In a significant ruling, the Karnataka High Court has emphasized that when a recognized government hospital refers a government employee to a non-empanelled private hospital under exceptional circumstances, the employee is entitled to reimbursement of medical expenses. This directive was issued by the court while addressing a petition filed by a government servant seeking compensation for his medical bills, which were rejected by the Suvarna Arogya Suraksha Trust of the state government.

Justice Hemant Chandangoudar, while presiding over the case, ruled in favor of the petitioner, Nagabhushana B, an assistant court officer at the Karnataka High Court. Nagabhushana had challenged the rejection of his medical claim by the Trust, which was based on the argument that his situation did not fall under the emergency circumstances outlined in a Government Order (GO) issued on November 5, 2014.

The petitioner had initially been admitted to the Jayadeva Institute of Cardiovascular Sciences and Research, located on the premises of KC General Hospital in Malleswaram, Bengaluru. However, due to the complexity of his medical condition, he was referred to the Mazumdar Shaw Medical Centre, a private and non-empanelled hospital, for further treatment by a pulmonologist. After receiving treatment, Nagabhushana submitted a claim for reimbursement of Rs 2.63 lakh, supported by all necessary documents, including prescriptions, bills, and a discharge summary issued on December 23, 2022.

In addition to submitting the required documents, the petitioner provided a detailed explanation to the Registrar General of the Karnataka High Court, outlining the emergency circumstances that necessitated his treatment at a non-empanelled hospital. The Registrar General subsequently communicated the details to the Suvarna Arogya Suraksha Trust. Despite this, the Trust rejected Nagabhushana’s reimbursement claim on January 23, 2023, asserting that the case did not meet the criteria for emergency circumstances as defined in the 2014 GO.

The GO, however, provides certain provisions for government employees who are referred to non-empanelled private hospitals under exceptional situations. It clearly states that if a recognized government hospital refers a government servant to a private hospital due to special circumstances, the employee is eligible for reimbursement of medical expenses. The GO further clarifies that these referrals must be documented and justified by the government hospital in question.

The High Court, after reviewing the case, ruled that the petitioner was entitled to reimbursement under Clause 5 of Paragraph 3 of the 2014 GO. This clause permits government employees to seek reimbursement at predetermined rates for treatment received at private hospitals, as long as the referral is made by a recognized government hospital. The court stressed that the referral in this case was valid, as the petitioner’s condition required specialized care that was not available at the government hospital, justifying his treatment at a private institution.

Justice Chandangoudar quashed the order issued by the Suvarna Arogya Suraksha Trust, which had initially rejected Nagabhushana’s claim. The court directed the Trust to reconsider the petitioner’s claim for reimbursement, provided all necessary documents were submitted. The ruling underscored that government servants should not be penalized for seeking urgent medical care at non-empanelled hospitals if they were referred by government institutions under exceptional circumstances. It emphasized that the Trust’s rejection of the claim was not in line with the provisions of the GO, which is designed to support government employees in such situations.

The court’s decision has broader implications for public sector employees in Karnataka, as it reinforces the principle that medical expenses should be reimbursed if a government hospital refers a patient to a non-empanelled private hospital. This ruling helps clarify the rights of government servants to seek medical reimbursement and holds government bodies accountable for following the established guidelines in such cases.

The High Court also noted that this ruling should serve as a reminder to government agencies and trusts responsible for processing medical claims. They must ensure that legitimate claims, especially those involving referrals from recognized government hospitals, are not unfairly rejected. The court’s intervention in this case sends a strong message about the importance of following due process and ensuring that public servants receive the benefits they are entitled to under the law.

In conclusion, the Karnataka High Court's ruling in favor of Nagabhushana B not only quashed the rejection of his medical claim but also directed the Suvarna Arogya Suraksha Trust to review the claim with a view to reimbursing the petitioner. The decision highlights the rights of government employees to medical reimbursement and underscores the need for government agencies to adhere to the guidelines set forth in the 2014 GO.

(Input from various sources)

(Rehash/Yash Kamble)