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Judgment
K. Haripal, Member J
Applicant was Dy.General Manager (Finance), retired from the service of Bharath Sanchar Nigam Limited, BSNL for short, from its Kollam office. He is aggrieved by the non-granting of medical expenses incurred by him for the period from 04.11.2019 in MGM Muthoot Hospital, Kozhenchery as well as in Aster Medcity, Ernakulam. The claim made by him was rejected by Annexure-A5 order on the ground that he had taken treatment from a non-empannelled hospital, that is Aster Medcity, despite there are well established empannelled hospitals, Lakeshore and Amrita (AIMS) in Ernakulam. Aggrieved by the same, he has approached this Tribunal for quashing Annexure-A5 and for a declaration that he is entitled to get full reimbursement of medical expenses furnished in Annexure-A12, also seeking damages of Rs.10 Lakh for the torments and agonies suffered by him due to the arbitrary acts of the respondents 2 and 3.
The applicant says that he is suffering from Crohn's disease for long. While so, on 04.11.2019, he was admitted in MGM Muthoot , Kozhenchery, an empannelled hospital and was treated there till 13.11.2019. The matter was duly intimated to the 3rd respondent and had obtained approval. In the Muthoot hospital, he underwent a procedure of inserting a stent into his left ureter for damaged kidney. For the treatment an amount of Rs.1,07,246/- was spent. He was eventually put to a contra-CT scan on 16.11.2019 which revealed a dense growth of tissues in the abdomen warranting an emergency surgical intervention. As the case was too complicated, he was referred to Dr.Prakash K, Surgical Gastroenterologist at Aster Medcity, Kochi. Annexure-A2 is the reference letter. He was admitted in Aster Medcity on 19.11.2019 and on 20.11.2019 was subjected to Sigmoid Colectomy, removal of a portion of the colon, an emergency surgery, which took more than eight hours. Admission in Aster Medicity was reported to the authorised officer of the BSNL, Kochi, who had carried out an enquiry as evident from Annexure-A4. He spent an amount of Rs.3,75,582/- for inpatient treatment in Aster Medicity from 19.11.2019 to 28.11.2019. However, by Annexure-A5 order that claim for reimbursement stands rejected. He filed Annexures-6 and 7 appeals to the 2nd respondent, which have not yet been decided. Meanwhile, the biopsy result showed that he is suffering from High Grade B cell Lymphoma, abdominal cancer, and was referred by the Department of Surgical Gastroenterology of Aster Medcity to its Department of Medical Oncology, where he underwent seven cycles of chemotherapy and spent an amount of Rs.5,83,842/-. Such claims for reimbursement also remain unattended. Subsequently, he underwent numerous inpatient treatments and further spells of chemotherapy would be warranted. Altogether he was admitted eight times in Aster Medcity and four times in MGM Muthoot during 19.11.2019 to 24.12.2020 and paid an amount of Rs.9,59,424/- in Aster Medcity, Rs.1,98,147/- in Muthoot hospital, aggregate Rs.11,57,571/-. The actual expenses comes to more than Rs.20 Lakhs. But even 75% of the actual amounts have not been reimbursed. Moreover, while filing the Income Tax returns for the financial year 2020-2021 he found that an amount of Rs.5,846/- was deducted towards Tax at source against a purported income of Rs.1,06,545/- from the BSNL. That means, he has not been paid any amount, instead, has been made to pay tax for the unpaid money. He has tabulated amounts due to him in Annexure-A12.
According to the applicant, denial of medical reimbursement is unjust, unfair, illegal and discriminatory. He was referred to Aster Medcity from an empannelled hospital by the Gastroentrologist there. At that time, himself and his wife alone were there. They were not aware about the gravity of the situation and had no control over the reference made, therefore, for the mere reason that he was referred to a non-empannelled hospital, his legitimate claim for getting the amount reimbursed cannot be denied. The fact that he was subjected to surgery on 20.11.2019, the date following admission itself suggests the emergent situation. Due to the medical condition he was too distracted to think about whether Aster Medcity was an empannelled hospital or not. It was the decision of Dr. Peter Manak, Gastroenterologist in Muthoot hospital, Kozhenchery, for which adverse inference cannot be drawn against him. Reasons for not reimbursing the amount are not justifiable. Delay in considering the representations also are not acceptable.
