Central Administrative Tribunal - Ernakulam
S Lekha vs M/O Railways on 8 November, 2017
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CENTRAL ADMINISTRATIVE TRIBUNAL
ERNAKULAM BENCH
Original Application No. 180/00241/2016
Wednesday, this the 81h day of November, 2017.
CORAM:
Hon'ble Mr. E.K.Bharat Bhushan, Administrative Member
S. Lekha, aged 57 years, W/o. D. Somasundaran,
Sr. Divisional Audit Officer, Southern Railway,
Trivandrum Division, Residing at TC 19/131-M,
Chandralekha (VPS 300k), Armada P.O., Thirumala,
Thiruvananthapuram- 695 032.
Applicant
(Uy Advocate- Mrs. Shameena Salahudheen)
Versus
I. Union of India, Represented by the General Manager,
Southern Railway, Chennai - 600 003.
'!.'he ChiefMedical Superintendent, Southern Railway,
Trivandrum- 695 014.
.,
. '. Chief Medical Director, IV Floor, Moor Market Complex,
Park Town, Chennai - 600 003.
Financial Advisor & Chief Accounts Officer,
Office of the FA & CAO, Chennai- 600 003.
·I'he Divisional Railway Manager,
Southern Railway, Trivandrum - 695 014.
Respondents
(B)' Advocate- Mr. Millu Dandapani)
This Original Application having been heard on 25.10.2017, the Tribunal on 8.11.2017
delivered the following:
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OA241/2016
ORDER
Original Application No.241/2016 is filed by Smt.S.Lekha who is presently working as Senior Divisional Audit Officer, Trivandrum under the respondents, aggrieved by Annexure Al whereby her claim for reimbursement of medical expenses incurred by her for Total Hip Replacement surgery was rejected on the ground that she failed to establish the emergency nature of the surgery. Under challenge is the communication issued by the 2nd respondent vide Annexure Al dated 08.01.2016.
2. The prayer contained in the O.A. is as follows:
(I) To call for the records leading to Annexure A 1 and set aside the same.
(II) Declare that the applicant is entitled to get reimbursement of the medical expenses claimed as per Annexure A2.
(Ill) Direct the respondents to immediately process Annexure A2 claim and pay the amount.
(IV) Such other reliefs as may be prayed for and this Hon'ble Tribunal may deem fit to grant.
(V) Grant the cost of this Original Application.
3. The brief facts of the case are as below.
The applicant while working as Assistant Audit Officer, Trivandrum had suffered severe pain of hip and back on 19.2.2012. She went to S.P Fort Hospital Trivandrum and was admitted there. On examining her, the Consultant Orthopedic Surgeon, Dr.Kailas Viswananth, recommended immediate Total Hip Replacement surgery as the only remedy for her physical condition and the operation was performed on 20.2.20 12. After post operational care, she was discharged on 24.2.2012. She availed medical leave lor 2 months and joined duty thereafter. The expenses incurred for treatment came to Rs. l ,94,864. As she was eligible for reimbursement of medical expenses as per < ...
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• • 3 OA241/2016 provisions of IRMM, she applied for the same with documents to respondent no. 2. The claim papers are at Annexure A2. The 2nd respondent forwarded the same to the 3rd respondent who in tum forwarded the papers to the 4th respondent. The 4th respondent returned the papers with communication dated 11.12.2014 mentioning that the emergency nature of the treatment undertaken had to be established. It was pointed out in the said communication that the CMD's verbatim views are necessary on the emergency nature of the treatment received. CMD is the 3rd respondent. It was further pointed out that the 2nd respondent had not furnished essentiality 'certificate as in Annexure III of the standard application form.
4. Thereupon the applicant obtained a certificate from the Doctor who had treated her at the private hospital viz., S.P. Fort Hospital and forwarded the same (Annexure A
5). The 3rd respondent again informed the 2nd respondent that the claim of the applicant cannot be considered for processing on account of the emergency nature of the treatment .not being clearly established (Annexure A6). The applicant made a representation to the 2nd respondent on 16.05.2012 (Annexure A7). This was negatived by the impugned order issued by the 2nd respondent.
S. As grounds, it is pointed out by the applicant that there is a provision for reimbursement of medical expenses under IRMM and denial of the same is illegal, arbitrary and unreasonable and is violative of the relevant Articles of the Constitutiort of India. Under IRMM there is no ban on a Railway employee being treated in a private hospital. The applicant was forced to undergo Total Hip Replaceme~t surgery on an emergency basis as she was in a non- ambulatory condition and expert medical advice rendered at the private hospital had indicated that this was the only mode for treating her disability. There is no case made by the respondents that the claim is not genuine
- L • • • 4 OA241/2016 and it is not denied that she had undergone the said surgery. Denying her right to get proper treatment, amounts to denial of her legal rights, citing flimsy excuses.
6. Per contra on behalf of the respondents 1 to 3 & 5 a statement has been liled pointing out that the applicant had gone to S.P. Fort Hospital, Trivandrum, which is a private hospital, on her own volition. The emergency certificate furnished by the private doctor merely states that she had severe pain and had restricted movements. 'Ther~ is nothing to suggest that if surgery is postponed, the disease will get exacerbated or endanger the life of the applicant. Further in the discharge certificate the disease is mentioned as 'rheumatoid arthritis' which is not a declared medical emergency. Under IRMM there is a specific provision for admitting reimbursement of medical expenses claims incurred at a private facility but this is only on condition thal the emergency nature of the care is to be clearly established. The facility of Total Hip Replacement surgery is not available at Railway Hospital Trivandrum. However it is available at Perambur in Tamil Nadu, where she would have been referred by the 2nd respondent. It appears that the applicant did not contact the 2nd respondent before undergoing the treatment. There is no recommendation which is absolutely necessary from either CMS (respondent No. 2) or the CMD (respondent No. 3) on the emergency nature of the applicant's disability which warranted immediate surgery at a private hospital.
