The Bombay High Court has come down heavily on the Centre & CGHS for refusing to fully reimburse the medical expenses of a retired government officer who underwent a heart transplant. The court directed that ₹30 lakh be paid to the petitioner, terming the denial of full reimbursement as unjust, overly technical, and a violation of his right to life and healthcare.
The petitioner, a retired Assistant Commissioner from the Central Excise and Customs Department, took voluntary retirement in 2008 and has since been receiving a pension. He had been suffering from cardiomyopathy since 2009. By 2019, his heart condition had severely deteriorated, and doctors recommended an urgent heart transplant. However, neither CGHS-empanelled hospitals nor government hospitals were performing the procedure at that time.
Facing a life-threatening situation, the petitioner opted for the transplant at a private hospital and sought full reimbursement from CGHS, supported by an estimated cost of ₹25 lakh. Despite multiple communications and requests, the CGHS only offered partial reimbursement, citing that the procedure was planned and not an emergency, and that reimbursements must follow CGHS rules.
Rejecting this reasoning, the court said the High Power Committee’s conclusion that a heart transplant is not an emergency is baseless. The judges emphasized that such procedures become essential only when the heart is failing, leaving the patient with little to no time for alternatives.
The court observed that the authorities adopted a rigid and inhumane stance, ignoring the critical nature of the surgery. It stressed that retired government employees must be treated equitably, especially in life-threatening medical situations, and that reimbursement should not be limited to outdated CGHS package rates when urgent and specialised treatment is required.
A division bench of Justices G.S. Kulkarni and Advait M. Sethna noted that insisting on pre-fixed CGHS rates in such complex cases is unrealistic and discriminatory. They pointed out that the CGHS rates have not been updated regularly and, therefore, do not reflect the actual costs of specialised treatments like heart transplants.
The court further remarked that CGHS had no evidence to show that such a transplant could have been conducted promptly in any of their empanelled hospitals. Therefore, it was entirely justified for the petitioner to seek treatment at a facility where an organ was available immediately.
Concluding that the rejection of full reimbursement was arbitrary and unreasonable, the High Court ordered CGHS to reimburse the entire amount of ₹30 lakh incurred by the petitioner, setting a precedent for how life-saving treatment expenses should be handled in exceptional cases involving retired government servants.