Central Administrative Tribunal - Madras
M/O Science And Technology vs Neela Laskhminarayanan on 3 April, 2023
I OA 257/2020 é " CENTRAL ADMINISTRATIVE TRIBUNAL CHENNAI BENCH MA/310/00280/2022 in & OA/310/00257/2020 Dated Monday the 3" day of Apri! Two Thousand Twenty Three CORAM: HON'BLE MS. LATA BASWARAJ PATNE, Member (F) Mrs. Neela Lakshminarayanan, W/o. Late G. Lakshminarayanan, - Retd Scientist, . , . (CSIR-CIMFR, Dhanbad), Flat No. 3, 1" Floor, Mahalakshmi Flats, a 26, Tank Bund Road, Nungambakkam, Chennai 600034. ... Applicant By Advocate M/s. D, Solomon Pandian Vs 1 Union of India, - rep by the Secretary, Government of India, Ministry of Science & Technology, Department of Science & Technology, | ' * Technology Bhavan, New Mehrauli Road, New Delhi 110016. 2.The Director General & Secretary, Council of Scientific and Industrial Research, Anusandhan Bhawan, 2, Rafi Marg, New Delhi 110001. 3.The Director, Council of Scientific and Industrial Research, Sardar Patel Road, Adyar, Chennai 600020, 4, Additional Director, , Office of the Additional Director, Central Govt Health Scheme, E2C, Rajaji Bhavan, Chennnai 600090. -..éRespondents By Advocates Mr. M. Kishore Kumar, SPC (R2, R3) Mr. J. Vasu (R4) E32 2 OA 2357/2020 ORAL ORDER
(Pronounced by Hon'ble Ms. Lata Baswaraj Patne, Member(J)) By this OA, the applicant has prayed the following reliefs :-
a "To recall the 3" respondent impugned orders No. 7(2) EDT 2019 dated 27 Jan 2020 and set aside the same and prays for the following relief:
i. The Hon'ble Tribunal may be pleased to direct the respondents to sanction the balance amount of the medical claim of Rs. 16,11,740/-;
ii. It is therefore prayed that this Hon'ble Tribunal may be pleased to allow my petition as prayed for and thus render justice."
we The brief facts of the case in nutshell are as under :~ The applicant's husband late G. Lakshminarayanan joined CSIR as Junior Scientific Assistant on 23.09.1965 and came'to be retired as Scientist (El) from Central Institute of Mining and Fuel Research (CSIR-CIMFR), Dhanbad on 30.09.2003 after serving for 38 years and 8 days. The applicant contended that her deceased husband under deteriorated medical condition was admitted at Apollo Hospitals on 14.12.2017 and underwent Transcatheter Aortic Valve _ Replacement (TAVR). The applicant's deceased husband had submitted his claim for medical reimbursement of total claim of Rs. 17,88,159/- on 26.12.2017, However, an amount of Rs. 1,76-419/- has been sanctioned by the authorities on 14.03.2018. The balance medical reimbursement claim of Rs.
16,11,740/- has not been sanctioned. Even after the death of her husband, the applicant had requested to release the said balance amount, However, the respondents refused the applicant's claim by restricting the claim in accordance
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é 3 OA 257/2020 with the CGHS rates as well as with the approval of the competent authority. Being aggrieved, the applicant has approached this Tribunal praying for aforesaid relief.
3.1 After notice, the respondents have appeared through their counsel and filed their detailed reply and contended that the CSIR-CLRI employees, | pensioners and their dependents or pensioners of other laboratories/institutes of CSIR availing medical facility from CERI are not covered by Central Government Health Scheme. They avail medical facilities from the CLRI dispensary and are covered by the provisions of Central Services (Medical Attendance) Rules viz., CSMA Rules. Under the provisions of CSMA rules, the cost of medica] expenditure is reimbursed limited to CGHS rates. li. It is submitted that the. reimbursement of expenditure on medical treatment is restricted as per CGHS rates, However, CGHS has not prescribed any rate for TAVR. As per extant CGHS instructions, in case CGHS has not prescribed anv rate, the reimbursement may be allowed as per the AIIMS rate. However, even ATIMS has not prescribed any rate for the TAVR. ji. It is submitted that late Shri. G. Lakshmi Narayanan, pensioner had submitted a medical claim dated 22.12.2017 for Rs. 17,88,159/- incurred ' towards inpatient medical treatment for TAVR and pacemaker surgery at Apollo
- Hospitals, Chennai from 14,12,2017 to 20.12,2017 and requested to consider his medica] treatment as an emergency. Apollo Hospital is a CLRI approved hospital and hence the medical expenditure is reimbursed as per CGHS rates as 4 0A 257/2020 per provisions of CSMA rules. Since the medical treatment of TAVR and
- pacemaker surgery was obtained 'by late G. Lakshmi Narayanan without referral letter of the Medical Officer, CLRI, the medical claim of Shri. G. Lakshmi Narayanan was referred to the Medical Officer, CLRI Dispensary for comments/certification as to whether the treatment could be treated as an emergency case.
iv. The Medical Officer, CLRI after examining the matter, opined that the case could not be considered as an emergency because these are planned procedure and his claim could not be admitted for reimbursement.
v. Late G. Lakshmi Narayanan vide his letter dt. 22.01.2018 again requested CLRI to reconsider his claim for reimbursement. His request was placed before the Health Services Committee, CLRI, Chennai. The Committee recommended to admit the claim to the extent admissible for hospitalization as per CGHS rates.
