Central Administrative Tribunal - Jodhpur
Samuel Masih vs M/O Health And Family Welfare on 9 August, 2018
10012216090818290.txt CENTRAL ADMINISTRATIVE TRIBUNAL JODHPUR BENCH, JODHPUR Original Application No.290/00122/2016 RESERVED ON: 02.08.2018 Jodhpur, this the 9th August, 2018 CORAM Hon'ble Smt Hina P. Shah, Administrative Member Samuel Masih S/o Shri Lal Masih aged about 62 years r/o B-101 Prithviraj Nagar, Pali Raod, Jodhpur-342005. Last served in the office of Commander Works Engineer (Air Force) MES, Jodhpur as Technical Officer, superannuated on 31st March, 2012. (Now Advocate practicing in Rajasthan High Court, Jodhpur Bench.) ........Applicant By : Mr Samuel Masih, applicant in person. Versus 1. Secretary, Ministry of Health & Family Welfare, Government of India, Nirman Bhawan, New Delhi. 2. Additional Director, Government of India, Central Government Health Scheme, Kendriya Sadan Parisar 'B' Block, Ground Floor, Sector-10, Vidhyadhar Nagar, Jaipur-302039. 3. Goyal Hospital & Research Centre Pvt. Ltd., 961/3, Residency Road, Jodhpur-342003. ........Respondents By Advocate : Mr. K.S. Yadav. ORDER
The present Original Application has been filed u/s 19 of the Administrative Tribunals Act, 1985 seeking following reliefs:-
(i) That respondents be directed to reimburse all the medical claims w.e.f. August, 2015 for availing treatment and tests carried out on the applicant and his wife, and also the bills which have not been forwarded to respondent No. 2 for reimbursement as the first medical bill was refused to be reimbursed by the later.
(ii) The respondents may be also be directed to reimburse all the medical bill in future for treatment from Goyal Hospital & Research Centre Pvt. Ltd., 961/3, Residency Road, Jodhpur-342003 as long as the respondent No. 3 remains empanelled by the Ministry of Health & Family Welfare, Govt. of India.
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(iii) Any appropriate order or relief which the Hon'ble Tribunal deems fit in favour of the applicant.
(iv) Cost of Original Application may kindly be awarded to the applicant.
2. The facts of the case, in brief, are that the applicant is a Central Government Health Scheme beneficiary, holds a valid CGHS card and lives in Jodhpur. He availed treatment for diabetes in the month of August, 2015 from Goyal Hospital & Research Centre Pvt. Ltd (Hereinafter referred to as Goyal Hospital), Jodhpur, which is an empanelled hospital vide MoH&FW OM No. S.14021/37/2003-MS dated 16th June, 2011 and OM dated 02.09.2015 (Annex. A/2 & A/3). Thereafter, the applicant preferred medical bill to the Additional Director, CGHS (respondent No. 2) through CMO I/c of CGHS Wellness Centre No. 4, D-143 A/2, Basant Marg, Bani Park Jaipur for reimbursement but the medical bill of the applicant was returned by the respondent No. 2 vide letter dated 28.09.2015 (Annex. A/5) stating that medicines purchased in OPD are not reimbursable and only inpatient treatment and post operative follow up treatment are allowed. Vide letter dated 03.10.2015 (Annex. A/6), the applicant again submitted his medical claim to respondent No. 2 for re-considering the same for reimbursement in light of MoH&FW OM dated S.14021/37/2003-MS dated 16.06.2011 but the same was rejected vide letter dated 09.10.2015 on the ground that claim does not pertain to emergency treatment, as well as the inpatient treatment and hence, the same not in order for reimbursement. Aggrieved of rejection of his medical claim for OPD treatment in Goyal Hospital, Jodhpur, the applicant has preferred the present OA.
