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Judgment
Om Prakash VII, Member (J)
Shri Rajesh Kumar, learned counsel for the applicant and Shri Shivaji Singh, learned counsel for the respondents, were present at the time of hearing.
The instant original application has been filed by the applicant seeking following relief:
“(i) The Hon’ble Tribunal may be pleased to quash and set aside the impugned order dated 06.04.2024 & 24.10.2024 (Annexure A-1 and A-2 respectively to this O.A.) passed by the respondents.
(ii) This Hon’ble Tribunal may be pleased to direct the respondents to make payment amounting to Rs. 2,88,668/- (Rupees Two Lack Eighty Thousand Six Hundred Sixty Eight Only) as medical reimbursement for total knee operation conducted at All India Institute of Medical Sciences, New Delhi along with interest.
(iii) This Hon’ble Tribunal may be pleased to direct the respondents to pay the suitable compensation to the applicant for unnecessary harassment and mental torture of 73 years old senior citizen.
(iv) This Hon’ble Tribunal may be pleased to issue any such other or further orders/directions in favour of the applicant for which this Hon’ble Tribunal may deem fit just and proper in the facts and circumstances of the case and for which the applicant may be entitled under Law, otherwise, the applicant will suffer irreparable loss and injury.
(v) Award the cost of the petition.”
The instant original application has been filed by the applicant, who is a senior citizen, seeking quashing of the order dated 06.04.2024 & 24.10.2024 passed by the respondents vide which the applicant’s claim of medical reimbursement regarding his both knees surgery undergone at All India Institute of Medical Sciences, New Delhi, which the applicant claims to be a recognized hospital under central government, has been rejected. The applicant has contended that he had availed the treatment under emergency and therefore as per the extant rules and various rulings of the Apex Court, his claim is liable to be accepted and thus, he is entitled for payment of Rs. 2,88,668/- towards his medical reimbursement claim.
I have heard learned counsel for the parties and perused the records.
Learned counsel for the applicant submitted that the applicant is a retired employee of the respondents’ department and is currently aged about 73 years. He is covered under the scheme of RELHS and is eligible for cashless / free indoor treatment as well as reimbursement of medical expenses of himself and his wife. It was argued that Railway Board vide circular dated 06.03.2003 provides that railway employees whether serving or retired are entitled for reimbursement of medical expenses if, (i) Treatment has been taken in recognized hospital (ii) without any reference by authorized medical officer of railway hospital railway, (iii) due to emergent circumstances. The applicant was suffering from knee problems and acute pain since a long time requiring surgery. The applicant visited his family members in Greater Noida and during that visit, both the knees of the applicant got locked and froze with acute pain in the last week of November 2023 and thereafter the applicant got himself checked up at All India Institute of Medical Sciences, New Delhi on 04.12.2023 where Dr (Prof.) H L Nag advised him for total knee replacement urgently and admitted him for surgery. Thus, the applicant underwent total knee replacement surgery in AIIMS, New Delhi where his right leg knee surgery was done on 07.12.2023 and left leg knee surgery was done on 12.12.2023. The applicant was discharged on 15.12.2023 and subsequently he submitted his reimbursement claim form along with emergency certificate and all medical bills of Rs. 2,88,668/- duly signed by the doctor of AIIMS, New Delhi on the prescribed proforma on 18.01.2024. The applicant was informed vide letter dated 06.04.2024 by the office of Principal Chief Medical Officer, BLW/Varanasi that the claim for reimbursement of medical expenses incurred cannot be reimbursed as there was no emergency. In his reply to the aforesaid letter, the applicant submitted the application dated 18.04.2024 stating that his treatment was taken in emergent and urgent condition in AIIMS, New Delhi. Certificate of necessity cum emergency which was issued by Dr. Vivek Shankar of AIIMS, New Delhi was submitted by the applicant along with the reimbursement form, as surgery had taken place on 07.12.2023 & 12.12.2023. The applicant even submitted before the respondents the judgment dated 13.04.2018 of the Hon’ble Supreme Court of India in Writ Petition (Civil) No. 694/2015 titled Shiva Kant Jha Vs Union of India & others through his application dated 15.07.2024. The applicant claims that his case is squarely covered by the ratio laid down in the said judgment. It is further argued that the claim of the applicant is also liable to be allowed in view of the Railway Board Letter dated 29.08.2024 vide which guidelines/instructions on medical treatment were issued. Thus, referring to entire facts and circumstances, learned counsel for the applicant argued that the impugned orders are illegal and therefore liable to be set aside and respondents be directed to confer the payment of Rs. 2,88,668/- in favour of the applicant towards his claim for medical reimbursement.
