When Mohammad Ashraf Mir, a Government employee in Jammu and Kashmir, learnt that his ten-year-old son was battling ependymoma – a serious neurological tumour classified Grade II by the WHO – the instinct of every parent took over. He moved the child first to SKIMS Soura, and when the gravity of the condition demanded more specialised intervention, he did what any father would: he spent the money and sought care wherever that care could be found. The bill came to thirty lakh rupees, drawn entirely from his own pocket. His subsequent claim for reimbursement was rejected by the DC, Budgam, but the CAT bench at Srinagar has since set aside that order, directing the authority to reassess the claim. The Tribunal’s reasoning is legally sound: the State cannot deny a legitimate claim solely because a critically ill patient was treated in a specialised facility that bureaucratic procedure had not pre-approved.
Yet the ruling, welcome as it is, must not be allowed to substitute for a comprehensive policy overhaul. The Mir case is not an exception; it is a symptom. J&K’s framework for medical reimbursement was designed in a different era and has not kept pace with the realities of modern healthcare. Service rules, much like group insurance policies, maintain a list of empanelled hospitals and impose upper ceiling limits on reimbursable expenditure. In routine cases, such structures may be defensible. In critical care – brain surgery, cardiac intervention, oncological treatment – it becomes a death sentence dressed in administrative language. The Government has not been entirely indifferent. The Ayushman Bharat scheme has been extended to all residents of J&K. However, Government hospitals remain chronically overcrowded. Private hospitals in the UT lack the specialist infrastructure for high-acuity procedures. The result is an inevitable outward migration of patients who require critical care.
This paradox demands resolution at the policy level, not case-by-case adjudication. Ambiguity serves no one. The way forward requires action on two fronts. First, service rules must be amended to provide for an emergency waiver of the empanelment condition in life-threatening cases, subject to post-facto verification of genuineness and medical necessity. Second, the ceiling limits on reimbursement must be periodically revised to reflect actual costs at specialised institutions – a cap set in 1990 bears no relation to the cost of neurosurgery in 2024. Practically, no employee should have to fight for their genuine rights.
Follow our WhatsApp channel
