(Prayer: This Writ Petition is filed under Articles 226 and 227 of the Constitution of India praying to quash the impugned email communications dated 07/10/2024, 20/11/2024, and 04/03/2025 sent by respondent No. 3 produced at Annexures-M, P, and T, respectively, and further issue a writ of mandamus direct the respondents to make full reimbursement of the medical reimbursement claim of the petitioner dated 26/12/2023 in respect of the CRT-D implantation of the late husband of the petitioner as acknowledged by R-3 as per their receipt/acknowledgement Bearing MRC No. 3559/2023/BNGLR/BA04 as per Annexure-G and etc.)

Oral Order

1. The Petitioner is before this Court seeking for the following reliefs:

          WHEREFORE it is most respectfully prayed that this Hon'ble Court be pleased to issue a writ of certiorari or any other appropriate writ order or direction quashing the impugned email communications dated 07/10/2024, 20/11/2024, and 04/03/2025 sent by Respondent No. 3 produced at Annexures- M, P, and T, respectively, and further issue a writ of mandamus directing the Respondents to make full reimbursement of the medical reimbursement claim of the Petitioner dated 26/12/2023 in respect of the CRT-D implantation of the late husband of the Petitioner as acknowledged by Respondent No. 3, as per their receipt/acknowledgement bearing MRC No. 3559/2023/BNGLR/BA04 as per Annexure- G, and allow this writ petition with costs, and grant such other reliefs as this Hon'ble Court deems fit to grant in the circumstances of the case, in the interest of justice and equity.

2. The Petitioner is a retired officer from the Indian Administrative Service from the Madhya Pradesh cadre, having retired in the year 2010. Her husband was working in the Madhya Pradesh Tourism Development Corporation as an Executive Director. After her retirement, the Petitioner and her husband were residing in Bangalore.

3. The petitioner, being a retired IAS officer, is covered under the Central Government Health Scheme (CGHS), and as such, she is entitled to all the benefits thereunder.

4. The husband of the Petitioner, being a cardiac patient, underwent two major bypass surgeries, and ever since then, he has been under cardiac supervision. In the month of April 2023, the Petitioner's husband experienced severe chest discomfort and, in an emergency, was shifted to Narayana Institute of Cardiac Sciences for treatment, where he was admitted to the Cardiac Care Unit (CCU), where his ventricular ejection fraction had been reduced to 20%. Hence, he was put on Heart Failure Management Protocol. In the month of October, 2023, the condition of the husband of the Petitioner worsened when again he was treated at Narayana Institute of Cardiac Sciences due to an emergency, and at the diagnosis and prognosis of the Doctors was given a CRT-D implant to protect against sudden death on account of ectopic beats in the heart, which was implanted on 31.10.2023. As regards which the Petitioner had incurred an expense of Rs.15,30,093/- including the cost of the implant CRT-D implant being Rs.13,17,487.36/- as regards which an invoice has been issued. The Petitioner submitted a medical reimbursement claim with Respondent No.3 for a sum of Rs.15,30,093/- on 26.12.2023, which claim was confirmed by way of SMS by Respondent No.3. Unfortunately, the Petitioner's husband on 18.03.2024 suffered from severe breathlessness and nausea and though he was rushed to the hospital, he could not be revived. Until then the claim of the Petitioner had not been satisfied.

5. The Petitioner had submitted a representation on 28.06.2024 requesting for full reimbursement and disbursement of the amounts due. Finally, on 11.09.2024, Respondent No.3 sent an email to the Petitioner requesting the Petitioner to submit the ECG report, which was submitted with great difficulty since the implantation had been done a year earlier on 31.10.2023, and a claim had been submitted on 26.12.2023. Despite the said submission, Respondent No.3 did not proceed with the processing of the reimbursement, but on 07.10.2024, rejected the claim, stating that the experts had opined that the emergency CRT-D was not justified and no reimbursement could be ordered.

6. In pursuance thereof, the Petitioner addressed an email to Respondent Nos.1 and 2, requesting them to furnish a copy of the detailed deliberation. When an email was received stating that a decision had been made that CRT-D implantation was not required, as it was not an emergency. Despite several emails which had been addressed by the Petitioner to the Respondents, the amounts have not been reimbursed. It is in that background that the Petitioner is before this court seeking for the aforesaid reliefs.

