Central Administrative Tribunal - Cuttack
Biswaranjan Pattanaik vs Health And Family Welfare on 16 May, 2025
1 O.A.Nos. 260/00450 of 2024
CENTRAL ADMINISTRATIVE TRIBUNAL
CUTTACK BENCH, CUTTACK
O.A.Nos. 260/00450 of 2024
Reserved on 13.05.2025 Pronounced on 16.05.2025
CORAM:
HON'BLE SHRI PRAMOD KUMAR DAS, MEMBER (ADMN.)
Biswaranjan Pattanaik, aged about 55 years, S/o.
Late Dibakar Pattanaik, Qr.No. H-123, Old AG
Colony, Unit-IV, Bhubaneswar, Khordha, at present
Working as Dresser/MA(MTS), under Addl.
Director, CGHS, BBSR.
....Applicant
For the Applicant : Mr. S.K.Ojha, Counsel
-Versus-
1. Union of India represented through its Secretary,
Government of India, Ministry of Health & Family
Welfare, Room No. 201-D, Nirman Bhawan, New
Delhi, PIN-110011.
2. Director General, Government of India, Ministry of
Health and Family Welfare, Central Government
Health Scheme (CGHS), 545-A, Nirman Bhawan,
New Delhi, PIN-110011.
3. Director, Ministry of Health and Family Welfare,
Central Government Health Scheme (CGHS), 545-A,
Nirman Bhawan, New Delhi, PIN-110011.
4. Additional Director, Central Government Health
Scheme, Old A.G. Colony, Unit Bhubaneswar,
Khordha, PIN-751 001.
..... Respondents
For the Respondents: Mr. S.K.Varma, Counsel
2 O.A.Nos. 260/00450 of 2024
ORDER
PRAMOD KUMAR DAS, MEMBER (ADMN.):
The applicant is a MTS working as Dresser posted at the O/o the Additional Director, CGHS, Bhubaneswar. His grievance in this OA is that the respondents rejected his claim for reimbursement of medical expenses incurred by him for treatment of his wife at Universals Hospital, Pune on mechanical and technical grounds, which is not sustainable in the eyes of law. Accordingly to him, the applicant is a CGHS beneficiary. His wife was under treatment under Govt. Hospital, Bhubaneswar who referred the matter for Stem Cell Transplantation on 07.0-2.2020. The treating physician felt the need of her stem cell transplantation. Since the said treatment was not available in any of the CGHS dispensaries, he submitted application on 07.02.2020 enclosing thereto all necessary documents seeking permission of the authority concerned to treat her wife at the premier hospital of kidney related disease at Universals Hospital, Pune. Since, nothing was intimated to him, taking into consideration the urgent need of the treatment of her wife to save her life, by applying leave, he took her wife to Universals Hospital, Pune for treatment where her wife was admitted on 12.02.2020 and after necessary treatment, she was discharged on 24.02.2020, after which, the applicant reported to duty and submitted 3 O.A.Nos. 260/00450 of 2024 medical bills to the tune of Rs. 3,52,330/- on 12.03.2020 for sanction and reimbursement of the expenses incurred by him. In letter dated 31.12.2020, he was intimated as under:
"...it is to inform you that the case is examined in this ministry and after going through the documents attached it is found that the procedure performed is not mentioned in the discharge slip except in the bill. Hence, the reimbursement of the claim is regretted."
2. The applicant again submitted an application with detailed information requesting for reimbursement, which was duly forwarded to the competent authority vide letter dated 09.12.2020. In letter dated 19.01.2021, the applicant was intimated as under:
"...it is to inform you that the case is examined in this ministry and after going through the documents, it is found that the procedure performed is not mentioned in the discharge slip. Hence, the reimbursement of the claim is regretted."
3. Thereafter, in letter dated 05.04.2021, it was further intimated to the applicant as under:
"...it is to inform you that the case is examined by the ministry and after going through the documents attached, it is found that the procedure performed is not mentioned in the discharge slip, it is mentioned only in the bill. In addition, it is also stated that the PRP Cell transplantation is not an approved therapy. Hence, the case is regretted."
