(Prayer: Writ Petition filed under Article 226 of the Constitution of India to issue a Writ of Certiorari calling for the records from the file of the 1st respondent in O.A. No. 258 of 2020 dated 03.04.2023 and quash the same.)
C.V. Karthikeyan, J.
1. The respondents in O.A. No. 258 of 2020 on the file of the Central Administrative Tribunal, Chennai, aggrieved by the Order dated 03.04.2023 have filed this Writ Petition.
2. O.A. No. 258 of 2020 had been filed by the respondent herein seeking a direction against the respondents therein (petitioners in this Writ Petition) to grant the balance medical reimbursement amount of Rs. 1,97,199/-. The Tribunal had granted the said relief and directed the respondents therein (petitioners in this Writ Petition) to process there claim and reimburse the said balance amount within a period of two months from the date of receipt of a copy of the Order.
3. Mr. G. Lakshminarayanan, the late husband of the respondent herein had joined CSIR as Junior Scientific Assistant on 23.09.1965 and retired as Scientist (EI) from Central Institute of Mining and Fuel Research (CSIR CIMFR), Dhanbad on 30.09.2023 after serving for 38 years and 8 days. He underwent Transcatheter Aortic Valve Replacement (TAVR) on 15.12.2017 at Apollo Hospitals, Chennai. Later, on 16.10.2019, he had to be admitted at Apollo Hospitals in an emergency state. He expired on 21.10.2019. The respondent submitted a claim for Rs.3/- lakhs. It was sanctioned for a sum of Rs.1,02,801/- in accordance with the CGHS rates and rejected for the balance amount of Rs.1,97,199/-. Placing reliance on the dictum laid down in the ruling of the Hon’ble Supreme Court in Shiva Kant Jha vs Union of India, reported in AIR 2018 SC 1975 : (2018) 16 SCC 187, which also related to a medical claim which had been rejected on the basis of the CGHS rates, the respondent herein filed the aforementioned Original Application before the Tribunal. The Order of the Tribunal dated 03.04.2023 allowing the Application is under challenge in this Writ Petition.
4. Mr. K. Ramananmoorthy, learned Senior Panel Counsel for the petitioners pointed out that the Hon’ble Supreme Court in Shiva Kant Jha, referred supra, had clarified that the relief granted in that case was with respect to that case alone. Learned Counsel further pointed out that the said position had been reiterated by a Division Bench of the Bombay High Court in Bina Saxena vs Union of India and others, reported in 2023 SCC OnLine Bom 1265 : (2023) 5 AIR Bom R 479, wherein, while considering Shiva Kant Jha, the High Court had held that the Supreme Court had exercised its jurisdiction under Article 142 of the Constitution of India, which jurisdiction, the4 High Court and certainly, the Tribunal does not possess.
5. Learned Counsel further argued that the claim submitted had been processed in accordance with the CGHS rates. He pointed out that CSIR-CLRI employees, pensioners and their dependents availing medical facilities from CLRI dispensary are covered under the provisions of the Central Services (Medical Attendant) Rules and medical reimbursement is limited to CGHS rates. The learned Counsel therefore stated that the directions of the Tribunal would have to be interfered with.
6. Mr. K. Mohamed Hussen, learned Counsel for the respondent however argued that the respondent was eligible for reimbursement of the entire claim. He argued that the dictum laid down by the Hon’ble Supreme Court in Shiva Kant Jha, referred supra, was directly applicable to the facts of this case and therefore urged that the Writ Petition should be dismissed and the directions of the Tribunal be upheld.
7. We have carefully considered the arguments advanced and perused the material records.
8. Mr. G. Lakshminarayanan, the late husband of the respondent had joined CSIR as Junior Scientific Assistant Grade II 0n 23.09.1965 and retired on attaining the age of superannuation as Scientist EI from Central Institute of Mining and Fuel Research (CSIR-CIMFR) on 30.09.2003. He was covered under the Central Services (Medical Attendance) Rules CSMA Rules. Under the provisions of CS (MA) Rules, the cost of medical expenditure iOS reimbursed limited to CGHS Rules.
9. The Central Government Health Scheme for Reimbursement for Specialised Tests and Treatments has provided in Annexe I the rates applicable for treatment in emergency.
10. Mr. G. Lakshminarayanan underwent Transcatheter Aortic Valve Replacement (TAVR) on 15.12.2017 at Apollo Hospitals, Chennai. Seeking reimbursement for the medical expenses incurred for that treatment, the respondent had filed O.A. No. 257 of 2020 before the Tribunal and challenging the directions issued by the Tribunal, the petitioners herein had filed W.P. No. 20860 of 2023, which was disposed on 03.06.2025 recording medical reimbursement in full and final settlement. He had to be subsequently admitted in an emergency state to the same Hospital on 16.10.2019 but did not recover from the emergency state and expired on 21.10.2019. A claim for Rs. 3/- lakhs was presented by the respondent herein. A sum of Rs. 1,02,801/- was admitted but a sum of Rs.1,97,199/- was rejected necessitating filing of O.A. No. 258 of 2020 before the Tribunal. This application was allowed by the Tribunal by Order dated 03.06.2025.
