The Punjab and Haryana High Court has delivered a landmark judgment, ruling that medical reimbursement claims cannot be denied solely because treatment was received at a non-empanelled hospital. In a significant decision, the court directed an organization to fully reimburse a retired employee Rs 20.30 lakh for his son's emergency heart transplant surgery, which was performed at a hospital not on the approved list.
Court's Emphasis on the Right to Life
Justice Harpreet Singh Brar, presiding over the case, underscored that the preservation of human life is not only instinctive but also a fundamental right enshrined under Article 21 of the Constitution of India. The court observed that this right must always retain the highest priority, especially in medical emergencies where timely care is crucial.
Background of the Case
The petitioner, a retired employee, had a son diagnosed with a severe heart condition since birth. Medical advice necessitated a heart transplant. Initially, the son was admitted to empanelled hospitals approved by the organization. However, when no suitable donor was available at these facilities, the family moved him to another hospital that was not empanelled. This hospital successfully found a donor, and the surgery was conducted in August 2023.
Tragically, the son passed away the day after the surgery, as confirmed by the death certificate. The petitioner then applied for medical reimbursement of Rs 20.30 lakh, but the organization only reimbursed Rs 10.08 lakh, leading to the legal dispute.
Key Findings and Legal Principles
The court highlighted that the test of "essentiality and emergency" is paramount in such cases. It ruled that if a medical procedure is undertaken in an emergency, based on a doctor's advice and medical records to save a life, reimbursement must be granted regardless of the hospital's empanelment status. In this instance, the heart transplant was deemed essential and urgent, satisfying this criterion.
Furthermore, the court stated that the state has an obligation to ensure timely medical care for citizens. It emphasized that individuals should not be deterred from seeking urgent treatment due to bureaucratic hurdles like hospital empanelment. The court found the organization's conduct unfair and unreasonable, violating the petitioner's fundamental rights under Article 21.
Arguments Presented
Advocate Ketan Antil, representing the petitioner, argued that the surgery was performed under emergency circumstances as no donor was available in empanelled hospitals. He contended that the partial reimbursement was illegal and discriminatory, lacking proper justification in the August 2025 order.
On the other hand, advocate Vikrant Pamboo, for the organization, defended the reimbursement of Rs 10.08 lakh, asserting it was based on all available records. However, the court rejected this stance, emphasizing the need for full reimbursement in life-saving situations.
Court's Directive
The Punjab and Haryana High Court has ordered the concerned organization to reimburse the entire medical claim of Rs 20.30 lakh to the petitioner within four weeks. This amount excludes the Rs 10.08 lakh already released. The judgment sets a precedent for similar cases, reinforcing that emergency medical care should not be compromised by administrative technicalities.
This ruling is expected to have far-reaching implications for medical reimbursement policies across India, ensuring that citizens' right to life and health is upheld in critical situations.