4. Whereupon, applicant submitted an appeal on 08.07.2021 passionately praying for reconsideration of his grievance followed by reminders but his grievance did not yield any result. It is submitted by 4 O.A.Nos. 260/00450 of 2024 the Ld. Counsel for the applicant that the treatment of the wife of the applicant at Universals Hospital, Pune and the expenses incurred and submitted are not in dispute. If, according to the respondents, the procedure followed for the treatment was not mentioned in the discharge slip, it was within the right of the employee concerned to get the same validated from the concerned hospital but denying him the reimbursement on such hypertechnical ground is unjust, inhumane and is in violation of the Fundamental Right to Life enshrined in Article 21 of the Constitution of India. In this regard, Ld. Counsel for the applicant has placed reliance on the decision of the Hon'ble Apex Court in the case of Shibakanta Jha Vs. UOI & Ors, AIR 2018 SC 1975 and has sincerely prayed to quash the letters dated 31.12.2020 (Annex.A/4), 19.01.2021 (Annex.A/5) & 05.04.2021 (Annex.A/6) and to direct the Respondents to sanction and pay the reimbursement of the medical expenses incurred in connection with the treatment of his wife with 12% interest.
5. The stand point taken in oppugnation in counter filed by the respondents has been reiterated by the their Ld. Counsel by stating that applicant on 07.02.2020 applied for Earned Leave from 11.02.2020 to 29.02.2020 for treatment of his wife in the hospital located at Pune City without any referral from any doctor and proceeded on leave without waiting sanction of the competent authority. However, his leave was 5 O.A.Nos. 260/00450 of 2024 regularized and sanctioned in a post facto manner on 05.03.2020. After joining, he submitted the medical claim for reimbursement incurred for the treatment of his wife in Universal Hospital, Pune. Since, settlement of his claim was beyond the administrative jurisdiction of the Additional Director, CGHS, Bhubaneswar, the same was referred to the Directorate of CGHS, New Delhi for ex post facto approval on 22.04.2020. In pursuance of the letter of the Directorate of CGHS clarification was sought from the applicant in compliance of which applicant submitted OPD prescription dated 07.02.2020 of BMC Hospital, Old Town, Bhubaneswar on 04.11.2020, which he had not produced ever before. The medical claim was duly processed with reference to the rules and procedure in vogue and the same was rejected on the ground mentioned in the letters dated 31.12.2020, 19.01.2021 & 05.04.2021, which are just and proper leading no interference and the OA is liable to be dismissed.
6. After considering the submissions of the parties, the pleadings and documents filed in support thereof including the decision relied on have been gone through.
7. The relevant portion of the of a decision of the Hon'ble Apex Court relating to medical treatment and reimbursement claim in the case of Paschim Banga Khet Mazdoorsamity & Ors Vs State Of West Bengal & Anr, AIR 1996 SC 2426, is quoted hereunder:
6 O.A.Nos. 260/00450 of 2024
"The Constitution envisages the establishment of a welfare state at the federal level as well as at the state level. In a welfare state the primary duty of the Government is to secure the welfare of the people. Providing adequate medical facilities for the people is an essential part of the obligations undertaken by the Government in a welfare state. The Government discharges this obligation by running hospitals and health centres which provide medical care to the person seeking to avail those facilities. Article 21 imposes an obligation on the State to safeguard the right to life of every person. Preservation of human life is thus of paramount importance. The Government hospitals run by the State and the medical officers employed therein are duty bound to extend medical assistance for preserving human life. Failure on the part of a Government hospital to provide timely medical treatment to a person in need of such treatment results in violation of his right to life guaranteed under Article 21."
8. The relevant portion of the decision of the Hon'ble Apex Court in the case of Kirloskar Brothers Ltd vs Employees' State Insurance Corpn, AIR 1996 SC 3261, is produced hereunder:
"In Consumer Education & Research Center & Ors. v. Union of India & Ors. [(1995) 3 SCC 42] a three-Judge Bench of this Court held that the jurisprudence of personhood or philosophy of the right to life envisaged in Article 21 of the Constitution enlarges its sweep to encompass human personality in its full blossom with invigorated health which is a wealth to the workmen to earn his livelihood, to sustain the dignity of person and to live a life with dignity and equality. The expression 'life' assured in Article 21 does not connote mere animal existence or continued drudgery through life. It has a much wider meaning which includes right to livelihood, better standard of living, hygienic conditions in the workplace and leisure facilities and opportunities to eliminate sickness and physical disability of the workmen. Health of the workmen enables him to enjoy the fruits of his labour, to keep him physically fit and mentally alert. Medical facilities, therefore, is a fundamental and human right to protect his health. In that case health insurance, while in service or after retirement was held to 7 O.A.Nos. 260/00450 of 2024 be a fundamental right and even private industries are enjoined to provide health insurance to the workman."
