Sh. Balram Sharma v. Union of India

After suffering from a heart attack, the petitioner had sought treatment at a government hospital. Taking into consideration his critical condition and the length of time that it was expected it would take for him to receive treatment at that hospital, the doctors recommended that the petitioner seek treatment at a private hospital immediately. Thereafter, the petitioner, a government employee, approached the respondent state under the ‘Central Government Health Services’ (CGHS) scheme. Under this scheme, government employees were entitled to reimbursement of all medical expenses incurred by them. The petitioner thus communicated with his employers seeking approval to obtain treatment at the private hospital. He stated that he would only claim expenses based on the rates charged at the government hospital and would pay the balance out of his pocket. After his treatment, the petitioner was reimbursed a part of his medical expenses based on the rates charged at government hospitals.

The petitioner subsequently approached the Central Administrative Tribunal (CAT) seeking full reimbursement of the expenses incurred by him. However, the CAT dismissed his claim, stating that the government hospital had all the necessary facilities and the petitioner did not necessarily have to get treated at a private hospital. After the petitioner’s claim was denied, he filed the current appeal before the High Court seeking an order for the reimbursement of the balance that he claimed was due to him. The petitioner argued that the nature of his illness necessitated treatment on an urgent basis and he was thus justified in approaching the private hospital. Further, the assurance to only seek reimbursement at government rates was obtained from him under duress as the respondent state would have rejected his claim for reimbursement in its entirety otherwise.

On the other hand, counsel for the respondent state argued that the petitioner was entitled to reimbursement under the CGHS Rules only at the rates approved by the government and not on the basis of actual expenses incurred. The petitioner could not be allowed to rescind from his undertaking to pay the balance out of his own pocket.

The Court held that the respondent state must reimburse the full medical expenses based on the actual medical expenses incurred by the petitioner. Since it was not possible for the state to ensure a rational relationship between rates at public and private facilities, employees were not entitled to claim full reimbursement in all instances of treatment at private hospitals. However, in this case, the private hospital where the petitioner was treated was empanelled by the CGHS and was a ‘recognised’ private hospital. Additionally, the petitioner had initially sought treatment at a government hospital and had to approach the private hospital only out of necessity.

The Court determined that the petitioner’s undertaking to claim reimbursement at the rates charged in government hospitals and to pay the balance amount out of his pocket could not be enforced against the petitioner. Since the petitioner was faced with dire circumstances, his consent was found to have been obtained involuntarily and under compulsion.

The Court held that the state had the duty to reimburse medical expenses incurred by a government employee suffering from an ailment that required treatment at a specialized approved hospital. This is in light of the right to health that is concomitant to the right to life under article 21 of the Indian Constitution.

Thus, the Court held that a government employee could claim reimbursement if the following conditions were met: “a) The private hospital where the treatment is taken by a Government employee is on the approved list of the Government. b) The illness for which the treatment is required is an emergency which needs immediate attention and either the Government hospitals have no facilities for such treatment or it is not possible to get treatment at Government hospital or it may take unduly long for the patient to get treatment at Government hospital. c) The concerned employee/patient takes permission to get treatment at a Government hospital, which is granted and/or referred by the Government hospital to such a private hospital for treatment.”

The petitioner satisfied these criteria, and was thus entitled to full reimbursement of medical expenses.

"9. Now we come to the plea, which has been taken by the respondent in the counter affidavit. It has been contended in para 11 of the counter affidavit that it is the duty of the citizens to see and ensure that such recognized hospital do not charge excess of the package rates. How a citizen can ensure that a hospital does not charge over and above the package rate? (sic) The power to law down guidelines is with the respondent. A citizen is a mere spectator to what State authority do (sic) and decide. If the hospital has charged over and above the package rate, the respondent is under an obligation to pay such charge as the petitioner has incurred over package rates at the first instance and if in law State can recover from the hospital concerned, they may do so but they cannot deny their liability to pay to the Government employee who is entitled for medical reimbursement.”

"8.The Supreme Court had duly noted in State of Punjab and Ors. v. Mohinder Singh Chawla etc. (supra) that "the right to health is an integral to right to life. Government has constitutional obligation to provide the health facilities. If the Government servant has suffered an ailment which requires treatment at a specialized approved hospital and on reference whereat the Government servant had undergone such treatment therein, it is but the duty of the State to bear the expenditure incurred by the Government servant. Expenditure, thus, incurred requires to be reimbursed by the State to the employee."