7. Learned counsel for the Petitioner relies upon the decision of the Hon'ble Apex Court in the case of Shiva Kant Jha Vs. Union of India (2018) 16 SCC 187, more particularly, paras 2, 3, 18 and 19 thereof, which are reproduced hereunder for easy reference:

          "2. The petitioner herein is a CGHS beneficiary (retired pensioner) having a CGHS Card valid for whole life for medical treatment in Private Ward. The petitioner herein submitted two sets of his Medical bills under the Central Government Health Scheme (CGHS) for reimbursement on account of his treatment done in November, 2013 in the Fortis Escorts Hospital, New Delhi for Rs. 9,86,343/- for his cardiac ailments involving the implant of CRT-D device and two sets of bill amounting to Rs.3,98,097/- for his treatment at Jaslok Hospital, Mumbai for cerebral stroke and paralytic attack.

          3. The petitioner herein submitted the first Bill on 02.01.2014 and the second Bill (two) on 19.07.2014 to the authority concerned. The first Bill was considered by the Technical Standing Committee in May 2014 and the claim was rejected without informing him of the reasons for rejection. The case was again considered by the Standing Committee on 10.07.2014 and was rejected on the ground that CRT-D implant was not required. Aggrieved of the above, the petitioner herein filed a representation before the Secretary, Ministry of Health & Family Welfare. The said representation was again considered by the Standing Committee on 15.01.2015 and was rejected for the reason that "Prior approval for such device implant was not sought". Again, in fourth attempt, the petitioner herein approached the Director General of the CGHS. After presenting the memorial to the Director General of the CGHS, the government credited an amount of Rs. 4,90,000/- in the petitioner's Bank Account, however, he was never heard on any point nor any speaking order was ever communicated to him.

          18. This is hardly a satisfactory state of affairs. The relevant authorities are required to be more responsive and cannot in a mechanical manner deprive an employee of his legitimate reimbursement. The Central Government Health Scheme (CGHS) 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. It was in furtherance of the object of a welfare State, which must provide for such medical care that the scheme was brought in force. In the facts of the present case, it cannot be denied that the writ petitioner was admitted in the above said hospitals in emergency conditions. Moreover, 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. The doctors did his operation and had implanted CRT-D device and have done so as one essential and timely. Though it is the claim of the respondent-State that the rates were exorbitant whereas the rates charged for such facility shall be only at the CGHS rates and that too after following a proper procedure given in the Circulars issued on time to time by the concerned Ministry, it also cannot be denied that the petitioner was taken to hospital under emergency conditions for survival of his life which requirement was above the sanctions and treatment in empanelled hospitals.

          19. In the present view of the matter, we are of the considered opinion that the CGHS is responsible for taking care of healthcare needs and well being of the central government employees and pensioners. In the facts and circumstances of the case, we are of opinion that the treatment of the petitioner in non- empanelled hospital was genuine because there was no option left with him at the relevant time. We, therefore, direct the respondent-State to pay the balance amount of Rs. 4,99,555/- to the writ petitioner. We also make it clear that the said decision is confined to this case only."

8. By relying on Shiva Kant Jha's case, he submits that in a similar situation, where, due to an emergency, a CRT-D device had been implanted. Though the Technical Standing Committee had rejected the claim, the Hon'ble Supreme Court set aside the said rejection and directed the payment of the monies on the ground that when a treatment is made by a doctor and the doctor had advised for the implantation of the CRT-D device, 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.

9. For the very same reasons, I am of the considered opinion that the Respondents in this matter are also required to make payment of the amounts. The Central Government Health Scheme is one of the incentives which is offered by the State to a Government employee to join the Government services, so that the health benefits are taken care of. Otherwise, the Government servant would have to avail of private insurance when a government servant or his family member obtains Medical treatment. It is but required that the said expenses are taken care of by the State since that is the promise which had been held out by the State when the person joined the Government Service.

10. In the present matter, from the facts, it is clear that the husband of the Petitioner was suffering from cardiac issues and had undergone bypass surgery on two occasions and due to which he had been shifted on an emergency basis to Narayana Institute of Cardiac Science, where the doctor had advised the CRT-D implant. Subsequently, the husband of the Petitioner having expired, it cannot lie for the Respondents to contend that the decision taken by the doctors was not proper and there was no emergency requiring a CRT-D device to be implanted. The facts also indicate that though the CRT-D implant was made on 31.10.2023, he expired on 18.03.2024, it is probably due to the implantation of the CRT-D device that he survived for so many months. 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 to decide after more than a year that there was no emergency when they were not present and they were not the treating doctors.

11. As observed by the Hon'ble Apex Court in Para 16 of Shiva Kant Jha's judgment, the State of affairs is hardly satisfactory, and the mechanical manner in which the CGHS has acted deprives an employee of their legitimate reimbursement.

