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Rajasthan High Court · body

2019 DIGILAW 2051 (RAJ)

Shiv Ratan Sharma v. Chairman And Managing Director

2019-07-29

SANGEET LODHA, VINIT KUMAR MATHUR

body2019
JUDGMENT Sangeet Lodha, J. - By way of this writ petition, the petitioner has questioned legality of order dated 19.9.18 passed by the Central Administrative Tribunal, Jodhpur Bench, whereby the original application preferred by the petitioner questioning the legality of the action of the respondents in rejecting his claim for medical reimbursement, has been dismissed. 2. The facts relevant are that the petitioner was initially employed in the Department of Post and Telegraphs, Government of India. Later, he was absorbed in Bharat Sanchar Nigam Limited (BSNL) w.e.f. 1.10.2000. After attaining the age of superannuation, the petitioner retired from service on 31.5.07, as Senior TOA (TG). The petitioner suffered a severe heart attack in the last week of January, 2017 and due to emergent health condition, he was taken to SAL Hospital Ahmedabad on 23.1.17, where he undergone Coronary Artery Bypass Grafting Surgery on 25.1.17. He was discharged on 2.2.17 and thus remained admitted to the hospital for 11 days. The petitioner submitted the medical reimbursement bill amounting to Rs.2,47,022/-, which has been rejected by the respondents vide communication dated 7/14.08.17, without assigning any reason. In these circumstances, assailing the action of the respondents in rejecting the claim, the petitioner preferred an original application before the Tribunal and sought directions to the respondents to make payment of Rs.2,47,022/- with interest @ 12% per annum, which stands dismissed by the order impugned. Hence, this petition. 3. The original application preferred by the petitioner was contested by the respondents by filing a reply thereto, taking the stand that in the first instance, the petitioner was admitted to Mathuradas Mathur Hospital Jodhpur, where Angiography was done on 13.1.17. As per report of Angiography, the petitioner was suffering from Coronary Artery Disease (CAD)/Triple Vessle Disease. According to the respondents, the petitioner concealed the material fact and had only mentioned in the original application that on emergency, he was admitted in SAL Hospital, Ahmedabad. The respondents contended that after 10 days of Angiography done in MDM Hospital the petitioner was admitted to SAL Hospital, Ahmedabad, which clearly indicates that it was not a case of emergency and the petitioner could have intimated the authorities for taking further treatment in SAL Hospital, Ahmedabad. The respondents contended that after 10 days of Angiography done in MDM Hospital the petitioner was admitted to SAL Hospital, Ahmedabad, which clearly indicates that it was not a case of emergency and the petitioner could have intimated the authorities for taking further treatment in SAL Hospital, Ahmedabad. The respondents submitted that as per the guidelines issued by the BSNL Corporate Office dated 15.10.04, in all cases of extreme emergency, the employee concerned is required to inform SSA Head or Controlling Officer soon after hospitalization for indoor treatment so that a designate officer of the BSNL may visit hospital and verify the authenticity of the beneficiary. Precisely, the case of the respondents was that since the petitioner did not inform about his admission to the concerned hospital, the physical verification could not be done and therefore, the claim submitted by him has rightly been rejected. 4. After due consideration of the rival submission, the Tribunal arrived at the finding that the petitioner's case does not fit in the definition of emergency and therefore, it cannot be said that in an emergent condition, he was required to be admitted in SAL Hospital, Ahmedabad. The court observed that since the petitioner took medical treatment in unrecognized hospital, without duly informing or taking permission from the respondents and without the case of sudden and grave emergency, he is not entitled for reimbursement as per the BSNL Medical Reimbursement Scheme. While dealing with the decision of the Apex Court in Shiv Kant Jha vs. Union of India, (2018) AIR SC 1975 , relied upon by the petitioner, the Tribunal opined that the said decision cannot ipso facto be made applicable to the petitioner's case inasmuch as, the same was confined to that case only. Accordingly, the original application has been dismissed. Hence, this petition. 