Central Administrative Tribunal - Chandigarh
Unknown vs Union Of India on 24 March, 2015
CENTRAL ADMINISTRATIVE TRIBUNAL
CHANDIGARH BENCH
OA. No. 1463/PB/2013
Reserved on: 11.03.2015
Pronounced on: 24.03.2015
CORAM:HONBLE MRS.RAJWANT SANDHU,MEMBER(A)
HONBLE DR. BRAHM A.AGRAWAL,MEMBER(J)
Ram Pal son of Sh. Mukhtiar Singh, Station Master, Chhajali (Sangrur), now residing at Ward no. 10, Furniture Market, Lehra Gaga, Tehsil Lehra Gaga, Distt. Sangrur.
Applicant
Versus
1. Union of India, Ministry of Northern Railway (Govt. of India), through its Secretary, Baroda House, New Delhi.
2. The Divisional Railway Manager, Northern Railway, Ambala Cantt. Haryana.
3. Chief Medical Director, Northern Railway, Baroda House, New Delhi.
4. Chief Medical Superintendent, Northern Railway, Ambala Cantt. Haryana.
Respondents
Present: Sh. Karnail Singh, counsel for the applicant.
Sh. Lakhinder Bir Singh, counsel for the respdts.
ORDER
HONBLE MRS. RAJWANT SANDHU, MEMBER(A):-
1. This OA has been filed under Section 19 of the Administrative Tribunals Act, 1985, seeking the release of medical reimbursement claim of Rs. 5,78,825/- with interest in respect of Cochlear implantation surgery undertaken by the daughter of the applicant.
2. The background of the matter is that Ms. Harjit Kaur, daughter of the applicant who is posted as Sation Master Chhajali, is suffering from hearing and speaking impairment since infancy. The applicant contacted ADMO Dhuri on 18.7.2011 for the treatment of his daughter and she was thereafter referred to DMO(Physician), Ambala for further treatment vide OPD Slip No. 3869 dated 18.7.2011 having Reference No. 113 dated 19.7.2011 (Annexure A-3). The applicant was referred to PGI by Dr. Atit and reference slip was countersigned by Dr. I.P. Sharma, Chief Medical Superintendent, Northern Railways, Ambala Cantt (Annexure A-5). The applicant alongwith his daughter visited PGI on 26.7.2011 and continued to visit the Institute thereafter with gaps of fifteen days to one month for testing vide Central Registration No. 3276644 of PGI. On 27.9.2011, the Head of Department of ENT, PGIMER, recommended Ms. Harjit Kaur for Cochlear implantation surgery. Ms. Harjit Kaur was admitted in PGI on 6.1.2012 and underwent surgery for Cochlear implantation. She was discharged on 17.1.2012 and directed to come for follow up treatment at PGI on the dates advised (Annexure A-7). The applicants daughter is continuing to visit PGI for follow up treatment. The expenditure incurred on the treatment was Rs. 5,78,825/- and the applicant arranged for this huge amount by pledging his house for Rs. 6,00,000/-. When the bill for reimbursement of medical expenses was submitted to the Chief medical Superintendent, Ambala Cantt on 24.2.2012, objections had been raised on the same and till date no payment had been released on this account. Hence, this OA.
3. In the written statement filed on behalf of the respondents, it has been stated that the reimbursement of medical expenses to the Railway employees and their family members is governed by the Railway board guidelines dated 31.12.2009 (Annexure R-2). As per clinical practice, Cochlear implantation surgery is usually performed on prelingually deaf children below five years of age, whereas patient Ms. Harjit Kaur was 18 years old. Beyond five years of age, the outcome of surgery declines, as the brain loses its natural plasticity. Speech development after surgery also becomes poor if done after five years of age. Railway Board guidelines (Annexure R-2) for reimbursement lay down an age limit of ten years for Cochlear Implant surgery in case of prelingually deaf children. Before the Railway employee goes in for the said treatment for which reimbursement is to be claimed, the proposal for the surgery is to be sanctioned by Railway Board. Besides, satisfying the conditions laid down in Annexure R-2, the proposal should, inter alia contain report and recommendation of Medical Board, with at least one member being a Railway Medical officer having Post Graduate Qualification in ENT Branch. The proposal should be duly recommended by Chief Medical Director and concurred by Associate Finance before being sent to Railway Board for sanction.
