Sanjay Kanhaiya vs Govt. Of NCT Of Delhi And Ors

The applicant has filed this OA seeking the following reliefs:-

"a) Quash and set aside the impugned order dated 30/03/2017 placed at Annexure A/1 and

b) Direct the respondents to reimburse the remaining balance of Rs.4,10,055/- (Rs. Four Lakh Ten Thousand Fifty Five only) incurred on account of medical expenses.

c) Accord interest @ 15% p.a.

d) Accord all consequential benefits.

e) Award costs of the proceedings; and

f) Pass any order/relief/direction(s) as this Hon'ble Tribunal may deem fit and proper in the interests of justice in favour of the applicant."

It is the case of the applicant that his wife was taking treatment during her pregnancy from March 2015 from Shanti Mukund Hospital, Vikas Marg, Karkardooma, Delhi and the said Hospital is one of the empanelled hospitals of Govt. of NCT of Delhi. However, on 13.10.2015, when the delivery of the babies was due, the concerned authorities of Shanti Mukund Hospital directed them to take the patient to a higher centre for nursery requirement 33 + 3 with twins with previous 2 LSCS with LP/V. Accordingly, applicant shifted his wife to Fortis Le Femme Hospital on 13.10.2015 which has capacity of pre-mature deliveries of the twins and also had neo-natal nursery facilities/incubators nursery facilities. However, when the applicant submitted the medical reimbursement claim, only part of the claim, that is an amount of Rs.1,55,441/- was sanctioned as per the entitlement and approved rates of DHS for empanelled hospital. Thereafter, the applicant made representation against the deduction and the matter was referred to DHS and in accordance with the Office Memorandum dated 2.2.2010, the DHS referred the matter to a three member Technical Standing Committee. The Committee after perusal of relevant documents, observed that the patient was stable at the time of admission to Fortis La Femine Centre, Greater Kailash and the case does not fit into the provisions contained in OM dated 2.2.2010. The said Technical Committee did not recommend the applicant's case for full reimbursement of amount.

Counsel for the respondents contended that the respondents have acted fully as per rules and have given the applicant whatever was considered to be the entitlement as per the recommendation of three members Technical Standing Committee. Copies of report of Technical Committee as well as OM dated 2.2.2010 are annexed as Annexures R-1 and R-2 respectively and the recommendations of the said Committee was communicated to the applicant through Assistant Labour Commissioner endorsement dated 20.4.2017.

Heard both learned counsel for the parties and also perused the records.

The applicant has been able to show that they sought to avail medical treatment in Shanti Mukund Hospital which was an empanelled hospital of Govt. of NCT of Delhi and the applicant was forced to shift the pregnant wife to higher centre for nursery requirement 33 + 3 with twins with previous 2 LSCS with LP/V as per the directions of the said Shanti Mukund Hospital and the applicant has been able to show that shifting of his wife to another hospital was on the direct advice of the referring hospital, i.e., Shanti Mukund Hospital and quite clearly the referring hospital did not mention any name of hosopital to which he should go. Hence, the applicant could not be faulted for using own resources to find another hospital where his wife could be treated. Hence, the decision of the said Technical Committee to disallow reimbursement of expenses incurred in the second hospital cannot be said to be fair and as per rules, as the Technical Committee is required to examine the necessity for taking the treatment in the second hospital and to give the reimbursement for the amounts which are permissible under the different heads. This is not the wilful action of the applicant to shift his wife to the said second hospital having the said facilities but it was only done as advised by the Shanti Mukund Hospital. This point has been totally disregarded by the said three members Technical Committee which has said that they did not find that the condition of the applicant's wife was not such as to cause her to be shifted to another hospital.

The applicant in this case is not a medical practitioner who has the knowledge to dispute the advice made by the said Shanti Mukund Hospital and accordingly should not be penalized for accepting the medical advice and going to another hospital.

Accordingly, the respondents are directed to again evaluate the entitlement of the applicant in the light of the finding that the applicant's action was bonafide and it is the medical advice of the Shanti Mukund Hospital, which is one of the empanelled hospitals of Govt. of NCT of Delhi, in which the wife of the applicant was admitted for treatment. Accordingly, the respondents shall pass fresh orders in this matter and reimburse the permissible amounts to the applicant. The claim of the applicant shall be finalized within a period of six weeks from the date of receipt of certified copy of this Order.

This Court also brings to the notice of the respondents, that Shanti Mukund Hospital, which is an empanelled hospital of Govt. of NCT of Delhi, is the one who created the present imbroglio. Hence, we direct the respondents to take appropriate steps in the matter so that such type of situation(s) would not arise in future by issuing clear cut instructions as to what action is to be taken by a person entitled to treatment, if he is directed to suddenly take his patient/go to a higher level facility as the treating hospital directs him to do so.

In the result, for the foregoing reasons, the present OA is disposed of in terms of the aforesaid directions. There shall be no order as to costs.