Case at a Glance
A 72-year-old retired Assistant Grade I of the Food Corporation of India, a member of its Post-Retirement Medical Scheme, was diagnosed with urothelial carcinoma and underwent surgery at Aster Medicity, a non-empanelled private hospital, on 26 December 2023 at a cost of ₹3,64,126. FCI rejected his claim because the hospital was not empanelled, arguing that the surgery was elective and that he could have been treated where it was first advised. A Single Judge set aside the rejection, and a Division Bench dismissed FCI’s appeal, holding, on the basis of Shiva Kant Jha v. Union of India, (2018) 04 SC CK 0027, that a patient facing a grave, potentially life-threatening condition cannot be forced to run from hospital to hospital.
The respondent retired from FCI as an Assistant Grade I and was a paying member of the FCI Post-Retirement Medical Scheme (PRMS). He was diagnosed with malignant urothelial carcinoma; a certificate from Amrita hospital recorded the need for radical surgery. Amrita offered robotic surgery only after a wait of several weeks. Fearing that the disease would spread, he went to Aster Medicity, which operated almost immediately, on 26 December 2023, at a cost of ₹3,64,126.
FCI rejected his reimbursement claim on the ground that the treatment had been taken at a “non-CGHS empanelled private hospital”. It contended that under PRMS reimbursement is available only for empanelled hospitals, with the enhanced ‘Special Life Time Ceiling’ limited to government, FCI-empanelled or notified hospitals of national repute; that his own letters showed the surgery was elective; and that he could have continued treatment at Amrita. A Single Judge allowed his writ petition on 17 February 2025 and set aside the rejection; FCI appealed.
The Key Question Before the Court
Can a retired employee’s medical reimbursement for urgent cancer surgery be refused only because the surgery was done at a hospital not empanelled under the employer’s scheme?
Grave Illness, Doctor’s Choice and the Empanelment Rule
The Division Bench found that the disease and the need for radical surgery were established by the Amrita certificate, leaving only the question whether treatment at a non-empanelled hospital was permissible. Applying Shiva Kant Jha v. Union of India, it held that decisions on lifesaving treatment are governed by the doctor’s choice and treatment protocols, and that a patient “cannot be forced to run from hospital to hospital” to verify empanelment. It also followed Union of India v. K.J. Joseph, (2026) 06 KL CK 1227, an earlier decision of the High Court which the Bench treated as a similar case.
The Bench rejected FCI’s reliance on inconsistencies in the respondent’s correspondence; they did not show that his condition was not urgent. His wish to obtain a second opinion was “normal human behaviour and response” and did not mean the surgery was elective. The condition was grave and potentially life-threatening, not a matter of choice. The Bench added that the relief rests on the peculiar facts of the case, since each case must be decided on its own facts, and dismissed the appeal, confirming the Single Judge’s views and directions.
What the Court Actually Held
- Surgery for malignant urothelial carcinoma requiring radical surgery was not elective; the condition was grave and potentially life-threatening.
- Following Shiva Kant Jha v. Union of India, a patient in such a situation cannot be forced to run from hospital to hospital to check empanelment.
- Inconsistencies in the patient’s letters and his wish for a second opinion did not show that the treatment was not urgent.
- FCI’s writ appeal was dismissed and the Single Judge’s judgment setting aside the rejection of reimbursement was confirmed.
Why This Judgment Matters
- Retired employees in contributory medical schemes are frequently denied claims over hospital empanelment.
- It applies the Supreme Court’s patient-centred approach in Shiva Kant Jha to a post-retirement scheme of a public sector body.
- It explains why a second opinion or delay at one hospital does not make surgery elective.
What Should Advocates Take Away From the Judgment?
For Retired Employees and Patients
- Keep medical certificates showing the diagnosis, the urgency and any waiting period offered by the first hospital.
- A claim rejected solely for non-empanelment can be challenged where the treatment was urgent and necessary.
- Seeking a second opinion is not by itself evidence that the surgery was optional.
For Counsel
- Rely on Shiva Kant Jha v. Union of India and Union of India v. K.J. Joseph for treatment at non-empanelled hospitals in emergencies.
- Frame the record around the medical urgency, not the correspondence with the employer.
- Note the Bench’s caution that relief turns on the facts of each case.
Key Takeaways
- Urgent cancer surgery at a non-empanelled hospital is reimbursable on these facts.
- A patient cannot be made to run from hospital to hospital.
- A second opinion is normal human behaviour, not proof of elective surgery.
- FCI’s appeal dismissed; Single Judge’s directions confirmed.
Frequently Asked Questions
Did the Court strike down FCI’s empanelment rule?
No. It held that on the facts the respondent’s grave condition justified treatment at a non-empanelled hospital, and it said each case must be decided on its own facts.
What is the Post-Retirement Medical Scheme?
It is FCI’s contributory medical scheme for retired employees; the respondent was a paying member. FCI argued it reimburses treatment only at empanelled hospitals.
Which Supreme Court decision did the Court follow?
Shiva Kant Jha v. Union of India, which holds that treatment decisions rest with the doctor and that treatment at a non-listed hospital does not by itself bar reimbursement.
Conclusion
The Division Bench placed the patient’s situation ahead of the administrative rule: a 72-year-old facing cancer surgery cannot be expected to wait or shop for an empanelled hospital. The employer’s reliance on stray lines in his letters could not convert an urgent operation into an elective one.
Practical takeaway: If a medical claim is refused only because the hospital was not empanelled, gather the medical record of urgency and waiting time — under Shiva Kant Jha, that can carry the claim.
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