Makardhwaj vs Union Of India & Ors

Om Prakash-VII, Member (J)

This O.A. has been filed by the learned counsel for the applicant for direction to the respondents to pass the medical reimbursement amount of Rs. 1,98,139/- along with market rate interest.

The brief facts of the case are that applicant is employee of office of Garrison Engineer j(Air Force) Gorakhpur and applicant’s son namely Maheshwar Kumar Verma agedabout 22 years is wholly dependent upon the applicant, as such he is eligible for treatment and reimbursement of medical claim. Son of the applicant became seriously ill and he was referred by Dr. Saurabh Kedia on 23.10.2015 to SGPGI, Lucknow for urgent surgery but SGPGI refused (Annexure A-2 to the O.A.) to admit the patient as such he was not admitted in SGPGI. Applicant sought permission from the department on 23.10.2015 for Admission and Surgery in Sahara India Hospital, Lucknow. Applicant submitted application dated 28.10.2015 for medical advance for payment to the hospital. PCDA raised certain objection for payment of medical advance for Rs. 4,90,300/- as claimed by the Sahara Hospital, Lucknow. Applicant submitted application dated 20.11.2015 along with medical claim of Rs. 4,79,069/- but the same has not been paid to the applicant. Applicant filed O.A. No. 243/2016 but during the pendency of the O.A., respondents paid part of claimed reimbursement. Applicant submitted total claim of Rs. 5,84,043/- but only 3,85,904/- has been paid to the applicant and Rs. 1,98,139/- is still not paid. O.A. No. 243/2016 has been withdrawn by the applicant.

Counter affidavit has been filed by the learned counsel for respondents stating therein that five medical bills were received in the office of Audit and payment, out of which 3 medical bills were passed and 2 are returned under objection. It is stated that it is seen during audit that amount shown by the applicant in1st medical claim was Rs. 451618/- + 23000/- (shown as ambulance charge but no receipt enclosed) and total Rs. 479069, which is a totaling error and erroneous amount has been shown as claimed by the claimant. It is also intimated that total disallowed amount was Rs. 1,65796/-details of that amount is annexed as CA.

Heard the learned counsel for the parties.

Learned counsel for the applicant argued that applicant is legally entitled for full reimbursement of medical claim but respondents have passed for Rs. ,3,85,904 out of Rs. 5,84,043/-arbitrarily and illegally. Denial of Rs. 1,98,139/- is not in accordance with rules. Learned counsel for the applicant also placed reliance of the judgment of Hon’ble Supreme Court in Writ Petition (Civil) No.694 of 2015 decided on 13.4.2015 (Shiva Kant Jha Vs. Union of India).

Learned counsel for respondents argued that medical claim was passed in accordance with rules. It is further argued that along with the bill amounting to Rs. 4,79,069/- (actual bill was Rs. 451618 + 23000 shown as ambulance charge) but no receipt was enclosed. It is further argued that as regard to bill amounting to Rs. 4451 and 1041, the bill was returned under audit objection. However, till date bill has not been re-submitted by the unit duly settling the audit objection. It is further argued that reasons for disallowance of the items has been shown in Annexure R-1 to the annexed along with C.A.

I have considered the rival submissions and have gone through the entire record.

In the case of Shiva Kant Jha Vs. UOI (supra), Hon’ble Apex Court has observed as under:-

“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.

16) Further, with regard to the slow and tardy pace of disposal of MRC by the CGHS in case of pensioner beneficiaries and the unnecessary harassment meted out to pensioners who are senior citizens, affecting them mentally, physically and financially, we are of the opinion that all such claims shall be attended by a Secretary level High Powered Committee in the concerned Ministry which shall meet every month for quick disposal of such cases. We, hereby, direct the concerned Ministry to device a Committee for grievance redressal of the retired pensioners consisting of Special Directorate General, Directorate General, 2 (two) Additional Directors and 1 (one) Specialist in the field which shall ensure timely and hassle free disposal of the claims within a period of 7 (seven) days. We further direct the concerned Ministry to take steps to form the Committee as expeditiously as possible. Further, the above exercise would be futile if the delay occasioned at the very initial stage, i.e., after submitting the relevant claim papers to the CMO-I/C, therefore, we are of the opinion that there shall be a timeframe for finalization and disbursement of the claim amounts of pensioners. In this view, we are of the opinion that after submitting the relevant papers for claim by a pensioner, the same shall be reimbursed within a period of 1 (one) month.

17) In view of the foregoing discussion, we dispose of the petition filed by the writ petitioner with the above terms.”

In the instant case, claim of the applicant was not denied by the respondents. Respondents have paid the part of the medical claim of the applicant and remaining part has not been paid due to audit objection , bill of ambulance not enclosed and some of the payment are not liable to be paid and is not admissible as per CGHS rules. He has also disclosed the reasons for not paying the amount. The case law relied upon by the learned counsel for the applicant will not support the case of the applicant because in that case, Hon’ble Apex Court has observed that respondents cannot deny the payment of reimbursement claim of treatment taken in private hospitals (non-empanelled hospital). In the present case, reimbursement was made to the applicant as per CGHS norms. In few bills, as and when audit objection will be removed, the same will be paid by the respondents. The court is of the view that applicant is not entitled for the reimbursement of the amount which is not admissible as per CGHS rules.

Accordingly, O.A. is dismissed.

No order as to costs.