Central Administrative Tribunal - Ernakulam
Vinoop K vs M/O Defence on 13 February, 2019
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CENTRAL ADMINISTRATIVE TRIBUNAL,
ERNAKULAM BENCH
Original Application No. 180/00940/2017
Wednesday, this the 13th day of February, 2019
CORAM:
Hon'ble Mr. Ashish Kalia, Judicial Member
K. Vinoop, S/o. Vijayakumar,
Aged 25 years, Machinist (Skilled) Factory,
T. No. 1490, Naval Armament Depot,
Aluva - 683563. ..... Applicant
(By Advocate : Mrs. N. Shobha)
Versus
1. Union of India, represented by its Secretary,
Ministry of Defence, New Delhi - 110 001.
2. The Chief of Naval Staff, Naval Head Quarters,
New Delhi - 110 011.
3. The Flag Officer Commanding in Chief, Southern Naval Command,
Naval Base, Kochi - 682 004.
4. The Chief General Manager, NAD, Aluva - 683563.
5. The Senior Accounts Officer, Area Accounts Office (Navy),
Medical Section, Kochi - 682 015. ..... Respondents
(By Advocate : Mrs. P.K. Latha, ACGSC)
This application having been heard on 13.02.2019 the Tribunal on the
same day delivered the following:
O R D E R(Oral)
Hon'ble Mr. Ashish Kalia, Judicial Member -
The applicant claimed relief as under:
"(i) Call for the entire records leading to Annexure A7 and A8 and set aside the same.2
(ii) Declare that the applicant is entitled to get the full amount of medical reimbursement as mentioned in Annexure A5 discharge bill issued by the Lakeshore Hospital, Kochi and also entitled to get future medical expense of an amount of Rs. 10,365/-
(iii) Pass such other orders deemed fit in the facts and circumstances of the case.
(iv) Grant the applicant the costs of the Original Application."
2. The present Original Application is filed for getting full amount of medical reimbursement as per Annexure A5 discharge bill issued by the Lakeshore Hospital and also entitled to get future medical expenses of an amount of Rs. 10,365/-.
3. The brief facts of the case are that the while working on 11.4.2017 felt severe pain on his right shoulder and he was sent to medical inspection room, Aluva and the staff nurse after medical checkup and giving first aid referred the applicant to the Medical College, Kalamassery, Ernakulam and the applicant was taken by Ambulance on 11.4.2017 itself. The medical officer treated him at Kalamassery Medical College till 2.5.2017 and on discharge summary it was advised as per Annexure A1 to admit the applicant to Lakeshore Hospital and applicant was further advised to take rest till 31.7.2017. The applicant thereafter got admitted himself to Lakeshore Hospital on 3.5.2017. It is submitted by the applicant that he had deposited Rs. 1,25,000/- as advance amount and the receipt is produced as Annexure A4. The Lakeshore Hospital on 5.5.2017 issued medical bill of Rs. 1,48,124.22 being the gross amount incurred by the applicant as medical expenses. The balance amount of Rs. 22,319/- was paid to the hospital by 3 Annexure A5 & A6 receipts. Respondent No. 4 has issued letter dated 25 th October, 2017 stating therein that the claim of Rs. 46,072/- is passed and the balance amount of Rs. 78,928/- was ordered to be recovered. Feeling aggrieved the applicant has approached this Tribunal.