9. The Hon'ble Apex Court in the case of Vincent Vs. Union of India, (1987) 2 SCC 165, have held that the employer cannot deprive its employee of the full reimbursement of the amount on the premise of non-recognition of the hospital, Indraprastha Apollo Hospital. The Supreme Court approved the decision of the High Court of Madras in W.P.No.4980 of 2006 in the following words:
"In regard to the reasons as to the non-inclusion of the Hospital in Government Order for denial, this Court cannot brush aside the advancement in modern medical treatment. Specialty Hospitals are established for treatment for 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 Specialty Hospital by itself would deprive the beneficial order of the Government, solely on the ground that the said Hospital is not included in the Government Order. It cannot be so, as the Government Order should be read keeping the purpose for which the same was issued."
10. Further, it is found that the leading decision of the Hon'ble Apex Court is in the case of Shibakanta Jha (supra) an excerpt from it reads as under:
"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 8 O.A.Nos. 260/00450 of 2024 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 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.
14) 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 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 concerned Ministry, 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."
11. I find that the applicant had submitted application on 07.02.2020 addressed to Additional Director, CGHS, Bhubaneswar seeking special permission for better treatment of his wife in Universal Hospital, Pune 9 O.A.Nos. 260/00450 of 2024 which is a premier hospital for kidney related disease. The said application was forwarded by the concerned authority to AD, CGHS, Bhubaneswar for necessary action. The respondents in their counter have admitted that applicant submitted application for leave from 11.02.2020 to 29.02.2020 to go to Pune for treatment of his wife but nothing has been placed on record that the said prayer has been rejected on any ground and intimated to the applicant before he proceeded on leave or rejected subsequently. It is also found that in compliance of the decision fo the Hon'ble Aped Court in the case of Sibakanta Jha (supra), the Govt. of India, MHFW, New Delhi issued an exhaustive OM on 06.06.2018 providing the manner and the procedure of considering the reimbursement claim of employees concerned. Thus, I have examined the order of rejections dated 31.12.2020, 19.01.2021 & 05.04.2021 with reference to the law laid down above vis a vis the Govt. of India OM dated 06.06.2008. I find that the claim of the applicant has been rejected in letters dated 31.12.2020, and 19.01.2021 on hyper- technical ground that the procedure performed has not been mentioned in the discharge certificate though it was mentioned in the bills and, therefore, this Tribunal finds sufficient force on the submission of the Ld. Counsel for the applicant that if it was not mentioned in the discharge certificate but in the bills, the authority concerned should 10 O.A.Nos. 260/00450 of 2024 have obtained the same from the concerned hospital by making necessary communication or should have asked the applicant to get the things right from the concerned hospital instead of rejecting the claim in hyper-technicality.
12. The impugned orders speak that the rejection has been made by the Ministry and not by the High Power Committee as provided in the OM dated 06.06.2018, which was issued after the decision of the Hon'ble Aped Court in the case of Sibakanta Jha (supra). The respondents produced a copy of the OM dated 05.10.2016 wherein it has been provided that the delegation of power for permission/ex post facto approval/settlement of Medical Reimbursement Claims of individual beneficiaries/hospital bills in respect of Unlisted procedure/Implants (no CGHS rates). If there is no CGHS package rate for treatment/CGHS Ceiling rate for implant approval shall be granted as per AIIMS package rate (if only procedural charge, if shall not be considered as package rates)/ AIIMS rate for implant and if there is no CGHS/AIIMS rate approval shall be grant4ed as per actual rate. In view of the discussions made above, since another opportunity is still available to the applicant for consideration of his grievance by the High Power Committee, for the ends of justice, it is held as under: 11 O.A.Nos. 260/00450 of 2024
(i) Opportunity is given to the applicant to submit an exhaustive representation, enclosing thereto all connected records and copy of this order, within a period of 15 days from the date of receipt of a copy of this order before the Additional Director, CGHS, Bhubaneswar.
(ii) The Additional Director, CGHS, Bhubaneswar on receipt of the same shall forward the same within a period of seven (7) days of receipt of such representation to the Directorate for placing the matter before the High Power Committee as provided in OA dated 06.06.2018.
(iii) Whereupon, the authority concerned shall place the matter before the High Power Committee, who shall examine the matter keeping in view the fact that the applicant is a low paid employee and took her wife for treatment as advised by the Govt. Hospital, Bhubaneswar that too after asking for permission from his immediate authority vide application dated 07.02.2020.12 O.A.Nos. 260/00450 of 2024
(iv) Based on the decision of the High Power Committee, further course of action be taken in the matter of reimbursement of expenses claimed by the applicant;
(v) The entire drill as directed above shall be completed by the authority concerned within a period of 90 days under intimation to the applicant.
13. In the result, the OA stands allowed to the extent stated above. No costs.
(PRAMOD KUMAR DAS) Member (Judicial) RK/PS