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O R D E R
The applicant is a retired employee and a pensioner of the Employees' State Insurance Corporation (ESIC), Regional Office (Kerala), Thrissur. She is also a lifetime member of the ESIC Pensioners Medical Scheme which came into force with effect from 01.04.2006. Consequent to the directions of the Hon'ble Supreme Court in the case of Shiv Kant Jha vs. Union of India & Ors., AIR 2018 Supreme Court 1975 and the directions of the Government of India, Ministry of Health and Family Welfare O.M.No.Z-15025/38/2018/DIR/CGHS/EHS dated 22.05.2018 the Director General, ESIC constituted the High Powered Committee for Grievance Redressal of ESIC employees/pensioners pertaining to medical claims, vide O.M.No.D-12/17/1/7/11-E.IV dated 11.10.2018 on the matter of relaxation of rules for consideration of reimbursement in excess of the approved rates pertaining to medical claims.
The applicant submitted a medical reimbursement claim for getting full imbursement of the medical expenses of Rs.1276458/- incurred by her for her inpatient treatment for the period from 21.08.2023 to 12.10.2023Central Administrative Tribunal at Aster Medcity, Kochi. This is one of the private empanelled hospitals for medical treatment to ESIC employees and pensioners. It is submitted that although the applicant was entitled to full reimbursement as per condition (c), she was sanctioned Rs.508854/- only. She is aggrieved by the decision of the respondents disallowing a major chunk of the claim of Rs.767604/- and seeks full reimbursement.
The applicant has produced the revised guidelines issued by the 5th respondent vide Memorandum dated 25.05.2021 produced as Annexure A-4 as per which she is entitled to get cashless medical treatment and medical treatment on a reimbursement basis. It is argued that as per the terms of the revised guidelines she is entitled to the following -
Super Speciality Treatment which provides as – pensioners would be eligible for all kinds of medical treatment including SST from the date of entry/re-entry into the Scheme.
Medical treatment which includes –
(1)Cashless Medical Treatment which may be
(a)Treatment in emergency.
(b)Treatment at ESIC Hospital and
(c)Treatment from a private hospital empanelled with ESIC
Central Administrative Tribunal(2) Treatment on reimbursement basis -
(i)In case no tie up hospital is available for emergency treatment
(ii)All treatments taken in Government Hospital and
(iii)Treatment in tie-up/non tie-up hospitals without permission/referral.
The applicant was under inpatient treatment at the Aster Medcity for the continuous period from 29.07.2023 to 12.10.2023 but cashless treatment was granted to her from 29.07.2023 to 21.08.2023 only. From 21.08.2023 to 12.10.2023 she was under treatment of the Physical Medicine and Rehabilitation Department of the same hospital, shifted as per medical advise and she had no role in this. However, the cashless treatment was denied to her for the treatment she has availed of from the department for the period from 21.08.2023 to 12.10.2023 for which she had to pay a huge amount of Rs.1276458/- while claiming the amount through reimbursement she was sanctioned Rs.508854/- only disallowing Rs.767604/-. It is submitted that the same was done without referring her claim to the High Powered Committee as mandated as per the O.M dated 11.10.2018. It has been argued that as per the terms of the decision of the Hon'ble Supreme Court in Shiv Kant Jha (supra) the right to medical claim cannot be denied merely because the name of the hospital is not included in the Government Order. The real test must be the factum of treatment. Para 13 of the order reads as under -Central Administrative Tribunal
“13.It is a settled legal position that the Government employee during his life time or after his retirement is entitled to get the benefit of the medical facilities and no fetters can be placed on his rights. It is acceptable to common sense, that ultimate decision as to how a patient should be treated vests only with the Doctor, who is well versed and expert both on academic qualification and experience gained. Very little scope is left to the patient or his relative to decide as to the manner in which the ailment should be treated. Speciality Hospitals are established for treatment of specified ailments and services of Doctors specialized in a discipline are availed by patients only to ensure proper, required and safe treatment. Can it be said that taking treatment in Speciality Hospital by itself would deprive a person to claim reimbursement solely on the ground that the said Hospital is not included in the Government Order. The right to medical claim cannot be denied merely because the name of the hospital is not included in the Government Order. The real test must be the factum of treatment. Before any medical claim is honoured, the authorities are bound to ensure as to whether the claimant had actually taken treatment and the factum of treatment is supported by records duly certified by Doctors/Hospitals concerned. Once, it is established, the claim cannot be denied on technical grounds. Clearly, in the present case, by taking a very inhuman approach, the officials of the CGHS have denied the grant of medical reimbursement in full to the petitioner forcing him to approach this Court.”
