The Punjab and Haryana High Court has reaffirmed that the right to health under Article 21 of the Constitution overrides rigid procedural conditions in post-retirement medical schemes. In a significant ruling, the Court held that denial of reimbursement for treatment at a NABH-accredited hospital, merely due to lack of formal empanelment at the time of treatment, is arbitrary and unconstitutional.
Background & Facts
The Dispute
The petitioner, a retired Manager (Quality Control) of the Food Corporation of India (FCI), sought reimbursement of medical expenses incurred for a right total knee replacement under the Post Retirement Medical Scheme (PRMS), notified by FCI in December 2016. The PRMS provides a lifetime ceiling of Rs. 4,00,000 for treatment of specified major diseases, including joint replacement, at government hospitals, FCI-empanelled hospitals, or "such other hospital of national repute as may be notified" by the CMD, FCI.
Key Facts
- The petitioner underwent right total knee replacement surgery at Amandeep Hospital, Amritsar, during two treatment periods: 11.09.2017 to 21.08.2017 and 05.12.2017 to 20.12.2017.
- The treatment was for a specified condition under Clause 6.8 of the PRMS: joint replacement surgery.
- Amandeep Hospital was not formally empanelled or notified by FCI as a hospital of national repute at the time of treatment (December 2017).
- The hospital, however, was accredited by the National Accreditation Board for Hospitals & Healthcare (NABH).
- The petitioner submitted all original medical bills, discharge summaries, and doctor certifications.
- The Chief Medical Officer, FCI, opined that since the hospital was neither empanelled nor notified, reimbursement was not permissible under Clause 6.8.
- The FCI returned the bills and rejected the claim via communications dated 19.09.2018 and 07.01.2019.
- Subsequent to the rejection, Amandeep Hospital was empanelled by FCI.
- The petitioner did not seek prior approval before undergoing treatment.
- No dispute exists regarding the genuineness of the treatment, authenticity of bills, or medical necessity.
Procedural History
- December 2016: PRMS notified by FCI.
- 05.12.2017 to 20.12.2017: Petitioner underwent knee replacement surgery at Amandeep Hospital.
- 19.09.2018: First rejection letter issued by FCI.
- 07.01.2019: Second rejection letter issued, reaffirming denial.
- 23.12.2019: Writ Petition (CWP-34830-2019) filed before the Punjab and Haryana High Court.
- 23.03.2026: Judgment delivered by Justice Sandeep Moudgil.
Relief Sought
The petitioner sought quashing of the rejection orders dated 19.09.2018 and 07.01.2019, and a direction to FCI to reimburse medical expenses up to Rs. 4,00,000 under Clause 6.8 of the PRMS.
The Legal Issue
The central question was whether the term "hospital of national repute" under Clause 6.8 of the Post Retirement Medical Scheme must be confined strictly to hospitals formally notified by the FCI CMD, or whether it can include institutions with recognized medical standards, such as NABH accreditation, even in the absence of prior formal empanelment.
Arguments Presented
For the Petitioner
Learned counsel argued that the PRMS is a welfare scheme designed to ensure post-retirement medical security, and must be interpreted purposively. The term "hospital of national repute" is inherently broad and cannot be reduced to a mere administrative label. Amandeep Hospital’s NABH accreditation demonstrated its competence and credibility at the time of treatment. Denial on technical grounds violates Article 14 and the constitutional right to health under Article 21. Reliance was placed on Shiva Kant Jha v. Union of India and Surjit Singh v. State of Punjab to establish that genuine medical need overrides procedural technicalities.
For the Respondent/State
The respondents contended that the PRMS is a policy scheme with clearly defined eligibility criteria. Clause 6.8 explicitly limits reimbursement to government hospitals, empanelled hospitals, or those specifically notified by the CMD. At the time of treatment, Amandeep Hospital was neither empanelled nor notified. Subsequent empanelment cannot have retrospective effect. No emergency or prior approval was established to justify deviation. The petitioner had already received reimbursement for non-empanelled treatment up to permissible limits, and no further claim was maintainable.
The Court's Analysis
The Court began by anchoring its analysis in Article 21, recognizing the right to health as an essential component of the right to life. It observed that while the State may frame welfare schemes, it cannot administer them in a manner that renders the benefit illusory.
"The right to medical claim cannot be denied merely because the name of the hospital is not included in the Government Order. The real test must be the factum of treatment."
The Court cited Shiva Kant Jha v. Union of India to emphasize that the ultimate decision on treatment rests with the treating physician, not bureaucratic classifications. The Court rejected the notion that a patient, particularly a retired senior citizen, must navigate complex empanelment lists before seeking urgent care.
It further noted that the expression "hospital of national repute" in Clause 6.8 is not a closed category. The NABH accreditation of Amandeep Hospital was not merely a post-facto validation - it was a contemporaneous indicator of medical standards. The Court held that subsequent empanelment, while not retrospective, carries persuasive evidentiary value in assessing whether the hospital met the standard of "national repute" at the time of treatment.
The Court also rejected the argument that prior approval was mandatory. Clause 6.8 contains no such condition. To impose it would be to add a term not present in the scheme and impose an impractical burden on elderly claimants.
The Court concluded that the rejection was hyper-technical, arbitrary, and inconsistent with the constitutional ethos of dignity and health. The State’s rigid adherence to procedural formalities, in the face of undisputed medical necessity and expenditure, amounted to a violation of Article 14.
The Verdict
The writ petition was allowed. The impugned orders dated 19.09.2018 and 07.01.2019 were set aside. The respondents are directed to process and release the petitioner’s claim for medical reimbursement up to Rs. 4,00,000 under Clause 6.8 of the PRMS. Any amount found due shall be released within six weeks from the date of receipt of a certified copy of this order. No interest shall be payable, as the petitioner has waived any claim for interest on arrears.
What This Means For Similar Cases
Medical Reimbursement Cannot Be Denied on Technical Grounds
- Practitioners representing retired employees must now argue that denial of reimbursement under welfare schemes like PRMS or CGHS is unconstitutional if the treatment is genuine, necessary, and rendered by a hospital with recognized accreditation (e.g., NABH, NABL).
- The burden shifts to the authority to prove that the hospital lacked credibility at the time of treatment - not merely that it lacked formal notification.
NABH Accreditation Is a Valid Proxy for "National Repute"
- NABH accreditation is now a legally recognized benchmark for assessing hospital quality in medical reimbursement disputes.
- Authorities cannot ignore accreditation merely because formal empanelment was pending.
- Future claims should be supported by NABH certificates, hospital credentials, and treating doctor affidavits.
Prior Approval Is Not Mandatory Unless Explicitly Required
- Where a scheme does not expressly require prior approval, authorities cannot impose it as a condition.
- Retired employees, especially those with chronic or emergency conditions, must be allowed to seek timely treatment without bureaucratic delays.
- Any scheme requiring prior approval must clearly state this condition in writing.
