Ramjee Rai vs The Union Of India & Ors.

Per: Justice Narendra Kumar Johari, Member (Judl.) :-

Case of the applicant, in brief, is that the applicant has retired from the post of Stock Verifier, ECR, Danapur, on 31.01.2014. The wife of the applicant, namely, Chinta Devi, became seriously ill when the applicant was in service i.e. in the month of December, 2013. She underwent treatment at Railway Hospital where it has been found that she is suffering from Chronic Hepatitis as well as other diseases like Hypothyroidism, etc. On 06.12.2013 her condition became serious. The applicant took her to the Railway Hospital, Danapur, who referred his wife to Gastroenterology Department, IGIMS, Patna. He moved for IGIMS Patna by ambulance but since the condition of his wife became serious on the way, therefore, he approached to the Doctors at Paras Hospital, Patna, which is situated on the way and he admitted his wife in Emergency Department. The Doctors at Paras Hospital diagnosed that his wife is suffering from Liver Cancer. The applicant applied for the advance money from his department for the medical expenses but the same could not be paid to him. The Doctors at Paras Hospital, Patna treated his wife and she became well and returned back on 09.12.2013 after discharge from the Hospital. Again on 16.12.2013 the applicant’s wife became seriously ill. Therefore, the applicant admitted her in the same Paras Hospital, Patna, where she remained admitted till 14.01.2014 and was discharged on 15.01.2014. Again the applicant demanded some advance money as medical expenses from the department but the same was not paid to him. The applicant submitted the bills of Rs.37220/- + Rs.24200 (total Rs.61420/-) for reimbursement as the aforesaid money was incurred by him towards the treatment of his wife, but the same could not be paid. The applicant retired from service on 31.01.2014. After his retirement, again on 28.04.2014 his wife became seriously ill then she was again got treated by Doctors of Paras Hospital, Patna where the Doctors suggested for her treatment in Super Speciality Hospital in Mumbai. She was discharged from the Paras Hospital on 01.05.2014. For the treatment of aforesaid period he incurred Rs.25,898/-towards the treatment of his wife. On the request of applicant, the Doctor of the Railway Hospital, Danapur has also referred her wife for treatment from Jagjivan Ram Hospital, Western Railway, Mumbai. Thereafter, the applicant took his wife to Jagjivan Ram Hospital, Mumbai for further and better treatment for Liver Cancer. After the treatment from Mumbai, the applicant returned back to Patna. After returning from Mumbai the applicant submitted the medical bill which was incurred by him from 28.04.2014 to 01.05.2014, at Paras Hospital, for a sum of Rs.25,898/- but the same has also not been paid. Since the applicant has already taken loan from Bank for education of his son as well as Home Loan and loan for the marriage of his daughter, therefore, he was in financial hardship. He made several requests to the concerned authorities for reimbursement of the aforesaid pending medical bills but the same has not been paid despite representation dated 22.09.2016. Thereafter, the applicant approached this Tribunal by way of filing OA No. 137 of 2017 which was decided by the Tribunal on 28.02.2017 with direction to the opposite parties to decide the representation of the applicant by way of reasoned and speaking order. In that connection the counsel for the applicant also sent the representation on 23.03.2017 to the concerned authorities of Railway with regard to medical reimbursement of medical expenses amounting to Rs.87,318/-. The opposite party/concerned authority rejected his representation vide order dated 19.04.2017 with contention that the treatment sought was not of emergency nature hence, the claim for reimbursement of medical bills is not maintainable. Aggrieved by the above order the applicant filed the present OA with the following relief:-

The opposite parties in their written statement have submitted that the applicant had produced three bills of Rs. 37220 + Rs.24220 + Rs.25898 = Total Rs.87318/- for reimbursement as he had taken the treatment of his wife, Chinta Devi, from Paras HMRI Hospital, Patna. The aforesaid claim of the applicant was rejected on the grounds that –

The applicant, in reply of the written statement, has submitted the rejoinder in which, with regard to paragraph nos. 1,2,5,7,8,9, 10, 11, 12, 13, 14, 15, 16, 17 & 18 of the written statement, it is mentioned that the statements made by the opposite parties in above paragraphs are not correct and misleading. The wife of the applicant died in year 2019 and the applicant is also suffering from ailments. Apart from that, the applicant has reiterated the contentions as mentioned by him in the OA.

Counsel for the applicant has submitted that the applicant has retired from the Railway services; being the permanent employee of Railway he has been provided the facilities of reimbursement of medical expenses in accordance with the IRMM during the service period and also after retirement. The applicant has submitted genuine bills of medical expenses incurred towards treatment of his wife which is permissible under Rules even then the payment of reimbursable amount has been denied on the false grounds.