It is submitted that on 21.07.2023 the applicant fell seriously ill and was admitted as an emergency case at Amala Institute of Medical Sciences, Amala Nagar, Thrissur, one of the private empanelled hospitals under the 1st respondent for providing treatment to ESIC Pensioners under the ESIC Pensioners’ Medical Scheme. She was diagnosed with “Guillain-Barré Syndrome (anti-GM1 (IgM) and anti-GD1a antibodies positive)/Hypertension” and remained under inpatient treatment from 21.07.2023 to 29.07.2023. She was provided cashless treatment at the said hospital for the entire period from 21.07.2023 to 29.07.2023. Thereafter, on the night of 29.07.2023, she was shifted to Aster Medcity, Kochi, another private empanelled hospital under the 1st respondent for treatment of ESIC Pensioners under the ESIC Pensioners’ Medical Scheme. She remained under inpatient treatment there from 29.07.2023 to 12.10.2023. On 21.08.2023, she was shifted to the Department of Physical Medicine and Rehabilitation, where she continued to receive inpatient treatment for “Acute Inflammatory Demyelinating Polyneuropathy – AMAN variant with quadriparesis; Bronchiectasis in left lower lobe”.
The applicant was granted cashless treatment at Aster Medcity for the period from 29.07.2023 to 21.08.2023 up to 19:45 hours. However, cashless treatment was denied from 21.08.2023 at 19:46 hours onwards, notwithstanding that she continued to remain admitted in the sameCentral Administrative Tribunal hospital and that the treatment in the Department of Physical Medicine and Rehabilitation was a continuation of the treatment already being provided to her. Consequently, she was compelled to bear the medical expenses incurred during the said period.
The total inpatient bill for the period from 21.08.2023 at 19:46 hours to 12.10.2023 at 17:15 hours amounted to Rs.1326458/-. After allowing a discount of Rs.50000/- by the hospital, the applicant was required to pay a sum of Rs.1276458/-. A separate Discharge Summary was issued by Aster Medcity in respect of the treatment received in the Department of Physical Medicine and Rehabilitation, showing the date of admission as 21.08.2023 and the date of discharge as 12.10.2023. The said treatment was, in substance and continuity, a continuation of the cashless treatment that the applicant had already been receiving in the same hospital. A copy of the Discharge Summary issued by Aster Medcity, Kochi, showing DOA as 21.08.2023 and DOD as 12.10.2023, is produced as Annexure A-6. A copy of the Inpatient Provisional Bill (Summary) dated 12.10.2023, for a total amount of Rs.1326458/-, is produced as Annexure A-7. Copies of the Inpatient Final Bill containing the detailed particulars in 34 pages, dated 12.10.2023, for an amount ofCentral Administrative Tribunal Rs.1326458/- towards the treatment received during the period from 21.08.2023 at 19:46 hours to 12.10.2023 at 17:15 hours, are produced as Annexure A-8.
In the above circumstances, the applicant submitted a medical reimbursement claim in Form PMS-6 (Application Form for Reimbursement of Medical Expenses) dated 15.11.2023, seeking reimbursement of the amount of Rs.1276458/- actually borne by her, along with all the relevant supporting documents, to the 4th respondent. She specifically requested that the entire amount be reimbursed under special circumstances in terms of Condition (c) of Annexure A-4 Office Memorandum issued by the 5th respondent.
