R.N. Singh vs The State of Rajasthan and Others

Sandeep Mehta, J.—By way of the instant writ petition, the petitioner seeks a direction to be issued to the respondents to reimburse the medical expenses borne by him for his treatment, which he had to undergo for the procedure of coronary artery bypass crafting conducted at the AIIMS, New Delhi in September 2009.

The petitioner retired from the post of Principal, Medical College, Jodhpur from the Medical and Health Department of the State of Rajasthan on 31.12.1992 and was issued with a PPO and also a medical diary by the respondents.

It is averred in the writ petition that the petitioner fell ill in June 2009. He submitted a request for being referred to AIIMS New Delhi for treatment. The Medical Board duly constituted by the authorities for examining the petitioner''s request recommended his treatment at AIIMS New Delhi. After the Board''s recommendation, the petitioner got admitted at the AIIMS, New Delhi and was subjected to Coronary Artery Bypass Surgery (CABG), wherein a total expenditure of Rs. 1,07,900/- was incurred. The petitioner submitted the duly verified bills of medical expenses to the respondent department and claimed reimbursement thereof but the same was not accepted by the respondents. Hence, the petitioner has approached this Court for issuance of a writ or order to the respondents to reimburse the medical bills of the petitioner.

Learned counsel for the petitioner submits that despite the fact that the petitioner submitted all the duly verified treatment papers and medical bills, which were ample proof of his having undergone CABG at the AIIMS, New Delhi, the authorities in a mechanical fashion, demanded a further proof from the petitioner regarding his admission at the AIIMS. He contends that duly verified bills and the original treatment documents were submitted by the petitioner to the authorities, thus, there was no justification for the authorities to have delayed the reimbursement of his medical bills. He contends that the letter (Annex.P/6), whereby the petitioner was asked to submit a proof of his admission at AIIMS is nothing but a ploy to justify the unreasonable and unexplained delay in reimbursement of the petitioner''s medical claim.

Learned counsel for the respondents has vehemently opposed the submissions advanced by the learned counsel for the petitioner. However, he candidly conceded that in similar matters, this Court has directed reimbursement of the medical expenses borne by the retired employees in accordance with the applicable reimbursement scheme.

The controversy regarding the entitlement of the retired government employees to receive medical reimbursement has already been settled by this Court in a catena of decisions including the judgments rendered in the case of Gyanendra Kumar Pareek Vs. State of Rajasthan and Others, (2009) 4 RLW 3134 and in the case of Anil Kumar Surolia Vs. State of Rajasthan and Others, (2005) 3 RLW 2169 : (2005) 3 WLC 14 .

This Court considered the issue of emergent situation in the case of Gyanendra Kumar Pareek Vs. State of Rajasthan and Others, (2009) 4 RLW 3134 and held that when a family member suffers from cardiac ailment, the prime objective of the other family member would be to save his/her life. At that time, services of whichever hospital is suited could be utilized because emergency knows no law and no procedure and when human life is at stake, in such situation, ultimate responsibility of the State cannot be washed off. This Court relied upon the decision of the Division Bench of this Court in Anil Kumar Surolia Vs. State of Rajasthan and Others, (2005) 3 RLW 2169 : (2005) 3 WLC 14 wherein the Division Bench observed as under:--

"Government cannot insist upon an employee to get himself treated at recognized government institution. All that the Government in these circumstances can do is to reimburse the concerned employee at the rates that may be applicable in the recognized government institution. Reference in this connection may be made to the judgment of the Hon''ble Supreme Court in Surjit Singh Vs. State of Punjab and Others, (1996) 1 AD 1003 : AIR 1996 SC 1388 : (1996) 2 JT 28 : (1996) 1 SCALE 648 : (1996) 2 SCC 336 : (1996) 1 SCR 1095 : (1996) 1 UJ 523 and State of Punjab and Ors. v. Mohan Lai Jindal reported in (2001) 9 SCC-217. Consequently, the reimbursement of the medical expenses borne by the State Government employees and pensioners has to be done even if the treatment is undertaken at unrecognized hospital outside the State even though reference may not have been taken prior to treatment."

Certain amendments were made in the Rajasthan State Pensioners Medical Concession Scheme vide order dated 19.12.2004, which are relevant for the purpose of disposal of this writ petition and are reproduced hereinbelow:--

"The Governor is pleased to make the following amendments in the Rajasthan State Pensioners Medical Concession Scheme, namely-

In the said Scheme.

The existing words "Implantation of Pacemaker and Angioplasty/Balloonplasty" appearing in the sub-para 4B(i) shall be deleted and the existing sub-para 4B (ii) may be re-numbered as sub-para 4B(iii) and new sub para 4B(ii) may be inserted as under:--

"(ii) A Pensioner and the members of his family as defined in sub-para (5) of para 3 of the scheme shall be entitled for grant of financial assistance in respect of specialized treatment of implantation of Pacemaker and Angioplasty/Balloonplasty taken in Government Hospital within the State of Rajasthan as under:

(a) Pacemaker

Actual cost of Pacemaker subject to the maximum of Rs. 60,000/-

(b) Angioplasty/Balloonplasty

Actual expenditure incurred subject to the maximum of

(c) For Stent/Stents

Actual expenditure incurred subject to the maximum of Rs. 75,000/-."

The existing para 4E shall be substituted by the following namely.

