Region: Asia
Year: 2006
Court: Central Administrative Tribunal - Delhi
Health Topics: Chronic and noncommunicable diseases, Health care and health services, Health systems and financing, Hospitals
Human Rights: Right to health, Right to life
Tags: Access to treatment, Emergency care, Heart disease, Private hospitals, Reimbursement, Secondary care, Tertiary care
The applicant worked as a section officer in the Department of Foods and then became a pensioner post retirement. As a central government employee, he was entitled to reimbursement of medical expenses incurred by him or his family members under the Central Government Health Scheme (CGHS).
In 2001 the applicant and the applicant’s wife incurred certain medical expenses for emergency surgeries and treatment of diabetes and hypertension. Although the applicant requested reimbursement for these claims, the respondents did not reimburse the full amount because the CGHS had a ceiling limit prescribed for reimbursement with additional amounts to be borne by the beneficiary.
The applicant brought a representation in 2002 for the balance of the reimbursement which the respondent did not respond to. In 2006, he again brought a representation for reimbursement of the balance, along with interest.
The Court held that, as the treatment had occurred in a hospital which was recognized and approved by the medical scheme and as the criteria for reimbursement should be “actual reimbursement” (instead of reimbursement as restricted by the ceiling rates), the applicant was entitled to reimbursement of balance (without interest).