12. The Hon'ble Apex Court in Shiva Kant Jha v. Union of India has authoritatively delineated the constitutional contours governing medical reimbursement under the Central Government Health Scheme. As noticed in paragraphs 2 and 3 of the judgment, the petitioner therein, a CGHS beneficiary and pensioner, had undergone implantation of a CRT-D device in emergency circumstances, and his claim was repeatedly rejected by technical committees on the ground that such implantation was "not required". The factual matrix of the present case is strikingly similar, both in nature of ailment and in the reasoning adopted by the Respondents for rejection.

13. In paragraph 18, the Hon'ble Apex Court unequivocally held that the CGHS is a welfare measure intended to ensure that government employees and pensioners are "not left without medical care after retirement", and that authorities cannot, in a mechanical manner, deprive a beneficiary of legitimate reimbursement. The Court specifically recognised that in emergency situations, the law does not require prior permission, as survival of the patient is of paramount consideration. This pronouncement squarely answers the Respondents' contention that the CRT-D implantation in the present case was "not justified" or "not an emergency".

14. The emphasis placed in paragraph 18 on the primacy of medical judgment is of particular relevance. The Hon'ble Apex Court held that where treating doctors consider implantation of a CRT-D device to be essential and timely, the patient cannot be faulted, nor can reimbursement be denied, on the basis of a contrary technical opinion formed subsequently. The Respondents' attempt in the present case to sit in appeal over the contemporaneous clinical assessment of the treating cardiologists is thus directly contrary to the law declared by the Supreme Court.

15. The constitutional underpinning of this approach is implicit in the reasoning adopted by the Apex Court. Though Article 21 is not expressly cited, paragraph 18 unmistakably anchors the CGHS in the concept of a welfare State and the obligation to protect life and health, which form an inseparable part of the right to life under Article 21. Denial of reimbursement for emergency life-saving treatment, despite eligibility under the scheme, would therefore render the right illusory and defeat the constitutional guarantee of dignified existence.

16. The right to health and timely medical treatment is now firmly recognised as an integral facet of the right to life guaranteed under Article 21 of the Constitution of India. The obligation of the State does not cease with the provision of mere access to medical facilities, but extends to ensuring that the financial burden of life-saving treatment does not render the right illusory. Where a government servant or pensioner is compelled, by reason of medical emergency, to undergo critical treatment, denial of reimbursement in spite of eligibility under an existing health scheme directly impinges upon the dignity and security that Article 21 seeks to protect.

17. 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. Any interpretation of the scheme that results in a pensioner being left to bear catastrophic medical expenses incurred for survival, particularly in emergency situations, would amount to an unreasonable restriction on the right to life and health. The State cannot, after the event, substitute its administrative assessment for the contemporaneous medical judgment of treating specialists, when such substitution has the effect of negating the constitutional guarantee.

18. Paragraph 19 of Shiva Kant Jha's judgement further clarifies that even treatment in a non-empanelled hospital, if undertaken in genuine emergency due to lack of alternatives, must be reimbursed. The Hon'ble Apex Court categorically rejected a narrow or technical construction of the scheme and directed payment of the balance amount, notwithstanding objections regarding procedure or rates. The present case stands on an even stronger footing, as the treatment was rendered at a specialised cardiac institute and the emergency nature of the condition is undisputed on record.

19. The arbitrariness deprecated by the Hon'ble Supreme Court in paragraph 18 equally attracts the mandate of Article 14 of the Constitution. In Shiva Kant Jha's case, repeated rejections without hearing, without disclosure of reasons, and without a speaking order were held to be unsatisfactory and impermissible. In the present case, the Respondents have not only delayed the decision for over a year, but have also failed to furnish the detailed deliberation or reasoning sought by the Petitioner, thereby rendering the decision opaque and manifestly arbitrary.

20. The impugned action of the Respondents also fails the test of Article 14 of the Constitution. 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. Arbitrariness in State action is antithetical to Article 14. A welfare scheme intended to provide uniform protection to similarly situated government servants and pensioners cannot be administered in a manner that is mechanical, opaque, or indifferent to individual circumstances, particularly where life- saving treatment is concerned.

21. The Hon'ble Apex Court's reasoning also reinforces the doctrine of legitimate expectation. As evident from paragraphs 2, 3, and 18, a CGHS beneficiary proceeds on the assurance that genuine medical expenses incurred for survival will be reimbursed. This expectation is neither speculative nor unfounded; it flows from the very object of the scheme as recognised by the Hon'ble Apex Court. The Petitioner, having acted on this assurance, cannot be non-suited by post-event technical objections.

