Central Administrative Tribunal - Delhi
Tara Chand vs M/O Railways on 17 May, 2023
1
O.A. No. 182/2021
Central Administrative Tribunal
Principal Bench: New Delhi
O.A. No. 182/2021
Reserved on: 16.03.2022
Pronounced on: 17.05.2023
Hon'ble Mr. Manish Garg, Member (J)
Tara Chand, aged 62 years
S/o Lt. Sh. Hari Chand,
Retired Head Manager Canteen,
Northern Railway, General Store, Shakurbasti,
New Delhi.
R/o H-2 Block, H. No. 102, Sultanpuri,
Delhi - 86
...Applicant
(By Advocates: Mr. Yogesh Sharma)
Versus
1. Union of India through the General Manager,
Northern Railway, Baroda House, New Delhi.
2. Principal Chief Medical Director,
Northern Railway Headquarter,
Baroda House, New Delhi.
3. Chief Medical Superintendent,
Northern Railway, Divisional Hospital,
Delhi.
...Respondents
(By Advocates: Mr. Ranjan Tyagi with Mr. Anchal Baliyan)
2
O.A. No. 182/2021
ORDER
1. BRIEF FACTS :-
The applicant, who is a Railway employee, has retired from the post of Head Manager Canteen on 31.12.2018, while working in General Store Depot, Northern Railway, Shakurbasti Railway Station in Delhi Division and therefore, he is entitled for all the medical facilities, which are applicable and available for the Railway employees and their families for treatment after retirement, since the retired employee adopted the Retired Employees Liberalized Health Scheme (RELHS) of the Railway. On 16.01.2019, the wife of the applicant became seriously ill due to breathing problem, i.e., Lower Respiratory Tract Infection with Urinary Tract Infection and he took her to a nearby hospital, i.e., Maharaja Agrasen Hospital, where she was admitted in Intensive Care Unit in emergency situation and ultimately, discharged on 30.1.2019. On 08.02.2019, when applicant's wife was taken for follow-up as per advise of the Hospital, she was again admitted considering her medical conditions due to Lower Respiratory Tract with Urinary Tract Infection and was discharged on 13.02.2019.3 O.A. No. 182/2021
1.2 That Maharaja Agrasen Hospital charged total of amount of Rs.2,32,204/- (First period) and Rs. 60,143/-
(Second period) from the applicant for treatment. It is submitted that he deposited the said amount at the time of discharge of her wife from the said hospital. The applicant submitted his claim for medical reimbursement amounting to Rs.2,32,204/- (First period) and Rs. 60,143/- (Second period) along with hospital bills and all other documents to the respondents through proper channel, i.e., through Addl. Chief Medical officer, Northern Railway, Shakurbasti. The Addl. Chief Medical Officer, Shakurbasti after considering all the documents on records and medical situation of wife of the applicant, certified that this is a case of emergency and thus, the treatment and admission of her in emergency condition in private hospital is considered justified vide certificate dated 13.07.2019 and recommended the case of the applicant for reimbursement of medical claim. However, the Addl. Chief Medical Superintendent, Delhi vide impugned orders dated 04.10.2019 (colly.) (Annex. A/2) rejected the claim of the applicant by passing separate orders for each period. In the impugned orders, the sole reason has been given that the "emergency treatment is not justified", whereas the concerned authority has not disputed the sickness of applicant's wife as also the treatment, and, 4 O.A. No. 182/2021 therefore, there is no reason and justification to say that emergency treatment is not justified. Against the orders dated 04.10.2019, the applicant submitted his appeal to the Chief Medical Director, Northern Railway, New Delhi, vide dated 11.11.2019 followed by further representation dated 04.03.2020, requesting the appellate authority to consider his claim. The respondent No.2 vide impugned order dated 07.01.2021 (colly.) (Annex.A/1) rejected the appeal of the applicant by passing separate order for each period only on the ground that treatment taken by the patient was not emergent in nature, which is totally illegal and arbitrary order, as the concerned hospital as well as Addl. Chief Medical Officer of the Railway justified the emergency while taking the treatment. Accordingly, the whole action of the respondents in not considering and non granting the claim of the applicant for medical reimbursement in respect of the treatment of his wife is totally illegal, arbitrary and against the Rules. Hence, this O.A. 1.3 Based on above, the applicant has sought following relief(s):-
"(i) That the Hon'ble Tribunal may graciously be pleased to pass an order of quashing the impugned order dated 7.1.21 (Annex. A/1) and orders dated 4.10.2019 (Annex. A/2) declaring to the effect that the same is illegal, arbitrary and against the rules and consequently pass an order directing the 5 O.A. No. 182/2021 respondents to full reimburse the medical claim of the applicant of Rs.2,32,204/- (First period) and Rs.
