No Denial of Ayushman Bharat Benefits Due to Delayed Documentation: Rajasthan High Court

Subheadline: High Court orders Ramsnehi Chikitsalaya to reimburse patient’s medical expenses under Ayushman Bharat Scheme
The Rajasthan High Court has ruled in favor of a patient insured under the Ayushman Bharat Mahatma Gandhi Rajasthan Swasthya Bima Yojna, directing Ramsnehi Chikitsalaya and Anusandhan Kendra to reimburse Rs. 1,16,420 incurred for heart surgery. The judgment delivered by Justice Vinit Kumar Mathur on May 28, 2024, underscores that a delay in submitting insurance documentation does not disqualify a patient from receiving benefits.
The case originated when Nanuram, the respondent, suffered a heart ailment and was treated at Ramsnehi Chikitsalaya. Although he was insured under the Ayushman Bharat scheme, the hospital charged him Rs. 1,24,000 for the treatment, which Nanuram paid upfront. Post-discharge, Nanuram submitted the necessary documents to the District Collector for reimbursement, but the hospital claimed they had not received the insurance documentation, leading to the filing of a writ petition by the hospital against the order of the Permanent Lok Adalat, Bhilwara.
Justice Mathur highlighted the critical nature of the patient's condition at the time of admission, acknowledging that neither the patient nor his family might have been in the right state of mind to submit the documents immediately. The court stated, "The fact that requisite documents showing the respondent No.1 being covered under the ‘Ayushman Bharat’ Scheme were not produced by him at the time of admission in the hospital will not disentitle the respondent No.1 to get the benefit under the scheme".
The court dismissed the petitioner’s argument that the delayed submission justified charging the patient. It emphasized the responsibility of healthcare providers to ensure that eligible patients receive benefits, regardless of when the documentation is submitted, provided it is done within a reasonable time after treatment.
The Permanent Lok Adalat had initially ruled in favor of Nanuram, awarding him the reimbursement and a cost of Rs. 5000, which the hospital contested. Justice Mathur upheld the reimbursement order but set aside the cost imposed by the Lok Adalat, directing the hospital to refund the amount within two weeks upon receipt of the necessary documents from Nanuram. Furthermore, the hospital was instructed to coordinate with the State Government for the reimbursement under the scheme.
The judgment reaffirms the entitlement of patients to insurance benefits under the Ayushman Bharat scheme, even if documentation is delayed, provided it is eventually submitted. This ruling aims to safeguard patients' rights and ensure they are not unfairly burdened with medical expenses due to procedural delays.

Date of Decision: May 28, 2024