3. In reply, the respondents have stated that in case of non-emergency treatment from the hospital approved under CSMA Rules and ECHS Scheme, it is necessary to obtain prior approval from CMO In-charge of concerned Wellness Centre. As the applicant's CGHS Card is registered with CGHS Wellness Centre No. 4, Jaipur, he was required to take prior approval before taking treatment from a recognized hospital. The applicant did not take approval; therefore, he is not entitled for reimbursement of his medical claim. It has been further averred in reply that reimbursement of cost of medicines is barred by OM dated 24.07.1995 as the same is required to be issued from concerned CGHS Dispensary. As per OM dated 27.04.2011, in-patient treatment and post operative follow up treatment is allowed. Further, as per OM dated 02.11.2012 which deals with pensioners living in non-CGHS area, it is provided that the pensioners who have settled in non-CGHS area have an option to join Health Care Scheme by getting themselves enrolled with CGHS and can avail OPD as well as IPD medical facilities from any CGHS Dispensary as well as empanelled hospitals convenient to them by following procedure laid Page 2 10012216090818290.txt down for this purpose. Only in case of emergency, such incumbents are allowed to take treatment from any recognized hospital which is reimbursable to the extent of CGHS approved rates. Likewise, the facility of IPD medical treatment and post operative follow up treatment from the hospitals in non-CGHS areas recognized under CSMA Rules and ECHS can be taken for which they required to submit the medical claim to Additional/Joint Director of CGHS or the CMO In charge of CGHS Wellness Centre where they are registered. For medical treatment one is required to follow the procedure laid odwn under OM dated 27.04.2011. In this case, the applicant's claim is neither pertaining to emergency treatment nor pertaining to in-patient treatment. Hence, the relief claimed by the applicant is barred by operation of rules and OMs on the subject and OA is liable to be dismissed.
4. In rejoinder, the applicant reiterated that bills for treatment in OPD at Goyal Hospital, Jodhpur, which is an empanelled hospital is reimbursable in terms of MoH&FW OM dated 02.11.2012 and 02.09.2015.
5. Heard both the parties.
6. The applicant in rejoinder, relied upon upon para 11 & 12 of MoH&FW OM dated 16.06.2011 (Annex. A/2) & 02.09.2015 (Annex. A/3). As per OM dated 02.09.2015, the applicant submitted that the pensioner CGHS beneficiaries and their dependents & eligible family members are entitled to avail medical facilities in Goyal Hospital, Jodhpur. The pensioner CGHS beneficiaries would make payment for the medical treatment and submit the claim to Addl. Director, CGHS through CMO i/c of the CGHS Wellness Centre, where the CGHS Card of the beneficiary is registered. Accordingly, he submitted the bill to respondent No. 2 for reimbursement but the same was returned twice vide letter dated 28.09.2015 (Annex. A/5) and 09.10.2015 (Annex. A/7). He further contended that as per OM dated 02.11.2012 (Annex. R/3) of MoH&FW, GOI, pensioners who have been settled in non-CGHS areas can avail both, OPD as well as IPD medical facilities. Furthermore, it is not feasible for a pensioner to avail treatment in Jodhpur and get his medicines issued from CGHS Wellness Centre at Jaipur for his treatment. The applicant thus contended that returning of his medical claim by respondent No. 2 is violative of Article 14, 16 and 21 of the Constitution of India and prayed that respondent No. 2 may be directed to reimburse his medical claim returned twice and all future medical bills for OPD treatment availed in Goyal Hospital, Jodhpur. In support of his arguments, he relied upon the following judgments :
(i) Himachal Pradesh High Court Judgment in Sudarshan Kumar Sharma Versus Union of India through Secretary-Home, New Delhi reported in 2013(1) SCT 817.
(ii) Himachal Pradesh High Court Judgment in Union of India and Page 3 10012216090818290.txt another Versus Shankar Lal Sharma reported in 2016(1) SCT 414.
(iii) CAT Jodhpur Bench Judgment in Smt Kamlesh Versus Union of India & Ors. (OA No. 290/00216/2016) dated 08.03.2017.
(iv) Apex Court Judgment in Surjit Singh Versus State of Punjab & Ors, 1996 (2) SCT 234.
