Can't deny govt staff's med claim over hospital non-empanelment: HC TNN / Updated: May 23, 2023, 06:16 IST
NEW DELHI: The Delhi high court (HC) ruled that medical claim of a government employee for reimbursement of treatment undertaken in emergency should not be denied merely because the hospital was not empanelled with the Central Government Health Scheme (CGHS).
A division bench of Justices V Kameswar Rao and Anoop Kumar Mendiratta observed that the test would be to see whether the claimant had actually undertaken the treatment in an emergency as advised and if this contention is supported by records.
"Preservation of human life is of paramount importance. The state is under an obligation to ensure timely medical treatment to a person in need of such treatment and a negation of the same would be a violation of Article 21 of the Constitution," the bench said in a judgment dated May 10.
It made the observations while dismissing a plea moved by the central government challenging an order passed by the Central Administrative Tribunal directing it to reimburse a retired pensioner employed as a senior carpenter with the government, for the balance amount incurred by him due to emergency medical treatment for "trigeminal neuralgia" at the VIMHANS hospital in Delhi, which was not empanelled with CGHS.
The respondent, the Centre, submitted that the treatment was undertaken by the pensioner at a non-empanelled hospital on his own volition and, thus, he was not entitled to reimbursement as per policy.
Neutral Citation Number: 2023:DHC:3138-DB
W.P.(C) 10684/2022 Page 1 of 9 #
IN
THE HIGH COURT OF DELHI AT NEW DELHI Judgment reserved on: 20.04.2023 Judgment
delivered on:10.05.2023 +
W.P.(C)
10684/2022 & CM APPL. 31035/2022 UNION OF INDIA & ANR. .....
Petitioners Through: Mr. Syed Abdul Haseeb, Senior Panel Counsel for UOI.
versus SHRI. JOGINDER SINGH ..... Respondent Through: Mr. Padma Kumar S and Ms.
Thithiksha Padmam, Advocates.
CORAM:
HON'BLE MR. JUSTICE V. KAMESWAR RAO HON'BLE MR. JUSTICE ANOOP KUMAR MENDIRATTA
J U D G M E N T ANOOP KUMAR MENDIRATTA, J.
1. The challenge in this petition is to an
order dated September 03, 2021 passed by the Central Administrative Tribunal
(hereinafter referred to as the „Tribunal‟) in O.A. No.4664/2018 whereby the
petitioners were directed to reimburse the respondent, the balance amount
against his claim for the expenditure of Rs.2,60,000/- incurred by him on
medical treatment at Rancan Gamma Knife Centre-VIMHANS Hospital, Nehru Nagar,
Delhi after adjusting the amount of Rs.31,556/- already paid to the respondent.
2. In brief, as per the facts noticed in
O.A. No.4664/2018, the respondent retired as Senior Carpenter on March 30, 2016
and is a pensioner availing Neutral Citation Number: 2023:DHC:3138-DB W.P.(C)
10684/2022 the CGHS facility. On November 03, 2017, the respondent fell
unconscious and was taken to Mata Chanan Devi Hospital, Janak Puri, Delhi
wherein he was examined in the Neurology Department and advised further
treatment at Rancan Gamma Knife Centre-VIMHANS Hospital, Nehru Nagar, Delhi
specializing in Neurosurgery cases. The wife of the respondent accordingly took
him in emergency to VIMHANS Hospital wherein respondent underwent a surgery on
November 04, 2017 and was discharged on November 05, 2017.
3. Respondent thereafter submitted the
medical bills amounting to Rs.2,60,000/- as raised by VIMHANS, for
reimbursement on November 14, 2017 along with the emergency certificate at CGHS
Dispensary, Rajouri Garden. However, respondent was reimbursed only an amount
of Rs.31,556/- against the claim for Rs.2,60,000/-.
4.
Aggrieved by the rejection of his claim, vide letter dated October 16, 2018,
respondent preferred O.A. No.4664/2018 before the Tribunal.
5. The claim of the respondent was opposed
by the petitioners herein and it was submitted before the Tribunal that
emergency certificate was not submitted by the respondent from Mata Chanan Devi
Hospital, wherein he took the treatment on November 03, 2017. The case of the
respondent was also examined by the Standing Technical Committee on October 10,
2018 which did not find justification in the treatment availed by respondent,
as it was not a case of medical emergency and the treatment is stated to be
available in several Government hospitals at lower price.
