Ghanshyam Singh Rathore, S/o. Ramdan Singh v. Secretary, Finance Department, Government Of Rajasthan
2025-11-14
FARJAND ALI
body2025
DigiLaw.ai
Order : FARJAND ALI, J. 1. The instant writ petition under Article 226 of the Constitution of India has been preferred by the petitioner being aggrieved of the action of the respondent in denying reimbursement of the medical bills under the RGHS. 2. The petitioner had served in the Police Department, Government of Rajasthan and retired from the post of Additional Superintendent of Police and as such he is eligible for Rajasthan Government Health Scheme (RGHS) and is entitled to avail all the benefits provided under the said scheme. The said scheme also provided healthcare benefits to the family members of the pentioners under Section 3(3) of the Scheme’s Guidelines (Memorandum). The petitioner's wife Mrs. Anand Kanwer was diagnosed with Right eye full thickness macular hole and she underwent treatment of right eye Vitrectomy (PPV) + ILMPEELING + C3F8 gas tamponade under LA, at Netralaya-Super Speciality Eye Hospital at Ahmedabad and later on the bill of this procedure was submitted on portal for RGHS reimbursement but it has been "REJECTED" with the remark that rejected because this is case is "This a Non-Emergency Condition”. 3. Learned counsel for the petitioner submits that the reimbursement claim of the petitioner under the RGHS was rejected assigning the only reason that the treatment was availed at a non-recognized hospital without there being emergent situation. However, the fact remains that the petitioner’s wife suffered acute pain and vision loss in the right eye, upon which she was taken to Dr. Kaushalendra Kumar (M.S. Phaco Surgeon) at the Rajasthan Eye Hospital and Dr. Kumar, Laser Phaco Center, Sumerpur, Pali, where she was diagnosed with right eye full thickness molecular hole in retina, which could led to distorted vision in the affected eye and required surgical intervention to repair and there was as such no facility and specility doctors in Jodhpur or Pali to perform this surgery, therefore, the doctor referred the patient to Netralaya Super Speciality Eye Hospital at Ahmedabad, where the petitioner underwent the required surgery. Learned counsel for the petitioner submits that the RGHS does not define non-emergent and emergent conditions, therefore, the department should rely on fair and consistent interpretation of the terms, potentially guided by the medical experts. He further submis that there are no restriction or embarge udner the rules of RGHS which could prevent reimbursement to the petitioner despite submitting all the relevant documents through RGHS portal. 4.
He further submis that there are no restriction or embarge udner the rules of RGHS which could prevent reimbursement to the petitioner despite submitting all the relevant documents through RGHS portal. 4. It was urged that treatment undertaken in an emergency cannot be denied reimbursement merely because it occurred in a private or non-recognized hospital, as the right to medical relief is integral to Article 21 of the Constitution. The respondents’ inaction, it was argued, reflects administrative apathy, violates Articles 14, 16, and 21, and frustrates the object of the welfare scheme. The petitioner, having suffered prolonged financial and mental distress, thus seeks full reimbursement with interest. 5. Learned counsel for the respondents submitted that the petitioner’s grounds are mere reiterations of earlier contentions already dealt with in the reply to the legal notice served by her. The impugned action is lawful, justified, and in conformity with the applicable rules. Under the RGHS, reimbursement of actual expenses incurred in a non-recognized private hospital is impermissible, except to the extent admissible at recognized rates. Reliance is placed on the order passed by a co-ordinate Bench of this court in the case of B.L. Verma v. State of Rajasthan (SBCWP No.2864/1995 decided on 20.05.2008) wherein this Hon’ble Court held that reimbursement is limited to rates prescribed for recognized institutions. 6. It is further urged that the petitioner cannot claim benefits de hors the rules, circulars, or judicial precedents, nor raise new grounds during arguments without affording rebuttal. Hence, the writ petition is devoid of merit and liable to be dismissed with costs. 7. I have heard the learned counsel for the parties and gone through the niceties of the matter as also the material placed on record. 8. Having heard the learned counsel for the parties and upon a meticulous perusal of the record, this Court finds that the controversy pivots around a narrow yet significant issue: whether the petitioner is entitled to reimbursement of medical expenses incurred for the treatment of his wife at Netralaya Super Speciality Eye Hospital, a private institution situated outside the State, under the ambit of RGHS. 9.
9. The petitioner’s wife suffered from pain and vision loss in the right eye, upon which she was taken to nearby specialists, where she was diagnosed with right eye full thickness molecular hole in retina, which could led to distorted vision in the affected eye and required surgical intervention to repair. Since there was as such no facility and specility doctors in Jodhpur or Pali to perform this surgery, therefore, the doctor referred the patient to Netralaya- Super Speciality Eye Hospital at Ahmedabad, where the petitioner underwent the required surgery. The respondents in their reply to the legal notice served by the petitioner has stated that the claim of the petitioner was rejected for the reason that treatment was taken from a non-recognized hospital without there being any emergent situation. However, this court is of the considered opinion that possibility of vision loss or distorted vision definitely constitutes an emergent circumstances requiring immediate medical intervention. The respondents in their reply to the legal notice have referred to the point No.11 of the notification dated 16.07.2021 issued by the Finance Department under the Medical Attendance Rules, wherein it is clearly provided that the reimbursement shall be allowed to the extent as per RGHS rates or actual, whichever is less, even in case of treatment from private unrecognized hospital within the State or outside the State in case of grave emergency, however, the emergent nature of hospitalization in private hospital has to be established by an affidavit of the employee supported by a certificate of the treating doctor. In the case at hand, the petitioner has submitted an additional affidavit alongwith the Exterme Uregency Certificate (??????????? ?????? ????) issued by the treating doctor. The petitioner has also annexed all the other relevant documents alongwith the writ petition explaining the emergent circumstances. 10. It is trite that the right to medical aid forms an inseparable facet of the right to life guaranteed under Article 21 of the Constitution of India. The State, being a model and welfare employer, is under a constitutional as well as moral obligation to safeguard the health and well-being of its employees and their dependents. Denial of reimbursement merely because treatment was availed at a private or non-recognized institution, particularly during an emergency, is antithetical to the spirit of the welfare State and the mandate of Articles 14, 16, and 21. 11.