5. Learned counsel appearing for the petitioner contended that the claim of the petitioner for medical reimbursement was rejected by the respondents without assigning any reason and therefore, the original application should have been allowed by the Tribunal on this count alone. Learned counsel submitted that the petitioner's claim for reimbursement was supported by the record duly certified by Doctor/Hospital concerned and thus, as laid down by the Apex Court in Shiv Kant Jha's case (supra), the claim could not have been denied on technical grounds. Learned counsel submitted that the petitioner's claim for reimbursement was supported by the record duly certified by Doctor/Hospital concerned and thus, as laid down by the Apex Court in Shiv Kant Jha's case (supra), the claim could not have been denied on technical grounds. Without prejudice to the claim of the petitioner for the reimbursement of the medical claim as submitted, learned counsel submitted that in any case, the claim of the petitioner as such could not have been rejected by the respondents and they were under an obligation to reimburse the claim to the extent of rates applicable to a hospital recognized by the BSNL and thus, the Tribunal has seriously erred in dismissing the original application. 6. On the other hand, learned counsel appearing for the respondents contended that admittedly, the factum of the petitioner's undergoing Angiography in MDM Hospital, Jodhpur before being admitted for surgery in SAL Hospital, Ahmedabad was not disclosed by him in the original application. Learned counsel submitted that the petitioner having ignored the guidelines issued for treatment in emergency by the BSNL, his claim being not covered by the guidelines of BSNL, the same has rightly been rejected. Learned counsel submitted that as a matter of fact, the controversy involved in this case is covered by a Bench decision of this court in Narendra Singh Panwar vs. BSNL (D.B.C.Writ Petition No.6330/15, decided on 8.3.18) wherein the court agreeing with the reasons given by the Tribunal in identical case declined to interfere, observing that the petitioner's wife had enough time to seek permission that her husband be permitted to take treatment at a Super Specialty. 7. We have considered the rival submissions and perused the material on record. 8. Indisputably, the petitioner being a retired employee of BSNL is entitled to claim reimbursement of medical expenses incurred for Coronary Artery Bypass Grafting Surgery as per the Scheme for medical reimbursement notified by the BSNL, however, his claim for reimbursement has been rejected solely for the reason that the conditions wherein the petitioner undergone the surgery at SAL Hospital, Ahmedabad is not covered by the emergent situations as specified. The respondents have arrived at the conclusion as aforesaid inasmuch as, in the first instance, the petitioner was admitted to Mathuradas Mathur Hospital Jodhpur and thereafter, after a lapse of 10 days, he was admitted in SAL Hospital, Ahmedabad for surgery. 9. The respondents have arrived at the conclusion as aforesaid inasmuch as, in the first instance, the petitioner was admitted to Mathuradas Mathur Hospital Jodhpur and thereafter, after a lapse of 10 days, he was admitted in SAL Hospital, Ahmedabad for surgery. 9. It is true that the factum of the petitioner being admitted to Mathuradas Mathur Hospital Jodhpur has not been specifically mentioned in the original application filed, but the allegation of the respondents that the petitioner concealed the factum of his undergoing process of Angiography at Mathuradas Mathur Hospital Jodhpur, does not appear to be correct. It is noticed that the factum of the petitioner being admitted to Mathuradas Mathur Hospital Jodhpur is specifically mentioned in the Discharge Summary issued by the SAL Hospital, which was submitted by the petitioner to the respondents as also before the Tribunal alongwith the original application. Be that as it may, the conclusion of the respondents regarding there being no emergent condition for the petitioner to undergo the surgery in a non recognized hospital, is based on the time gap between the admission to Mathuradas Mathur Hospital in the first instance and thereafter in SAL Hospital, Ahmedabad. In the considered opinion of this court, merely because, the petitioner's Angiography in the first instance was done at Mathuradas Mathur Hospital Jodhpur, it cannot be presumed that the petitioner did not suffer the severe attack subsequently on 23.1.17. Thus, the conclusion drawn by the respondents as aforesaid is not supported by any substantial evidence on record, rather, it is only an inference drawn on the basis of the fact situation noticed as above. 