Dwarka Das Soni, s/o. Sh. Sita Ram Ji Soni v. State of Rajasthan, through the Secretary to the Government
2025-11-07
FARJAND ALI
body2025
DigiLaw.ai
ORDER : FARJAND ALI, J. 1. By way of filing this writ petition under Article 226 of the Constitution of India, the petitioner has prayed for issuance of an appropriate writ, order or direction to the respondents to consider and allow his medical reimbursement claim submitted on 15.11.2007 to respondent No. 3, in accordance with the provisions of the RAJASTHAN STATE PENSIONERS MEDICAL CONCESSION SCHEME . The petitioner has further sought a direction to the respondents to pay interest at the rate of 12% per annum on the delayed reimbursement amount, and to extend any other consequential or appropriate relief deemed just and proper in the facts and circumstances of the case. 2. During the pendency of the present writ petition, the petitioner unfortunately expired on 29.12.2011. The death certificate issued by the Municipal Corporation, Bikaner, on 16.01.2012 is placed on record. The right to seek reimbursement of medical expenses, being a part of the petitioner’s accrued and heritable benefits, survives to his legal representatives. 3. Breifly stated facts of the case are that , the petitioner, retired from the post of Office Superintendent on attaining the age of superannuation on 30.04.1997 and has since been receiving pension regularly vide P.P.O. No. 603720 and T.S. No. 11426. Being a retired government employee, the petitioner was issued a lifetime Medical Diary under the RAJASTHAN STATE PENSIONERS MEDICAL CONCESSION SCHEME (hereinafter referred to as “the Scheme”), entitling him to medical benefits admissible to pensioner. It is not in dispute that the petitioner has a long history of cardiac ailments, having remained admitted to P.B.M. Hospital, Bikaner between 07.10.1996 and 18.10.1996 and having undergone angiography at S.M.S. Hospital, Jaipur on 18.03.1997. In the year 2006, while visiting Ahmedabad for medical consultation of his ailing wife, the petitioner experienced chest pain and, upon medical advice, underwent a T.M.T. test which revealed arterial blockage. On experiencing acute pain again in August 2006, he underwent angiography at Ahmedabad on 28.08.2006, which confirmed triple vessel coronary artery disease, necessitating urgent bypass surgery. Accordingly, the petitioner was admitted to S.A.L. Hospital and Medical Institute, Ahmedabad, where Coronary Artery Bypass Graft (CABG) surgery was performed on 25.09.2006 and he was discharged on 04.10.2006. For the said treatment, the petitioner incurred expenses amounting to Rs. 1,14,410/-, including Rs. 9,410/- for angiography and Rs. 1,05,000/- for bypass surgery, supported by relevant bills.
Accordingly, the petitioner was admitted to S.A.L. Hospital and Medical Institute, Ahmedabad, where Coronary Artery Bypass Graft (CABG) surgery was performed on 25.09.2006 and he was discharged on 04.10.2006. For the said treatment, the petitioner incurred expenses amounting to Rs. 1,14,410/-, including Rs. 9,410/- for angiography and Rs. 1,05,000/- for bypass surgery, supported by relevant bills. Subsequently, on 11.04.2007, the petitioner again suffered chest pain and was admitted to P.B.M. Hospital, Bikaner, where he incurred an additional expenditure of Rs. 945.30 on medicines. After recovery, the petitioner submitted his medical reimbursement claim in three sets, duly certified, to respondent No. 3 on 15.11.2007. It is stated that respondent No. 3 forwarded the claim to respondent No. 2 on 15.01.2008, but no decision has been communicated to the petitioner during his lifetime, and the claimed amount has not been reimbursed till date. The petitioner also made a representation requesting expeditious settlement of his claim, but to no avail. The grievance of the petitioner is that despite submission of the claim in the prescribed manner and the Scheme providing for reimbursement of such medical expenses, the respondents have failed to take any decision thereon. Being aggrieved by the inaction of the respondents in not deciding or reimbursing the medical claim for a considerable period, the petitioner’s legal representatives has approached this Court by way of the present writ petition seeking appropriate directions for redressal of his grievance. 4. The counsel for the petitioner submitted that the petitioner(Since deceased) had undergone treatment in an emergent and life-threatening situation to save his life, and thus, under Rule 4E(b) of the Scheme, the respondents are legally bound to consider and decide his claim for reimbursement even in absence of prior recommendation. The petitioner had duly submitted the prescribed claim form in January 2008, which was forwarded to respondent No. 2, yet despite lapse of considerable time, the claim remains undecided without any justifiable reason. Such inaction is arbitrary, unreasonable, and violative of Articles 14 and 300- A of the Constitution of India. The petitioner, having spent his retiral benefits for the said treatment and presently facing financial hardship due to his wife’s illness, is in dire need of reimbursement. In these circumstances, the respondents’ failure to decide and release the admissible claim is unsustainable in law, and on these grounds alone, the writ petition deserves to be allowed. 5.
