Pensioners’ Medical Reimbursement: Supreme Court Directs Timely CGHS Payments

The case of Shiva Kant Jha vs. Union of India addresses the issue of medical reimbursement for retired government employees under the Central Government Health Scheme (CGHS). The petitioner, a retired pensioner, challenged the delay and partial rejection of his medical reimbursement claims, citing unfair treatment of pensioners under CGHS policies.

The petitioner had incurred significant medical expenses due to emergency treatments at private hospitals but was only reimbursed partially by the CGHS. After multiple attempts to get full reimbursement, the petitioner approached the Supreme Court under Article 32 of the Constitution, arguing that the denial of rightful reimbursement violated his fundamental rights.

Arguments by the Petitioner (Shiva Kant Jha)

• The petitioner argued that the rejection and partial reimbursement of his medical claims were arbitrary and unjust.
• He contended that CGHS officials did not provide a fair hearing and rejected his claims without valid reasoning.
• The petitioner claimed that retired government employees were being unfairly treated under CGHS policies, leading to financial and emotional distress.
• He urged the Supreme Court to intervene and ensure proper medical reimbursement for all pensioners.

Arguments by the Respondent (Union of India)

• The government argued that the petitioner’s medical treatment was taken at a non-empanelled hospital without prior approval, which was against CGHS guidelines.
• It stated that CGHS reimbursement was processed as per standard rates, and any excess charges by private hospitals could not be covered.
• The respondents maintained that providing special reimbursement to the petitioner would lead to large-scale violations of policy and create financial burdens.

Supreme Court’s Observations

The Supreme Court took a strong stance against the unjust treatment of retired government employees under CGHS. The key observations included:

• The government has a duty to provide medical benefits to retired employees, and reimbursement cannot be denied on technical grounds.
• Medical treatment decisions are made by doctors, and pensioners cannot be expected to follow bureaucratic procedures during medical emergencies.
• The rejection of reimbursement without giving the petitioner an opportunity to be heard was unfair and violated principles of natural justice.
• CGHS officials must be more responsive and accountable when dealing with pensioners’ medical claims.

Final Judgment

The Supreme Court ruled in favor of the petitioner and directed the following:

• The government must reimburse the remaining amount of Rs. 4,99,555/- to the petitioner.
• A high-powered committee must be formed within the Ministry of Health to ensure timely resolution of pensioners’ medical reimbursement claims.
• All pending and future medical claims must be processed and reimbursed within one month of submission.
• These directions apply to all pensioners under CGHS and aim to prevent unnecessary hardships in the future.

This landmark ruling reinforces the rights of retired government employees to fair medical reimbursement and ensures accountability in CGHS operations.

Petitioner Name: Shiva Kant Jha.
Respondent Name: Union of India.
Judgment By: Justice R.K. Agrawal, Justice Ashok Bhushan.
Place Of Incident: New Delhi.
Judgment Date: 13-04-2018.

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