(v) Apex Court Judgment in State of Punjab & Ors Versus Mohinder Singh Chawla & Ors, 1997(1) SCT 716
7. Per contra, learned counsel for the respondents contended that the applicant opted for CGHS Card at his residential address of Jodhpur with CGHS Wellness Centre No. 4, Jaipur. The medicines prescribed during OPD treatment are provided by the CGHS Wellness Centre itself and hence, any medicine purchased during OPD treatment from outside is not reimbursable. For OPD treatment, the applicant was required to take prior permission of respondent No. 2, which is required as per OM dated 27.04.2011. Hence, the medical bill of the applicant was returned as the same was neither pertaining to the 'emergency' nor had he taken in-patient treatment. Thus, the action of the respondents in returning the medical bill as being non-reimbursable is proper, justified and legal.
8. I have considered the rival contentions and perused the record as well as judgment cited by the applicant. I find that the primary issue, which needs to be decided, in this OA is whether OPD treatment by a pensioner CGHS beneficiary without permission of the competent authority is reimbursable under the various circulars relied upon by the applicant. The secondary issue is whether, in the facts and circumstances of the present case, this Tribunal is justified in issuing direction to the respondents to reimburse all future OPD treatment bill of the applicant from M/s Goyal Hospital, Jodhpur?
9. The applicant relied upon the para 10 of OM dated 02.09.2015 (Annex. A/3) whereby the Ministry of Health & Family Welfare, Govt. of India recognized Goyal Hospital & Research Centre (P) Ltd., Jodhpur for treatment of Central Government employees, which reads as under :
10. The hospital shall also provide treatment/investigation facilities to the CGHS beneficiaries and their eligible dependent family members at its own rates or rates approved under CS (MA) Rules, whichever is lower. The hospital shall provide treatment to pensioner CGHS beneficiaries after authentication through verification of valid CGHS cards.
However, para 8 and 9 of the aforesaid OM reads as under:
8. In case of non-emergencies, the beneficiary shall have the option of availing specific treatment/investigation from any of the empanelled hospitals of his/her choice (provided the hospital is recognized for that treatment procedure/test), after the specific treatment/investigation has been advised by Authorized Medical Page 4 10012216090818290.txt Attendant and on production of valid ID card and permission letter from his/her concerned Ministry/Department.
9. The hospital shall honour permission letter issued by Competent Authority and provide treatment/investigation facilities as specified in the permission letter.
Though the OM dated 02.09.2015 is an extension of recognition of Goyal Hospital, Jodhpur for treatment of Central Government employee but conjoint reading of the same makes it clear that in case of non-emergency treatment, permission of the competent authority is required for serving as well as retired employees. The applicant relying upon the MoH&FW, GOI OM dated 02.11.2012 submitted that pensioners residing in non-CGHS areas can avail both, OPD as well as IPD medical facilities from any empanelled private hospitals and diagnostic centres convenient to him. The relevant part of the OM dated 02.11.2012 reads as under :
(ii) Pensioners living in Non-CGHS Areas : The pensioners who have settled in non-CGHS areas have also been provided an option to join this healthcare Scheme by getting themselves enrolled with CGHS after following the due procedure. They can avail both, OPD as well as IPD medical facilities from any CGHS dispensary and empanelled private hospitals and diagnostic centres convenient to him by following the laid down procedures. They can also get the medical treatment from any hospital in case of emergency, and claim reimbursement subsequently from CGHS which will be allowed as per CGHS approved rates. They have also been granted the facility to obtain in-patient medical treatment and post-operative follow up treatment from the hospitals in non-CGHS areas, recognised under CS (MA) rules, 1944, ECHS and submit the medical reimbursement claim to the Additional Direction/Joint Director of CGHS or the CMO in charge of CGHS Wellness Centre, where he is registered. For obtaining medical treatment and claiming reimbursement they are to follow the procedures laid down in this Ministry's OM No. S. 11011//99-CGHS (P) dated 27th April, 2011 (copy enclosed).
The last lines of the aforesaid OM stipulates that for obtaining medical treatment and claiming reimbursement procedure laid down in OM dated 27.04.2011 is required to be followed. The relevant para a(ii) of the aforesaid OM laid down following procedure :
a (ii) In case of non-emergency treatment from hospitals approved under Central Services (Medical Attendance) Rules, 1944 and Ex-Servicemen Contributory Health Scheme (ECHS), it is necessary to obtain prior approval from CMO in charge of concerned Wellness Centre where the CGHS card is registered.
