Full Reimbursement Ordered for Heart Transplant | Bombay HC Slams HPC's Mechanical Rejection as 'Travesty of Justice', Directs CGHS to Pay Within Four Weeks
Isabella Mariam
The High Court of Judicature at Bombay Division Bench of Justice G. S. Kulkarni and Justice Advait M. Sethna has held that a retired Central Government employee who underwent a heart transplant at a private hospital is entitled to full medical reimbursement, notwithstanding the CGHS rate ceiling. The Court directed the Central Government Health Scheme (CGHS) authorities to process and release the balance amount of Rs. 22,08,440 within four weeks. The Court invalidated the rejection communicated by the High-Power Committee (HPC), terming its reasoning as narrow, mechanical, and contrary to the constitutional guarantee of the right to life under Article 21. It was further observed that the refusal to reimburse the entire medical expenditure incurred on an urgent heart transplant, despite the absence of requisite facilities at CGHS empanelled hospitals, amounted to a glaring violation of fundamental rights. Accordingly, the Court allowed the writ petition in full and made the Rule absolute.
The petitioner, a voluntary retiree from the Central Excise and Customs department and a senior citizen, sought full reimbursement of Rs. 22,08,440 towards a heart transplant surgery performed at Sir H. N. Reliance Foundation Hospital, a non-empanelled hospital under CGHS. The petitioner, who had been suffering from Cardiomyopathy since 2009, was advised in October 2019 to undergo an urgent heart transplant due to a critical decline in heart function.
At the relevant time, no CGHS-empanelled hospital in Mumbai had the license or capacity to perform heart transplants. Wockhardt Hospital, though empanelled, obtained its license to perform such procedures only in April 2020, well after the petitioner had taken preparatory medical steps. Given the critical nature of his health, the petitioner opted for treatment at Sir H. N. Reliance Foundation Hospital, which was not empanelled under CGHS.
On 3 December 2020, the petitioner formally requested CGHS Mumbai to consider reimbursement of the estimated Rs. 25,00,000. The CGHS authorities granted permission for treatment, simultaneously endorsing that reimbursement would be subject to CGHS rates and that any excess would be borne by the petitioner. Relying on this, the petitioner underwent the surgery on 8 December 2020, incurring a total bill of Rs. 29,96,020.35.
The petitioner later filed a reimbursement claim of Rs. 23,69,245 after deducting amounts already received. The CGHS authorities approved Rs. 1,60,805 and denied further payment. Following this, the petitioner approached the Ministry and submitted further representations, including a request for the matter to be placed before the HPC under the Office Memorandum dated 6 June 2018, which provides for full reimbursement in special or emergency cases.
Despite extensive correspondence and RTI applications, the petitioner received a rejection letter dated 30 November 2021 from CGHS headquarters, stating that the treatment was elective and the petitioner had accepted CGHS rate conditions beforehand. The HPC later reiterated this view in its meeting on 30 March 2022 and the decision was formally communicated to the petitioner on 13 April 2022.
The petitioner challenged this decision in a prior writ petition (No. 1377 of 2022), which was disposed of upon the statement by respondents that the matter would be considered by HPC. When the rejection persisted, the petitioner filed the present Writ Petition No. 7546 of 2022.
In response, the CGHS argued that the petitioner had knowingly accepted CGHS rate limitations and therefore was not entitled to full reimbursement. It was also argued that the petitioner had an alternate remedy before the Central Administrative Tribunal (CAT). The respondents contended that the procedure was not an emergency and that the petitioner had opted for elective surgery.
In a rejoinder, the petitioner contested the applicability of CAT, arguing that the claim arose from the constitutional right to health and was not a service matter. He also argued that acceptance of CGHS rates was under duress due to the medical urgency, and cited the disparity between CGHS rates in Mumbai and those of other metro cities.
The petitioner further stated that CGHS hospitals in Mumbai were not licensed for heart transplants at the time and that his surgery was necessitated by an immediate availability of a donor organ. Multiple expert medical opinions submitted by the petitioner confirmed the critical and urgent nature of the procedure.
"We find that the impugned decision as taken by the High-Power Committee denying the petitioner full reimbursement of the medical expenses incurred by the petitioner for the heart transplant on the ground that CGHS permitted rates are required to be followed, is not the correct and a legal stand of the respondents."
The Court took critical note of the reasoning adopted by the HPC: "From the impugned decision, it appears to us that a narrow, pedantic and/or a too technical view has been taken by the HPC in rejecting the full medical reimbursement to the petitioner."
Rejecting the argument that the treatment was elective and non-emergency, the Court stated: "It is clear that a provision is made for relaxation in reimbursement of the medical expenses incurred in special cases, in peculiar circumstances, as also in cases of emergency and other special circumstances... a heart transplant is required only when the heart is failing, the consequences of which are just to be imagined."
The Court recorded that CGHS hospitals lacked the facility to conduct heart transplants and remarked: "The respondents have not come with a case that immediate transplant facility was available or the organ was available for transplant, in any of its empanelled or CGHS hospitals."
Referring to Article 21, the Bench recorded: "Not granting full reimbursement, in these circumstances in our opinion, is not only violative of the fundamental rights but strikes at the very root, purpose and essence of these basic human rights as guaranteed by the Constitution, i.e., Right to Life under Article 21."
On the failure of the HPC to act in a fair manner, the Court noted: "It was necessary for the High-Power Committee to weigh the case of the petitioner with human sensitivity... the High-Power Committee in its usual, routine and mundane method appears to have taken the impugned decision without hearing the petitioner."
On the argument that CGHS rates were binding, the Court responded: "It also cannot be that the rules governing reimbursement are sacrosanct and nothing outside the rules in exceptional/special cases and especially deserving cases, can be considered for reimbursement by the Central Government."
"In many of such reimbursements, there may not be any issue or dispute on the amount of reimbursement, however, this would not mean that in very peculiar, serious, specialized cases of medical treatment, the reimbursement needs to be only as per the rates which are pre-determined."
"The High-Power Committee ought to have been humanely sensitive in dealing with the petitioner’s case and ought not to have adopted a mechanical and a narrow-minded approach."
The Court issued the following directions: "We have no manner of doubt that looked from any angle, the petition needs to eminently succeed. It is, accordingly, allowed in terms of prayer clauses (A) and (B)."
Accordingly, the Court directed: "Needful reimbursement be done to the petitioner within a period of four weeks from today."
The Bench also made the Rule absolute and concluded: "Rule is made absolute in the aforesaid terms. No costs."
Advocates Representing the Parties:
For the Petitioner: Mr. Prakash Shah, Senior Advocate with Mr. Anil Balani, Mr. Durgaprasad Poojari, Mr. Jas Sanghavi, Ms. Priyasha Pawar, Mr. Vikas Poojary, instructed by PDS Legal
For the Respondents: Mr. Y.R. Sharma with Mr. Vinit Jain, Mr. Ashok Varma
Case Title: Anirudh Prataprai Nansi v. Union of India & Ors.
Neutral Citation: 2025: BHC-AS:22550-DB
Case Number: Writ Petition No. 7546 of 2022
Bench: Justice G. S. Kulkarni and Justice Advait M. Sethna
[Read/Download order]
