A landmark ruling by the High Court of Tripura has affirmed that government employees cannot be denied medical reimbursement solely due to the absence of a prior referral certificate from the Standing Medical Board when emergency treatment is sought outside the state. The judgment underscores that the right to life under Article 21 includes the right to timely and adequate medical care, and procedural formalities must yield to medical necessity.
Background & Facts
The Dispute
The petitioner, Sri Sanjib Das, a government employee of the Tripura State Electricity Corporation Ltd. (TSECL), traveled to Kolkata on 10 January 2023 on commuted medical leave to assist a relative. Upon arrival, he suddenly experienced severe chest pain and was rushed to Rabindranath Tagore International Institute of Cardiac Sciences (RTIICS), Mukundapur - a hospital empanelled by the Government of Tripura as a referral center. He was diagnosed with double-vessel coronary artery disease, underwent coronary angiography on 11 January 2023, and received PTCA with stenting to the LAD on 13 January 2023. His discharge summary confirmed the urgency and medical necessity of the intervention.
Procedural History
- 10 April 2023: Petitioner submitted two medical reimbursement bills totaling ₹3,45,505 in Form No. 49 to TSECL, duly certified.
- 22 August 2023: Deputy General Manager (DGM) requested re-submission with a referral certificate from the Standing Medical Board (SMB).
- 4 December 2023: Director of Health Services informed TSECL that no referral certificate was available and advised use of the revised medical bill form.
- 2 January 2025: SMB issued a letter rejecting ex-post facto approval, claiming similar treatment was available at Agartala’s Government Medical College & GBP Hospital.
- 23 February 2026: Petitioner filed W.P.(C) No. 435 of 2025 before the High Court of Tripura.
Relief Sought
The petitioner sought a writ of mandamus to quash the SMB’s rejection letter and direct the respondents to process and approve his medical reimbursement claim, including interest for delay.
The Legal Issue
The central question was whether the absence of a prior referral certificate from the Standing Medical Board can justify denial of medical reimbursement to a government employee who sought emergency cardiac treatment at an empanelled hospital outside the state, where delay could have been life-threatening.
Arguments Presented
For the Petitioner
Learned Senior Counsel relied on Shiva Kant Jha v. Union of India (2018) 16 SCC 187, arguing that the factum of treatment is the sole criterion for reimbursement, not technical compliance. He emphasized that coronary angiography is a time-sensitive procedure where waiting for SMB approval could be fatal. He also cited Surjit Singh v. State of Punjab (1996) 2 SCC 336 and prior Tripura High Court judgments in WP(C) No. 1479 of 2017 and WP(C) No. 830 of 2019, which held that procedural requirements are directory, not mandatory, in emergencies.
For the Respondent
The State and TSECL contended that Rule 11 of the Tripura Health Policy (2022) mandates prior or ex-post facto referral from the SMB for reimbursement. They relied on State of Punjab v. Ram Lubhaya Bagga (1998) 4 SCC 117, asserting that reimbursement rates are tied to SMB-approved packages and that the petitioner’s failure to follow procedure invalidated his claim. They argued that since Agartala had cardiac facilities, the treatment was not medically necessary outside the state.
The Court's Analysis
The Court undertook a rigorous analysis of the constitutional right to life under Article 21, distinguishing between administrative convenience and human survival. It noted that coronary artery disease, particularly when presenting with acute chest discomfort and positive TMT, demands immediate intervention. The Court observed:
"If the petitioner did not undergo angiography that could lead to danger of his life and based upon the advice of the concerned Medical Officers he undergo this angiography and in that case it was not possible on his part to come back to Agartala for obtaining reference of the Standing Medical Board."
The Court rejected the State’s argument that similar treatment was available in Agartala, noting that availability does not equate to immediate accessibility. It highlighted that the Government’s own memorandum dated 22.12.2022 explicitly permits ex-post facto approval for emergencies arising while on station leave outside the state. The Court further distinguished State of Punjab v. Ram Lubhaya Bagga, clarifying that while reimbursement rates may be capped, eligibility cannot be denied on procedural grounds in life-threatening situations.
The Court also affirmed its own precedents in WP(C) No. 1479 of 2017 and WP(C) No. 830 of 2019, holding that the requirement of a referral certificate is directory, not mandatory, when delay would endanger life. It emphasized that the right to health is inseparable from the right to life, and bureaucratic delays cannot override medical urgency.
The Verdict
The petitioner won. The Court held that denial of medical reimbursement solely due to lack of a prior or ex-post facto referral certificate is unlawful when treatment is sought in an emergency at an empanelled hospital outside the state. The SMB’s rejection letter dated 02.01.2025 was set aside, and the respondents were directed to process the claim within two months, failing which interest at 9% per annum would accrue.
What This Means For Similar Cases
Emergency Treatment Overrides Procedural Hurdles
- Practitioners must now argue that any life-threatening condition - including cardiac events, stroke, acute trauma, or severe infections - automatically triggers the exception to referral requirements.
- Medical records from empanelled hospitals, including discharge summaries and doctor certifications, are sufficient to establish entitlement.
- Denial based on "availability of treatment locally" is invalid if timely access is not practically feasible.
Ex-Post Facto Approval Is Legally Recognized
- Government circulars permitting ex-post facto approval (e.g., Memo 22.12.2022) are binding and enforceable.
- Employees need not prove they attempted to obtain prior approval; they need only prove the sudden onset of emergency and immediate medical necessity.
- Rejection letters citing procedural non-compliance must be challenged on grounds of arbitrariness and violation of Article 21.
Reimbursement Claims Must Be Processed Promptly
- Delays in processing legitimate claims attract interest, as held in this judgment (9% p.a.).
- Departments must establish internal mechanisms to fast-track emergency claims without waiting for SMB ratification.
- Legal officers should advise clients to retain all medical documentation and immediately file claims upon return, citing this judgment as binding precedent.