In reply respondents have submitted that out of the 12 inpatient bills submitted by the applicant from December 2019, 11 have been sanctioned. Thus out of the total sum of Rs.11,57,571/-claimed by the applicant, Rs.6,16,651/- has already been sanctioned and paid to the applicant. There was no justification for proceeding to Aster Medcity, an unpannelled hospital, whereas there are two well established hospitals, Lakeshore and AIMS, in Ernakulam. However, after considering the representations of the applicant, the 2nd respondent has sanctioned amounts for the treatment obtained in Aster Medcity as well, as per CGHS rates. Such amounts have already been granted to the applicant after deducting 5.2% TDS. Regarding the remaining one bill for Rs.1,07,246/- for the treatment in MGM, Muthoot, an amount of Rs.55,448/- has already been sanctioned, payment of which is under process and it will be paid on receipt of funds from the Corporate office.
The applicant filed a rejoinder contending that fetters cannot be put as to how a person should be treated, it is for the treating doctor to decide and the medical claim cannot be denied on technical grounds once factum of treatment is established. In this connection, he relied on the decision in Shiva Kant Jha vs Union of India [AIR 2018 SC 1975]. According to the applicant, fact that only negligible amounts have been reimbursed, cannot be accepted.
I heard the learned counsel for the applicant as well as the learned Standing Counsel for the respondents.
The medical history of the applicant is not in dispute. It is evident that the applicant, a native of Karunagappally in Kollam District, has sought treatment in MGM Muthoot hospital in Kozhenchery, Pathanamthitta District, fully conscious of the fact that he has to obtain treatment from an empannelled hospital. Thus at the first spell he was admitted and treated in Kozhenchery hospital from 04.11.2019 to 13.11.2019, for which an amount of Rs.1,07,246/- was spent and the entire amount was sought to be reimbursed. The reply suggests that out of that claim, a sum of Rs.55,448/- has already been sanctioned, but payment is pending for want of allotment of funds from the Corporate office. Thereafter, on reference from the Muthoot hospital, Kozhenchery he was admitted in Aster Medcity, Ernakulam and underwent treatment initially from 19.11.2019 to 28.11.2019. At that time he underwent surgical intervention. The result of biopsy indicates that he is suffering from Lymphoma, abdominal cancer, for which he underwent inpatient treatment including chemotherapy in Medical Oncology Department on numerous occasions. The grievance of the applicant is that even though he has spent more than Rs.20 lakhs for treatment and submitted bills for Rs.11,57,571/- for reimbursement, the respondents are sitting over it and that made him to approach this Tribunal.
According to the respondents, he had made a claim for Rs.11,57,522/-, out of which a sum of Rs.6,16,651/- has already been sanctioned, from it except Rs.55,448/- balance amounts have been released to him on 20.06.2022 and on 29.10.2022 as shown in the table incorporated in the second paragraph of the reply. According to them, even though the applicant had obtained treatment from a non-empannelled hospital, the 2nd respondent sanctioned such claims also, as per the CGHS rates.
According to the respondents, they are obliged to sanction the amount of treatment expenses incurred in an empannelled hospital. Initially, they hesitated to consider the claims of amounts expended in Aster Medcity, which is a non-empannelled hospital. However, after institution of this Original Application, the 2nd respondent took up the matter and sanctioned amounts as per CGHS rates, which cannot be called in question.
That means, by subsequent events major part of the grievance of the applicant has been redressed. Even though the applicant stated that he had no say in the matter of referring to the Aster Medcity, it is very obvious that he is conscious that he has to obtain treatment from an empannelled hospital. That was why it was pointed out earlier that a resident in Karunagappally in Kollam district had chosen to obtain treatment from an empannelled hospital in Pathanamthitta district. Such a diligence was not shown while obtaining treatment from Aster Medcity, which is not an empannelled hospital. As rightly pointed out by the learned Standing Counsel for the respondents, there are well established empannelled hospitals in Ernakulam itself. Whatever it may be, now the claims have been considered and reimbursable amounts as per CGHS rates have already been reimbursed, which is recorded, an amount of Rs.55,448/- for the treatment in MGM Muthoot hospital awaits to be reimbursed. It shall be disbursed to the applicant at the earliest.
The contention that he was made to pay Rs.5,846/- as TDS for the amounts not paid to him also cannot sustain. Details of the amounts paid to the applicant and tax deducted are inferable from Annexure-A11. Such payments do tally with the amounts reimbursed as per the table shown in the reply statement. Contention of the applicant that he was made to pay tax for the sum not paid to him is not correct.
With this observation, the Original Application is disposed of. M.A.837/2022 is allowed and the 4th respondent is deleted from the party array.
(Dated, this the 17th October, 2023)