Karnataka High Court Quashes CGHS Emergency Reimbursement Denial And Asks Centre To Consider Phased Cashless Treatment For Emergency, Critical Care Cases
Safiya Malik
The High Court of Karnataka Single Bench of Justice Suraj Govindaraj allowed a writ petition challenging the denial of reimbursement under the Central Government Health Scheme (CGHS) for emergency cardiac treatment and directed the Union of India to pay the full medical costs, with 12% interest, within the timelines set out in the order. The dispute arose after CGHS authorities rejected a retired beneficiary’s claim relating to a CRT-D implantation undertaken during critical care, on the view that the procedure was not justified as an emergency. Alongside quashing the rejection communications, the Court also directed the Union to examine, at the appropriate administrative level, phased implementation of a cashless CGHS mechanism for emergency and critical care, observing that such a model would advance Article 21 and Article 14 values.
The writ petition was filed by a retired government officer covered under the Central Government Health Scheme (CGHS), seeking quashing of email communications issued by CGHS authorities rejecting her medical reimbursement claim and seeking a direction for full reimbursement. The claim arose from emergency cardiac treatment undertaken by her spouse, who suffered from severe cardiac ailments and underwent implantation of a CRT-D device at a specialised cardiac institute.
The petitioner incurred substantial medical expenses towards the treatment and submitted a reimbursement claim under CGHS, which was acknowledged by the authorities. Despite repeated representations and submission of additional documents sought by the authorities, the claim was rejected on the ground that the implantation of the CRT-D device was allegedly not justified as an emergency procedure.
The petitioner contended that the treatment was undertaken in an emergency situation based on medical advice and that the rejection was arbitrary, delayed, and unsupported by a speaking order. Reliance was placed on the Supreme Court decision in Shiva Kant Jha v. Union of India concerning reimbursement for emergency medical treatment under CGHS. The respondents defended the rejection on the basis of expert opinion obtained internally.
The Court recorded that the petitioner was a CGHS beneficiary and that her spouse had a long history of cardiac illness requiring continuous medical supervision. The Court noted that the medical treatment was undertaken in emergency circumstances and that the decision to implant the CRT-D device was taken by the treating doctors.
The Court observed that “the patient would not be in a position to assess whether it was required or not. The decision being that of the doctor, the Respondent was required to make payment of the due amounts.”
Referring to the Supreme Court precedent, the Court stated that “the Central Government Health Scheme was propounded with a purpose of providing health facility scheme to the central government employees so that they are not left without medical care after retirement.”
The Court recorded that “the law does not require that prior permission has to be taken in such situation where the survival of the person is the prime consideration.” It further observed that “it is for the officers of the CGHS to consider any application for reimbursement in a humane manner and act on the same instead of in technical manner.”
The Court found fault with the post facto scrutiny undertaken by CGHS authorities and noted that “the Respondents, who were neither present at the time of treatment nor responsible for the medical management of the patient, cannot sit in appeal over the professional judgment of cardiologists.”
On arbitrariness, the Court observed that “the rejection of the Petitioner's claim on the basis of an ex post facto technical opinion, without furnishing a speaking order, without disclosing the deliberative process, and after inordinate delay, is manifestly arbitrary.”
The Court also linked the issue to constitutional principles, recording that “medical reimbursement under the Central Government Health Scheme is therefore not a matter of administrative discretion or charity, but a component of the constitutional obligation of the State flowing from Article 21.”
The Court further recorded concern regarding systemic issues in CGHS reimbursements and noted that “a reimbursement-based model places an onerous and often insurmountable financial burden upon government servants and pensioners.”
The Court ordered that “the writ petition is allowed. A certiorari is issued, [and] the impugned email communications dated 07.10.2024, 20.11.2024 and 04.03.2025 sent by Respondent No.3 at Annexure-M, P and T respectively, are quashed.”
The Court issued a mandamus “directing Respondents to make full reimbursement of the medical costs incurred by the Petitioner for the CRT-D implantation.” Such reimbursement shall be made “within a period of 30 days from today.” The reimbursement shall be “along with interest calculated from 30.10.2023 when the Petitioner made payment of the due amounts at the rate of 12% per annum,” and that the said amount shall be paid “within 30 days from the date of receipt of a copy of this order.”
“The Respondents are further directed to examine and consider, at the appropriate administrative level, the feasibility and phased implementation of a cashless medical treatment mechanism under the Central Government Health Scheme, particularly for emergency and critical care.” The Court clarified that such consideration is intended “so as to obviate situations where serving or retired government employees and their dependent family members are compelled to initially bear substantial medical expenses and thereafter pursue prolonged reimbursement claims.”
Advocates Representing the Parties
For the Petitioner: Sri A. Madhusudhana Rao, Advocate
For the Respondents: Smt. Reshma K.T., Central Government Counsel
Case Title: Mrs. Ivy Miller Chahal v. Union of India & Ors.
Neutral Citation: NC: 2025: KHC:50803
Case Number: Writ Petition No. 27013 of 2025
Bench: Justice Suraj Govindaraj