7. By way rejoinder, the applicant has stated that even if she had gone for surgery at Railway Hospital as a patient she was liable to make payment for the implants and the cost of the special equipments would itself have come to over lakh of rupees. She was made to understand that the Railway Hospital at Peramboor had a long waiting period for being slotted for surgery. As evidenced by the certificate of the private doctor she was in no condition to wait that long.
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8. The respondents have filed an additional reply statement rebutting the contention made in the rejoinder. It is not true that the patient is requird to pay for any facility at the Railway Hospital. The implants if required are invoiced and purchased by the Railway Medical Store for operations done at the hospital.
9. Ms. Shameena Salahudheen appeared on behalf of the applicant and Ms.Taniya Joy representing Sri. Millu Dandapani appeared on behalf of the respondents. Smt. Shameena Salahudheen pointed out that the facility of Hip Replacement was one of the admitted medical conditions for which reimbursement is allowed in the Indian Rai I ways. The private hospital doctor who had seen the patient had recommended that she had to undergo Total Hip Replacement surgery. There is no contention made on behalf of the respondents that this is a fake medical claim. Also according to the applicant she was facing a situation by which she was completely bed ridden. Ms. Tanya Joy representing the respondents pointed out that the respondents, Indian Railways, have a generous medical reimbursement policy as enshrined in the IRMM guidelines. However, in the case at hand there has been no recommendation by the respondent no. 2 or the respondent no. 3 who are the medical professionals authorized to make such recommendations. The applicant had not chosen to contact respondent no. 2 who is at Trivandrum itself before going to a private facility. So the view taken by respondent no. 4 that this claim cannot be admitted is just and fair. A copy of the judgment in O.A. 125/2016 was also produced, where medical expenses incurred by the applicant in that case were rejected on the ground that he could not establish that the treatment was availed in a state of emergency.
10. We have examined the case in detail and also perused pleadings entered by the two counsels in court. IRMM prescribes the following under 'treatment in emergency' .
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OA241/2016
"Where, in an emergency, a Railway employee or his dependant has to go for treatment (including corifinement) to a Government hospital or a recognised hospital or a dispensary run by a philanthropic organisa tion, without prior consultation with the Authorised Medical Officer, reimbursement of the expenses incurred, to the extent otherwise admissible, will be permitted as detailed below. In such a case, before reimbursement is admitted, it will be necessary to obtain, in addition to other documents prescribed, a certificate in the prescribed form as given in part C of certificate B ofAnnexure III to this Chapter from the Medical Superintendent of the hospital to the effect that the facilities provided were the minimum which were essential for the patient's treatment. "
The applicant in this case has obtained a certificate which is presented as Annexure AS:
"This is to certify that Mrs. Lekha 53 years IP No.2012/000982 was admitted in this hospital with severe pain ® hip and restricted movements. Since the patient was not in an ambulatory condition, we started the treatment on emergency basis. THR done on 20.2.2012 and discharged on 24.2.2012. This is for your kind information Dr. Kailas Viswanath Consultant Orthopedic Surgeon "
As can be seen, the certificate produced from the private facility is only to the effect that the patient has 'severe pain in the hip and restricted movements'. In other terms there is no mention about any emergency measure required. Further on an examination of the documents submitted as part of Annexure A2, it is seen that the endorsement made by the respondent No.2 is also only for ananging re-reimbursement 'as admissible' whereas the form clearly mentions the following:
"If the treatment was received at a hospital other than a government hospital necessary details and certificate of the authorized medical attendant that the requisite treatment was not available in any nearest railway or government hospital should be fitrnished. "
1I. We cannot come to the conclusion that the claim of the applicant has been rejected in an arbitrary action. Firstly she has gone to a private facility without first consulting the respondent no. 2 who is the head of the medical facility of the respondents posted at the same station. Afterwards she has also failed to obtain an essentiality certificate from the respondent No.2 (CMS) which is required as mentioned • • 7 OA 241/20 ((, in Annexure A3. Without these necessary documentation, the respondent no. 4 who is thu ''naneial head mandated with the powers to disburse the funds have correctly declined the reimbursement claim.
11.. Under these circumstances we find no reason to favourably consider the ":or1kntions raised in the O.A. O.A is rejected as finding no merit in the case. No costs.
(E.K.BLAT BHUS~N)
ADMINISTRATIVE MEMBEH.
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OA 241/2016
List of Annexures of applicant
Annexure A-1 True copy of the communication No.
V/MD.3AIRHE/PVT/38/2012 issued by the 2nd
respondent dated 08.01.2016
A true copy of the application for claiming Medical expenses submitted by the applicant dated 04.07.2012.
Annexure A-3 True copy of the letter No. MD/138/F/1/RHENol.61 dated 11.12.2014.
Annexure A-4 True copy of the communication No. MD/34/1/Pvt/3115/3115 dated 19.12.2014.
Annexure A-5 True copy of the certificate dated 10.02.205 issued by Dr. Kailas Viswananth.
Annexure A-6 True copy of the communication No. MD/34/1/Pvt/3115/3115 dated 12.05.2015 Annexure A-7 True copy of the representation submitted by the applicant to the 2nd respondent dated 16.05.2012.
Annexures of Respondents NIL