6. Considering the records of treatment at
VIMHANS, the Tribunal Neutral Citation Number: 2023:DHC:3138-DB W.P.(C)
10684/2022 observed that there is no reason to refute the emergency as
indicated in the certificate issued by VIMHANS and the fact that the respondent
was operated on November 04, 2017 makes it clear that this was a medical
emergency. Further, relying upon the judgments passed by Hon‟ble Supreme Court
in Shiva Kant Jha Vs. Union of India, (2018) 16 SCC 187 and Basant Dabas Vs.
Government of India & Others, W.P. (C) No.9849/2015 decided on July 31,
2019 by High Court of Delhi, the O.A. preferred on behalf of the respondent was
allowed and the impugned order dated October 16, 2018 rejecting the claim of
the respondent was set aside.
7. Learned counsel for the petitioners
assails the impugned order passed by the Tribunal on the ground that there was
no emergency prescription from Mata Chanan Devi Hospital dated November 03, 2017
and the prescription dated November 03, 2017 from VIMHANS stated that the
patient complained of Severe Rt V1V2 Trigeminal Neuralgic since last four
months and is conscious/awake/oriented. It is contended that the case of the
respondent was placed before the Standing Technical Committee for full
reimbursement on October 10, 2018 and as per the opinion of experts, the
condition of the respondent was not a case of emergency. Further, treatment for
the same is available at many Government hospitals at lower price. It is
contended that the treatment was undertaken by the respondent at VIMHANS, a non
empanelled hospital at his own choice and as per the policy and Standing OMs,
the respondent is not entitled to reimbursement as it may open flood gates for
similar cases. Reliance is also placed upon a subsequent report of the Standing
Technical Committee dated October 13, 2022 which observes as under:- Neutral
Citation Number: 2023:DHC:3138-DB W.P.(C) 10684/2022 “The committee members
reviewed the case file provided in detail. The committee unanimously observed
that the patient was suffering from Trigeminal neuralgia which is not an
emergency to be treated by Gamma knife.”
8.
On the other hand, the order passed by the Tribunal is supported by the learned
counsel for the respondent. It is urged that in the initial report dated
October 10, 2018 of the experts relied by the petitioners, the claim was stated
to be not justified on the ground that the condition is not an emergency and
the treatment is usually available at many Government hospitals at much lower
price but the said report was signed only by two experts instead of four
experts who were called for attending the meeting. It is contended that only in
a recent subsequent meeting dated October 13, 2022 the opinion has been further
improved by Technical Committee without giving any reasons for differing with
the opinion of the treating Neurosurgeon at VIMHANS, who was in the best
position to take the call for treatment/surgery at the relevant time of admission
in emergency.
9. We have given considered thought to the
contentions raised. Respondent is a retired pensioner, who was merely employed
as a Senior Carpenter with the Central Government. On November 03, 2017, he was
initially taken to Mata Chanan Devi Hospital, Janak Puri, Delhi since he fell
unconscious and was duly examined. Further, as advised at Mata Chanan Devi
Hospital, respondent was taken by his wife for treatment to Rancan Gamma Knife
Centre-VIMHANS Hospital, Nehru Nagar, Delhi which specializes in Neurosurgery
and underwent surgery on November 04, 2017. Neutral Citation Number:
2023:DHC:3138-DB W.P.(C) 10684/2022
10. It may be noticed that “Trigeminal
Neuralgia” is a chronic pain condition affecting the trigeminal nerve in the
face which carries the sensation from the face to the brain. The symptoms of
the disease range from mild to severe facial pain often triggered by chewing,
speaking or brushing of teeth. The treatment available to alleviate the
debilitating pain may be with combination of medication, surgery and
complementary therapies. Generally, if a patient does not respond to the
medication or condition worsens over a period of time, surgical option may have
to be preferred, which includes stereotactic radiation surgery using gamma
knife and cyber knife.
11. It is pertinent to note that
prescription dated November 03, 2017 issued by Dr. Jayant Misra, MS M Ch.
Consultant Neurosurgeon, Rancan Gamma Knife Centre reflects that „the
respondent was advised Gamma Knife Radiosurgery as emergency treatment‟ apart
from other treatment as advised therein. Merely because the respondent was
conscious, awake and oriented at time of admission at VIMHANS cannot lead to an
inference that his claim of being admitted in emergency, is false. It may
further be noticed that an emergency treatment certificate was again issued on
October 18, 2018 by Dr. Jayant Misra certifying that the respondent was
admitted on November 04, 2017 after OPD consultation on November 03, 2017 on
emergency basis for his severe „Right Sided V1V2 Region Trigeminal Neuralgia.‟
The certificate also reflects that the respondent was unable to
eat/drink/sleep/wipe his face/speak at the time of admission on November 04,
2017. In the facts and circumstances, there existed continued emergent
condition for undertaking the treatment by respondent at VIMHANS, as Neutral
Citation Number: 2023:DHC:3138-DB W.P.(C) 10684/2022 advised at Mata Chanan
Devi Hospital. Merely because the respondent was suffering from the „Right Sided
V1V2 Region Trigeminal Neuralgic‟ for past four months, does not lead to an
inference that the medical condition did not require emergent treatment, which
was undertaken as a last resort by the respondent as advised.
