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Judgment
O R D E R
The applicant is challenging the order dated 15.11.2022 (Annexure A-1) by which his claim for medical reimbursement for treatment of his father has been rejected by the respondents.
Brief facts of the case, as stated in the Original Application, are that the father of the applicant was hospitalized in an emergent condition on 20.11.2021 at Bhatia Hospital, Mumbai during his visit to Mumbai. He underwent treatment of PTCE (Percutaneous Transluminal Coronary Angioplast) of the LAD (Left Anterior Descending Arteries) for which an expense to the tune of Rs.3,09,875/- was incurred. During the period of treatment of his father, the applicant was on leave from 15.11.2021 to 18.11.2021 suffixed by closed holidays on 19.11.2021 & 20.11.2021. He joined the office on 22.11.2021. The applicant informed about his father’s treatment on 22.11.2021. The applicant submitted the form under Central Services (Medical Attendance) Rules, 1944 along with the complete documents including the emergency medical certificate and bills incurred on his father’s treatment for getting the reimbursement amount of Rs.3,09,875/-. However, vide the communication dated 21.03.2022 (Annexure A-6), the respondent No.3 informed him that his claim has been rejected on account of getting his father’s treatment done in the private hospital and without any prior approval from the office. The applicant submits that Appendix VIII of CS (MA) Rules, 1944, provides reimbursement where the treatment has been taken in a private hospital in case no Government or recognized hospital is available nearer than the private hospital. The applicant again raised the matter with respondent No.3 quoting the extracts of the provision contained in Appendix VIII of CS (MA) Rules. However, his claim has been rejected vide the impugned order dated 15.11.2022 (Annexure A-1).
In their reply, the respondents have stated that the claim of the applicant has been rejected on the following grounds:
No prior intimation was given by the applicant nor any permission for treatment at Mumbai in a private hospital was granted by the respondents.
The applicant vide letters dated 22.11.2021, 27.12.2021 and 25.01.2022 had intimated three different reasons for his father visiting Mumbai viz; due to necessary works, for stay at Mumbai and for Mumbai darshan etc.
The Emergency certificate/certificate ‘B’ should have been signed by the treating doctor, Shri Ajay Pandey with his seal. However, it was signed by an other official of the hospital.
The treatment required, if any, should have been taken in the nearest Govt. Hospital or a CGHS empanelled hospital. However, it was intentionally taken in a private hospital.
Further, Para 1 of Appendix – VIII of Central Services (Medical Attendance) Rules stipulates that in emergent cases involving accidents, serious nature of disease etc., the person/persons on the spot may use their discretion for taking the patient for treatment in a private hospital in case no Government or recognized hospital is available nearer than the private hospital. However, the applicant did not admit his father to a nearby Government or recognized hospital instead he admitted him in a private hospital. The case of the applicant does not fall under the category of ‘emergency cases’ as referred under Appendix-VIII (supra).
Heard learned counsel for the parties and perused the pleadings and the documents available on record. Parties were also directed to file their written submission within a period of fifteen days. However, no written submission has been filed by either side.
The question for consideration is whether a medical reimbursement claim can be rejected merely because the treatment was taken in a private hospital which was not empanelled under CGHS, particularly when the treatment was undertaken in an emergency and the claimant had no access to obtain treatment from a CGHS empanelled hospital.
The right to health has been recognised by the Hon'ble Supreme Court as an integral part of the right to life guaranteed under Article 21 of the Constitution. In the case of State of Punjab v. Mohinder Singh Chawla, (1997) 2 SCC 83; AIR 1997 SC 1225, the Hon'ble Supreme Court has held that the right to health is an integral part of the right to life and that the Government has a constitutional obligation to provide health facilities to its employees.
The issue of reimbursement for treatment obtained in a non-empanelled/non-recognised hospital has been specifically considered by the Hon'ble Supreme Court in Shiva Kant Jha vs. Union of India, (2018) 16 SCC 187, wherein the Hon’ble Supreme Court has held, in substance, that the right to medical reimbursement cannot be defeated merely because the hospital where treatment was actually taken was not included in the Government's list. The real test is whether the treatment was actually undertaken and whether the factum of treatment is supported by duly certified medical records. Once genuine treatment is established, the claim cannot be rejected merely on technical grounds. The Hon’ble Supreme Court has also emphasised that, in an emergency, the survival of the patient takes precedence over procedural requirements.
The aforesaid principle has subsequently been reiterated in Union of India & Anr. v. Joginder Singh, W.P.(C) No.10684/2022, decided on 10.05.2023, wherein the Hon’ble Delhi High Court has held that a medical claim for treatment undertaken in an emergency should not be denied merely because the hospital was not empanelled. The Hon’ble High Court has observed that the relevant test is whether the claimant actually underwent the treatment in an emergent condition and whether the same is supported by the medical records.
In the present case, the fact that the Bhatia Hospital, Mumbai was not a CGHS empanelled hospital, by itself, cannot constitute a conclusive ground for rejection of the claim of the applicant. The rejection of the claim on the ground that the emergency certificate is not signed by the duty Doctor is not tenable. It is necessary to bear in mind that an emergency cannot be judged with the benefit of hindsight. A patient or his/her attendant confronted with a serious medical condition cannot reasonably be expected to undertake a detailed search of the CGHS empanelled hospital or wait for prior authorisation before securing life-saving medical treatment. The Hon'ble Supreme Court's reasoning in Shiva Kant Jha (supra) makes it clear that medical reimbursement provisions are intended to facilitate medical care Central Administrative Tribunaland should not be applied in an unduly technical or mechanical manner when the genuineness of treatment and the emergent circumstances are established.
In view of the aforesaid legal position, the rejection of the medical reimbursement claim of the applicant on the ground that treatment was taken in a non-CGHS empanelled hospital is set aside. The respondents are directed to reconsider and process the claim afresh in terms of the applicable CGHS reimbursement/package rates and the Government instructions governing emergency treatment in a non-empanelled hospital. If required, the respondents may crosscheck whether the treatment has actually been taken by the applicant’s father on the designated dates in the said Hospital. The admissible amount shall be reimbursed to the applicant within a period of 120 days from the date of receipt of a copy of this order. However, no interest shall be payable on such amount.
Accordingly, this Original Application is allowed. No order as to costs.