MEMBER-SECRETARY, BOARD OF TRUSTEES, RAJ. STATE PENSIONERS MEDICAL CONCESSION SCHEME vs SHIV KARAN JOSHI

THIS appeal is directed against the order of the learned District Forum, Sri Ganganagar dated 30.10.2002 whereby the complaint filed by the respondent has been allowed and the appellants have been directed to pay to the respondent within a period of two months an amount of Rs. 64,000/- with interest @ 9% p.a. with effect from the date of presentation of the complaint i.e., 2.5.2001 till payment along with compensation and cost of litigation at Rs. 1,000/- each.

FACTS relevant for disposal of this appeal in brief are that the respondent Shiv Karan Joshi has been and employee of State of Rajasthan and retired from the post of Patwari in its Irrigation Department. He got his wife Smt. Geeta Devi medically examined by the Medical Board at SMS Hospital, Jaipur on 20.8.1999 and was advised for Coronary Artery By-pass Surgery (CABG). As the respondent desired for getting the treatment of his wife at Escorts Heart Institute, New Delhi instead of at SMS Hospital, Jaipur; the Medical Board and the Principal, SMS Medical College, Jaipur recommended vide its letter dated 22.8.1999 that the complainant be allowed to take his wife to Escorts Heart Institute, New Delhi subject to the condition that reimbursement of medical expenses should be limited at Rs. 50,000/- which is permissible at the SMS Hospital, Jaipur. The respondent underwent the treatment at Escorts Heart Institute, New Delhi and received the reimbursement amount of Rs. 56,000/- on final settlement. The case of the respondent has been that the respondent in fact is entitled to reimbursement upto 80% (Rs. 64,000/- of the total expenses of Rs. 1,60,500/- incurred by him at New Delhi, relying upon the Government order dated 12.5.1998 and having failed to receive the amount, he approached the learned District Forum and claimed 18% interest p.a. on the said amount of Rs. 64,000/- along with compensation at Rs. 5,000/- and cost of Rs. 5,100/-.

This complaint was resisted by the appellant by filing a written version. The stand of the appellant has been that Coronary Artery By-pass Surgery costs Rs. 50,000/- at SMS Hospital, Jaipur and that it was only at the desire of the respondent that it was communicated by the Medical Board and Principal, SMS Medical College, Jaipur vide its letter dated 22.8.1999 that the respondent could be allowed reimbursement upto a limit of Rs. 50,000/- since the facility of such surgery is available at the SMS Hospital, Jaipur. It is also urged that the respondent having received the amount of Rs. 56,000/- in full and final settlement of his claim, he is now stopped from re-opening this issue and that complaint should be dismissed.

THE learned District Forum after consideration of the controversy raised between the parties decreed the claim of the respondent as stated earlier. It is now urged by the learned Counsel for the appellant that once the respondent had received an amount of Rs. 56,000/- in full and final settlement of his claim, he now, cannot reagitate the claim advanced by him for reimbursement of rest of the alleged expenses more so when the facility of Coronary Artery By-pass Surgery has been available at the SMS Hospital, Jaipur. As against it, the learned Counsel for the respondent has supported the impugned order.

WE have given due thought and consideration to the issues raised in this appeal by the appellant and have carefully gone through the material available on the record. There is no dispute that the wife of the complainant-respondent was clinically examined by a duly constituted Medical Board which by its communication dated 20.8.1999 has observed that the "wife of the respondent is suffering from advanced CAD and that Coronary Angiography reveals severe Three Vessel disease with E.F. 55% and that she needs early Coronary Artery By-pass Surgery, the facilities for which are available at the SMS Hospital, Jaipur" and that the approximate expenditure involved would be Rs. 50,000/-. In this communication which has been addressed to the Principal, SMS Medical College and Controller of Attached Hospitals, Jaipur, the Medical Board has also informed that the patient and her family wants CABG to be done at Escorts Heart Institute, New Delhi and that she may be permitted to go while the entitlement will be limited to Rs. 50,000/- only. It appears that consequent upon this observation, the respondent opted to get her wife treated at Escorts Heart Institute, New Delhi. The complainant advanced his claim on the ground that since in pursuance of the order of the State Government dated 12.5.1998 for the existing words and figures in Sub-para 1 of para 4 (A) of the Rajasthan State Pensioners Medical Concession Scheme the words and figures "at the rate of 80% of hospital expenses or Rs. 1,20,000/- whichever is less" has been substituted, the respondent is entitled to get the balance amount of Rs. 64,000/- calculated at the rate of 80% of the expenses at New Delhi amounting to Rs. 1,60,500/-. We find force in this stand of the respondent. The reasons are that, even before the amendment made in the Rajasthan State Pensioners Medical Concession Scheme on 12.5.1998 the respondent was held entitled to reimbursement of Rs. 50,000/-. The reliance by the appellant that as per decision taken by the sub-committee of the appellant trust on 30.9.2000, the respondent being entitled for reimbursement of Rs. 56,000/- within the total permissible limit of Rs. 70,000/- when such facility is available at All India Institute of Medical Sciences (AIIMS), New Delhi and further that the respondent having accepted the aforesaid amount of Rs. 56,000/- in full and final settlement of his claim, the appellants are within their rights not to acceede to the request of the respondent for reimbursement of the balance amount as claimed now by him.

WE fail to understand that when the appellant has taken a decision to pay an amount of Rs. 56,000/- within the permissible limit of expenditure at AIIMS, New Delhi that to as per decision taken by its sub-committee dated 30.9.2000, the decision of which was decidedly taken after the complainant''s wife took the treatment between the period 1.9.1999 and 11.9.1999; how could it decline to reimburse for the balance amount of Rs. 64,000/- in terms of the amendment made on 12.5.1998 whereby it has enhanced the limit of Rs. 50,000/- to "80% of the expenditure or Rs. 1,20,000/- whichever is less". Admittedly in this case, the complainant-respondent has spent an amount of Rs. 1,60,000/-. When once a latitude has been given to the Pensioner to get the surgery done at the Escorts Heart Institute, New Delhi; the Medical Board could not place a condition that the reimbursement to the respondent would be limited to Rs. 50,000/- only; more so when the sub-committee has approved the payment of Rs. 56,000/- on the lines of people getting treatment as AIIMS, New Delhi.

BE that as it may, we are of the firm opinion that the respondent is entitled for reimbursement of 80% of the hospital expenditure or Rs. 1,20,000/- whichever is less in terms of the total expenses incurred by him at the Escorts Heart Institute, New Delhi. The learned District Forum has committed no error in arriving at the aforesaid conclusion. Consequently, we find no substance and merit in this appeal which is dismissed with cost on parties. Appeal dismissed.