vi. It is submitted that the matter-concerning the issue of reimbursement of TAVR was referred to CSIR on 06.06.2019. In response, CSIR vide its letter dt. 22.07.2019 and 17.09.2019 informed to prowess the case after discussing with CMO, CLRI on medical claims of late Shri. G. Lakshmi Narayanan towards TAVR surgery and Pacemaker, cost of implant and it may be regulated on the basis of clause (h) of MoHFW OM No. 2-2/2014/CGHS/HQ/PPT/CGHS(P) dated 25.08.2014. Clause (h) of the OM dt. 25.08.2014 provides that in cases . Where any unlisted implant/device is installed, reimbursement shall be limited to 5 OA 257/2020 the CGHS rate of nearest similar implant/device. Addl. Director of the city/zone shall take a decision based on justification in such cases in consultation with experts in the field, if necessary.
vii. In respect of respondent no. 4, it is contended that the applicant claims that her late husband is a CGHS beneficiary and availing medical facility through respondent no. 3, CSIR-CLRI, Chennai. It is submitted that as per extant CGHS rules, the employees and pensioners of autonomous bodies are not automatically covered under the scheme unless approved by Ministry of Health and Family Welfare. As such the employees and pensioners of CSIR-CLRI, Chennai are not covered by CGHS, Chennai at present. The Medical Reimbursement Claim in respect of treatment undergone by her late husband at ' Apollo Hospitals, Chennai during the period from 14.12.2017 to 20.12.2017 was decided by the Health Services Committee of 'CSIR-CLRI, Chennai (respondent no, 3) as stated in its letter dt, 06.06.2019 and not by the respondent no. 4 ie., CGHS, Chennai.
vill. ft is submitted that as per MoH&FW OM No. 215025/51/2018/DIR/CGHS/EHS dated 06.06.2018 (A-D), the High Powered Committee will consider the representation only in respect of those beneficiaries having a valid CGHS card and seeking full reimbursement. As the applicant's husband was riot holding CGHS card, this OM would not be applicable in this case.
ix, The medical reimbursement claim in respect of treatment undergone by 6 OA 2537/2020 her late husband at Apollo Hospitals, Chennai during the period from 14.12.2017 to 20.12.2017 was decided by the Health Services Committee of CSIR-CLRI, Chennai (respondent no. 3 ) ag 'stated in its letter dt. 06.06.2019 and not by the respondent no. 4, CGHS, Chennai. Respondent no. 3 referred the matter to respondent no. 4, CGHS, Chennai vide its letter dt. 05.08.2019 to clarify the amount reimbursable in respect of device implant. Respondent no. 4 vide its letter dt. 13.09.2019 advised the respondent no. 3 to take up the matter with DDG Medical, DGHS, Ministry of Health and Family Welfare, New Delhi.
The Directorate General of Health Services (Medical General Section), New Delhi vide its letter dt. 02.12.2019 informed lie respondent no. 3 that "CS (MA) Rules, 1944 are not applicable to pensioners. Hence, this case cannot be considered further. However, case may be settled by the concerned office/organization, in consultation with the concerned Administrative Ministry/Départment. If a patient is a CGHS pensioner, the case may be taken
- up with Director, CGHS, Delhi": Accordingly, the respondents have prayed for dismissal of the OA. ,
4. The applicant has filed rejoinder and additional documents in respect of discharge summary from Hospital and medical bills.
5. Heard learned counsel for both sides, perused the pleadings and materials placed on record.
6. Learned counsel for applicant relies upon the judgment of the Hon'ble * Supreme Court in WP (C) No. 694 of 2015, dt. 13.04.2018 in the case of Shiva é . .
7 OA 257/2020Kant Jha Vs. Union of India and order of the Principal Bench of this Tribunal dt, 23.08.2018 in OA No. 2041/2017 in the case of Shri. Raj Kumar Sharma Vs. East Delhi Municipal Corporation and anr,
7. It is to be noted that now that respondents no. 1 to 3 have brought to the " notice of this Tribunal various eters issued to the applicant as well as CGHS authority since the year 2018 onwards. It has.also brought to the notice of this Tribunal the letter dt. 30.09.2019 addressed to the DDG Medical, Directorate General of Health Services. The respondents have not disputed that the applicant's deceased husband has taken treatment in the Apollo Hospital in emergency. Learned counsel for respondents no. 1 to 3 has only raised his objection in respect that when Indiag manufactured valve were available why the applicant had sought for imported TAVR. He also contended that since the applicant is unable to give the lexplanation for the same, if at all this Court is issuing directions, the respondent authority will consider the claim of the applicant in accordance with the rates which are payable in respect of the Indian manufactured valve. The submissions made by the respondent no. 4 in the reply statement is not at all acceptable and hence it is rejected.
a ~~ i , 8. The respondents are direbted té place the matter of the applicant before
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-* the committee which is constituted according to the direction of the Hon'ble Supreme Court in the case of | Shiva Kant Jha (supra). The claim which is rejected in respect of imported ITAVR that can be restricted and reimbursed by the respondents at the rate of the Indian manufactured unit. However, the other 3 OA 257/2020 . claims may be reimbursed. The decision may be taken by the committee within one month from the date of receipt of a copy of this order. Accordingly, the reimbursement may be made thereafter within a period of two weeks after the decision of the committee. As such the whole exercise may be completed by the respondents within a consolidated period ofisix weeks.
9, OAs disposed of. Connected MA 280/2022 stands disposed of. No order as to costs.
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