Chandan Kumar Singh vs Union Of India & Ors

Rajnish Kumar Rai, Member J

Shri Rajesh Kumar, counsel for the applicant and Shri K.K. Ojha, counsel for the respondents are present and heard.

This O.A. has been filed by the applicant for direction to the respondents to reimburse the medical claim to the tune of Rs.69,496/-along with 18% interest on account of emergency surgery of wife of applicant namely Mrs. Sushmita Singh, by praying the following relief(s):

“(i) This Hon'ble Tribunal may graciously be pleased to direct the respondents to reimburse the medical expenses / claim of the applicant amounting Rs. 69496/- along with 18% interest from the date it was submitted till the date of actual payment.

(ii) Any other relief, which this Hon'ble Tribunal may deem fit and proper in the circumstances of the case may be given in favour of the applicant.

(iii) Award the costs of the original application in favour of the applicant.”

The facts of the case, as per pleadings in the O.A., are that the applicant is working as Deputy C.I.T. at Kanpur under the North Central Railway. The applicant is the beneficiary of free medical facility from the railway department. Counsel for the applicant submitted that the wife of applicant had been suffering with some problem in her left ear for which treatment was taken from the Railway Hospital. The treatment was given by Dr. Urvashi Yadav, Assistant Divisional Medical Officer, N.C. Railway, Kanpur Railway Hospital. However, on account of sudden emergency, she has approached to the empanelled hospital by the railways namely ‘Regency Hospital Limited’, Sarvodaya Nagar, Kanpur. Counsel for the applicant further submitted that on account of emergency admission, the wife of applicant has undergone tympanomastoid surgery and thereafter a bill for surgery amounting to Rs.69,496/-, which was paid to the Regency Hospital and same was submitted for reimbursement to the respondents’ department, however, the reimbursement has not been paid till date. He has further submitted that the bill was returned by the railway department because there was no referral letter and accordingly same has been denied. Counsel for the applicant has placed reliance upon the certificate dated 28.08.2023 issued by the Regency Hospital Limited vide which it has been stated by the empanelled hospital that the wife of applicant Mrs Susmita Singh was admitted in emergency on 28.08.2023 at 10.17 A.M. and after diagnosis, there is need of right tympanomastoid surgery hence, the surgery was performed immediately and the emergency certificate/letter was issued by the Regency Hospital Limited on 28.08.2023.

Counsel for the respondents submitted that the claim of applicant has been denied on account of non-referral and same was not a emergency case and it was not a plan get surgery hence, the applicant is not entitled for reimbursement.

Considering the submission of counsel for the parties and from perusal of record, it is clear that there is no dispute with regard to treatment of applicant’s wife as she had been under the treatment of Railway Hospital and later on she has approached, on account of referral, to Regency. Counsel for the applicant submitted that the empanelled hospital is authorized in case of emergency to treat the patient in accordance with the prescribed rules. There is no dispute with the fact of admission in emergency in the empanelled hospital namely Regency Hospital. Accordingly, the applicant is entitled for the claim of reimbursement for the surgery of his wife in accordance with CGHS rules. In this regard, the counsel for applicant has relied on various Judgments and Orders of Hon’ble Supreme Court as well as of this Tribunal. In the case of Shiva Kant Jha Vs. Union of India and others in Writ Petition (Civil) No. 694 of 2015, decided on 13.04.2018, the Hon’ble Supreme Court has held as under: -

“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. Specialities 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."

From the record, it is clear that the wife of applicant has undergone with surgery in Regency Hospital-a empanelled hospital. Accordingly, I am of the opinion that the applicant is entitled for the reimbursement of the amount incurred during the surgery. Accordingly, the O.A. is disposed of with direction to the applicant to submit all the relevant document regarding surgery at empanelled hospital within 15 days from today and thereafter, the respondents are under the obligation to consider the same and release the amount of Rs.69,496/- as per extant rules and as per discussion above and also as per the case law within a period of three months from the date of receipt of a certified copy of this Order along with relevant documents as directed to the applicant. The decision so taken on the medical reimbursement of applicant shall be intimated to him forthwith. All the pending MAs shall be deemed to have been disposed of. No order as to cost.