Along with the claim, the applicant enclosed all relevant and necessary documents relating to the medical treatment received by her in the Department of Physical Medicine and Rehabilitation at Aster Medcity for the period from 21.08.2023 to 12.10.2023. The claim was submitted to the 4th respondent through the 1st respondent, who is the Nodal Officer for the ESIC Pensioners’ Medical Scheme in the Kerala Region. It is submitted that the 4Central Administrative Tribunalth respondent, being the Chairperson of the High Powered Committee constituted by the 5th respondent in terms of the Government of India, Ministry of Health and Family Welfare, Office Memorandum dated 22.05.2018, and acting in conformity with the principles laid down by the Hon’ble Supreme Court in Shiva Kant Jha (supra), is bound to consider the applicant’s representation seeking full reimbursement of the medical expenses incurred by her, amounting to Rs.1276458/-, under Condition (c) of Annexure A-4 Office Memorandum. A copy of the representation dated 15.11.2023 submitted by the applicant to the 4th respondent, requesting sanction of full reimbursement of the medical expenses of Rs.1276458/- as a special case, is produced as Annexure A-9. A copy of the reimbursement claim in Form PMS-6 dated 15.11.2023, submitted by the applicant for Rs.1276458/-along with the supporting documents, is produced as Annexure A-9(a). A copy of the representation dated 15.11.2023 submitted by the applicant to the 1st respondent, requesting onward transmission of the claim along with all its enclosures to the 4th respondent, is produced as Annexure A-9(b).
After the lapse of more than 50 days from the date of submission of the medical reimbursement claim, the 2Central Administrative Tribunalnd respondent returned the medical claim along with the enclosures to the applicant vide letter No. 54.D.12.12.5.1.2022(P)-Cash dated 10.01.2024, directing her to furnish three additional documents for further processing of the claim. A copy of the said letter issued by the 2nd respondent returning the medical claim and directing the applicant to cure the defects is produced as Annexure A-10. Accordingly, the applicant complied with the requirements pointed out by the 2nd respondent, cured the defects and re-submitted the medical reimbursement claim along with all the requisite documents to the 1st respondent vide representation dated 14.02.2024, requesting expeditious action for securing full reimbursement of the medical expenses incurred by her. A copy of the representation dated 14.02.2024 submitted by the applicant to the 1st respondent, along with the medical reimbursement claim and the documents curing the defects, is produced as Annexure A-11.
Thereafter, upon re-submission of the medical reimbursement claim, the applicant received a Sanction/Disallowance Memo dated 09.04.2024 issued by the 2nd respondent. The said Sanction/Disallowance Memo was enclosed with letter No. Z-15014/20/2022-ACCOUNTS dated 25.04.2024Central Administrative Tribunal issued by the 3rd respondent. From the said Sanction/Disallowance Memo, it was revealed that, out of the total amount of Rs.1276458/- claimed by the applicant, only an amount of Rs.508854/- had been sanctioned, while the remaining amount had been disallowed. A copy of the Sanction/Disallowance Memo dated 09.04.2024 issued by the 2nd respondent and enclosed with letter No. Z-15014/20/2022-ACCOUNTS dated 25.04.2024 issued by the 3rd respondent is produced as Annexure A-12. A copy of the said letter dated 25.04.2024 issued by the 3rd respondent to the applicant, enclosing the aforesaid Sanction/Disallowance Memo, is produced as Annexure A-13.
The respondents have filed reply statement wherein they have stated that the Physical Medicine and Rehabilitation Department at Aster Medcity, Kochi in not empaneled under ESIC for cashless facility. Further, as per MH&FW O.M dated 11.03.1993 the expenditure incurred on treatment taken at Government/Referral/Private empaneled hospitals/diagnostic centres is reimbursable by the respective Departments/Ministries and is restricted to the limits prescribed by the MH&FW from time to time. The O.M further states that the expenditure incurred in excess of the limits prescribed has to be borne by the beneficiary himself. Thereafter an additional reply statement has been filed by the respondents wherein as regards full reimbursement it is statedCentral Administrative Tribunal that the deductions were made as per valid CGHS Rules since Aster Medcity, Kochi is empaneled under ESIC.
