Frame SOP for medical reimbursement: HC to Central Government Health Scheme Director

The Punjab and Haryana High Court has told the Director, Central Government Health Scheme (CGHS), to formulate a comprehensive standard operating procedure (SOP) governing the entire mechanism of medical reimbursement for employees and retirees.

The direction came as Justice Harpreet Singh Brar imposed Rs 1 lakh in costs on Punjab State Power Corporation Limited for “inordinate, unreasonable and undignified” delay in settling a retiree’s medical claim.

“The policy shall clearly lay down the procedure for the submission, verification and approval of medical bills, including the list of documents, along with their issuing authority, necessary for processing such claims,” Justice Brar ruled.

The Bench also made it clear that the policy might also prescribe a fixed timeline for disbursement. Setting a three-month deadline for formulating the policy, Justice Brar called for an affidavit on the compliance of the directions. The order was also directed to be supplied to the CGHS Director, Chandigarh, for immediate compliance.

Noting that a petitioner had already spent over Rs 3.69 lakh on his wife’s medical treatment, Justice Brar asserted: “The long-term service rendered by the petitioner before retirement entitles him to be reimbursed for medical expenses incurred by him. Denying him this right by taking an insensitive and lackadaisical approach cannot be condoned by this court in any way.”

The ruling came in a case where a retired employee incurred Rs 3,69,113 on his wife’s treatment and submitted all requisite documents for reimbursement. Despite this, the amount was not released. The Director, Health and Family Welfare, Punjab, returned the case, seeking “an item-wise breakup of the package amount”.

Justice Brar asserted that the delay arose solely due to the respondent-hospital’s inability to provide an item-wise breakup, which in any case the petitioner could not be compelled to obtain”. The Bench asserted that an MoU existed between the corporation and the hospital prescribing CGHS package rates for the treatment of retired employees and their dependents. Once such an MoU was in force, the respondents could not deviate from the same.

Allowing the petition, Justice Brar directed the corporation and another respondent to reimburse the full medical expenses incurred for the treatment of the petitioner’s wife’s along with 6 per cent annual interest from the date of submission till realisation.