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2022 DIGILAW 214 (MEG)

Mohan Lal Goswami v. Union of India

2022-08-12

W.DIENGDOH

body2022
JUDGMENT 1. The petitioner herein was a retired Junior Engineer in the Department of Military Engineering Service. As a retired Central Government employee, the petitioner is also covered by the Central Government Health Scheme (CGHS) which entitles him to be reimbursed for any medical treatment that he undergoes. 2. In the month of February 2018, the petitioner along with his son went on a personal trip to Chennai. However, while in Chennai, he developed serious urinary problem and was required to urgently go for medical check-up. Being in great pain and discomfort, on 09.02.2018, he was taken to the Apollo Hospital which is the nearest hospital from the hotel where he was staying. In the out-patient department (OPD), the attending doctor advised the petitioner to get all the necessary tests and investigations done urgently which was done so on the next day, that is, on 10.02.2018. On the basis of the results of the tests, he was diagnosed to have left Renal Tumor with Renal Calculi and was advised for immediate surgery. Accordingly, the petitioner was admitted to the hospital on 12.02.2018 in the Urology Department and underwent surgery procedure Laparoscopic left Radical Nephrectomy on 13.02.2018 and was discharged on 15.02.2018. 3. According to the petitioner, the whole treatment process costs him Rs. 2,63,294/- (Rupees two lakhs, sixty-three thousand, two hundred and ninety-four) only. Being a holder of a valid Central Government Health Scheme (CGHS) card, the petitioner had duly submitted his medical reimbursement claim (MRC) in the prescribed form to the appropriate authority on 09.03.2018 vide his letter dated 07.03.2018. 4. It is also the case of the petitioner that the respondent authorities most illegally and arbitrarily by being hyper technical had settled the medical reimbursement claim and paid the petitioner only a sum of Rs. 33,384/- (Rupees thirty-three thousand three hundred and eighty-four) only towards his claim as aforesaid. 5. The petitioner not being satisfied with the action of the respondent authorities has caused issuance of a pleader's notice dated 30.06.2018 requesting the authorities to reimburse the full and actual expenditure incurred for the actual treatment. 6. The respondents vide letter No. CGHS/ESH/HOSP/43/6261-62 dated 27.07. 2018 in reply to the said pleader's notice had informed the petitioner that his medical claim was not entertained on the grounds stated therein. 6. The respondents vide letter No. CGHS/ESH/HOSP/43/6261-62 dated 27.07. 2018 in reply to the said pleader's notice had informed the petitioner that his medical claim was not entertained on the grounds stated therein. It transpired that the case of the petitioner was re-scrutinized by a Committee with the Additional Director as Chairman and three other members and the Committee in its meeting held on 06.07.2018 had rejected the claim of the petitioner mainly on the ground, inter alia, that the treatment of the petitioner was not in the emergency life threatening condition. 7. Again, the said Committee met on 13.07.2018 wherein the petitioner was also present. The minutes of the meeting was circulated vide letter dated 16.07.2018. Copy of the above-mentioned minutes along with the Report of the re-scrutinizing meeting of 06.07.2018 were all enclosed with the reply to the said pleader's notice. 8. The petitioner in his quest for justice which was allegedly denied to him, has accordingly approached this Court seeking invocation of the extraordinary writ jurisdiction for redressal of his grievances. Hence this petition. 9. Ms. P.D. Bujarbaruah, learned Sr. counsel appearing for the petitioner has submitted that the fact that the petitioner has been admitted at the Apollo Hospital, Chennai on 13.02.2018 to undergo surgery has not been denied. That the petitioner has to spend a sum of Rs. 2,63,294/- (Rupees two lakhs sixty-three thousand, two hundred and ninety-four) only has also not been challenged by the respondents. 10. The only dispute according to the petitioner is the non- acceptance of the respondent authorities that the case of the petitioner is an emergency one. The fact that the attending Physician who had examined the petitioner at the hospital has advised that he should undertake surgery at the earliest implies that there is an element of emergency, submits the learned Sr. counsel. 11. It is also submitted that the Office Memo dated 28.05.2018 issued by the Government of India, Ministry of Health and Family Welfare which provides for the relaxation in case of medical emergency in excess medical reimbursement is applicable to the petitioner who is clearly covered under conditions a(1) and b(iii) of the same. 12. counsel. 