Bombay High Court ruled in favour of a retired central govt officer denied heart transplant reimbursement. Court said rejecting his claim violated Article 21 and ordered full payment within 4 weeks.
Mumbai: In a recent judgment, the Bombay High Court recently ruled in favour of a retired central government officer who was denied full medical reimbursement for a heart transplant conducted at a private hospital.
The court said that in such serious medical conditions, the patient has the right to choose an appropriate hospital, especially when no empanelled hospital is equipped to handle such cases.
The court ordered that the entire amount spent on the surgery must be reimbursed to the pensioner within four weeks.
The case was filed by Anirudh Nansi, a Mumbai resident and former Assistant Commissioner with the Central Excise and Customs, Pune.
He had taken voluntary retirement in March 2008. Nansi underwent a heart transplant on December 29, 2020, after suffering from cardiomyopathy since 2009, a condition that had worsened by October 2019.
At that time, the empanelled hospitals under the Central Government Health Scheme (CGHS) were either not performing such surgeries or lacked the required permissions and expertise.
Therefore, he opted for another private hospital in Mumbai.
Despite this, the central government denied his claim of Rs 22 lakh (along with 9% annual interest), stating that reimbursements for surgeries in non-empanelled hospitals can only be processed at CGHS-approved rates and that the balance amount must be borne by the patient.
His claim was officially rejected in April 2022. Nansi then approached the Bombay High Court in 2022.
The division bench of Justice Girish Kulkarni and Justice Advait Sethna strongly criticised the government’s decision, calling it a violation of fundamental rights under Article 21 of the Constitution, which guarantees the right to life.
The court made several key observations, stating that
“to make the man suffer for the refund was a glaring travesty of justice and violation of his fundamental rights.”
It also 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.”
The judges clarified that the central government is bound to consider medical reimbursement claims on a case-to-case basis and should not rely on rigid rules.
the court said,
“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,”
Highlighting the critical nature of heart transplants, the court noted that
“a heart transplant was certainly serious and emergent”, and therefore deserved “to be treated with humane sensitivity and not mechanically in a narrow pedantic view.”
They further stated,
“Any employee, merely because he retired, ought not to be differently treated when it comes to genuine and realistic need.”
The court rejected the reasoning of the High-Powered Committee (HPC) that had denied Nansi full reimbursement on technical grounds.
Addressing the Centre’s stand that the heart transplant was a planned surgery and not an emergency, the court said this was
“not the correct and a legal stand of the Centre.”
It strongly disagreed with the HPC’s justification and said,
“Heart transplantation was a planned surgery and not an emergency” was not a valid reason to deny full reimbursement.
The judges highlighted the seriousness of the procedure and said:
“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.”
They observed that even if there were no specific relaxation guidelines, the HPC should have used its discretionary powers to allow full reimbursement.
The court stated,
“Even if there were no relaxation guidelines, in deserving cases, the HPC should exercise its discretion to award full medical reimbursement.”
Nansi was represented by senior advocate Prakash Shah and advocate Anil Balani, who argued that his surgery was conducted under grave and critical circumstances.
The Centre’s legal representatives, Sharma and Jain, reiterated the guidelines which allowed reimbursements only at CGHS rates for non-empanelled hospitals.
After hearing both sides, the court remarked:
“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.”
It questioned whether in such a pressing medical 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 court further examined whether the standard reimbursement rules could be applied rigidly in such life-threatening cases.
The judges held that:
“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.”
They continued, stating that such a policy would be
“most unrealistic, unfair, and discriminatory as in the present situation.”
In response to the Centre’s stance that the planned nature of the surgery was reason enough to deny full compensation, the High Court firmly stated:
“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.”
It stressed that rules for reimbursement cannot be treated as absolute, especially in exceptional and deserving situations:
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“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.”
Concluding the case, the judges said:
“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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