60,143/- (Second period) in respect of treatment of his wife in Maharaj Agresan Hospital, New with interest.
(ii) Any other relief which the Hon'ble Tribunal deem fit and proper may also be granted to the applicants along with the costs of litigation." 1.4 In support of his contention, the learned counsel for applicant submitted as under:-
(i) The learned counsel for the applicant submitted that para No.6.48 (2) of Indian Railway Medical Manual (IRMM), there is a provision for reimbursement of the claims where the treatment has been taken in private / non-recognized hospital in emergent circumstances and, therefore, the case of the applicant should be considered for reimbursement of medical claim. The sickness of the applicant's wife and her critical position is also not disputed in the impugned order and the provision for reimbursement of the medical claim while taking the treatment in private / non-
recognized hospital during emergency is also available and, therefore, in such circumstances, rejecting the claim of the applicant totally on baseless grounds, is illegal and arbitrary in the eyes of law. The respondents considered the appeal of the applicant 6 O.A. No. 182/2021 and rejected the same vide impugned order dated 07.01.2121, even without considering the correct facts, which is totally wrong.
(ii) The learned for the applicant stated that the case of the applicant is fully covered by the number of judgments passed by the various courts of law on the same issue and some of the citations are as under; Tribunal
i) V.S. Raghvan Vs. Union of India, 2006 (3) ATJ 414.
ii) Smt. Rekha Saxena Vs. Union of India &
Ors. 2006 (3) ATJ 50.
iii) OA No. 1937/2014 titled Tika Singh Versus Union of India & Ors on 08.07.2015, Apex Court
iv) Suman Rakhija Vs. State of Haryana & Anr., 2006 SCC (L&S) 890.
v) Parmod Kumar Vs. Union of India, 2005 (3) CAT SLJ 173.
(vi) Shiva Kant Jha Vs UOI, WP No. (C) No.694/2015 decided on 13.4.2018.
7O.A. No. 182/2021
2. Per contra, opposing the grant of reliefs, learned counsel for respondents relied upon averments made in counter reply and stressed upon that the wife of the applicant was admitted in a non-railway/private hospital as a non-referred case on 16.01.2019 at 03:29:37 PM with complaints of cough with expectoration for 07 days and high fever from 03 days. She had sufficient time to go to Northern Railway Central Hospital, New Delhi (for short 'NRCH/NDLI') or Divisional Hospital, Delhi (in short 'DH/DLI') for treatment and management. Her complaints are of 07 days. There is no evidence on record to suggest that she had contacted or tried to contact Railway Health Services, i.e., NRCH/NDLI, DH/DLI or any other nearest registered health unit for her treatment. Hence, treatment is not justified as an emergent one. She was admitted again at same hospital on 08.02.2019 at 10:52:38 AM with complaints of vertigo, constipation and cough for 02 days. At the time of admission, patient's vitals were within normal limits and she could have been taken to Railway Hospital, where Indoor treatment facilities/referral facilities are available for railway beneficiaries 'free of cost'. Her complaints are of 02 days and it is clear from the records that patient had visited the hospital on 08.02.2021 for follow-up. Hence, there is no emergency substantiated. The 8 O.A. No. 182/2021 applicant resides in Sultanpuri, Delhi and he had travelled to Maharaja Agrasen Hospital, Punjabi Bagh, i.e., approx. 08 to 09 KM and Railway Central Hospital is just 11 KM and not far away from private hospital, Punjabi Bagh. Hence, patient could have been easily shifted or admitted to NRCH/NDLI for her treatment, where such facilities are available.