11. It is also submitted that the Office Memo dated 28.05.2018 issued by the Government of India, Ministry of Health and Family Welfare which provides for the relaxation in case of medical emergency in excess medical reimbursement is applicable to the petitioner who is clearly covered under conditions a(1) and b(iii) of the same. 12. Reference was also made to the case of Shiva Kanta Jha v. Union of India in Writ Petition (Civil) No. 694 of 2015, wherein the Apex Court has observed that right to medical claim cannot be deprived merely because the name of the hospital is not included in the Government order. The observations of the Apex Court at para 15 of the said case of Shiva Kanta Jha, wherein it was mentioned that the decision shall be confined to the said case, meaning that it shall not apply to any other case, including the case of the petitioner is also not correct, submits the learned Sr. counsel as the oblique reference was made only to the amount of Rs. 4,99,555/- (Rupees four lakh ninety nine thousand five hundred and fifty- five) only and not to the other findings and observations made in the case. 13. It is finally submitted that the case of the petitioner being a genuine one as he had to undergo surgery on an emergency mode, as such, he is entitled to reimbursement for the full amount spend for his treatment. 14. Mr. R. Debnath, learned CGC appearing on behalf of the respondents-Union of India has submitted that there is no merit in the case of the petitioner for which the same ought to be dismissed. 15. The learned CGC has admitted the fact that the petitioner had gone to Chennai with his son in connection with some domestic matters. It is also admitted that the petitioner had gone to the out-patient department (OPD) at Apollo Hospital Chennai on 09.02.2018 and was advised by the doctor to undertake necessary tests for which he did so on 10.02.2018. On being admitted at the said hospital on 12.02.2018, he underwent surgery procedure being laparoscopy left Radical Nephrectomy on 13.02.2018 and was discharged on 15.02.2018. 16. It is submitted that the claim of the petitioner for reimbursement of a sum of Rs. On being admitted at the said hospital on 12.02.2018, he underwent surgery procedure being laparoscopy left Radical Nephrectomy on 13.02.2018 and was discharged on 15.02.2018. 16. It is submitted that the claim of the petitioner for reimbursement of a sum of Rs. 2,63,294/- (Rupees two lakh, sixty-three thousand, two hundred ninety-four) only as medical claim was done so without following due procedure and rules governing the same, particularly under the Central Government Health Scheme (CGHS). However, to the extent admissible, a sum of Rs. 33,384/- (Rupees thirty-three thousand three hundred eighty-four) only was disbursed to him. 17. The learned CGC went on to submit that the case put forth by the petitioner is that since it is an emergency situation, he could not have got himself admitted into any of the empaneled CGHS hospitals. However, the physical examination findings of the petitioner would show that on 09.02.2018 as an OPD patient was NAD (Nothing Abnormality Detected). In this regard, it is also noticed that the petitioner was not given any medication or treatment from 09.02.2018 to 12.02.2018 (almost 72 hours) except for investigation and tests conducted on him, which clearly shows that no emergency treatment was required during the relevant period. 18. Reference was also made to the Office Memorandum issued by the Ministry of Health and Family Welfare, Government of India being No. Z.15025/38/2018/ DIR/CGHS/EHS dated 22.05.2018 (Annexure-V of the writ petition), the subject matter being 'Relaxation of Rules for consideration of reimbursement in excess of the approved rates pertaining to medical claims', wherein a provision is found dealing with the request for full reimbursement only under certain defined criteria being seven in numbers, however the relevant criteria as regard the case of the petitioner would be the following: 'a (1) Treatment was obtained in a private unrecognized hospital under emergency and the patient admitted by others when the beneficiary was unconscious or severely incapacitated and was hospitalized for a prolonged period.' 19. The learned CGC has also submitted that in view of the complaint of the petitioner portrayed in the legal notice dated 30.06.2018, the respondent authorities has convened an emergency meeting on 13.07.2018 to discuss the same. The convening order dated 12.07.2018 was also issued upon the petitioner for his attendance. 20. The learned CGC has also submitted that in view of the complaint of the petitioner portrayed in the legal notice dated 30.06.2018, the respondent authorities has convened an emergency meeting on 13.07.2018 to discuss the same. The convening order dated 12.07.2018 was also issued upon the petitioner for his attendance. 