10. It is pertinent to note that as per clause 7.2 of the instructions issued by the BSNL vide order dated 23.7.10, Coronary Artery Bypass Graft does fall within the emergent condition. It cannot be disputed that as per the guidelines, after admission to the non recognized hospital for undergoing Bypass Surgery, the petitioner was required to inform the concerned authority. But then, on this count, the respondents was not justified in rejecting the petitioner's claim altogether and the same could have been restricted to rates applicable to a hospital recognized by the BSNL. 11. In Narendra Singh Panwar's case (supra), relied upon by the counsel appearing for the respondents, the petitioner therein was admitted to Mathuradas Mathur Hospital Jodhpur on 13.7.13 and was discharged on 18.7.13. 11. In Narendra Singh Panwar's case (supra), relied upon by the counsel appearing for the respondents, the petitioner therein was admitted to Mathuradas Mathur Hospital Jodhpur on 13.7.13 and was discharged on 18.7.13. The court observed that the discharge summary of Mathuradas Mathur Hospital Jodhpur did not refer him to a Super Specialty Hospital and accordingly, the court agreed with the finding arrived at by the Tribunal that it was not a case of emergency justifying the petitioner to travel from Jodhpur to Ahmedabad for Super Specialty Treatment. 12. We are of the opinion that the fact situation in Narendra Kumar's case (supra) and the petitioner's case as discussed above cannot be considered to be identical. That apart, the matter with regard to the reimbursement of the claim atleast at the rates applicable to the recognized hospital was not even raised and considered by the Court. Moreover, in our considered opinion, the petitioner's case is covered by the decision of the Supreme Court in Shiv Kant Jha's case (supra), wherein while discussing the approach required to be adopted by the Government in the matter of reimbursement of medical claim of the Government employees during their lifetime and after retirement, the Court observed: "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. 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." (emphasis added) 13. In the backdrop of authoritative pronouncement of the Apex Court in Shiv Kant Jha's case (supra), adverting to the facts of the present case, the factum of the petitioner suffering from Coronary Artery Disease (CAD)/Triple Vessle Disease and having undergone Coronary Artery Bypass Grafting Surgery stands established beyond doubt on the basis of the documents placed on record, genuineness whereof is not disputed by the respondents before this court. In this view of the matter, the respondents could not have rejected the claim of the petitioner as such solely on the ground that he had not sought permission for undergoing the surgery at non recognized/non empanelled hospital. In our considered opinion, the respondents are under an obligation to consider the claim of the petitioner for medical reimbursement on the basis of the documents produced and the medical reimbursement if not in full, atleast to the extent of the claim admissible at the rates applicable for a particular hospital recognized by the BSNL, deserves to be allowed. 14. In the result, the petition succeeds, it is hereby allowed. The order impugned dated 19.9.18 passed by the Central Administrative Tribunal, Jodhpur Bench, is set aside. The original application preferred by the petitioner is allowed. The respondents are directed to consider the claim of the petitioner for medical reimbursement submitted as aforesaid, within a period of four weeks from the date of this order. It is made clear that if the petitioner's claim is not reimbursed in full, he will not be denied the reimbursement to the extent of the claim for which he would have become entitled had he undergone the surgery in recognized/empanelled hospital of BSNL. It is made clear that if the petitioner's claim is not reimbursed in full, he will not be denied the reimbursement to the extent of the claim for which he would have become entitled had he undergone the surgery in recognized/empanelled hospital of BSNL. The amount of the medical reimbursement to be determined as aforesaid shall be paid to the petitioner forthwith. If the respondents fail to reimburse the medical claim of the petitioner within the period of four weeks, the same shall carry interest @ 9% per annum. No order as to costs.