Counsel for the opposite parties has argued that the present OA has been filed by the applicant with false contentions. There was no documentary proof that the applicant’s wife, Chinta Devi, was suffering from Liver Cancer. The medical treatment for which the applicant’s wife was admitted to Paras Hospital was not the step to meet emergency. The applicant himself has not fulfilled the necessary requirement; therefore, the claim of the applicant is not admissible.

We have heard the contentions of both the learned counsel and perused the record.

The applicant in para 4.5 and 4.16 of the OA has specifically mentioned that his wife is suffering from Liver Cancer but to prove that disease neither any report of Doctor/Hospital or investigation has been submitted by the applicant on record. Annexure- 1 is the referral letter was issued by the Chief Medical Superintendent, ECR, Danapur which indicates that since the patient is suffering from HCV (+ve), therefore, the Doctor of Railway Hospital has referred the patient (wife of applicant) to the Department of Gastroenterology, IGIMS, Sheikhpura, Patna. In medical terminology HCV (+ve) means the patient is suffering from Hepatitis ‘C’ Virus infection. Medically this type of disease is fully curable by proper and timely medications. It is neither fatal nor does it require emergency treatment because the disease Hepatitis ‘C’ is typically a slow progressing chronic condition of Liver. It does not cause acute organ failure in general.

The applicant has stated in para 4.3 of the OA that in the first week of December, 2013 his wife became seriously ill, therefore, she was referred by the Doctor of Railway Hospital to IGIMS Patna. The applicant was going to IGIMS along with his wife but all of a sudden his wife became serious and senseless, therefore, the applicant approached to the Paras Hospital in emergency for her treatment. In this regard the applicant has submitted the Discharge Summary of Paras Hospital which shows that the patient, Chinta Devi, was admitted on 06.12.2013 and was discharged on 09.12.2013. At the time of admission the complaint of patient was –

* suffering from fever 6 months;

* not taking food since 5-6 days;

* increased weakness;

* increased fever since last 10 days; and

* incontinence of urine with stool.

Under ‘Brief History’ of the patient it has been mentioned that the patient was asymptomatic 6 months back then she suddenly presented with fever which was on and off in nature since last 10 days. Fever is continuous in nature. Patient is also not able to take meals since last once week. Patient was also presented with incontinence of urine with stool. She was suffering from K/C/O Hypothyroidism, HTN, HCV (+ve). The Discharge Summary also contains the report of investigation wherein it has been shown that X-ray, USG Whole Abdomen shows mild hepatomegaly with Grade-I Fatty Liver and Widal Test was +ve.

According to above Discharge Summary it appears that the wife of the applicant was suffering from Hepatitis problem since long back and was gripped with fever since last ten days. The complaint, as mentioned by the Paras Hospital, does not show that condition of patient, Chinta Devi, was very serious or any delay of few minutes was fatal to the life of the patient. Counsel for the applicant admitted in his argument that the distance between Paras HMRI and IGIMS Patna is less than one kilometre and both the hospitals are in the same locality. Indira Gandhi Institute of Medical Sciences (IGIMS), Patna is a renowned Institute not only in Patna but in entire Bihar. It has well established departments including Gastroenterology Department with renowned Doctors. Considering the distance between above two hospitals if we believe the contention of the applicant that on 06.12.2013 the condition of his wife became serious, then the applicant was able to carry her to Government hospital i.e. IGIMS, Patna where the Railway Doctor had referred the patient. As such, both the Hospitals i.e. IGIMS and Paras Hospital situates in Patna in the same locality and hardly within the distance of one kilometre. Applicant was carrying the wife through vehicle and in a very short time he could have admitted his wife in IGIMS Hospital but the applicant preferred to get treatment of his wife in Paras Hospital that too, when the physical condition of his wife was not so serious or emergent.

Record shows that after treatment of patient in Paras Hospital from 06.12.2013 to 09.12.2013, the applicant again visited the Paras Hospital on 16.12.2013 and 07.01.2014, thereafter on 15.01.2014 but these visits were in OPD. It appears that the patient had gone to Paras Hospital for follow up treatment. The record also indicates that after that the applicant visited the Paras Hospital along with his wife on 15.01.2015 but this visit of the patient was again in OPD.

Record also indicates that the applicant had admitted his wife Chinta Devi in same Paras Hospital on 28.04.2014 from where she was discharged on 01.05.2014 for the complaints of weakness, fatique, anxiety, decreased appetite for 20 days. For the above period under ‘Brief History’ in the Discharge Summary dated 05.05.2014 it has been mentioned that at the time of admission the patient was conscious, oriented, afebrile and hemodynamically stable. This admission also indicates that the patient was not admitted in the Hospital under emergent condition. In this regard counsel for the Opposite Parties has submitted that the emergency condition contains the condition of patient which resulted from any cause arising suddenly like road accident, acute heart attack and other type of accident which if not treated at the earliest convenience that would be detrimental to the health of the patient or will jeopardise the life of the patient. In such case if the patient takes the treatment in the nearest and suitable private hospital, the reimbursement claim of medical bill can be processed but only when the condition of emergency is certified by the Authorised Railway Medical Officer, ex-post facto. The referral letter dated 06.12.2013 issued by the Railway Doctor also does not show any emergent condition of patient.