4. It has further been stated that the patient was referred to PGI only once on 19.7.2011 for evaluation (not for surgery), but attended PGI 7 days later on 26.7.2011 in violation of instructions that require that the patient must attend the referred hospital within three days in non-emergency cases. The patient was not admitted in PGI on 26.7.2011 and was asked to go for PTA test. She did not report back to the Railway hospital alongwith the estimated cost of treatment in PGI for further recommendation by the Railway hospital as required by the mandatory instruction No. 2 in Annexure R-1. After a gap of nearly six months of being referred to PGI on 19.7.2011, the patient got admitted in PGI on 6.1.2012, underwent Cochlear Implant Surgery on 11.1.2012 without being re-referred by the concerned Railway doctor in terms of instruction No. 2, 5 dated 03.02.2014 (Annexure R-1) and the Railway Board Circular dated 31.12.2009 (Annexure R-2). The patient was discharged from PGI on 17.1.2012 and asked to come back for follow up treatment. She failed to report to the Railway doctor as required by instruction No. 5 which reads as under:-
If the patient is admitted in the referred hospital, he should report to the concerned doctor in the Railway hospital after discharge. Reimbursement for the period after discharge will not be payable. If he is recalled to the hospital, even then he must be re-referred by the concerned Railway doctor.
5. The respondents have contended that the applicants claim for medical reimbursement of Rs. 5,78,825/- for the hospitalization and surgery of his 18 yeard old daughter Harjit Kaur with history of deafness since birth has been declined vide Annexures A-1 and A-2 for violation of the Rules/Instructions for Medical Reimbursement. Though the applicant is working on the responsible post of Station Master and is aware of the Railway Rules and procedures, he did not produce the result of the PTA test, PGIs expert opinion and Cost Estimate for Cochlear Implant Surgery before the Railway Medical Officers for further reference and recommendation regarding appropriate treatment. The patient was attended by ENT doctors of PGI Chandigarh on 26.7.2011 and asked to come on 26.8.2011 for Pure Tone Audiometery (PTA) Test. The patient did not report back to Railway Hospital, Ambala after she was prescribed the said test at PGI Chandigarh. This violated Instruction No 2 of Annexure R-1 that if the patient is not admitted in the referred Hospital and is advised some test/investigation/procedure, she should again report to Railway Medical Officer for a fresh reference, otherwise reimbursement will not be paid.
6. Later the Chief Medical Director, respondent No. 3, constituted a medical board vide letter dated 6.5.2013 consisting of the Chief Medical Superintendent, Northern Railway, Ambala Cantt and three Railway Doctors including one Railway ENT specialist. The patient was admitted for assessment by the medical board and not for treatment. Hence, the applicants claim that she responded well to the treatment is patently false. The appeal of the applicant against the conclusion of the Medical Board was rejected by the respondent No. 3 vide letter dated 1.7.2013. Hence, no payment could be made to the applicant. The legal notice and the representation (Annexure A-10 & A-11) have no merit. The competent authority, the Chief Medical Director, Northern Railway, respondent No. 3 rejected the claim of the applicant on 1.7.2013 with the observations : Railway Board guidelines and referral procedures do not allow for reimbursement of expense for Cochlear implant carried by ignoring extant instructions. The representation (Annexure A-11) was replied to on 9.9.2013 informing that the reimbursement claim had been rejected by the competent authority.