The applicant has also filed rejoinder and addtional rejoinder in this case wherein she has relied on the order dated 30.11.2021 in O.A.No.789/2016 passed by the Jaipur Bench of this Tribunal in the case of R.P.Sharma vs. Union of India & Ors. It is ordered therein that the applicant is entitled to full medical reimbursement as he has taken treatment in a Government empaneled hospital and directed to pay the remaining balance amount with interest at GPF rate, rejecting the averments of the respondents relying on O.M issued by the Government of India, Ministry of Health and Family Welfare O.M dated 11.03.1993 that no reimbursement under the CGHS is admissible in excess of the ceiling rates prescribed for tests/treatment/implants. In the additional rejoinder the applicant has submitted that her claim seeking full reimbursement was submitted to the 4th respondent, the proper authority, through the 1st respondent, as per Condition (c) of the Annexure A-3. But it is pointed out that without forwarding the claim to the 4th respondent, the 1st respondent disallowed Rs.767604/- out of a total amount of Rs.1276458/- and sanctioned only Rs.508854/- which is irregular andCentral Administrative Tribunal perverse. It is submitted that 1st respondent/2nd respondent has no authority to consider representations seeking full reimbursement under special circumstances, which are not notified, only the 4th respondent is competent to consider such representations.
It is evident from the foregoing discussion as well as from the rejection memos produced as Annexures A-11 and A-12 that the applicant’s claim was dealt with directly by the office of the Regional Director without referring the matter to the High Powered Committee. The relevant rules make it clear that the amount actually incurred by the patient towards the treatment is liable to be reimbursed. In such circumstances, imposing a restriction based on package rates is unwarranted and cannot be sustained. There is also no dispute regarding the genuineness of the applicant’s claim or the factum of the treatment undergone by her. Therefore, once the applicant is found entitled to reimbursement, restricting the reimbursement to a part of the eligible amount is not justified.
In the present case, the reimbursement has been considered in accordance with the rules and the terms and conditions contained inCentral Administrative Tribunal clause (c) (2)(iii) of the Office Memorandum dated 25.05.2021, produced as an Annexure-A to the said circular wherein it is stated that for treatment in Tie-up/Non tie-up hospital without permission/referral, if the pensioner takes any elective treatment/investigations from the tie-up/non tie-up hospital in normal circumstances without any advice of ESIC Doctor/Government Specialist or without permission/referral, the request for ex-post facto approval of such treatment shall be considered by the sanctioning authority and reimbursement shall be limited to CGHS rates. Accordingly, the applicant's claim was to be considered by the competent authority in accordance with the aforesaid provision and the applicable rules, than being restricted to on the basis of packages rates.
Furthermore, in this particular instance, no reference has been made to High Powered Committee. Hence, the matter may be referred to the High Powered Committee for consideration and full reimbursement of the applicant's medical claim in terms of the decision of the Hon'ble Supreme Court in the case of Shiva Kant Jha (supra), and if found admissible the same may be granted within a period of one month from the date of receipt of a copy of this order.Central Administrative Tribunal The O.A is disposed of accordingly. No costs.
List of Annexures in O.A.No.180/00647/2024
Annexure A-1 – A true copy of the revised Pension Payment Order bearing PPO No.A-40/15/4869/2005/A/c.IV dated 17.02.2006 File No.435 dated 29.01.2018 issued by the 3rd respondent to the applicant on 29.01.2018.
Annexure A-2 – A true copy of the ESIC Medical Card No.1351/1 issued from the Office of the 1st respondent to the applicant.
Annexure A-3 – A true copy of the Office Memorandum No.D-12/17/1/7/11-E IV dated 11.10.2018 issued by the 5th respondent constituting an High Powered Committee.