"4E. Treatment of heart ailment in recognized hospital outside the State (with or without the recommendation of the Medical Board) (w.e.f. 5.8.2004).

(a) In case it is recommended by the Medical Board that by-pass surgery for heart is indicated, the pensioner can get himself operated in any of the hospitals recognized by the Government outside the State for this purpose. Such pensioner may be allowed 80% of hospital expenses limited to Rs. 48,000/- being 80% of General Ward charges of All India Institute of Medical Sciences, New Delhi.

(b) In case a pensioner undergoes by-pass surgery of heart (cardio Thoracic surgery) in any recognized hospital outside the State in emergent circumstances without any recommendation of the Medical Board, he may be allowed 80% of hospital expenses limited to Rs. 48,000/- i.e. 80% of General ward charges of AIIMS, New Delhi provided that he submits a Certificate from a cardiologist who took a degree of D.M. In Cardiology as MCH in Cardio Thoracic Surgery stating that pensioner''s condition was such that immediate treatment was essential.

In case a pensioner takes treatment of Angioplasty/Balloonplasty and stent(s) in recognised hospitals outside the state, he/she may be allowed financial assistance as under:--

(i) For Angioplasty/Balloonplasty

Actual amount of expenditure incurred subject to the maximum of Rs. 35,000/-

(ii) For Stent/Stents

Actual cost of Stent/Stents subject to the maximum of Rs. 60,000/- (80% of Rs. 75,000/-)"

It is undisputed that the petitioner after having retired from government service was enrolled as a member of the pension scheme and thus, is entitled for reimbursement of treatment charges in accordance with the Rajasthan State Pensioners Medical Concession Scheme. The petitioner suffered sudden cardiac discomfort on 2.6.2009 and was provided initial treatment for the said problem. Thereafter, he requested the Principal, Dr. S.N. Medical College, Jodhpur for constituting a Medical Board and referring him to AIIMS, New Delhi for his cardiac treatment. The Medical Board duly constituted by the Principal, Dr. S.N. Medical College and associate group of hospitals, by its report dated 23.9.2009 (Annex. 2) referred the petitioner for treatment to AIIMS, New Delhi. The Medical Board by a letter dated 23.9.2009 expressed an opinion that the reimbursement of the treatment undertaken at the AIIMS, New Delhi shall be according to the pensioners rules. The petitioner was thereafter subjected to Coronary Artery Bypass Graft surgery at the AIIMS, New Delhi. He submitted the duly verified bills and treatment papers of his treatment at the AIIMS and claimed reimbursement of the medical expenses by an application submitted to the authorities way-back in the year 2010. Admittedly, the original medical prescriptions/tickets and bills of expenditure etc. were submitted to the Pension Department alongwith the reimbursement application. The concerned official of the Pension Department acting in an arbitrary manner tried to delay the reimbursement of the medical bills on numerous grounds. Firstly the petitioner was given an intimation dated 4.1.2012 to the effect that the emergent situation was not established by the documents submitted for reimbursement. There was no cause for issuance of this letter as the petitioner undertook treatment at AIIMS New Delhi after due recommendation by the Medical Board and thus, there was no requirement of establishing the existence of an emergent situation for getting the reimbursement under the Concession Scheme. Thereafter, another communication (Annex. 6) dated 30.10.2012 was sent to the effect that proof of admission at the AIIMS, New Delhi in an emergent situation be furnished. Since, the Medical Board''s recommendation (Annex. 2) clearly reflected that the petitioner required emergent treatment at AIIMS for his cardiac problem, there was no occasion for the Pension Department to question the opinion of the Medical Board. The reimbursement of the medical expenses incurred by the petitioner in his treatment was mandatorily required to be done and that too without any delay. The letters (Annex. 6) dated 4.1.2012 and 30.10.2012 are apparently attempts made by the concerned official of the Pension Department to justify the delay occasioned in reimbursement of the petitioner''s justified medical claim. Thus, the delay is absolutely unexplained, unreasonable and unexcusable. The respondents have not disputed the petitioner''s right for reimbursement of his medical expenses in accordance with law.

Thus, the writ petition deserves to be allowed and the respondents deserve to be directed to forthwith reimburse the petitioner of the medical expenses, which he underwent for his treatment at AIIMS in the year 2009. Since the reimbursement of the medical claim submitted by the petitioner as per law was delayed for a period of nearly 6 years despite his admitted entitlement, the petitioner is also entitled to interest @ 9% per annum for the period of delay occasioned in making reimbursement of the medical expenses to the petitioner.

Accordingly, while accepting the writ petition, it is hereby directed that the respondents shall forthwith reimburse the amount of medical expenses borne by the petitioner in his treatment at the AIIMS, New Delhi in accordance with the Rajasthan State Pensioners Medical Concession Scheme. The reimbursement shall be made within a period of four weeks from the date of receipt of copy of this order. The amount paid to the petitioner shall also carry interest @ 9% per annum w.e.f. the date on which the bill were presented for reimbursement to the date of the actual payment. If the payment is delayed beyond the period of four weeks, the due amount shall carry interest @ 18% per annum.

The Pension Department shall also undertake an exercise for identifying the official/officials responsible for the delay in reimbursement of the petitioner''s medical claim and thereafter, the interest amount which the department has been burdened with on account of the unjustified delay in reimbursement of the petitioner''s medical claim shall be recovered from such official/officials.

No order as to cost.