Bombay high court orders full reimbursement for central govt pensioner denied heart transplant expenses incurred at private hospital

Time of India

a day ago

Mumbai: In what it said was a peculiar case of a dispute arising over a reimbursement claim by a central govt employee for a "heart transplant" conducted at a private hospital, the Bombay high court on Friday held that the affected man, a pensioner, was entitled to decide on a private hospital for the procedure in the absence of timely availability of such facilities in all the empanelled hospitals under the govt health scheme for employees.
The high court said he was entitled to full reimbursement of his "undisputed expenditure".
It said that to make the man suffer for the refund was a glaring travesty of justice and violation of his fundamental rights.
Anirudh Nansi, who took voluntary retirement in March 2008 as a central govt employee, is a Mumbai resident and petitioned the high court in 2022 over his December 2020 transplant. He was an assistant commissioner in the Central Excise and Customs, Pune.
The high court held that the money is to be paid in four weeks to the former employee. It held that the rejection by the Centre was "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 constitutional guarantee of right to life under Article 21".
A division bench of Justice Girish Kulkarni and Jistice Advait Sethna, tn the judgement pronouncement, held that the central govt was under an obligatory position to grant reimbursement on a case-by-case basis, with no straitjacket formula to fix reimbursement rates.
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The judges said a heart transplant was "certainly serious and emergent", hence, the former employee's case deserved to be treated with humane sensitivity and not mechanically in a "narrow pedantic" view.
Any employee, merely because he retired, ought not to be differently treated when it comes to genuine and realistic need, held the high court.
A high-powered committee (HPC) denying the pensioner full reimbursement on the grounds that the central scheme permitted rates are required to be followed, "is not the correct and a legal stand of the (Centre)", the high court noted.
It said it also disagreed with the HPC's reasoning to deny a full refund even under the Centre's relaxation of guidelines for special emergent cases, stating that "heart transplantation was a planned surgery and not an emergency".
The high court said that under the Centre's relaxation rules, it failed to understand how a heart transplant is not considered "extraordinary", emergent and inevitable surgery, "as a heart transplant is required only when the heart is failing, the consequences of which are just to be imagined".
Even if there were no relaxation guidelines, in deserving cases, the HPC should exercise its discretion to award full medical reimbursement, held the high court.
Through senior advocate Prakash Shah and advocate Anil Balani, Nansi sought reimbursement, saying he was being denied it. He sought reimbursement of Rs 22 lakh with 9% yearly interest. His claim was denied in April 2022 by the Centre.
The petitioner was suffering from cardiomyopathy since 2009.
In Oct 2019, his condition deteriorated, and he was advised to have a transplant. He said a private empanelled super-specialty hospital in Mumbai at the time was not performing heart transplants, hence he got his done at another one in Mumbai on Dec 29, 2020. He cited his then "grave and critical nature… and the lack of any CGHS empanelled hospitals having necessary licence, approvals, and expertise… .
" Before his surgery, he got an endorsement from the Centre noting that reimbursement at a non-empanelled hospital could only be given at CGHS rates and the difference would have to be borne by the petitioner.
"This medical condition is certainly not a routine affair for the hospitals, much less for the central govt hospitals or those under the Central Government Health Scheme," observed the high court after hearing the Centre's lawyers Y R Sharma and Jain. The issue before the high court was whether, in his pressing situation, he could be denied full reimbursement of the medical expenses incurred by him for such major treatment merely because he opted for a private hospital.
The question was also whether the rigours of the normal rule of medical reimbursement should make way for the case to be considered specially, the high court said, particularly as a heart transplant surgery is not a walk-in category of surgery.
While in many cases reimbursements may not involve any dispute on the amount, it cannot mean that in very peculiar, serious, specialised cases of medical treatment, the reimbursement needs to be only as per the rates which are pre-determined, the high court observed, as it would then "be most unrealistic, unfair, and discriminatory as in the present situation".
The high court added that even if it was a planned surgery, Nansi's claim for a full refund could not have been rejected, "or merely because the rates being notified, the petitioner ought not to be granted any reimbursement".
The high court said: "It 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 govt.
It would not require elaboration that in such matters, it is an accepted position that there is a free play in the joints and such category of cases are required to be considered on their merits.
"Certainly, the heart transplant surgery is one of urgency and critical importance, and could not have been postponed. It is a special circumstance. It is imperative that such surgeries are expedited in the interest of human life without an embargo of an expenditure which is secondary to human life."
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