Jayprakash Soni S/o Sh. Gopikishan Soni Advocate v. State of Rajasthan Through Secretary, State Insurance And Provident Fund Department, Secretariat, Jaipur
2025-01-13
ARUN MONGA
body2025
DigiLaw.ai
Order : 1. The petitioner inter alia seeks quashing of an order dated 03.09.2015, whereby his claim for reimbursement of medical expenses was rejected on the ground that the hospital is not in the panel [as per policy of State Insurance and Provident Fund Department, Group Mediclaim Insurance Policy (01.04.2015 to 31.03.2016)]. 2. Briefly stated the facts of the case, as pleaded in the petition, are as follows:- 2.1. The petitioner is working as Lower Division Clerk (LDC) in the Court of District and Sessions Judge, Jaisalmer and he has been firstly appointed on 05.05.2010. 2.2. It was pleaded that during the course of employment of petitioner, he has suffered a lot with regard to phaco problem in his left eye. The petitioner got his eye checked by the Medical Expert namely, Dr. Sanjay R. Gandhi working at Phaco Emulsification Centre, Ahmedabad. 2.3. The petitioner was advised by the Doctor for operation of his cataract on 20.05.2015 and accordingly, the petitioner was operated at the aforesaid Centre at Ahmedabad on 21.05.2025 and was discharged on the very same day. 2.4. The petitioner sent his mediclaim for reimbursement of Rs. 48,286/- through proper channel by his appointing authority but the same was rejected on the ground that the hospital is not in the penal as per the policy of the State Insurance and Provident Fund Department. 3. In the aforesaid backdrop, I have heard learned counsel for the petitioner as well as learned counsel for the respondents and have also perused the case file. 4. The relevant conceded stand of the respondents in the preliminary submissions of their reply, as stated in paragraph 2 of the reply, being relevant, is reproduced as follows:- “2. x – x – x – x – x According to the aforesaid condition, the reimbursement is payable for the treatment taken in hospital which are mentioned in point No.2 of policy. The petitioner has taken his treatment in Phaco Emulsification and Laser Centre, Ambawadi Amedabad which is not included in hospitals approved by the Government of Rajasthan outside Rajasthan. So, the claim was rightly rejected and same was forwarded to the petitioner vide letter dated 03.09.2015. Therefore, the writ petition is not sustainable and liable to be dismissed.” 5. From the aforesaid, it is clear that the treatment undergone by the petitioner for his cataract surgery is not disputed.
So, the claim was rightly rejected and same was forwarded to the petitioner vide letter dated 03.09.2015. Therefore, the writ petition is not sustainable and liable to be dismissed.” 5. From the aforesaid, it is clear that the treatment undergone by the petitioner for his cataract surgery is not disputed. It is only because he chose to undergo the procedure at a private hospital due to which his claim was rejected by the competent authority. 6. Once the treatment is not disputed, the competent authority, in the best scenario, ought to have allowed the petitioner’s claim as per the rates prescribed for such treatment under the service rules applicable to him. 7. Accordingly, the writ petition is allowed and the impugned order dated 30.06.2016 (Annex.5) is set aside. Liberty is granted to the competent authority to pass orders in accordance with the applicable service rules and the admissible rates as if he had undergone the treatment at an authorized hospital. If payment on admissible rates has already been made then no further action is warranted. 8. Any other application, if any, stands disposed of accordingly.