22. At this juncture, it is necessary to advert to the larger context in which medical reimbursement schemes such as the Central Government Health Scheme operate. A government servant, during the entirety of her service, accepts regulated service conditions, controlled remuneration, and statutory restrictions on alternative sources of income, in return for assured service benefits, including post- retirement social security measures. One of the most critical among these assurances is access to medical care for the employee and her dependent family members, particularly after retirement, when earning capacity substantially diminishes.

23. Unlike persons engaged in private employment or commercial activity, a government servant does not ordinarily accumulate medical insurance through private means during service, for the simple reason that the State itself holds out the CGHS as a comprehensive substitute. The promise of State- supported healthcare is thus not a discretionary benevolence, but a legitimate expectation flowing from the service compact between the State and its employees.

24. The doctrine of legitimate expectation is squarely attracted in the present case. Throughout her service career, the Petitioner was assured that medical needs of herself and her dependent family members would be taken care of under the CGHS, both during service and after retirement. This assurance is neither abstract nor aspirational; it is institutionalised through statutory rules, executive instructions, and consistent past practice. A government servant structures her financial planning and post-retirement security on the premise that such medical protection will be honoured. The sudden denial of reimbursement, after the expenditure has already been incurred in an emergency, defeats this legitimate expectation and undermines trust in public administration.

25. Equally, the principles underlying promissory estoppel is embedded in the judgment. The CGHS represents a continuing promise by the State to bear the cost of bona fide medical treatment of its employees and pensioners. As in Shiva Kant Jha's case, where the petitioner had already incurred the expenditure before rejection, the Petitioner herein altered her position irreversibly by incurring substantial medical expenses to try and save her husband's life. The State is constitutionally restrained from resiling from this assurance after such reliance by its employee/s.

26. The principle of promissory estoppel, restrains the State from resiling from representations that have been acted upon to the detriment of the citizen. The CGHS represents a clear and unequivocal assurance that eligible beneficiaries will be reimbursed for bona fide medical treatment, particularly in emergent circumstances. Acting on this representation, the Petitioner incurred substantial expenditure for the life-saving treatment of her husband. Having induced such reliance, it is not open to the Respondents to deny reimbursement by invoking technical objections or by questioning, with hindsight, the medical necessity of the procedure.

27. This financial vulnerability becomes even more pronounced after retirement. Pension, by its very nature, is intended to provide subsistence and dignity, not to absorb sudden and substantial medical expenditures running into several lakhs of rupees. A retired government servant, particularly one who has crossed the age of superannuation, is least equipped to bear the burden of emergency medical procedures involving advanced life-saving devices such as CRT-D implants, the cost of which is far beyond the routine medical expenses contemplated in ordinary circumstances.

28. To compel a pensioner to first incur such enormous expenditure from personal resources and thereafter deny reimbursement on hyper-technical grounds is to render the very purpose of the CGHS illusory. Such an approach would result in a situation where only those retirees with independent financial means can meaningfully access emergency healthcare, while others are left exposed to catastrophic financial distress, a consequence wholly inconsistent with the constitutional vision of a welfare State.

29. The present case, in fact, presents a more compelling equity than Shiva Kant Jha's case, as the Petitioner's husband ultimately succumbed to his illness during the pendency of the reimbursement claim. To deny reimbursement in such circumstances would not only be contrary to the law laid down in paragraphs 18 and 19 of the said judgment, but would also undermine the very ethos of a welfare State, which the Supreme Court sought to protect.

30. This Court is therefore bound by the ratio of Shiva Kant Jha v. Union of India and finds no legally sustainable basis to uphold the impugned rejection. The Respondents' action is inconsistent with the constitutional principles articulated therein and cannot be sustained.

31. It must also be borne in mind that medical emergencies do not afford the patient or the family any meaningful opportunity for deliberation, financial planning, or administrative compliance. When a patient is admitted with severe cardiac dysfunction, reduced ventricular ejection fraction, and a high risk of sudden cardiac death, the decision-making authority necessarily vests with the treating specialists. The patient or attendant cannot be expected to assess the clinical necessity of a CRT-D device, compare alternative treatment protocols, or evaluate reimbursement eligibility under the CGHS framework. Survival, at that moment, eclipses all procedural considerations.