Plain reading of the aforequoted para of OM dated 27.04.2011 makes it clear that prior approval of CMO in charge of concerned Wellness Centre, where CGHS card is registered, is necessary in non-emergency treatment from recognized hospitals approved under CS (MA) Rules, Page 5 10012216090818290.txt 1944. It is an admitted position of the applicant that his case is of non-emergency medical treatment in OPD and Goyal Hospital & Research Centre Pvt. Ltd, Jodhpur is empanelled under CS (MA) Rules, 1944. Thus, as per procedure laid down by the MoH&FW, GOI, it is clear that the applicant was required to obtain prior approval of the competent authority for his treatment in Goyal Hospital & Research Centre Pvt. Ltd, Jodhpur. He, however, did not do so and underwent OPD treatment in Goyal Hospital & Research Centre, Jodhpur in a non-emergent condition. Thereafter, he preferred medical reimbursement claim. Hence, the respondents were justified in returning/rejecting his claim.
10. It was contended by the applicant that had he applied for permission for OPD treatment in Goyal Hospital & Research Centre, Jodhpur from CMO in charge of CGHS Wellness Centre No. 4, Bani Park, Jaipur where his CGHS card is registered and granted the said permission, how come it would have been possible for him to collect medicines from Jaipur as medicines are provided by CGHS Wellness Centres concerned and are not reimbursable if medicines are available with them. He thus prayed that the respondents be directed to reimburse all future medical bill for his treatment from Goyal Hospital & Research Centre Pvt. Ltd., Jodhpur so long as it remains empanelled by the MoH&FW, GoI. Relying upon the judgments cited by him, applicant submitted that the Hon'ble Courts in catena of judgments held that necessity of prior permission should not come in the way of a genuine claim. I have gone through all the judgments relied upon by the applicant. It is common fact in all these cases that there was 'emergency' or treatment was of serious illness and the patient took treatment in IPD, not in OPD. Hence, the fact and issue involved in the present case is completely different from the judgments cited by the applicant and the same are not applicable in the present case. The issue that medicines purchased from outside in OPD treatment are not reimbursable as it is provided by CGHS is concerned, I find that respondents have categorically stated in their reply that the applicant applied for CGHS Card to be issued at his present address at Jodhpur registered with CGHS Wellness Centre No. 4, Bani Park, Jaipur instead of to be covered under CS(MA) Rules, 1944. It has been submitted on behalf of the respondents that it is not the case of the applicant that he did not know that Jodhpur falls in non-CGHS covered area while applying for the CGHS Card. It was his choice to opt for CGHS Scheme over CS (MA) Rules, 1944 otherwise he would have been given Fixed Medical Allowance in lieu of OPD treatment and covered under CS (MA) Rules, 1944 for reimbursement for treatment in the empanelled hospital in IPD. In my considered view, the Scheme is equal for all employees and Government is only obligated to reimburse the claim as per procedure contemplated in the Scheme. Applicant once opted for a particular Scheme as per his choice, should be reimbursed claim as Page 6 10012216090818290.txt per procedure contemplated in the Scheme itself. Moreover, it is not the case of the applicant that after according permission by the respondents, he underwent treatment and was not reimbursed the cost. Hence, it is abstract or hypothetical question and premature at this stage to examine the same.
11. Applicant also sought direction on the respondents to reimburse all the medical bill in future for treatment taken from M/s Goyal Hospital & Research Centre Pvt. Ltd., Jodhpur so long as it is empanelled by the MoH&FW, GOI. From the preceding paragraph, it is clear that in case of emergency, medical treatment in empanelled hospital is reimbursable. However, in case of non-emergency, the beneficiary required to take permission as per the policy evolved from time to time. It is not the case of the applicant that he has been denied the permission to obtain OPD treatment by the respondents or he challenged the Scheme in vogue. Therefore, as both the issues mentioned at para 8 above are in negative, no relief can be granted on the apprehensions as it is respondents' obligation to consider and grant or deny any such permission as contemplated in the Policy/Scheme itself.
12. In view of the discussions hereinabove made, the applicant is not entitled for any relief. Accordingly, OA is dismissed with no order as to costs.
[Hina P. Shah] Judicial Member Ss/-
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