20. In the minutes of the said meeting held on 13.07.2018 (Annexed by the petitioner as Annexure IV-G in the petition), apart from all the concerned officials, the petitioner and his counsel Shri G.C. Choudhury were also present. The relevant portion of the said minutes would be the reading out by the Addl. Director of the categories of conditions as per para a (1) to (7) of the Office Memorandum dated 22.05.2018 and upon enquiry, the petitioner has admitted that his case does not fall under any of the said seven categories, submits the learned CGC. 21. Therefore, in view of the categorical statement of the petitioner that his case does not fall under any of the said seven categories, the case of the petitioner not being an emergency case, he is accordingly not entitled to be treated at any of the hospitals apart from those hospitals empanelled under the CGHS and consequently, he is not entitled to the claim made by him except to the extent as found admissible by the respondent authorities, once again submits the learned CGC. 22. This Court has heard the parties and has also gone through the petition and the affidavit-in- opposition including all the related rejoinder and additional affidavits filed by the parties to bring on record the pleadings of the parties and additional facts thereto. 23. However, in the opinion of this Court, the only point to be considered is whether the case of the petitioner falls within the category of 'an emergency case' and whether he would qualify for reimbursement in excess of the CGHS rates? 24. Admittedly, there is no dispute that the petitioner has undergone a surgical procedure for his related complaint at the Apollo Hospital, Chennai which is obviously not one of the hospital empaneled under the CGHS. The rules however provides that he may be reimbursed for the actual amount spend only if it is proved that the procedure was carried on an emergency mode and that the beneficiary was unconscious or severely incapacitated and was also hospitalized for a prolonged period. 25. The rules however provides that he may be reimbursed for the actual amount spend only if it is proved that the procedure was carried on an emergency mode and that the beneficiary was unconscious or severely incapacitated and was also hospitalized for a prolonged period. 25. Records have shown that the petitioner went to the hospital on 09.02.2018, but was never admitted for treatment immediately on the same day, instead he was asked to get some tests carried out which was complied by him and was done on 10.02.2018 and 11.02.2018 since he was then actually hospitalized on 12.02.2018. As contended by the respondents, the criteria to qualify for an 'emergency' procedure is usually within 24 hours, being critical hours. In the case of the petitioner, this was not the case as even the physical examination on 09.02.2018 also record a finding that 'nothing abnormality detected'. It was also contended that even the expression 'severely incapacitated' would not apply to the case of the petitioner as it would mean that at the time of admission to the hospital, he has to be severely ill or gravely or even critically ill with incapacitated meaning to be deprived of strength or power or debilitated disabled, unfit, immobilized, paralyzed etc., which was not so in the case of the petitioner. 26. The above factors being present, it has been demonstrated that the treatment process of the petitioner is not one under emergency conditions, hence under the relevant rules, he ought to have got himself treated at one of the wellness centres recognized under the CGHS, irrespective of the nature of his ailment as has been indicated by the petitioner, even to the extent of the same being treatment required in the case of removal of 'left renal tumor measuring about 5.8 cm with left PUJ calculus measuring 1.9 cm' for which he was advised to undergo surgery ASAP (As soon as possible) but not necessarily immediately. 27. Another telling factor going against the case of the petitioner is that in the meeting held on 13.07.2018 which is a re-scrutiny committee to reconsider the case of the petitioner in which he along with his counsel are present, he has admitted that his case does not fall under any of the seven categories found in the said Memorandum dated 22.05.2018 (supra). Though he has denied this fact at the hearing, yet the fact remains that there was no representation or appeal for correction of the alleged wrong admission preferred before the relevant authorities. 28. On an overall consideration of the case in hand, this Court is of the considered opinion that the authorities concerned have not acted in such a manner as regard the case of the petitioner herein, so as to convince this Court that the same was done arbitrarily or illegally or in clear violation of the fundamental and legal rights of the petitioner. 29. The case of Shiva Kant Jha (supra) relied upon by the petitioner cannot be taken note of by this Court, primarily because the Hon'ble Supreme Court has made it clear at para 15 of the same that the decision made therein is to be confined only to the case under consideration. 30. This being the case, there is no merits in this petition, the same is accordingly dismissed. 31. Petition disposed of. No costs.