Denial of reimbursement merely because treatment was availed at a private or non-recognized institution, particularly during an emergency, is antithetical to the spirit of the welfare State and the mandate of Articles 14, 16, and 21. 11. The Hon’ble Division Bench of this Court in State of Rajasthan & Ors. v. Surendra Kumar Kalra [RLW 2008 (3) Raj. 1953] has lucidly enunciated that in cases of emergent medical exigency, the government cannot rigidly insist that its employees obtain treatment solely from government-recognized institutions. The Court held that when immediate medical intervention is imperative for saving life, delay can prove fatal, and hence, reimbursement must be accorded at rates applicable to recognized government hospitals. 12. Similarly, the Hon’ble Supreme Court in Suman Rakheja v. State of Haryana [ (2004) 13 SCC 562 ] held that where a patient was admitted in an emergent condition to a non- recognized private hospital, the employee was entitled to full reimbursement at AIIMS rates and 75% of the expenses exceeding such rates. The Apex Court underscored that emergency circumstances override procedural formalities, and the State’s duty to preserve life cannot be diluted by technicalities. 13. A Coordinate Bench of this Court, in Kanhaiya Lal Dave v. State of Rajasthan & Ors. [S.B. Civil Writ Petition No. 420/2009] and Gyanendra Kumar Pareek v. State of Rajasthan [2009 (4) WLC (Raj.) 95], reiterated that “emergency knows no law and no procedure,” emphasizing that when human life is imperiled, the State cannot abdicate its responsibility. It was held that reimbursement must be granted even if treatment was obtained at an unrecognized hospital or outside the State without prior reference, subject, however, to the rates prescribed for recognized institutions. 14. This legal position was reaffirmed in S.B. Civil Writ Petition No. 5714/2011 – Sohan Lal Sharma v. State Finance Department & Ors., decided on 04.12.2024 , wherein the Coordinate Bench, while drawing upon the aforementioned precedents, observed that reimbursement cannot be withheld merely on account of the treatment having been undertaken in an unrecognized hospital outside the State or without prior permission. The Court directed that reimbursement must be processed strictly in accordance with the prescribed rates, together with interest at 6% per annum after 30 days of submission of bills. 15.
The Court directed that reimbursement must be processed strictly in accordance with the prescribed rates, together with interest at 6% per annum after 30 days of submission of bills. 15. For ready reference, this Court recalls the following extract from Sohan Lal Sharma (supra) , which draws from the judgments in Kanhaiya Lal Dave and Gyanendra Kumar Pareek “When a family member suffers from a cardiac ailment, the prime objective of the other family member would be to save his/her life. Emergency knows no law and no procedure, and when human life is at stake, the ultimate responsibility of the State cannot be washed off. The Government cannot insist upon an employee to get himself treated only at a recognized government institution. All that the Government can do in such circumstances is to reimburse the concerned employee at the rates applicable to recognized government hospitals.” The judgment further relied on Surjit Singh v. State of Punjab [ AIR 1996 SC 1388 ] and State of Punjab & Ors. v. Mohan Lal Jindal [ (2001) 9 SCC 217 ], wherein the Supreme Court unambiguously held that reimbursement must be made even if the treatment is undertaken in an unrecognized hospital or outside the State, provided it is emergent in nature. 16. In the backdrop of these judicial pronouncements, it is abundantly clear that the petitioner’s case falls squarely within the ambit of an emergent medical situation, yet, even this amount admissible at the RGHS rates was never disbursed, reflecting administrative apathy and insensitivity. 17. This Court, therefore, finds that the denial of reimbursement in such circumstances not only frustrates the object of the RGHS but also infringes upon the petitioner’s fundamental rights under Article 21. The respondents were expected to act with fairness, empathy, and promptitude. 18. Accordingly, this Court reiterates that the petitioner is entitled to reimbursement of the medical expenses incurred for the treatment of his wife at Netralaya-Super Speciality Eye Hospital, restricted to the rates applicable to recognized government hospitals in Rajasthan (such as S.M.S. Hospital, Jaipur), as envisaged under the RGHS. 19. In the result, the writ petition thus succeeds and is hereby allowed to the extent indicated above. No order as to costs. Stay applications and all pending applications, if any, stand disposed of accordingly. 20.
19. In the result, the writ petition thus succeeds and is hereby allowed to the extent indicated above. No order as to costs. Stay applications and all pending applications, if any, stand disposed of accordingly. 20. The respondents are directed to verify the petitioner’s medical bills, process the same in accordance with the prescribed rates, and release the admissible amount after deducting any payment already made. The amount shall carry interest at the rate of 6% per annum from the expiry of 30 days after the submission of bills until the date of actual payment.