Life-saving treatment in non-empanelled hospital must be reimbursed: HC

The Punjab and Haryana High Court has held that medical reimbursement claims cannot be rejected merely because treatment is taken in a non-empanelled hospital, if the circumstances reveal an emergency. The high court also propounded the “test of essentiality and emergency” after holding that life-saving treatment, if undergone in compelling circumstances on medical advice, must be reimbursed even if taken in a non-empanelled hospital.

Stressing that the preservation of human life formed a part of Article 21 of the Constitution and was required to be accorded the highest priority, Justice Harpreet Singh Brar also made it clear that the State was obliged to ensure timely medical care and could not expect citizens to defer life-saving procedures only because the chosen hospital was not on its approved list.

“The test of essentiality and emergency comes into play, which dictates that if the medical procedure was undergone by the petitioner in an emergency, on the advice of a doctor based on medical record, the reimbursement for the same must be made,” Justice Brar asserted.

The Bench observed that the petitioner, a Haryana government employee, had undergone bypass surgery in February 2022 at a non-empanelled hospital. The court noted that the condition was critical and that “the petitioner underwent bypass surgery procedure, which was necessary at that moment in order to save his life, as also depicted by his medical record. Therefore, the test of essentiality and emergency stands satisfied to the extent of bypass surgery.”

At the same time, Justice Brar drew a distinction between essential life‑saving procedures and elective surgeries. Referring to a subsequent gallbladder operation, the Bench observed: “With regard to subsequent gallbladder surgery, it was not necessary at that point of time and the test thereof, essentiality and emergency is not satisfied, as the same was not conducted in an emergency.”

Referring to the constitutional dimension of medical access, the Bench asserted: “Not only is the preservation of human life instinctive, but it also forms a part of Article 21 of the Constitution of India, and therefore, it shall always retain the highest priority. Moreover, the State bears an obligation to ensure the availability of timely medical care to those in need. As such, it cannot expect the citizens to refrain from availing timely care, merely for the reason of non-empanelment of the hospital. Such conduct on the part of the State does not satisfy the criteria of fairness and reasonableness and therefore, amounts to a violation of the fundamental rights enshrined in Article 21.”

Partly allowing the writ petition, Justice Brar directed the authorities to release the reimbursement for the bypass surgery within four months. “The respondents are directed to make remaining payment incurred for the bypass surgery undergone by petitioner within a period of four months from the date of receiving a certified copy of this order,” the Bench ordered.

As for the gallbladder surgery, the court clarified that reimbursement would only be governed by existing policy. “Regarding the reimbursement of amount incurred on subsequent surgery of gall bladder by petitioner, the respondent(s)-competent authority shall pay the amount in terms of their applicable policy, if not made, till date,” Justice Brar ruled.

The ruling is significant as it lays down the principle that medical reimbursement cannot be mechanically denied for treatment in non-empanelled hospitals, and articulates a judicially evolved “test of essentiality and emergency” — a benchmark that is likely to govern future disputes over health-care claims by government employees and pensioners.