Union Of India vs Kiran Pal

Aradhana Johri, Member (A)

This Review Application is being filed against the order of this Tribunal in OA No.2277/2018 pronounced on 28.12.2018. While allowing the OA, the Tribunal held as follows:-

"11. In view of the facts and circumstances of the case there is no doubt that the admission of the applicant took place in an emergent condition, as admitted by the respondents in their counter. The sole reason for rejection of his claim is that the CGHS rates fall short of the actual amount spent on his treatment. This cannot be a hurdle for full reimbursement, as is clear from the aforementioned judgments, as well as other citations mentioned by the applicant in the OA.

I, therefore, allow this OA and set aside the impugned order dated 18.09.2017 (Annexure A-1). The respondents are directed to reimburse the balance amount of Rs.3,51,356/- incurred by the applicant on his treatment within a period of three months from the date of receipt of a certified copy of this order (after due verification, as per law). I am, however, not inclined to grant any interest on the same. No costs."

The review applicants are Union of India through different wings of the Railways, who were respondents in the OA No.2277/2018. They have stated that Railways have issued specific guidelines on the issue of reimbursement of medical expenses. The policy letter dated 31.01.2007 with details of calculation of the amount of reimbursement to be sanctioned out of the claimed amount reads as under:-

"II. Calculation of the amount of reimbursement to be sanctioned out of the claimed amount:

Once the emergency is established beyond doubt, then the case should be further processed for calculating the amount/money to the sanctioned.

For that, following guidelines are given:

a) Treatment taken in Govt. Hospital - Full admissible amount should be recommended for sanction.

b) Treatment taken in Recognized Private Hospital for an ailment for which it is recognized Rate as approved by Railway should be processed for sanction.

c) Treatment taken in a Recognized Private Hospital but for an ailment for which it is not recognized or treatment taken in a non-recognized Private Hospital:- Reimbursement should be made at the CGHS rates of that city or nearest city. CGHS (Central Govt. Health Scheme) approved rates are to be recommended/ processed as an upper limit for sanction.

III. The approved rates of private hospitals recognized by Railway should be put on the Wed sites of the Zonal Railways so that at all levels of processing/sanction these are accessible to all concerned.

IV. In medical Science, no list can be fully exhaustive. Hence, it is likely that there will be few occasions when a claim has been submitted which is not appearing exactly in the CGHS rate list. On these cases, the MD/CMS/MS in charge of Divisions will apply their mind and will come to a logical conclusion. Then, they will pass a speaking order to certify the rate/is being recommended, in consultation with Associate Finance."

It is the contention of the review applicants that this policy letter has also been upheld by superior courts and even though it was the part of the pleadings but was not taken into account by this Tribunal.

Learned counsel for the original applicant/respondent in this RA has stated that it was an emergency, the applicant got treatment from Artemis Hospital, which is a private hospital. Therefore, as per rulings of various courts, he is entitled to full reimbursement.

Heard Sh. VSR Krishna, learned counsel for the review applicants and Sh. Krishan Kant, learned counsel for the original applicant/respondent. I have also perused the material on record both in the RA and in the OA.

I find that the review applicants had included the policy letter dated 31.01.2007 in their pleadings, which has not been considered by the Tribunal in its order dated 28.12.2018. This policy letter has relevance on this case and defines the way in which such claims are to be disposed off. As per the said policy letter, the applicant would have been entitled to reimbursement of medical claim at CGHS rates.

In light of the above, review application is allowed. The Tribunal's order dated 28.12.2018 is recalled and the OA No.2277/2018 is restored to its original number. List the OA for hearing on 21.04.2020.