Case at a Glance
A Sorting Assistant of the postal department in Cuttack was referred from the Neurology OPD of SCB Medical College to neurosurgery in December 2018. In January 2019 his condition worsened and his family took him to KIMS, Secunderabad, where he underwent two surgeries costing ₹4,31,721. The department rejected reimbursement because he was treated outside the State without referral or prior permission. Relying on Shiva Kant Jha v. Union of India, (2018) 04 SC CK 0027, which says “The real test must be the factum of treatment”, the CAT quashed the rejections and directed sanction of the full ₹4,31,721 within 90 days.
On 18 December 2018 the applicant was seen at the Neurology OPD of SCB Medical College & Hospital, Cuttack and referred to Neurosurgery; the parties dispute whether he actually consulted a neurosurgeon. On 4 January 2019 his condition deteriorated; he was reportedly unconscious and advised immediate surgery, and his family says attempts at hospitals in Cuttack and Bhubaneswar failed. He was admitted to KIMS, Secunderabad from 6 to 9 January 2019 (surgery on 7 January; bill ₹1,74,116) and again from 29 January to 2 February 2019 (surgery on 30 January; bill ₹2,53,717).
His claims totalling ₹4,31,721 were rejected on 11 June 2020 for treatment outside the State without referral, and his appeal was rejected on 20 July 2020. In an earlier O.A. the Tribunal on 9 April 2021 directed a fresh representation to be decided by a reasoned order; it was rejected again on 6 July 2021. The department argued that there was no prior permission or referral, that emergency was not established, that empanelled hospitals in Odisha could have treated him, and that reimbursement is capped at prescribed rates.
The Key Question Before the Court
Can a central government employee be denied medical reimbursement for emergency surgery outside the State only because he lacked a referral or prior permission?
The Real Test Is the Factum of Treatment
The Tribunal considered Rule 6(4) of the CCS (Medical Attendance) Rules, 1944 and the Office Memoranda on referrals and emergency admission. It reproduced Shiva Kant Jha v. Union of India, where the Supreme Court held that “The real test must be the factum of treatment” and that “the law does not require that prior permission has to be taken in such situation” where survival is at stake.
It also relied on a Delhi High Court judgment (WP(C) No. 10684/2022, decided 10 May 2023) that emergency treatment should not be denied reimbursement merely because the hospital is not empanelled, and on Anirudh Prataprai Nansi v. State of Maharashtra, which held that claims in serious cases should be considered on merits with Article 21 in view. On that basis it concluded that the rejection was illegal. The respondents had cited State of Punjab v. Ram Lubhaya Bagga, (1998) 02 SC CK 0106 on approved rates and argued that Shiva Kant Jha was confined to its facts, but the order does not expressly deal with these points.
What the Court Actually Held
- The rejection orders dated 11 June 2020, 20 July 2020 and 6 July 2021 were quashed.
- Absence of referral or prior permission did not justify rejecting a claim for emergency treatment, applying the ‘factum of treatment’ test.
- The respondents must sanction reimbursement of ₹4,31,721 within 90 days of receiving the order.
- The O.A. was allowed without costs; no interest was mentioned.
Why This Judgment Matters
- Employees and pensioners in medical emergencies often cannot wait for referrals; the order supports reimbursement where treatment was genuinely needed.
- It applies Shiva Kant Jha to treatment outside the State, not just at non-empanelled hospitals.
- It shows that a remanded claim rejected again without proper reasons can be quashed outright.
What Should Advocates Take Away From the Judgment?
For Employees and Pensioners
- Keep OPD slips, referral notes and records of hospitals that could not admit you.
- File the claim promptly with all bills, and appeal if rejected.
- Emergency treatment without referral may still be reimbursable.
For Counsel
- Rely on Shiva Kant Jha’s ‘factum of treatment’ test against referral-based rejections.
- Anticipate the rate-cap argument from Ram Lubhaya Bagga; here full reimbursement was ordered.
- Cite the Delhi and Bombay High Court rulings on emergency treatment and Article 21.
Key Takeaways
- Lack of referral did not defeat a claim for emergency neurosurgery.
- The ‘factum of treatment’ test from Shiva Kant Jha was applied.
- Full reimbursement of ₹4,31,721 was ordered within 90 days.
- The order did not address interest or the rate cap.
Frequently Asked Questions
Can I get medical reimbursement if I was treated in another State without referral?
In this case, yes. The CAT Cuttack applied Shiva Kant Jha v. Union of India and held that the claim for emergency surgery could not be rejected merely for lack of referral or prior permission.
How much was ordered and by when?
The full claim of ₹4,31,721, to be sanctioned within 90 days of receipt of the order.
Was interest awarded?
The order does not mention interest.
Conclusion
The Tribunal looked past the referral paperwork to the reality: an employee with a serious neurological condition who needed surgery. Applying the ‘factum of treatment’ test, it set aside three rejections.
Practical takeaway: In emergency treatment claims, document the urgency and the attempts to get treatment locally; procedural lapses like a missing referral may not defeat a genuine claim.
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