Sh. Ajit Singh vs Union Of India & Ors.

Applicant, who appeared in person, submitted that he joined as Investigator in Ministry of Planning, Department of Statistics and was posted at NSSO (FOD) Lucknow under the respondents. He is covered under the CGHS. It is further submitted that the applicant suffered a heart attack on 18.06.2016 at Lucknow and on the advice of the Medical Officer of CGHS, he was admitted to CGHS empanelled Avadh Hospital & Heart Centre, Lucknow in emergency. An amount of Rs. 51,014/- was paid by him to the said Hospital. Subsequently, he was referred to Sanjay Gandhi Post Graduate Institute (SGPGI) of Medical Sciences, Lucknow by the concerned medical officer of CGHS where he had to undergo angioplasty operation on 27.06.2016. For this treatment, an amount of Rs. 69,154/- was paid by the applicant to SGPGI, Lucknow. He submitted both the bills for reimbursement against which the respondents passed only Rs. 43,358/- and Rs.22,354/- i.e. Rs.65,712/- in July 2017. The respondents have reimbursed only partially for STK Therapy charges of Rs. 5290/- instead of Rs. 10,000/- and did not reimburse for Pathology charges of Rs. 2946/-, cost of Stent implanted charges of Rs.46200/- plus miscellaneous charges for surgical procedure of Rs. 600/-. Thus, a total of Rs.53856/- paid by him towards his medical treatment were not reimbursed. Several representations were made by the applicant but the same were not considered. Vide impugned order dated 16.05.2019, the respondents rejected his claim for the remaining amount stating that there is no mention of Batch No. of the Stent implanted and also the outer pouch of the Stent has not been submitted by the officer with his medical claim, which are essential and necessary documents. Aggrieved by this action on the part of the respondents, the applicant has filed the present O.A. seeking the following reliefs:-

The applicant is primarily seeking quashing of the impugned order dated 16.05.2019 and directions to the respondents to grant full medical reimbursement i.e. the entire balance of Rs. 53,856/- along with interest @18% per annum, which has been denied. In support of his claim, the applicant has submitted that the respondents have illegally disallowed his medical claim as the SGPGI, Lucknow has already certified the Pouch Bar Code along with scanned copy of stent sticker. He has also relied upon the Ministry of Health and Family Welfare O.M. dated 22.05.2018 for relaxation of Rules for consideration of reimbursement in excess of the approved rates pertaining to medical claims, orders passed by this Tribunal in OA-2904/2005 (Achal Kumar Aggarwal Vs. UOI &Ors.) dated 23.08.2006, OA-179/2007 (Dr. M.A. Haque Vs. UOI &Ors.) dated 04.12.2007, the judgment of Hon. High Court of Judicature at Madras in WP-10392/1996 (E.V. Kumar Vs. UOI &Ors.) dated 28.07.2003 and judgment of Hon. High Court of Delhi in WP(C)-7540/2015 (UOI Vs. Smt. Shanti Devi) dated 10.08.2015. On 14.12.2021, the applicant appeared in person before the Tribunal and submitted that the original documents of the concerned hospital have been submitted by him to the respondents. However, inadvertently a copy of the same has not been retained by him and these may be available in file with the respondents. The Tribunal ordered the respondents to produce the relevant file of all the documents pertaining to the medical claim of the applicant including the medical certificates in this regard on the next date of hearing for perusal of the Tribunal. During the final hearing on 20.07.2022, this Tribunal had heard the parties and again directed the learned counsel of the respondents to produce records pertaining to the medical claim of the applicant within a week’s time. Subsequently, the documents were produced by the respondents and perused.

Counter-affidavit has been filed by the respondents submitting that the applicant has submitted two claims. Claim No.1 for reimbursement of Rs. 53,054/- for taking treatment from Avadh Hospital & Heard Centre, Lucknow during the period from 18.06.2016 to 22.06.2016. However, the supporting documents for Rs.2,040/- were not submitted, hence the same was disallowed and the balance claimed amount of R.51,014/- was considered and finally reimbursement of Rs.43,358/- was made to the applicant as per extant rules. As far as his claim No.2 for reimbursement of Rs. 69,154/- for treatment having been taken at SGPGI, Lucknow for coronary angiography & angioplasty is concerned, the same was taken during the period from 26.06.2016 to 28.06.2016. Out of Rs. 69,154/-, only Rs. 22354/- was approved and paid as per extant rules to the applicant and Rs.46,800/- was disallowed. It is further submitted that as far as the amount for stent implant is concerned, the applicant was supposed to submit the outer pouch of the stent packet along with the sticker on it claiming reimbursement. Since it was not submitted by the applicant along with medical claim, the same was denied to him. The respondents have also enclosed copies of the OM Nos. Misc.1002/2006/ CGHS(R&H)/CGHS(P) dated 31.10.2011 regarding revision of ceiling rates and guidelines for various coronary/vascular stents for CGHS/CS(MA) beneficiaries and Misc.1002/2006/CGHS(R&H)/CGHS (P) dated 21.02.2013 on the same subject.

Heard the applicant in person and Sh. Gyanendra Singh, learned counsel for the respondents.

