Model Representation -69
Medical claim for the son admitted in private hospital on emergency was rejected. The following appeal was made in that case
Sub: Appeal against the rejection of my medical reimbursement claim by SSPOs……..
Ref: SSPOs …………, Letter No. …………… dated 14.08.2020.
I humbly submit this appeal for your sympathetic and favorable consideration against the rejection of my medical reimbursement claim as per the referenced letter issued by the SSPOs………. Division.
I had admitted my son, Sri ………….., to …….. Hospital for emergency treatment and subsequently submitted my medical reimbursement claim for ₹95000- to the SSPos………. on ………2020, along with all the required supporting documents as per rules. However, my claim was returned with the statement: “Taking treatment in a private hospital is not permitted by the undersigned.” Aggrieved by this arbitrary decision, I submit this appeal for your kind intervention and redressal.
As per the extant CGHS rules, permission from the Head of Office is not required in cases of emergency treatment. Permission for treatment in CGHS-empanelled hospitals is granted by the CMO In-Charge of CGHS, not the Head of Office. In the case of emergency treatment in a private hospital, no prior permission is necessary from either the CMO In-Charge or the Head of Office. Therefore, the reason cited for rejecting my claim contradicts the medical reimbursement rules. Furthermore, my son experienced …….., a condition that required immediate medical attention. Given the critical nature of the situation, obtaining prior approval was not feasible.
It is pertinent to mention that, as per the Ministry of Health & Family Welfare, CGHS(P) Section O.M. No. 1967/2013/DEL/CGHS-SZ/D52-CGHS(P) dated 10.12.2015, reimbursement for medical treatment in private hospitals must be sanctioned by an officer of the rank of Joint Secretary. The O.M. explicitly states that “The Head of Office not below the rank of Joint Secretary to the Government of India may decide medical claims for emergency treatment obtained in private hospitals/nursing homes/clinics, subject to the overall ceiling of ₹2 lakhs per case.”
Further, the Ministry of Health & Family Welfare order No. S14025/14/2012-MS dated 11.06.2013 clarifies that medical claims for emergency treatments are to be allowed, and no other reason for rejection is valid. My son was admitted to the private hospital under emergent conditions, as laid down in the O.M. dated 20.02.2009. Hence, the rejection of my claim is arbitrary, unjust, and in violation of natural justice.
The SSPOs…….., has erroneously rejected my claim without referring the bill to the competent sanctioning authority. There is no provision in the CGHS/CS(MA) Rules that mandates contacting government hospitals during emergencies or providing proof of such an attempt. The reasoning given by the SSPOs….. is, therefore, not in line with the existing rules governing medical claims for emergency treatment in private hospitals.
This unexpected medical expenditure has placed a significant financial burden on my family. The denial of reimbursement exacerbates this hardship and creates undue financial stress.
I most humbly resubmit my claim bill along with this appeal for your sympathetic and favourable consideration. I kindly request you to review my case and grant the reimbursement I am entitled to under the rules.
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