2.2 Further, the case of the applicant had been examined by the higher authority, i.e., Principal Chief Medical Director, Northern Railway, Baroda House, New Delhi in the light of policy letter dated 31.01.2007 & 22.06.2010, and emergency treatment was not found sustainable. Hence, appeal was rejected by competent authority. Accordingly, the case of the applicant is not maintainable.
3. ANALYSIS :-
3.1 "Emergency Medical Condition" has not been defined anywhere, except under the provisions of Clinical Establishments (Registration & Regulation) Act, 2010 (hereinafter referred to as "the Act"). These provisions are Sections 1 (3), 2 (c), 2 (d), 2 (h), 2(o), 3, 10 (1), 11, 12, 13, 25 & 41 of the Act. This Act was notified on 28.02.2012 and came into force with effect from 01.03.2012.9 O.A. No. 182/2021
Notification pertains to four States, viz., Arunachal Pradesh, Himachal Pradesh, Mizoram and Sikkim and the Union Territories and, thus, applicable in the National Capital Territory of Delhi. The relevant parts of the Act read as under:-
"2. Definitions. - ..............
(a)..........
(b)..........
(c) "clinical establishment" means--
(i) a hospital, maternity home, nursing home, dispensary, clinic, sanatorium or an institution by whatever name called that offers services, facilities requiring diagnosis, treatment or care for illness, injury, deformity, abnormality or pregnancy in any recognised system of medicine established and administered or maintained by any person or body of persons, whether incorporated or not; or
(ii) a place established as an independent entity or part of an establishment referred to in sub-clause (i), in connection with the diagnosis or treatment of diseases where pathological, bacteriological, genetic, radiological, chemical, biological investigations or other diagnostic or investigative services with the aid of laboratory or other medical equipment, are usually carried on, established and administered or maintained by any person or body of persons, whether incorporated or not, and shall include a clinical establishment owned, controlled or managed by--
(a) the Government or a department of the Government;
(b) a trust, whether public or private;
(c) a corporation (including a society) registered under a Central, Provincial or State Act, whether or not owned by the Government;
(d) a local authority; and 10 O.A. No. 182/2021
(e) a single doctor, but does not include the clinical establishments owned, controlled or managed by the Armed Forces.
Explanation.-- For the purpose of this clause "Armed Forces" means the forces constituted under the Army Act, 1950 (46 of 1950), the Air Force Act, 1950 (45 of 1950) and the Navy Act, 1957 (62 of 1957);
(d) "emergency medical condition" means a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) of such a nature that the absence of immediate medical attention could reasonably be expected to result in--
(i) placing the health of the individual or, with respect to a pregnant women, the health of the woman or her unborn child, in serious jeopardy; or
(ii) serious impairment to bodily functions; or
(iii) serious dysfunction of any organ or part of a body;
(e).................
(f)..................
(g).................
(h) "recognised system of medicine" means Allopathy, Yoga, Naturopathy, Ayurveda, Homoeopathy, Siddha and Unani System of medicines or any other system of medicine as may be recognised by the Central Government;
(i).....................
(j)....................
(k)...................
(l)...................
(m)................
(n).................
11O.A. No. 182/2021
(o) "to stabilise (with its grammatical variations and cognate expressions)" means, with respect to an emergency medical condition specified in clause (d), to provide such medical treatment of the condition as may be necessary to assure, within reasonable medical probability, that no material deterioration of the condition is likely to result from or occur during the transfer of the individual from a clinical establishment."