32. Any post-facto scrutiny by administrative or technical committees must therefore be exercised with restraint, deference to medical expertise, and sensitivity to the circumstances under which the treatment was undertaken. The rejection of reimbursement on the premise that an alternative medical opinion could have been taken, or that the emergency was not sufficiently established, places an unrealistic and unjust burden upon the beneficiary and effectively penalises her for circumstances beyond her control.

33. In the present case, the financial implications are compounded by the fact that the Petitioner's husband ultimately succumbed to his illness. The Petitioner, a retired IAS officer, has not only suffered an irreparable personal loss but has also been left to shoulder a substantial financial liability arising directly out of life-saving treatment administered in good faith. The prolonged delay in processing the claim, followed by its rejection after more than a year, exacerbates this hardship and reflects a failure on the part of the Respondents to appreciate the human and financial dimensions of the matter.

34. A welfare scheme cannot be administered in a manner that is oblivious to ground realities. The State, having assured its employees of medical security both during service and after retirement, cannot resile from that assurance by subjecting genuine claims to rigid, post-event technical evaluation divorced from compassion, fairness, and common sense.

35. 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 who were entrusted with saving the life of the Petitioner's husband. The rejection of the claim on the ground that the CRT-D implantation was "not justified" or "not an emergency", after a lapse of nearly one year, is arbitrary, unreasonable, and contrary to the settled principles governing CGHS reimbursements.

36. It is also to be borne in mind that the Petitioner lost her husband during the pendency of the reimbursement claim. In such circumstances, the Respondents were expected to act with sensitivity and promptness, rather than subjecting the Petitioner to repeated correspondence and an opaque decision-making process, without furnishing any detailed deliberation or speaking order.

37. A welfare State governed by the rule of law cannot permit a situation where a retired government servant is forced to choose between saving the life of a spouse and risking financial ruin. Such an outcome would render Articles 14 and 21 nugatory in their application to the most vulnerable phase of a public servant's life. The constitutional promise of dignity, fairness, and non-arbitrariness demands that health schemes like the CGHS be interpreted and implemented purposively, humanely, and in a manner that advances, rather than frustrates, their underlying object.

38. Before parting with the matter, I consider it necessary to address the systemic issue that has repeatedly surfaced in cases relating to medical reimbursement under the Central Government Health Scheme. The present litigation itself demonstrates the inherent hardship caused by a reimbursement- based model, where beneficiaries are first compelled to incur substantial medical expenditure out of pocket and thereafter pursue reimbursement through prolonged administrative processes. In cases of emergency and critical care, such a model places an onerous and often insurmountable financial burden upon government servants and pensioners, particularly those who have no independent means beyond pensionary benefits.

39. The requirement to initially mobilise large sums of money during medical emergencies undermines the very object of a welfare health scheme. Emergency medical treatment, by its very nature, does not permit financial planning, administrative compliance, or prior approvals. Expecting a patient or family member to arrange several lakhs of rupees at short notice, and then to navigate procedural scrutiny for reimbursement, results in avoidable distress, delayed treatment, or post-treatment litigation. This is especially inequitable in the case of retired employees, whose earning capacity has ceased and whose financial security is limited.

40. A cashless treatment mechanism, particularly for emergency and life-saving procedures, would significantly mitigate these hardships and align the administration of the CGHS with constitutional values. Such a system would give meaningful effect to the right to health under Article 21, ensure non- arbitrary access to medical care under Article 14, and reinforce the State's obligation as a welfare employer. Importantly, directing the Respondents to consider the feasibility of such a mechanism does not amount to judicial encroachment into policy-making, but constitutes a constructive institutional suggestion arising from repeated administrative failures observed by this Court in adjudicating similar disputes.

41. The absence of a cashless mechanism also results in avoidable litigation, delayed settlements, and administrative inefficiency, burdening both beneficiaries and the State. A structured cashless framework, even if initially limited to empanelled hospitals and emergency care, would reduce disputes over reimbursement, enhance transparency, and ensure that beneficiaries are not left financially exposed at the most vulnerable moments of their lives. It is therefore appropriate that the Respondents examine this issue at the policy level, with a view to preventing recurrence of situations such as the present one.

42. For the above reasons, I pass the following:

ORDER

          i) Writ petition is allowed.

          ii) A certiorari is issued, 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.

          iii) A mandamus is issued directing Respondents to make full reimbursement of the medical costs incurred by the Petitioner for the CRT-D implantation within a period of 30 days from today along with interest calculated from 30.10.2023 when the Petitioner made payment of the due amounts at the rate of 12% per annum within 30 days from the date of receipt of a copy of this order.

          iv) 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, 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.