4. Notices were issued to the respondents. They entered appearance through Mrs. P.K. Latha, ACGSC who filed a reply statement contending that an amount of Rs. 78,928/- has been intimated as recovery from the applicant against the advance amount of Rs. 1,25,000/- as the reimbursement claim was audited and passed for Rs. 46,072 as per the prevailing CGHS, 2014 package rates (SL-1112+cost of implant). The medical reimbursement of the applicant can be reimbursed subject to the rate notified by Government of India if the patent had taken treatment from private hospital which is a recognized hospital for treatment of central government employees and his family members subject to referral either from a government hospital or central government empaneled hospital at Ernakulam. In the OA nothing is produced to show that it is a case of referral from a government hospital or from a central government empaneled private hospital at Ernakulam. Further the applicant in the OA stated that he had submitted a bill for Rs. 10,365 for physiotherapy and the bill has not been reimbursed. It is submitted that the post discharge treatment (physiotherapy) by the applicant was also taken from the same hospital and was not subject to referral. Hence, the claim of the applicant was returned to him in order to comply with the instructions from the audit authorities. The respondents submit that in Ernakulam, the hospitals 4 empaneled by the central Government are Indira Gandhi Hospital, Laksmi Hospital, Gautham Hospital. The applicant was required to avail treatment from any one of these hospitals. Lakeshore is a private hospital empaneled by the central government subject to referral. In the instant case the applicant on discharge from medical college, Ernakulam has taken treatment from Lakeshore hospital without referral which is against the rules framed under CSMA rules. Lakeshore Hospital is a private hospital empaneled by the Central Government subject to referral. Respondents allowed the maximum package rate of Rs. 46,072/- to the applicant post audit. The benefits under CGHS involves reimbursement of cost of treatment admissible at package rates prescribed. The amount spent on treatment when exceeds entitlement or the advance taken the same will be subject to recovery and therefore, the recovery is in order. The adjustment claim submitted by the applicant along with discharge summary shows the final diagnosis as Bony Bank Arts Lesion Right Shoulder and for this procedure the CGHS package rate is Rs. 13,200/-. The individual was rightfully paid the cost for carrying out procedure for inserting implants plus the cost of implants. The cost includes lumpsum cost of inpatient treatment including registration charges, admission charges, operation charges, doctor's fee, ICU charges, cost of medicines, physiotherapy charges, nursing charges etc. The individual is entitled to take treatment subject to referral and rates will however be restricted as per CGHS rates. Respondents pray for dismissing the OA.
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5. A rejoinder has been filed by the applicant relying upon the judgment of the Hon'ble High Court of Kerala in OP (CAT) No. 167 of 2017 - The Central Provident Fund Commissioner & Ors. v. N. Satheesan & Anr., dated 19.1.2018.
6. Heard the learned counsel appearing for the parties and perused the records.
7. The short point raised is whether the applicant is entitled for the medical reimbursement when he was referred by the medical college hospital to a private hospital or not?
8. Learned counsel for the applicant has drawn my attention to Annexure A1/2 wherein the applicant was referred to Lakeshore hospital and was treated there and the bills were submitted by him which he has paid. Respondents have considered the case of the applicant as non-referral case. As per the respondents this has not been referred by any Government hospital but their contention is not found in their favour by this Tribunal in terms of Annexures A1 and A2. The Government medical college has referred the applicant to Lakeshore Hospital thinking that Lakeshore Hospital is having the facility which is required for the treatment of the applicant.
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9. Therefore, this Tribunal is of the considered view that in terms of the order passed by the Hon'ble High Court of Kerala in the matter of N. Satheesan's case (supra) the present Original Application deserves to be allowed. Accordingly, the Original Application is allowed and this Tribunal declares that the applicant is entitled to get the medical bills reimbursed as applicable to the referral hospital. The respondents are directed to comply with the above order within sixty day of receipt of a copy of this order. No order as to costs.
(ASHISH KALIA) JUDICIAL MEMBER "SA"
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Original Application No. 180/00940/2017 APPLICANT'S ANNEXURES Annexure A1 - True copy of the report dated 11.4.2017 of the Staff Nurse of the MI Room, Aluva.
Annexure A2 - True copy of the discharge summary dated 5.5.2017 of the Lakeshore Hospital, Kochi.
Annexure A3 - True copy of the summary report 11.4.2017 issued by the Government Medical College, Ernakulam, Kochi. Annexure A4 - True copy of the receipt dated 5.5.2017 issued byt eh Lakeshore Hospital, Ernakulam, Kochi.
Annexure A5 - True copy of the discharge bill dated 5.5.2017 issued by the Lakeshore Hospital, Ernakulam, Kochi.
Annexure A6 - True copy of the receipt dated 5.5.2017 issued by the Lakeshore Hospital, Ernakulam, Kochi.
Annexure A7 - True copy of the letter dated 25.10.2017 of the 5th respondent to the 4th respondent.
Annexure A8 - True copy of the letter dated 8.11.2017 of the 4th respondent to the applicant.
Annexure A9 - True copy of the judgment dated 19.1.2018 in OP (CAT) No. 167/17 on the file of the Hon'ble High Court of Kerala.
RESPONDENTS' ANNEXURES Annexure R1 - Relevant page of CGHS Scheme with letter dated 29.1.2018 from audit.
Annexure R2 - Rules of reimbursement of specialised tests and treatments - CGHS.
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