CGHS Reimbursement Allowed for Non-Empanelled Hospitals if Referred by Govt: Karnataka HC

 CGHS Reimbursement Allowed for Non-Empanelled Hospitals if Referred by Govt: Karnataka HC

In a significant ruling, the Karnataka High Court has directed the Suvarna Arogya Suraksha Trust to reconsider a medical reimbursement claim filed by a government employee. The order was passed by Hon’ble Mr. Justice Hemant Chandangoudar on September 24, 2024, allowing the petitioner, Sri Nagabhushana B, to receive reimbursement of his medical expenses incurred at a non-empanelled hospital, provided the conditions of the applicable Government Order are met.

Background

Sri Nagabhushana B, an Assistant Court Officer at the Karnataka High Court, had sought reimbursement for his treatment expenses after suffering from CTD with ILD and pulmonary hypertension. Initially admitted to Sri Jayadeva Institute of Cardiovascular Sciences & Research, a recognized government hospital, he was subsequently referred to Mazumdar Shaw Medical Centre, a unit of Narayana Hrudayalaya, for specialized care. The petitioner incurred medical expenses amounting to Rs. 2,63,764, which he sought to get reimbursed.

However, the Executive Director of the Suvarna Arogya Suraksha Trust rejected the claim on the grounds that the treatment was not under emergency circumstances as defined in a Government Order dated November 5, 2014. The petitioner then filed a writ petition seeking relief from this decision.

Court’s Decision

The Hon’ble High Court, after considering arguments from both sides, found that the petitioner’s situation fell within the exceptional circumstances as stipulated by the Government Order. Justice Chandangoudar emphasized that the Government Order allows for reimbursement even when treatment is provided at a private hospital, given that a recognized government hospital refers the patient to a non-empanelled private hospital.

The court noted that Respondent No. 1, the Registrar General of the Karnataka High Court, had initially communicated to the Suvarna Arogya Suraksha Trust that the petitioner’s case met all necessary conditions, including those mentioned in the Government Order. Despite this, the Trust did not approve the reimbursement, which prompted the petitioner to seek judicial intervention.

Order Summary

Justice Chandangoudar issued the following directives:

• The writ petition is allowed: The earlier order issued by the Executive Director of Suvarna Arogya Suraksha Trust on January 23, 2023, has been quashed.
• Reimbursement at CGHS rates: Respondent No. 3, the Executive Director of Suvarna Arogya Suraksha Trust, has been directed to reconsider the medical claim at CGHS rates, subject to submission of complete documentation by the petitioner.
• Timeline: The Trust has been instructed to conclude the reimbursement process within two months from the date of submission of documents.

Key Insights

The court’s ruling underscores the importance of providing fair and timely reimbursement to government employees who have received necessary medical treatment at non-empanelled private hospitals due to a recognized referral. The decision reiterates that government authorities must exercise compassion and flexibility in dealing with healthcare-related claims, particularly in exceptional medical cases.