3.2 The right to medical reimbursement also imbibes a fundamental "right to life", i.e., to have effective and proper treatment from the doctor of his/ her choice within the four corners of Rule of Law, thus, not living in dignified manner would be in violation of Article 14 of the Constitution. 3.3 The Hon'ble Supreme Court in Consumer Education & Research Vs. Union of India & Others, reported in 1995 AIR 922 had observed as under:-
"Therefore, we hold that right to health, medical aid to protect the health and vigour of a worker while in service or post retirement is a fundamental right under Article 21, read with Articles 39(e), 41, 43, 48A and all related to Articles and fundamental human rights to make the life of the workman meaningful and purposeful with dignity of person." (emphasis supplied) Reliance was also placed on CESC Ltd. v. Subhash Chandra Bose, [1992) 1 SCC 441 : AIR 1992 SC 573], wherein His Lordship (K. Ramaswamy, J.) held that right to health of a worker is covered by Article 21 of the Constitution. It was also indicated that health does not mean mere absence of sickness but would mean complete physical, mental and social well- being. "Facilities of health and medical care generate devotion and dedication to give the workers' best, physically as well as mentally, in productivity. It enables the worker to enjoy the fruit of his labour, to keep him physically fit and mentally alert for leading a successful economic, social and cultural life. The medical facilities are, therefore, part of social security and like gift-edged security, it would yield immediate return in the increased production or at any rate reduce absenteeism on the ground of sickness."12 O.A. No. 182/2021
3.4 Reference was made to decision of Hon'ble Supreme Court in Bandhua Mukti Morcha v. Union of India, (1984) 3 SCC 161, wherein Bhagwati, J. (as His Lordship then was) referring to Francis Coralie Mullin v. Administrator, Union Territory of Delhi, (1981) 1 SCC 608 had stated;
"It is the fundamental right of every one in this country, assured under the interpretation given to Article 21 by this Court in Francis Mullen's case, to live with human dignity, free from exploitation. This right to live with human dignity enshrined in Article 21 derives its life breath from the Directive Principles of State Policy and particularly Clauses (e) and (f) of Article 39 and Articles 41 and 42 and at the least, therefore, it must include protection of the health and strength of workers men and women, and of the tender age of children against abuse, opportunities and facilities for children to develop in a healthy manner and in conditions of freedom and dignity, educational facilities, just and humane conditions of work and maternity relief. These are the minimum requirements which must exist in order to enable a person to live with human dignity and no State neither the Central Government nor any State Government-has the right to take any action which will deprive a person of the enjoyment of these basic essentials. Since the Directive Principles of State Policy contained in Clauses (e) and (f) of Article 39, Article 41 and 42 are not enforceable in a court of law, it may not be possible to compel the State through the judicial process to make provision by statutory enactment or executive fiat for ensuring these basic essentials which go to make up a life of human dignity but where legislation is already enacted by the State providing these basic requirements to the workmen and thus investing their right to live with basic human dignity, with concrete reality and content, the State can certainly be obligated to ensure observance of such legislation for inaction on the part of the State in securing implementation of such legislation would amount to denial of the right to live with human dignity enshrined in Article 21, more so in the context of Article 256 which provides that the executive power of every State shall be so exercised as to ensure compliance with the laws made by Parliament and any existing laws which apply in that State."13 O.A. No. 182/2021
3.5 What would be the "emergency" situation would depend on facts and circumstances of each case and that there can be no rigid formula in the matter of medical assessment.
3.6 There is set procedure in Railways to seek medical reimbursement, i.e., check list to be filled by serving employee and assessment to be made by Competent Authority (Annexure-A to letter No. 494-E/O Vll/E tY dated 29-2-99/31-3-99 , Ref PARA 645, 648, 653 , 659 of IRRM ). Hence, what is to be seen by the Competent Authority is compliance of the said rule position. However, the procedure to decide upon the medical claims must not be complex but ought to be rather simplified. 3.7 Parliament of India Rajya Sabha Department - Related Parliamentary Standing Committee on Health and Family Welfare, in its seventy first report, laid emphasis on "The Functioning of Central Government Health Scheme (CGHS) (Ministry of Health and Family Welfare)", which was Presented to the Rajya Sabha on 6th August, 2013 (Laid on the Table of Lok Sabha on 6th August, 2013); the relevant extract of which are reproduced herein below:- 14 O.A. No. 182/2021
"EMERGENCY SERVICES
41. The Committee has received numerous requests from experts and stakeholders to restart the emergency services at Wellness Centres as was available earlier in many dispensaries. It has also been requested that one doctor should be on duty at night at the CGHS Wellness Centres for dealing with the emergency cases.
