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Judgment
The applicant, retired employee of GNCTD has filed this OA under Section 19 of the Administrative Tribunal Act, seeking the following relief:-
a)Quashing and Setting Aside of 'RSKV' communication no. RSKV/WVN/2023/196 dated 07.07.2023 [Annexure A] to the extent it denies to the Applicant full reimbursement of his medical claim/expenses, with all consequential reliefs and benefits;
b)Directing Respondents to immediately release, pay to the Applicant the difference, balance of his full medical claim, cost of treatment incurred;
c)Costs of this Application may also be Central Administrative Tribunalgranted to the Applicant;
d)pass any such further or other orders as this Hon'ble Tribunal may deem fit and proper in the facts and circumstances of the case to grant complete relief to the Applicant.”
The facts as stated in the OA are that the applicant was suffering from Liver disease and he was advised liver transplant by the medical authorities as he was diagnosed Non-alcoholic fatty liver disease related eng stage liver disease MELD-32, Portal Hypertension, Ascites, Hepatic Encepaholpathy, Obstructive Sleep Apnea on 12.02.2022 by Dr. Rela Institute and Medical Centre, Chennai. He was further issued certificate dated 24.02.2022 by Department of Surgical Gastroenterology, Govt. Stanley Hospital, Chennai-I stating that he was diagnosed as NASH related and stage liver disease/hypertension/ Non bleeder/ Obstructive sleep apnea (MELD Na-30) and advised to undergo liver transplantation. Accordingly, he undergone liver transplant on 09.03.2022 and discharged from the hospital on 31.03.2022.
The applicant made claim of Rs. 44,26,752/-before the Authorities. However, his claim was restricted to Rs. 11,50,000/-. Therefore, the applicant has claimed the balance of amount Rs. 32,76,752/-. The said claim of the applicant was rejected by the respondents vide communication dated 07.07.2023 on the ground that the Committee after reviewing the case on the basis of clinical details and the circumstances finds that none of the mentioned clauses fits for full reimbursement.
After issuance of notices, the respondents have filed their counter reply and contested the OA by stating that the Directorate General of Health Services (DGEHS) provided a technical opinion in accordance with the provisions of the Delhi Government Employees Health Scheme (DGEHS). It is contended that the applicant’s liver transplant surgery was a planned procedure and not an emergency or life-saving surgery, as reflected in the discharge summary. The matter was examined by the Technical Standing Committee, which did not Central Administrative Tribunalfind the case fit for full reimbursement.
It is further submitted that reimbursement was made by the concerned department in accordance with the prescribed ceiling rates under the relevant Office Memorandum dated 27.02.2013, which stipulates a ceiling of ₹11,50,000 for liver transplant surgery. The respondents, therefore, submit that the reimbursement has been made in accordance with the applicable scheme provisions and that the present Original Application is liable to be dismissed.
In rejoinder, learned counsel for the applicant submits that the liver transplant surgery was essential and life-saving, and that the genuineness of the treatment and medical claim has not been disputed by the respondents. It is contended that reimbursement cannot be denied merely on technical grounds or restricted to CGHS ceiling rates in an emergency. Accordingly, the applicant seeks full reimbursement of the medical expenses incurred. Learned counsel for the applicant relies on the following judjments:-
Shiva Kant Jha v. Union of India, decided by the Hon’ble Supreme Court on 13.04.2018 in WP (C) No. 694/2015.
Mahendra Kumar Verma Vs Govt.of NCT of Delhi & Ors decided on 09.01.2023 in WP (C) No. 3272/2026.
Union of India and Anr. Vs Shri Joginder Singh, decided on 10.05.2023 by the Hon’ble High Court of Delhi in WP (C) No. 10684/2022.
In the matter of Hira Lal Bhat versus Chairman and Managing Director BSNL and Ors, decided by the Hon’ble Delhi High Court on 18.12.2024 in WP(C) No. 9176/2016.
The order passed by the Coordinate Bench of this Tribunal on 19.04.2018 in O.A. No. 1443/2014, Sawant Singh v. Govt. of NCT of Delhi & Ors.
Learned counsel for the respondents, on the other hand, submits that the present Original Application is not maintainable and is liable to be dismissed. He further submits the applicant has already retired from service. He further submits that the respondents issued an Office Memorandum dated 27.02.2013, which regulated medical reimbursement.
Learned counsel for the respondents further submits that pursuant to the provisions of the OM, the technical standing Committee has considered the case of the applicant and found that it was not fit for full reimbursement and the claim of the applicant is restricted to Rs. 11,50,000/- as per the CGHS rate. He submits that this is a technical matter and may be decided by technical Committee only and the Tribunal may not substitute its own view in place of the expert opinion of the technical standing Committee. He further submits that the Central Administrative Tribunalapplicant has not challenged the OM Dated 27.02.2013 which is governing the medical reimbursement. Therefore, no relief can be granted.
Learned counsel for the respondents further submits that the surgery was done on 09.03.2022 and the emergency certificate has been obtained on 09.07.2022, i.e. four months after the surgery. He submits that if it was an emergency situation, the applicant should obtain the emergency certificate on the date of the admission itself. However, obtaining the emergency certificate after four month shows that there was no emergency. Learned counsel for the respondents further submits that all the judgments relied upon by the learned counsel for the applicant pertains to the serving employees and not to the retired employees. He further submits that the applicant being retired employee, the judgments are not applicable in his case.
