, charge high amounts for treatment. The bench slammed the Centre for taking an “inhuman approach” by denying the benefits and directed reimbursement of the rest of the amount within a month.