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Judgment
The current O.A. has been filed by the applicant seeking full reimbursement of the medical claim of his wife and himself.
The facts of the case are that the applicant, who was working as Head Clerk with Rajkiya Pratibha VikashVidyalay, retired from service on 31.12.2008. Wife of the applicant fell ill on 04.06.2010 and was admitted in U.K. Nursing Home, Vikaspuri, New Delhi. The applicant submitted the original medical bills of his wife amounting to Rs. 40714/- to the Principal, Rajkiya Pratibha Vikas Vidyalaya, Basant Kunj, New Delhi (Respondent No.3). The competent authority held that the treatment has been taken in a private hospital not duly recognized under DGEHS. However, it was decided that since the treatment was reportedly emergent in nature, the case for reimbursement, as per entitlement may be sent to DGEHS for approval. After examination, payment of Rs. 5126/- as against the claim of Rs. 40714/- was made to the applicant after restricting the medical bill, as per guidelines on the subject.
Later, the applicant himself under-went medical treatment w.e.f. 14.09.2011 to 25.11.2012 in Rockland Hospital, Qutab Institutional Area, New Delhi. The applicant submitted the original bills of his medical treatment amounting to Rs. 5099/- on 19.09.2013. He was asked the reason for delay in submitting the medical bills.
The applicant gave the reason for delay in submitting the medical bill, as hospitalization of his daughter, who had some psychiatric problems. In this regard, the applicant also approached the Public Grievance Commission, Govt. of NCT of Delhi.
In the counter, the respondents have submitted that the applicant approached the non-empanelled hospital for the treatment of his wife. His case was sent to Regional Director of Education (South), being the competent authority, for approval for reimbursement as per entitlement under CS(MA) Rules. They submit that a payment of Rs. 5126/- was made to the applicant after restricting the bills as per the guidelines on the subject. The second medical bill of Rs. 5099/- pertaining to the applicant was time barred, having been submitted after a gap of nearly 10 months. As per Rule-66 of CS(MA) Rules, 1944, reimbursement of medical expenses of government servant are to be submitted within 03 months from the date of completion of treatment. The applicant was asked to submit a request for condonation of delay in submission of claim under Rule 67 of CS(MA) Rules, 1944 so that his claim could be forwarded to the competent authority for its approval, since the explanation given by the applicant for delay in submission of his medical claim was not found to be acceptable.
During the course of hearing, learned counsel for the respondents drew attention of the Bench to the details of expenditure and restriction of bills as DGEHS approved rate list, as per entitlement, under CS(MA) Rules (Appendix-VIII). He stated that the amount claimed by the applicant is far more than the admissible amount as is evident from the chart placed below:-
S.No.
Bill No. & Date
Description
Amount claimed
Amount admissible
Page No.
1.
16937/09/06/2010
Room harges (5 days)
3750 (750x5)
250(50x5)
48/C
2.
-do-
Anesthesia Free
3300
0
48/C
3.
-do-
Consultation (2x5)
4000 (400x10)
176 (32x1)=16x9)
48/C
4.
-do-
OT Charges
4000
0
48/C
5
-do-
Parenteral Fluid
1200
0
48/C
6.
-do-
Medicines
3500
3500
48/C
7.
-do-
Operation
10000
800
48/C
8.
-do-
Assistant Charges
3500
0
48/C
9.
-do-
Histopathy
650
85
48/C
10.
-do-
Blood sugar
750 (50x15)
315 (21x5)
48/C
11.
-do-
Nursing charges
2000
0
48/C
12.
45043/09/06/10
Medicine
603
0
47/C
13.
45209/16/06/10
Medicine
544
0
46/C
14.
1205/15/06/10
Medicine
240
0
45/C
15.
45356/22/06/10
Medicine
101
0
44/C
16.
45456/26/06/10
Medicine
257
0
43/C
17.
45491/28/06/10
Medicine
360.50
0
42/C
18.
45599/02/07/10
Medicine
310
0
41/C
19.
45768/08/07/10
Medicine
507.40
0
40/C
20.
45768/08/07/10
Medicine
1242
0
41/C
Total Amount
40714
5126
39/C
He contended that as against the claimed amount of Rs. 40714/-, only Rs. 5126/- was found to be admissible and has been paid to him.
Learned counsel for the applicant Sh. Bhakt argued that the wife of the applicant had undergone an emergent operation as is evident from the certificate dated 17.07.2010 of Dr. Usha Arora, U.K. Nursing Home stating that:-
"This is to certify that Mrs. Sarita Sachdeva W/o Mr. Harish Sachdeva was suffering from acute retention of urine c complete prelapse of uterus c OM . She was admitted on 4/5/10 and vaginal Hysterectomy and post ante repair done on 4/6/10 (as emergency opt)."
He emphasized that it is not the case of the respondents that the medical claim is fraudulent in any way. The respondents are convinced about the veracity of the claim. But the sanctioned, so called admissible amount is far too meager, hence the respondents need to be directed to reimburse the entire amount to him. In support of his contention, he relied upon the following judgments:-
(i) Surjit Singh Vs. State of Punjab and Ors., (1996)2 SCC 336.
(ii) J.K. Saxena Vs. Govt. of NCT of Delhi, 117(2005)Delhi Law Times 451.
(iii) Milap Singh Vs. UOI & Anr., 113(2004)Delhi Law Times 91.
During the hearing, it was informed by the learned counsel for the applicant that the medical claim of the applicant has been sanctioned by the respondents.
I have gone through the facts of the case and perused the record. There is no quarrel on the subject that the respondents have shown due sympathy towards the applicant by forwarding his case to the competent authority, despite the fact that he undertook the treatment in a non-empanelled hospital. Having said that, the fact still remains that the entitlement as per CS(MA) Rules (Appendix-VIII) as illustrated in the chart above, is to say the least, totally out of sync with the current day medical expenses. For example, many columns like Anesthesia (S.No.2), OT Charges (S.No.4), Nursing Charges (S.No.11) etc. show the admissible amount as zero. Room charges have been sanctioned at the rate of Rs.250/- as against Rs.750/- per day. Similarly, consultation fee of Rs.400/- stands reduced to Rs. 32/-& Rs.16/-. Assuming that these are the admissible amounts, a bare perusal leaves no doubt that these (admissible) amounts need a serious re-look by the respondents by a constituted Committee, which should make a realistic study of the current day rates, which should then be considered for revision accordingly. There can, however, be no admissible limit on the actual amount spent on medicines, during the treatment. It is not understood how these can be shown as O‟ in columns 12 to 20. Such unrealistic parameters, in my view, dilute the very purpose of the medical reimbursement Scheme. There is no allegation of inflated or fraudulent claim submitted by the applicant. Rather, the claim appears to have been rather modest keeping in view the current day prices. It is not disputed that the treatment and the operation had to be undertaken due to the emergent situation that the applicant‟s wife was in. This fact stands admitted by the respondents. In view of this backdrop, the respondents are directed to reimburse the entire claimed amount to the applicant subject to verification etc., as per law. O.A. is accordingly allowed. No costs.