Para 617 of Indian Railway Medical Manual (IRMM) permits the treatment of patient at unrecognised/non-empanelled hospital but reimbursement of medical expenses for such treatment is governed by specific conditions i.e., such treatment should be taken only in a medical emergency as saving life comes first. The Court/Tribunal can gather the emergency condition of the patient and may allow the claim of reimbursement of medical expenses in emergency or life threatening medical condition of Government employee or their family members, provided the treatment actually received is proved by the medical records that there was actual emergency condition of the patient, bills and hospital documents are available in order and the treatment is found to be genuine. In such cases, the authorities cannot reject the claim solely on the ground that the hospital was private/non empanelled if the emergency condition of the patient is established by the admissible documents.

The circumstances where delay in providing the treatment would breakdown or endanger the life of patient or their family members in such case, the attendant may take the patient to the nearest available hospital to save his life.

The counsel for opposite parties in this regard has submitted the policy of “Reimbursement of medical expenses – procedure of disposal” issued by Railway Board No. 2005/H/6-4/Policy-II, dated 31.01.2007 which reads as under:-

Para 617 of IRMM makes the following provisions:-

In view of the above provisions as well as Discharge Summary of the patient it can be concluded that on 06.12.2013 and on 28.04.2014 when the wife of the applicant was admitted in the Paras Hospital, her condition was not serious and it was not an emergency situation. The applicant was having sufficient opportunity and occasion to go to the Gastroenterology Department of IGIMS, Patna. Therefore, if the claim of the applicant for Rs. 37200/- which was incurred by the applicant in treatment of his wife at Paras Hospital has been denied by the opposite party, then in that case there is no illegality or irregularity in denying the same.

Applicant has claimed reimbursement of amount of Rs.24200/-towards the expenses incurred by him on 16.12.2013 and 15.01.2014 during the treatment of his wife at Paras Hospital. The record indicates that on above dates the wife of the applicant had visited the Doctors at Paras Hospital in OPD. According to medical reimbursement rule of the Railways the reimbursement of such medical bills generally is not permissible unless the private hospital is specifically empanelled under the Scheme like CGHS or State Government Health Scheme or specific prior approval is there. It has not been shown by the applicant that Paras Hospital was empanelled in the list of Hospitals prescribed for treatment of Government employees and their family members. Also the Medical Superintendent of Govt. Railway Hospital has not referred the patient to Paras Hospital, Patna. Therefore, in absence of any provisions of rule for reimbursement of OPD visit in private/non-empanelled hospital, the opposite parties have rightly denied the reimbursement claim of such medical expenses.

Counsel for the applicant has further submitted that the wife of the applicant was again hospitalised on 28.04.2014 and was discharged from there on 01.05.2014. She was not in a position to take food since last 20 days, therefore, the condition of the patient comes within critical condition. In this regard, the applicant has incurred expenses of Rs.25,898/-. Counsel for the opposite parties in para 5(iii), 9 & 11 of the written statement has mentioned that the claim of Rs.25898/- was submitted by the applicant on 19.05.2014 which was incomplete. He was advised vide letter no. HE/MED/EXP, dated 04.03.2017 to submit the requisite documents so that the said bill may be verified and also the authorities demanded some requisite documents to consider the above amount for reimbursement but the applicant failed to submit the same to the O/o of Chief Medical Superintendent, Danapur. The applicant has filed his rejoinder in which with regard to above paragraphs of written statement applicant has only mentioned that the contentions made in the above paragraphs are not correct and misleading. The applicant in specific word has not denied the contention made by the opposite party in above paragraphs. Nowhere the applicant has stated that he has removed the defect in the medical bill for reimbursement of Rs. 25898/-. Therefore, if reimbursement of medical expenses of Rs.25898/- has also been denied by the opposite parties due to some defects which have not been removed by the applicant, they have not committed any illegality or irregularity.

The orders cited by the counsel for the applicant passed by Principal Bench of the Tribunal in OA No. 2154 of 2023, dated 13.02.2025 as well as in OA No. 2239 of 2023, dated 13.02.2024, are factually different, therefore, not applicable in present case.

In view of the pleadings and documents available on record, arguments submitted by both the learned counsels of parties and as per above discussions, we are of the considered view that the OA has no merit. As such, the applicant is not entitled to get relief, as sought for. Accordingly, the OA is liable to be dismissed. The OA is dismissed with no order as to costs.