I have considered the rival submissions. I find that Hon’ble Supreme Court in the case of Shiva Kant Jha v. Union of India, in WP (C) No. Central Administrative Tribunal694/2015 in para 15 and 16 has held the following:-
“15.In the present view of the matter, we are of the considered opinion that the CGHS is responsible for taking care of healthcare needs and well being of the central government employees and pensioners. In the facts and circumstances of the case, we are of opinion that the treatment of the petitioner in non-empanelled hospital was genuine because there was no option left with him at the relevant time. We, therefore, direct the respondent-State to pay the balance amount of Rs. 4,99,555/- to the writ petitioner. We also make it clear that the said decision is confined to this case only.
Further, with regard to the slow and tardy pace of disposal of MRC by the CGHS in case of pensioner beneficiaries and the unnecessary harassment meted out to pensioners who are senior citizens, affecting them mentally, physically and financially, we are of the opinion that all such claims shall be attended by a Secretary level High Powered Committee in the concerned Ministry which shall meet every month for quick disposal of such cases. We, hereby, direct the concerned Ministry to device a Committee for grievance redressal of the retired pensioners consisting of Special Directorate General, Directorate General, 2 (two) Additional Directors and 1 (one) Specialist in the field which shall ensure timely and hassle free disposal of the claims within a period of 7 (seven) days.
16.We further direct the concerned Ministry to take steps to form the Committee as expeditiously as possible. Further, the above exercise would be futile if the delay occasioned at the very initial stage, i.e., after submitting the relevant claim papers to the CMO-I/C, therefore, we are of the opinion that there shall be a timeframe for finalization and disbursement of the claim amounts of pensioners. In this view, we are of the opinion that after submitting the relevant papers for claim by a pensioner, the same shall be reimbursed within a period of 1 (one) month.”
It is seen from the above judgment that the Central Administrative Tribunalabove judgment was passed by the Hon’ble Supreme Court in exercise of power under Article 142 and was directed to be not treated as precedence. I further find that the High Court of Judicature at Delhi in the case of Hira Lal Bhat versus Chairman and Managing Director BSNL and Ors, decided on 18.12.2024 in WP(C) No. 9176/2016, after considering the judgment of the Hon’ble Supreme Court in the matter of Shiva Kant Jha (Supra) has allowed the full reimbursement and set aside the order of this Tribunal passed in OA No. 3205/2018.
Learned counsel for the applicant states that in the matter of Sawant Singh v. Govt. of NCT of Delhi & Ors. in O.A. No. 1443/2014 passed on 19.04.2018 in wherein para 8 to 10 the following has been held:-
8.Learned counsel for the applicant stated that the Hon'ble Delhi High Court in the case of Daljit Singh v. Govt. of NCT of Delhi and Ors. in W.P. (C) No. 16651/2006 vide judgment dated 10.01.2013 has also held that a person is entitled to reimbursement of full amount of medical expenses.
He further submitted that placing reliance on the judgment of Hon'ble Delhi High Court in Daljit Singh's case (supra), the Central Administrative TribunalChandigarh Bench of this Tribunal has granted identical relief to the applicant in O.A. No. 850/2017 decided on 17.17.2017.
9.Learned counsel for the respondents reiterated the averments made in the reply and submitted that the reimbursement has been made as per the prescribed norms.
“10.I have considered the arguments of learned counsel for the parties and perused the pleadings. During the course of hearing both the parties clarified that Sir Ganga Ram Hospital is not a CGHS empanelled hospital for liver transplant. Admittedly, the applicant was suffering with the Hepatic encephalopathy disease and he was required immediate medical treatment. The respondents have not indicated anywhere that in any CGHS approved hospital such a liver transplant facility was available but the applicant did not avail that. Under these circumstances, no fault can be found in the action of the applicant to get himself admitted in Sir Ganga Ram Hospital for availing the treatment and undergoing the liver transplant for which he has incurred an expenditure of Rs.36,90,488/-. The respondents have also not explained as to what kind of norms have been applied by them in restricting the reimbursement to Rs.14,58,821/-. Placing reliance on the judgment of the Hon'ble Apex Court in Shiva Kant Jha's case (supra), I am of the view that the applicant is entitled for full reimbursement of the medical expenditure incurred over which he had no control. Accordingly, the OA is allowed.
The arguments made by the learned counsel for the respondents that the judgment cited by the learned counsel for the applicant pertains to Govt. of India and not GNCTD is not correct.
In view of the law laid down by the Hon’ble High Court and keeping in view the aforementioned order passed by this Tribunal, I find no reason to take a different view. Accordingly, respectfully following the aforesaid judgments, the respondents are directed to consider to reimburse the balance amount of ₹32,76,752/- to the applicant.
The respondents are directed to comply with the direction within a period of two months from the date of certified copy of this order.
The OA stands disposed of against the background of these directions. Pending MAs, if any, also stands disposed of accordingly. There shall be no order as to costs.