The applicant is CGHS beneficiary. He suffered heart attack on 18.06.2016 and took treatment in the CGHS empanelled Avadh Hospital & Heart Centre, Lucknow in emergency during the period from 18.06.2016 to 22.06.2016 for which he submitted claim for reimbursement of Rs.53,054/-. For this claim, the supporting voucher of Rs. 2040/- were not enclosed and hence the claimed amount was for Rs.51,014/-. The respondents approved an amount of Rs. 43,358/-and disallowed Rs. 7656/-. Subsequently, the applicant was referred for further treatment for coronary angiography & angioplasty to SGPGI, Lucknow. He took treatment for the same in SGPGI, Lucknow during the period from 26.06.2016 to 28.06.2016. He claimed a total amount of Rs. 69,154/-, which he paid toward his medical treatment. Of this claimed amount, the respondents approved and paid Rs. 22,354/- and disallowed an amount of Rs. 46,800/-. The applicant was advised vide Accounts Section letter No. G-21011/7/2015-16-B&A/501 dated 07.11.2017 to submit, in original, all details to consider his claim for payment. It is evident that certain amounts have been disallowed in claim No.1 and against the amount claimed, the amount admissible was approved for STK Theraphy and the amount claimed for Pathology charges was disallowed as no details were furnished. Similarly for claim No.2 for the treatment for coronary angiography and angioplasty taken at SGPGI, Lucknow, the claimed amount was Rs.69,154/-. Out of this Rs. 22,354/- was paid and Rs. 46,800/- was disallowed indicating that as per the rules, the outer pouch of the stent along with sticker on which details of the stent are printed, has not been submitted by the applicant, hence this amount was disallowed. The applicant made a representation against this order, which was not considered by the respondents and he was advised vide impugned order dated 16.05.2019 that as he has not submitted the required details of the stent as prescribed vide OM dated 31.10.2011, his reimbursement claim is not admissible. The applicant made further representation dated 16.10.2019 submitting that his surgery was done at SGPGI, Lucknow on 27.06.2016 which is a government hospital and as per new rule, outer pouch along with sticker cannot be supplied by hospital and only the bar code scan copy duly certified by the concerned Professor, Department of Cardiology, SGPCI, Lucknow is given. He further requested that the competent authority may seek confirmation from SGPGI, Lucknow about the same. The applicant has submitted copies of the discharge bills dated 28.06.2016 issued by SGPGI, Lucknow along with OT-Dossier/Unit items issue slip dated 27.06.2016 and copy of the final procedure bill details from SGPGI, Lucknow duly verified by Dr. Aditya Kapoor, Professor, Department of Cardiology, SGPGI, Lucknow. All these photo copies clearly indicate that he was provided with details of Stent-Stent Des Sirolimus Elut on Cobalt (Biomime Aura) (Meril) with the unit rate indicated as Rs.46200/- in all these three bills. These copies of bills have been verified by Professor, SGPGI, Lucknow and enclosed as Annexure A-13. In Annexure-13, the bar code has also been scanned on the unit item issue slip for the said stent.

The respondents in support of their action for not granting the full reimbursement for Stent have cited O.M. dated 31.10.2011 (Anneuxre R-1) wherein in para-3 it is mentioned as under:-

A reading of para-3 of this O.M. indicates that it is the responsibility of the empanelled hospital to quote the batch number when a coronary/vascular stent of any type is implanted in the case of a CGHS/CS (MA) beneficiary and also enclose a copy of the relevant invoices pertaining to the procurement of the stents by the hospital. It is the contention of the applicant that he had submitted the sticker etc. for the stent and did not keep a copy of the same. Be that as it may, it is evident that the applicant is a CGHS beneficiary and he was referred to SGPGI, Lucknow for treatment wherein a certain stent has been implanted. The respondents have also approved an amount of Rs. 22,354/- but disallowed the entire cost of Rs.46,800/- of the stent implanted on the ground that no details and stickers etc. have been furnished. It is observed that the SGPGI, Lucknow, which is a government hospital had clearly indicated the stent implanted with its details and a cost indicated is Rs.46,200/- and the same has also been verified by concerned Professor, SGPGI, Lucknow.

In view of the above, the rejection of the claim of the applicant for the cost of stent implanted on grounds of non submission of sticker cannot be accepted. In a catena of judgments, the aspect of medical reimbursement and the rejection of such reimbursement claims on flimsy reasons have been adversely commented. The respondents cannot deny the claim of the stent implanted if such a stent had been implanted only on the ground that the applicant did not have the original sticker etc. If required, it is the responsibility of the respondents to obtain confirmation for such a stent implanted from the empanelled hospital, SGPGI in this case and it is also the responsibility of the hospital to cite the same. Since the same has not been done, I do not find the action on the part of the respondents to be fair and justified.

In view of the above, the O.A. is allowed. The impugned order dated 16.05.2019 is set aside. The respondents are directed to verify these bills from the records and if necessary from SGPGI, Lucknow regarding the stent implanted and the cost for the same as charged by SGPGI, Lucknow shall be reimbursed to him within a period of eight weeks from the date of receipt of a copy of this order.

There shall be no order as to costs.