Annexure A-4 – A true copy of the revised guidelines issued by the 5th respondent vide Memorandum F.No.D-12/16/1/2012-E-VI. Vol.II dated 25.05.2021.
Annexure A-5 – A true copy of the judgment of the Hon'ble Supreme Court dated 13.04.2018 in W.P.(C) No.694 of 2015 in Shiv Kant Jha vs. Union of India, AIR 2018 SC 1975.
Annexure A-6 – A true copy of the Discharge Summary with DOA 21.087.2023, DOD 12.10.2023 issued from Aster Medcity, Kochi to the applicant.
Annexure A-7 – A true copy of the Inpatient Provisional Bill (Summary) dated 12.10.2023 totalling Rs.1326458/- issued to the applicant.
Annexure A-8 – A true copy of the Inpatient Final Bill (Details in 34 pages) dated 12.10.2023 issued to the applicant from Aster Medcity for Rs.1326458/- for the period from 21.08.2023 (19:46 Hrs) to 12.10.2023 (17:15 Hrs).
Annexure A-9 – A true copy of the representation dated 15.11.2023 submitted by the applicant to the 4th respondent requesting to sanction full reimbursement of the medical claim of Rs.1276458/- as a special case.
Annexure A-9(a) – A true copy of the reimbursement claim in Form PMS-6 dated 15.11.2023 for Rs.1276458/- submitted by the applicant along with her representation.
Annexure A-9(b) – A true copy of the representation dated 15.11.2023 submitted by the applicant to the 1st respondent requesting for onward submission of her claim along with its enclosures to the 4th respondent.
Annexure A-10 – A true copy of the letter No.54.D.12.12.5.1.2022(P) – Cash dated 10.01.2024 issued by the 2nd respondent to the applicant returning the claim.
Annexure A-11 – A true copy of the representation dated 14.02.2024 of the applicant re-submitting her medical claim after curing all defects.
Annexure A-12 – A true copy of the sanction/disallowance memo dated 09.04.2024 issued by the 2nd respondent to the applicant.
15.Central Administrative Tribunal Annexure A-13 – A true copy of the letter No.Z-15014/20/2022-ACCOUNTS dated 25.04.2024 issued by the 3rd respondent to the applicant enclosing the sanction/disallowance memo.
Annexure A-14 – A true copy of the order of the Hon'ble Central Administrative Tribunal, Principal Bench, New Delhi dated 07.03.2023 in O.A.No.689/2019 in Surendra Kumar Gaur vs. Union of India & Ors.
Annexure A-15 – A true copy of the judgment of the Hon'ble High Court of Delhi in W.P.(C) No.8280/2023, CM Application No.31826/2023 dated 06.09.2023.
Annexure A-16 – A true copy of the judgment of the Hon'ble Punjab & Haryana High Court dated 08.04.1996 in C.W.P.No.15942/1995 in Mohinder Singh Chawla vs. State of Punjab & Ors.
Annexure A-17 – A true copy of the order of the C.A.T., Jaipur Bench dated 30.11.2021 in O.A.No.789/2016.
Annexure A-18 – A true copy of the Government of India, O.M bearing F.No.2-1/2012/CGHS/VC/CGHS(P) dated 01.08.2013.
Annexure A-19 – A true copy of the ESIC Circular bearing No.D-12/16/1/2017-E-VI-Vol.I dated 28.11.2018.
Annexure A-20 – A true copy of the ESIC Circular bearing No.NO V-15/15/1/2006 Med I (MS) dated 08.05.2019.
Annexure A-21 – A true copy of the ESIC O.M.No.Pt.D-12/17/1/7/11-E.IV dated 10.08.2018 issued from the office of the 5th respondent.
Annexure A-21(a) – A true copy of the Government of India O.M.No.Z.15025/38/2018/DIR-CGHS/EHS dated 22.05.2018 enclosed along with the Annexure A-21 ESIC O.M.