11. The Writ petitioners have produced by way of further document the Claim Components for the Medical Claim of Rs.3/- lakhs and the Amount Admitted for the treatment of G. Lakshminarayanan at Apollo Hospitals, Chennai from 16.10.2019 to 21.10.2019.
12. The tabular column for the same is as follows :
| S.No. | Claim Component | Total Bill Amount in Rs. | Admissible Amount in Rs. |
| 1. | Assessment service | 2040.00 | 270.00 |
| 2. | Consultation | 18250.00 | 5670.00 |
| 3. | CSSD | 1740.00 | 60.00 |
| 4. | Equipment | 35470.00 | 12758.00 |
| 5. | Hospital Services (others) | 1000.00 | 0.00 |
| 6. | Invasive Procedures | 8480.00 | 4270.00 |
| 7. | Investigations | 53790.00 | 8986.00 |
| 8. | Medical Services | 13300.00 | 0.00 |
| 9. | Non Invasive Procedure | 2490.00 | 570.00 |
| 10. | Nursing & Hospital Utilities | 10440.00 | 0.00 |
| 11. | Nutritional and Functional Assessment charges | 1000.00 | 0.00 |
| 12. | Profile | 49540.00 | 4440.00 |
| 13. | Room Rent | 35600.00 | 18000.00 |
| 14. | Ward consumables | 10820.00 | 1480.00 |
| 15. | Ward Pharmacy | 78831.11 | 69088.00 |
| 16. | Discount | -22791.00 | -22791.00 |
| Total | 300000.00 | 102801.00 |
14. Even otherwise the Writ petitioners are bound by the Rules governing Settlement of Medical Claims as provided in Chapter 12 of the Central Government Health Scheme. The said Rules provide for reimbursement in excess of approved rates as provided in MH & FW, O.M. No. 4-18/2005-C7P [Vol. I - Pt.(I), dated 20.02.2009, (Annexe 12.II). It has been provided that “Reimbursement is, generally, allowed only at approved rates for the treatments/tests. However, reimbursement in full, in excess of approved rates, may be allowed by the Secretary (Health & Family Welfare) on recommendation by the Technical Standing Committee.” The circumstances under which such recommendation could be given have also be stated.
15. The Writ petitioners have not provided clarity whether they had referred the claim of the respondent before the Technical Standing Committee as provided in the Rules. There is no indication that they have done so.
16. We are conscious that the direction in Shiva Kant Jha, referred supra to pay the balance amount of medical expenditure incurred in that case is confined to that case also.
17. However in the very same judgment, the Hon’ble Supreme Court had expressed anguish at the inhumane approach taken by the officials of the CGHS to deny the grant of medical reimbursement in full. They have stated as follows in paragraph Nos. 13 and 14.
13) It is a settled legal position that the Government employee during his life time or after his retirement is entitled to get the benefit of the medical facilities and no fetters can be placed on his rights. It is acceptable to common sense, that ultimate decision as to how a patient should be treated vests only with the Doctor, who is well versed and expert both on academic qualification and experience gained. Very little scope is left to the patient or his relative to decide as to the manner in which the ailment should be treated. Speciality Hospitals are established for treatment of specified ailments and services of Doctors specialized in a discipline are availed by patients only to ensure proper, required and safe treatment. Can it be said that taking treatment in Speciality Hospital by itself would deprive a person to claim reimbursement solely on the ground that the said Hospital is not included in the Government Order. The right to medical claim cannot be denied merely because the name of the hospital is not included in the Government Order. The real test must be the factum of treatment. Before any medical claim is honoured, the authorities are bound to ensure as to whether the claimant had actually taken treatment and the factum of treatment is supported by records duly certified by Doctors/Hospitals concerned. Once, it is established, the claim cannot be denied on technical grounds. Clearly, in the present case, by taking a very inhuman approach, the officials of the CGHS have denied the grant of medical reimbursement in full to the petitioner forcing him to approach this Court.
14) 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 fter 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.
18. The Writ petitioners were duty bound to re-examine their Rules owing to the observations extracted above.
19. As pointed out by us earlier, there is no indication that the claim of there respondent had been referred to the Technical Standing Committee as provided in the Rules. It is also not the case of the Writ Petitioners that the respondent does not have the right to seek her claim to be placed before the Technical Standing Committee.
20. We would therefore direct the Writ Petitioners to place the claim of the respondent before the Technical Standing Committee as provided in MH & FW, O.M. No. 4-18/2005-C7P [Vol. I - Pt.(I), dated 20.02.2009, (Annexe 12.II) of the Rules governing Settlement of Medical Claims as provided in Chapter 12 of the Central Government Health Scheme. We direct the said exercise to be completed within a period of three months from this date.
21. The Writ Petition stands disposed with the above directions. No costs. Consequently, connected miscellaneous petition is also closed.