Safiya Malik

In a recent judgment, the Rajasthan High Court directed the state government to process a retired employee’s medical reimbursement claim for expenses incurred during an emergency treatment at a non-recognized hospital. The court ordered reimbursement at prescribed rates under the applicable scheme and included an interest component on the delayed payment.

The petitioner, Sohan Lal Sharma, retired as a Lecturer from the District Institute of Education and Training, Jodhpur, on January 31, 2002. As a retired employee of the state government, he was entitled to medical benefits under the Rajasthan Pensioners Medical Concession Scheme. The scheme provides free medical attendance and treatment for pensioners at recognized hospitals, clinics, and institutions. It also includes provisions for reimbursement of medical expenses incurred during emergencies, provided they align with the rules outlined under the scheme.

On May 25, 2007, the petitioner suffered a cardiac arrest and was admitted to Escorts Goyal Heart Center, Jodhpur, a private hospital that was not recognized under the scheme at the time. Given the severity of his condition, the petitioner underwent a bypass surgery on June 1, 2007, and was discharged on June 12, 2007. The hospital was equipped with cardiac care facilities in collaboration with Escorts Heart Institute, New Delhi, and was one of the few hospitals in the region capable of handling such emergencies.

Following his recovery, the petitioner submitted a claim for medical reimbursement totalling ₹2,03,063.86, supported by medical bills and an affidavit confirming the dates of his hospitalization. On June 16, 2008, the claim was rejected by the respondent authorities on the grounds that the treatment had been availed at a non-recognized hospital, which contravened the provisions of the scheme. The authorities asserted that only ₹48,000 could be reimbursed, the maximum amount permissible under the scheme for treatment at unrecognized facilities. This amount was subsequently disbursed to the petitioner.

Notably, in 2008, Escorts Goyal Heart Center was empanelled as a recognized hospital under the scheme. Medical reimbursement claims for other state employees treated there were processed and accepted without objection. The petitioner argued that his case deserved similar consideration, as his treatment was necessitated by an emergency, leaving no time to consider the hospital’s recognition status.

The petitioner further contended that the rejection of his claim violated judicial precedents, which consistently held that life-saving treatments in emergencies should be reimbursed, even if availed at non-recognized hospitals. He sought a direction from the court to quash the rejection order and process his claim in accordance with the applicable rules. The respondents, however, maintained that the claim did not meet the requirements of the scheme and that reimbursement beyond the authorized limit was impermissible.

The court observed that the petitioner’s situation clearly qualified as an emergency, which was not disputed by the respondents. It stated: “When a life-threatening condition arises, the primary concern is to ensure survival, rather than adhere to procedural requirements. The government cannot insist upon an employee to get treated at a recognized government institution in such circumstances.”

Referring to judicial precedents, the court cited the decision in Surjit Singh v. State of Punjab, where the Supreme Court held: “In emergent circumstances, the employee has the right to seek reimbursement for life-saving treatment, even if it is availed at a non-recognized hospital.”

The court also referred to the Division Bench judgment in Anil Kumar Surolia v. State of Rajasthan, which recorded: “Reimbursement of medical expenses borne by state government employees and pensioners has to be done even if the treatment is undertaken at unrecognized hospitals, provided it aligns with the rates prescribed under the scheme.”

Further, the court relied on the judgment in Kanhaiya Lal Dave v. State of Rajasthan, which noted that the state’s responsibility to reimburse life-saving treatments cannot be negated by procedural hurdles. In that case, it was recorded: “When human life is at stake, administrative requirements cannot override the obligation to provide financial relief to the employee.”

The court observed that the respondents had acknowledged the applicability of these judgments to the petitioner’s case and stated that these precedents had attained finality. It stated that the denial of full reimbursement in the petitioner’s case was inconsistent with the treatment of similar claims processed after the hospital’s empanelment.

Allowing the petition, the court directed the respondents to process the petitioner’s medical reimbursement claim at the rates prescribed under the Rajasthan Pensioners Medical Concession Scheme. It specifically recorded:
“The respondents are directed to verify and process the medical bills of the petitioner. If found in order, the balance amount, after deducting the ₹48,000 already paid, shall be reimbursed with interest at the rate of 6% per annum.”

The court further stated that the interest would be calculated from 30 days after the submission of the bills, ensuring that the petitioner is compensated for the delay in processing his claim. Any procedural formalities required for bill verification were to be expedited, and the balance amount was to be disbursed without unnecessary delay. Pending applications in the matter were disposed of as part of the order.

Case Title: Sohan Lal Sharma v. State Finance and Ors
Case Number: S.B. Civil Writ Petition No. 5714/2011
Bench: Justice Arun Monga

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