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2017 DIGILAW 1111 (KER)

K. J. Zacharia. SGT. (Retd. ) v. Adjutant General, Central Organisation Ex-Servicemen Contributory Health Scheme, Delhi Cantonment

2017-08-03

DEVAN RAMACHANDRAN

body2017
JUDGMENT : 1. The petitioner in this case appears to be placed in a very piquant situation. He says that he is an Ex-serviceman retired as a Sergeant from Indian Air Force. According to him, he has been enrolled to be a beneficiary under the Ex-servicemen Contributory Health Scheme (ECHS) having Reg.No.KC0036147. He says that the ECHS is a comprehensive scheme funded by the Government of India, Ministry of defence under which Ex-servicemen, pensioners and their dependents are authorised free treatment not merely in service hospitals but also in civil/private hospitals which are specifically empanelled with the ECHS. The petitioner has produced on record Exhibit P1, which is the copy of the scheme in support of his assertions. 2. The petitioner asserts that the fourth respondent Hospital (AIMS) is an empanelled hospital and, therefore, that the petitioner was entitled to the option of taking their services in the event of a health issue. He says that on 11.04.2010 he was admitted in the fourth respondent hospital with a debilitating attack of the Guillain Barre Syndrome (GBS), a rare disorder affecting the peripheral nervous system which can cause life threatening complications. He says that he underwent treatment for a long period and that he was discharged on 18.05.2010. It appears that the AIMS raised a bill for a total amount of Rs.7,41,902/- and that the ECHS sanctioned only an amount of Rs.5,08,283/-. The petitioner says that under the ECHS he was not obligated to make any payment to the hospital for his treatment. But he alleges that the AIMS, in violation of these provisions forced him, taking advantage of his peculiar condition at the time of his admission, to make payment of an amount of Rs.5,41,875/- as advance payment. According to him, since the ECHS had disbursed an amount of Rs.5,08,283/- to the AIMS, which was received by the hospital on 28.03.2012, they were enjoined in terms of the ECHS to refund the entire amount received from him as advance. He alleges that the AIMS, however, refunded only an amount of Rs.3,08,256/- on 24.09.2012, thus refusing repayment of the balance amount of Rs.2,33,619/-. The petitioner has, therefore, filed this writ petition seeking directions to the AIMS to refund the entire amount collected from him as advance. 3. I have heard Sri. R. Azad Babu, learned counsel for the petitioner, Sri. He alleges that the AIMS, however, refunded only an amount of Rs.3,08,256/- on 24.09.2012, thus refusing repayment of the balance amount of Rs.2,33,619/-. The petitioner has, therefore, filed this writ petition seeking directions to the AIMS to refund the entire amount collected from him as advance. 3. I have heard Sri. R. Azad Babu, learned counsel for the petitioner, Sri. Manoj Chandran, learned counsel for the fourth respondent and the learned Assistant Solicitor General for respondents 1 to 3. 4. The pleadings on record would show that the ECHS had sanctioned an amount of Rs.5,08,283/- to the fourth respondent on 24.09.2012. In the counter affidavit filed on behalf of respondents 1 to 3 they admit that the hospital had raised a claim of Rs.7,41,902/- for the treatment of the petitioner suffering from GBS for the period from 11.04.2010 to 10.05.2010. They say that they had, however, sanctioned only an amount of Rs.5,08,283/- against the bill of Rs.7,41,902/- raised by the hospital for two reasons. The reasons available from their counter affidavit are as under: “(a) 2nd spell of IV Immunoglobulin was disallowed amounting to 1,96,733/- by the empowered committee of MoD stating that administration of IV Immunoglobulin in two consecutive spells of fice days duration with a gap of four days is not justified. Extracts of recommendations of 'Association of British Neurologists' and 'Journal of Clinical Immunology May 2010' on the use of 2nd dose Intravenous Immunoglobulin in Neurological Diseases. (b) Other deductions were due to consultations and supportive therapy included in the Intensive Care Unit package and cost of extra consumables amounting to Rs.36,886/-.” It is obvious from the reasons recorded as above that respondents 1 to 3 has disallowed a claim of the hospital to an extent of Rs.1,96,733/-, which is the cost of immunoglobulin that was administered to the petitioner by the hospital, on the ground that two consecutive administration of immunoglobulin in five days duration is not recommended or justified as per the Association of British Neurologists and Journal of Clinical Immunology. In effect, what they say is that the administration of the second doze of immunoglobulin does not appear to be justified. But they do not say that the hospital did not administer it or that the bill raised by the hospital for the cost of immunoglobulin was in any manner false or confutative. In effect, what they say is that the administration of the second doze of immunoglobulin does not appear to be justified. But they do not say that the hospital did not administer it or that the bill raised by the hospital for the cost of immunoglobulin was in any manner false or confutative. The reasons stated in the counter affidavit would only show that, according to the view and opinion of the competent authority of the ECHS, a second administration of immunoglobulin in five days is not justified. It does not, however, say that this was not done. As long as the stand of the hospital that it had administered the second doze of immunoglobulin is not found to be incorrect or false, I am not sure how the ECHS could have declined payment of this amount on the grounds that are recorded as above. I say this more because the AIMS has now placed on record copies of all the documents relating to the petitioner while he was admitted in their care as Exhibits R4 (a) to R4 (f). Exhibit R4 (c) series among these documents are the bills raised by the hospital wherein all the medicines administered to the petitioner are shown and it includes both the dozes of immunoglobulin that they assert that was administered on the petitioner. If that be so, the view of the ECHS in their counter affidavit, that the administration of immunoglobulin in such quick succession was not justified, would not be sufficient reason for them to decline the claim raised by the petitioner for the cost of that doze also. As a matter of fact, the petitioner recovered from his illness completely and there is no case for the petitioner or for that matter even for the ECHS that the hospital was guilty of any misfeasance or medical negligence. It can only show that the doze of medicines administered by the hospital was justified leading to the complete recovery of the petitioner and, therefore, the stand of the ECHS in their counter affidavit that administration of the second doze of immunoglobulin was not justified cannot hold water and cannot obtain sustenance in law. 5. It can only show that the doze of medicines administered by the hospital was justified leading to the complete recovery of the petitioner and, therefore, the stand of the ECHS in their counter affidavit that administration of the second doze of immunoglobulin was not justified cannot hold water and cannot obtain sustenance in law. 5. In such view of the matter, I am firm in opinion that the reasons given by the ECHS for declining the payment of Rs.1,96,733/-, being the cost of the second doze of immunoglobulin administered on the petitioner, is not sustainable and deserves no favour at all. Since the petitioner had got himself admitted in the AIMS under the provisions of the ECHS and since the competent authorities under the ECHS are obligated under it terms to defray all the eligible expenses and cost of medicines suffered by the patient during such hospitalization, I am firm in my mind that the ECHS was not justified in declining this part of this claim and thus causing prejudice to the petitioner. As regards the second reason shown in the counter affidavit relating to Rs.36,886/- is concerned this amount has been declined by the ECHS because that was in relation to extra consumables. I do not think that the ECHS was wrong on this count and that they were justified in declining this amount. However, as regards the amount of second doze of immunoglobulin I have no doubt in my mind for the reasons that I have already recorded above that the action of the ECHS in declining that amount was completely irregular and improper. In such circumstances, I allow this writ petition and direct respondents 1 to 3 or such other competent authorities under the ECHS of the Government of India to pay to the petitioner the amount of Rs.1,96,733/-, declined by them with respect to the bill raised by the AIMS, within a period of three months from the date of receipt of a copy of this judgment.