12. The medical claim for treatment
undertaken in emergency should not be denied for reimbursement merely because
the hospital is not empanelled. The test remains whether the claimant had
actually undertaken the treatment in emergent condition as advised and if the
same is supported by record. Preservation of human life is of paramount
importance. The State is under an obligation to ensure timely medical treatment
to a person in need of such treatment and a negation of the same would be a
violation of Article 21 of the Constitution of India. Administrative action
should be just on test of fair play and reasonableness. Accordingly, keeping
into consideration the constitutional values, the executive instructions need
to be applied than rejecting the claim on technical ground of undertaking treatment
in a nonempanelled hospital, since the CGHS/State is responsible to ensure
proper medical treatment in an emergent condition and further cannot escape the
liability, if the treatment undertaken is genuine. Any denial of claim by the
authorities in such cases only adds to the misery of the Government servant by
further forcing him to resort to Court of law. Observations of the Hon‟ble Apex
Court in Shiva Kant Jha (supra), as reflected in paras 17, 18 & 19 may also
be beneficially reproduced:-
“17.
It is a settled legal position that the Government employee Neutral Citation
Number: 2023:DHC:3138-DB W.P.(C) 10684/2022 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. Before any medical claim is honored, 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 the 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.
18. This is hardly a satisfactory state of
affairs. The relevant authorities are required to be more responsive and cannot
in a mechanical manner deprive an employee of his legitimate reimbursement. The
Central Government Health Scheme (CGHS) was propounded with a purpose of
providing health facility scheme to the central government employees so that
they are not left without medical care after retirement. It was in furtherance
of the object of a welfare State, which must provide for such medical care that
the scheme was brought in force. In the facts of the present case, it cannot be
denied that the writ petitioner was admitted in the above said hospitals in
emergency conditions. Moreover, the law does not require that prior Neutral
Citation Number: 2023:DHC:3138-DB W.P.(C) 10684/2022 Page 8 of 9 permission has
to be taken in such situation where the survival of the person is the prime
consideration. The doctors did his operation and had implanted CRT-D device and
have done so as one essential and timely. Though it is the claim of the
respondent-State that the rates were exorbitant whereas the rates charged for such
facility shall be only at the CGHS rates and that too after following a proper
procedure given in the Circulars issued on time to time by the Ministry
concerned, it also cannot be denied that the petitioner was taken to hospital
under emergency conditions for survival of his life which requirement was above
the sanctions and treatment in empanelled hospitals.
19.
In the present view of the matter, we are of the considered opinion that the
CGHS is responsible for taking care of healthcare needs and well being of the
central government employees and pensioners. In the facts and circumstances of
the case, we are of opinion that the treatment of the petitioner in
non-empanelled hospital was genuine because there was no option left with him
at the relevant time. We, therefore, direct the respondent-State to pay the
balance amount of Rs. 4,99,555/- to the writ petitioner. We also make it clear
that the said decision is confined to this case only.”
13. It needs to be kept in perspective that
patient has a little scope to decide the nature of treatment and merely looks
forward to an expert guidance/treatment for relieving him from immense pain and
suffering. The patient in distress is not in a position to go against the
specialist medical advice for surgery in emergency. Even assuming that in
emergency, gamma knife surgery may not render an immediate relief as contended
by learned counsel for the petitioners, but it is an established alternative
medical treatment for trigeminal neuralgia as per literature. There may be a
difference of opinion Neutral Citation Number: 2023:DHC:3138-DB W.P.(C)
10684/2022 on the line of treatment to be adopted by the experts but only the
treating physician/surgeon appears to be the best placed to adopt the right
course of treatment in an emergent situation. Keeping in view the emergency
certificate and the treatment papers filed by the respondent, it cannot be said
that the treatment was not taken in an emergent condition or the respondent
should have deferred the immediate surgery by gamma knife, as advised by the
Specialist. For the foregoing reasons, we agree with the reasons and findings
of the Tribunal.
The writ petition is accordingly dismissed.
No order as to costs. Pending application, if any, also stands disposed of. (ANOOP
KUMAR MENDIRATTA) JUDGE (V. KAMESWAR RAO) JUDGE MAY 10, 2023/A/sd
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