7. In the rejoinder filed on behalf of the applicant, the grounds taken in the OA have been reiterated. It has also been stated that the applicants daughter was referred to PGI for evaluation and future management. IRMM describes the word management as evaluation and treatment. The applicant carried out all the instructions issued from time to time by the PGI Chandigarh. Once the case was referred for evaluation and treatment then there was no rule under which the applicant was required to produced the PTA test, PGIs expert opinion and cost estimate etc. for Cochlear implantation as there was no specific instruction to the applicant as such. Also, the Chief Medical Superintendent, Ambala Cantt had strongly recommended the claim of the applicant for reimbursement of the medical claim as per Annexure A-13.
8. Arguments advanced by the learned counsel for the parties were heard. Learned counsel for the applicant narrated the background of the matter and stated that Head of the ENT Department had issued a note titled To Whom It May Concern dated 27.9.2011 regarding condition of Ms. Harjeet Kaur and recorded that she was a suitable candidate for Cochlear implantation. The PGI carried out the surgery and the applicant had submitted claim for reimbursement of medical expenses. The claim had been rejected on flimsy grounds while the applicant was entitled to reimbursement of the same.
9. Learned counsel for the respondents drew attention to the referral slip on the reverse page of which instructions for Railway employees were printed that made it clear as to how they were to proceed in the matter of availing medical reimbursement (Annexure R-1). Learned counsel stated that the applicants daughter had been referred to PGI but as per para 2 of the instructions regarding reimbursement, if the patient was advised some investigation/test, he/she was required to report back to the concerned Railway Medical officer. Regarding Cochlear implantation, specific instructions had been issued vide letter No. 2007/H/6-1/Policy(I) dated 31.12.2009 (Annexure R-2) as per which selection criteria had been defined as under:-
(a) For pre-lingually deafened children: age group between 1 to 10 Yrs.
(B) For post-lingually deafened children/patients upto 21 years.
The applicants daughter was pre-lingual, she was eighteen years of age and hence she was not eligible for Cochlear implantation as per these guidelines. Moreover, the Centre/Surgeon doing the implant surgery was required to certify the possible result/outcome of the implant surgery, which should be more than 50%. The certificate issued by the Head of the ENT Department, PGI on 27.09.2011 did not mention this. Besides, as per the prescribed procedure, the report / recommendation of Medical Board (with at least one member being a Railway Medical officer having Post Graduate Qualification in ENT Branch) had to be further recommended by the Chief Medical Director concerned and concurred by Associate Finance before being sent to Railway Board for sanction. An assessment of the result of the surgery was also to be made after six months by the Railway ENT surgeons and subsequently after every six months upto two years and report sent to the concerned Chief Medical Director, Zonal Railway which was to send a final report to the Board.
10. In the case of Ms. Harjit Kaur, the prescribed procedure had not been followed and the applicant and his daughter decided to go ahead with the Cochlear implantation surgery on their own. He further stated that as per letter dated 31.12.2009, there were some approved centres for Cochlear implantation surgery and this list did not include PGIMER, Chandigarh. Hence, the reimbursement claim filed by the applicant is not admissible.
11. We have given our thoughtful consideration to the matter. From the material on record, it is clear that as per the guidelines of the Government of India/Railway Board issued vide letter dated 31.12.2009 (Annexure R-2), the daughter of the applicant being pre-lingual and eighteen years of age was not an eligible person for Cochlear implantation. The applicant and his daughter went ahead with the surgery although as per the instructions on the reverse page of referral slip dated 19.7.2011, the applicant was required to get in touch with the Railway medical authorities from time to time before actually going in for the surgery. The approval for the surgery had to be obtained from the Chief Medical Director/Railway Board and the surgery could only be conducted at the centres approved for Cochlear implantation as per the Circular of 31.12.2009. PGIMER was not one of these centres. The applicant has incurred heavy expenditure on the Cochlear implantation most of which was on account of the device, but since the surgery took place without requisite approvals reimbursement of the medical expenses on this account is clearly inadmissible. Hence, this OA, being devoid of merit, is rejected.
(RAJWANT SANDHU)
MEMBER(A)
(DR. BRAHM A.AGRAWAL)
MEMBER(J)
Dated: . .2015
ND*
1
OA. 1463/PB/2013