For mediclaim, PGIMER rates applicable only if facility is provided by institute: HC to Haryana - Hindustan Times
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For mediclaim, PGIMER rates applicable only if facility is provided by institute: HC to Haryana

By, Chandigarh
Sep 30, 2023 08:20 AM IST

Petitioner had approached the high court in 2017 after the government did not reimburse the money he had spent on liver transplant surgery at a Bengaluru hospital in 2016. After he filed the petition, a reimbursement of ₹10 lakh was made.

The Punjab and Haryana high court has ruled that the Haryana government can make reimbursement of mediclaim of an employee or a pensioner on PGIMER rates where the said facility is available in the hospital.

The Punjab and Haryana high court has ruled that the Haryana government can make reimbursement of mediclaim of an employee or a pensioner on PGIMER rates where the said facility is available in the hospital. (HT File)
The Punjab and Haryana high court has ruled that the Haryana government can make reimbursement of mediclaim of an employee or a pensioner on PGIMER rates where the said facility is available in the hospital. (HT File)

“…When the said surgery/treatment undertaken by the petitioner was not available in the PGIMER, Chandigarh, calculation of the medical reimbursement claim on the basis of the PGIMER rates is without any valid justification,” the bench of justice Harsimran Singh Sethi said while asking the government to re-consider reimbursement claim raised by one Subhash Sharma, who retired as chief accounts officer from the Haryana government.

Sharma had approached the high court in 2017 after the government did not reimburse the money he had spent on liver transplant surgery at a Bengaluru hospital in 2016. After he filed the petition, a reimbursement of 10 lakh was made.

Director general, treasuries and accounts department, Haryana, had stated in response to the plea in high court that according to the state’s reimbursement policy issued in 2005, for treatment taken from an unapproved hospital in emergency, amount equivalent to the rates charged for the treatment at PGIMER Chandigarh will be reimbursed. Accordingly, in this case, a sum of 10 lakh, which is equivalent to the PGIMER rates for liver transplant, has been reimbursed to the petitioner.

As per the plea, the petitioner was suffering from a liver ailment and after getting diagnosed, he was advised to undergo liver transplantation. As no donor was available in the North India, the petitioner got himself registered in Manipal hospital, Bengaluru, where he spent 24 lakh from his own pocket. Thereafter, he raised a medical claim for reimbursement of the amount. But the respondents did not reimburse the medical claim on the ground that no package was provided for undergoing liver transplantation.

The court recorded that it was a conceded position that though, initially the petitioner’s medical claim for reimbursement was not entertained by the respondents but thereafter, upon reconsideration, a sum of 10 lakh was approved.

The court observed that the argument from the government cannot be raised for the reason that it is a conceded position that no liver transplantation/surgery from a dead donor was being conducted at PGIMER, Chandigarh, at the relevant time and the said facility was only available at the hospital where the petitioner had undergone the surgery. “PGIMER, Chandigarh rates can only be applied/considered in case the said facility was very much available in the PGIMER, Chandigarh but still the claimant availed the same from the unapproved hospital due to emergent situation,” the bench said adding that government interpretation of 2005 policy was wrong.

Now it has been directed that his claim be reconsidered in view the observations of the court and whatever amount the petitioner was entitled to, be reimbursed to him. The government has been given eight weeks to take a decision and for whatever amount he is found entitled for is to be released within four weeks of the decision taken.

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