Learned counsel for the respondents vehemently opposed the prayer of the applicant and referring to his counter affidavit, he argued that the case of the applicant was considered and examined by the competent authority and it was found that there was no emergency established in the case of the applicant and therefore, in the light of the Railway Board’s letter dated 31.01.2007, his case was rejected by the competent authority. It was further argued that there was no case for the applicant to have approached AIIMS hospital. He could have attended the authorized medical officer at “Central Hospital New Delhi at Connaught Place, which is nearer to Greater Noida and where the facility of knee replacement is available. It was also argued that even when the applicant approached AIIMS, he could have obtained approval as per Railway Board’s guidelines from Authorised Medical Officer to get treated in AIIMS NDLS, but the same was not done on his part. Furthermore, the Osteoarthritis of knee is not an acute diseased but a chronic long standing disease. Furthermore, the guidelines dated 29.08.2024 which has been referred to by the applicant were issued subsequent to the dates on which the applicant had taken treatment and therefore the same won’t be applicable to the applicant. Thus, it was argued that there is no illegality, infirmity or perversity in the impugned order and the case of the applicant is liable to be dismissed being devoid of merits.
Rejoinder has been filed by the applicant reiterating the facts as have been narrated in the OA.
I have considered the rival contentions and carefully gone through the records.
As the brief facts of the case have already been narrated above, the same are not reiterated for the sake of brevity. Before discussing the submissions raised across the Bar, it will be useful to quote the case laws as relief upon by the learned counsel for the applicant:
Learned counsel for the applicant has relied upon the following quotation as contained in the judgment passed by the Hon’ble Supreme Court of India in the case of Shiva Kant Jha (supra):
“12) With a view to provide the medical facility to the retired/serving CGHS beneficiaries, the government has empanelled a large number of hospitals on CGHS panel, however, the rates charged for such facility shall be only at the CGHS rates and, hence, the same are paid as per the procedure. Though the respondent-State has pleaded that the CGHS has to deal with large number of such retired beneficiaries and if the petitioner is compensated beyond the policy, it would have large scale ramification as none would follow the procedure to approach the empanelled hospitals and would rather choose private hospital as per their own free will. It cannot be ignored that such private hospitals raise exorbitant bills subjecting the patient to various tests, procedures and treatment which may not be necessary at all times.
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.
14) This is hardly a satisfactory state of affairs. The relevant authorities are required to be more responsive and cannot in a mechanical manner deprive an employee of his legitimate reimbursement. The Central Government Health Scheme (CGHS) was propounded with a purpose of providing health facility scheme to the central government employees so that they are not left without medical care after retirement. It was in furtherance of the object of a welfare State, which must provide for such medical care that the scheme was brought in force. In the facts of the present case, it cannot be denied that the writ petitioner was admitted in the above said hospitals in emergency conditions. Moreover, the law does not require that prior permission has to be taken in such situation where the survival of the person is the prime consideration. The doctors did his operation and had implanted CRT-D device and have done so as one essential and timely. Though it is the claim of the respondent-State that the rates were exorbitant whereas the rates charged for such facility shall be only at the CGHS rates and that too after following a proper procedure given in the Circulars issued on time to time by the concerned Ministry, it also cannot be denied that the petitioner was taken to hospital under emergency conditions for survival of his life which requirement was above the sanctions and treatment in empanelled hospitals.
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.”
There is no dispute between the parties that treatment was obtained by the applicant from AIIMS Hospital, New Delhi, whereby both his knee joints were replaced. AIIMS Hospital, New Delhi is specialized for emergency treatment also. Applicant’s stand is that the aforesaid treatment was taken in emergency. However, the respondents are of the contention that the case of the applicant was not one pertaining to emergency and hence, prior approval of the authority concerned should have been taken by the applicant before undergoing the treatment. In this regard, it would be in the fitness of things to refer to reimbursement form dated 18.01.2024 submitted by the applicant before the respondents’ department along with which, the emergency certificate which was issued by Dr. Vivek Shankar of AIIMS New Delhi Hospital, was also enclosed. A perusal of the aforesaid certificate clearly establishes that the case of the applicant was an emergent one. Therefore, once the doctor concerned has recorded that the treatment of the patient was made taking it as an emergency case, no further doubts remain on that issue and thus, in all likelihood, the respondents should have reimbursed the amount of medical bills in favour of the applicant. It is needless to reiterate that in such serious scenarios where survival of the patient becomes the matter of prime consideration, taking administrative approvals and running from pillar to posts for completion of paper works becomes secondary. Therefore, there seems to be no reason why the payment of medical reimbursement should not be allowed to the applicant specifically when his case proves to be that of an emergency and also since the applicant had submitted the emergency certificate issued by the doctor concerned while submitting his claim for medical reimbursement.
Thus, in accordance with the deliberations quoted above and specifically in light of the law laid down by the Hon’ble Supreme Court of India in the case of Shiva Kant Jha (supra) as quoted above, this Tribunal is of the considered opinion that the instant case of the applicant is liable to be allowed. Thus, the impugned order(s) are quashed and the OA is allowed to the extent that the competent authority amongst the respondents is hereby directed to reimburse the entire amount of medical reimbursement to the applicant within a period of three months from the date of receipt of certified copy of this order. If payment is not made within the aforesaid period, respondent will pay 6% per annum simple interest on the bill amount.
All associated MAs stand disposed of accordingly.
There shall be no order as to costs.