The petitioner, having spent his retiral benefits for the said treatment and presently facing financial hardship due to his wife’s illness, is in dire need of reimbursement. In these circumstances, the respondents’ failure to decide and release the admissible claim is unsustainable in law, and on these grounds alone, the writ petition deserves to be allowed. 5. The counsel for the respondent filed a reply and submitted that the petitioner did not undergo treatment in an emergent situation but in a planned manner at Ahmedabad, and has also failed to produce the mandatory certificate from a qualified Cardiologist as required under Rule 4E(b) of the RAJASTHAN STATE PENSIONERS MEDICAL CONCESSION SCHEME . The petitioner has already been reimbursed for the treatment taken at P.B.M. Hospital, Bikaner. Therefore, the writ petition is devoid of merit and deserves to be dismissed. 6. Heard learned counsels present for the parties and gone through the materials available on record. 7. Having considered the rival submissions and upon careful examination of the record, this Court finds that the core issue that arises for adjudication is whether the petitioner, who underwent coronary bypass surgery at S.A.L. Hospital and Medical Institute, Ahmedabad, without prior recommendation of the Medical Board, is entitled to reimbursement of the medical expenses incurred, under the RAJASTHAN STATE PENSIONERS MEDICAL CONCESSION SCHEME , 1997. 8. It is a settled principle of law that the right to health and medical care is an integral facet of the right to life under Article 21 of the Constitution of India. The State, being a welfare employer, is under an obligation to ensure that no retired employee or pensioner is deprived of timely medical relief merely on technical or procedural grounds. 9. The object of the Scheme is to extend medical support to pensioners in need, and therefore, its provisions must receive a liberal and purposive interpretation rather than a pedantic or restrictive one. When the circumstances indicate a bona fide emergent medical situation, strict insistence upon prior approval or recommendation of the Medical Board would defeat the very purpose of the Scheme. 10. In the instant case, the material on record clearly establishes that the petitioner, aged 67 years, was suffering from a cardiac ailment and had previously undergone angiography at S.M.S. Hospital, Jaipur. Upon suffering acute chest pain at Ahmedabad, he was advised immediate coronary artery bypass surgery.
10. In the instant case, the material on record clearly establishes that the petitioner, aged 67 years, was suffering from a cardiac ailment and had previously undergone angiography at S.M.S. Hospital, Jaipur. Upon suffering acute chest pain at Ahmedabad, he was advised immediate coronary artery bypass surgery. The angiography report revealed a 100% arterial blockage, indicating a life- threatening condition. The surgery, therefore, cannot be treated as a planned or routine procedure, but rather as an emergent measure to save the petitioner’s life. 11. The Hon’ble Division Bench of this Court in State of Rajasthan & Ors. v. Surendra Kumar Kalra [RLW 2008 (3) Raj. 1953] and the Hon’ble Supreme Court in Suman Rakheja v. State of Haryana [ (2004) 13 SCC 562 ] have consistently held that where medical treatment is taken in an emergency, reimbursement cannot be denied merely on the ground that such treatment was undertaken in a private or non-recognized hospital, provided the expenses are restricted to the rates applicable to recognized government hospitals. Similar principles were reiterated in Surjit Singh v. State of Punjab [ AIR 1996 SC 1388 ] and State of Punjab v. Mohan Lal Jindal [ (2001) 9 SCC 217 ] 12. This Court in Kanhaiya Lal Dave v. State of Rajasthan & Ors. [S.B. Civil Writ Petition No. 420/2009] and Gyanendra Kumar Pareek v. State of Rajasthan [2009 (4) WLC (Raj.) 95] further observed that “emergency knows no law and no procedure,” emphasizing that when human life is at stake, the State’s responsibility cannot be abdicated on technicalities. 13. In Kanhaiya Lal Dave (supra), which in turn relied upon the Division Bench judgment in Anil Kumar Surolia v. State of Rajasthan [2005 (3) WLC (Raj.) 39 6], this Court elaborated upon the doctrine of emergent medical necessity in the following terms: “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. Government cannot insist upon an employee to get himself treated at a recognized government institution.
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. Government cannot insist upon an employee to get himself treated at a 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. 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 an unrecognized hospital outside the State even though reference may not have been taken prior to treatment.” 14. This exposition, drawing strength from Surjit Singh (supra) and Mohan Lal Jindal (supra), lays down that once emergent circumstances are established, reimbursement cannot be denied merely on the ground that treatment was obtained at an unrecognized hospital or without prior reference. 15. In view of these legal principles, and considering the petitioner’s age, medical history, and the nature of ailment reflected in the angiography report, this Court finds sufficient material to conclude that the treatment was undertaken in an emergent condition and squarely falls within Rule 4E(b) of the Scheme. The respondents’ stand that the treatment was “planned” is unsustainable and contrary to both medical evidence and the spirit of welfare jurisprudence. 16. The prolonged inaction of the respondents in deciding the petitioner’s claim despite submission in 2008 is highly unreasonable and arbitrary. Their failure to process the claim in accordance with the Scheme violates Articles 14 and 300- A of the Constitution, as it results in unjust deprivation of the petitioner’s legitimate entitlement. 17. Accordingly, this Court holds that the petitioner was entitled to medical reimbursement as per Rule 4E(b) of the RAJASTHAN STATE PENSIONERS MEDICAL CONCESSION SCHEME , and the said entitlement now survives tom his legal representatives, restricted to 80% of the hospital expenses, limited to the general ward rates of the All India Institute of Medical Sciences, New Delhi, along with interest at the rate of 6% per annum from the expiry of 30 days after submission of the bills till actual payment. 18.
18. The respondents are, therefore, directed to verify the petitioner’s claim and supporting documents, compute the admissible amount in terms of the Scheme, and release the same to the legal representatives of the deceased petitioner within a period of three months from the date of receipt of this order. 19. The writ petition is accordingly allowed to the aforesaid extent. No order as to costs.