42. The Committee was apprised that the reason behind the gradual closing of emergency shifts was low patients' attendance resulting in underutilization of the manpower and resources. Also, in case of medical emergencies, the beneficiaries may go to any hospital for treatment and claim the reimbursement as per the package rates. At present, there are only 6 Wellness Centres where emergency services are in operation.
43. The Ministry has also submitted that all CGHS Wellness Centres provide emergency medical facilities to its beneficiaries during working hours from 8.00 A.M. to 3.00 P.M. In addition, emergency medical facilities are also provided between 3.00 P.M. to 8.00 A.M. at six CGHS Wellness Centres/hospitals namely - North Avenue, South Avenue, Telegraph Lane, Pandara Road, Kingsway Camp and Timarpur. CGHS beneficiaries may go to any hospital whether empanelled or not in case of medical emergencies.
44. The Committee is of the view that Emergency services are meant to stabilize a suffering patient by providing initial treatment so that he gets time to reach the hospital for further management. If a patient gets emergency first aid at the wellness centre only, then he can be shifted to hospital in a given time. The Committee impresses upon the Ministry to explore the possibility of starting evening and the emergency services at all these Wellness Centres depending upon the number of the beneficiaries catered by the Centres. The Committee suggests that the services of the CGHS Wellness Centres should be made available round the clock on 24 hour basis on the lines of hospitals. There should be at least one doctor available at the wellness centre at all times. The staff can be appointed to work in shifts on rotation basis. Initially the scheme to introduce emergency services in CGHS Wellness Centres on round the clock basis can be started as pilot project in a few Wellness Centres and based on the feedback received from them, the scheme can be extended throughout the country.
45. The Committee was of the opinion that all the emergency units of CGHS should have ambulance service to attend to. The Committee, accordingly, recommends each emergency unit of CGHS should be equipped with ambulance service.
46. Further, the Committee also feels that the suggestion of opening mini-casualty centre for every 6-8 Wellness Centres to offload the hospital casuality wards as submitted by some of the witnesses may also be considered by the Department.15 O.A. No. 182/2021
47. The Committee is also of the opinion that a Control Room/ Call Centre should be set up to provide important information to the beneficiaries in dire need of emergency treatment. xxxxx BILL SETTLEMENT
90. For the settlement of medical reimbursement claims of the beneficiaries it was informed that the Department has laid new comprehensive procedure to ensure timely and hassle free disposal of medical reimbursement claims in order to facilitate prompt reimbursement of medical expenses to the pensioner beneficiaries. These initiatives include doing away with the requirement of verification of bills by the treating doctor and essentiality certificate, and issuance of specific guidelines for examination of requests for full reimbursement of claims. Also, the beneficiaries now have the option of submitting the original bills under any health insurance scheme that they may be subscribing and claim the balance amount from CGHS/Department that shall be as per CGHS rates and regulations. CGHS has also laid down guidelines to reimburse the expenses incurred on IVF treatment to CGHS beneficiaries.
91. The Committee takes note of the fact that the CGHS beneficiaries are no longer required to get their medical bills verified by the treating doctor and furnishing of essentiality certificate has also been done away with. However, the Committee has been given to understand that this facility is not available to those Central Government Employees who avail medical facilities under Medical Attendance Rules, 1954. The Committee, therefore, impresses upon the Department to immediately address this issue and extend the same facilities to those covered under M.A. Rules. The Committee also calls upon the Department to issue a fresh circular clarifying the procedures in this regard and dispelling misgivings, if any.
92. The Committee has been informed that in order to expedite the process of bill clearance, the Department has engaged UTI- TSL as Bill Clearing Agency under which the empanelled hospitals and diagnostic Centres are required to submit their bills after discharge of the patient which will pay them the applicable amount as per the package rates for the treatment within 10 days. Further, Committee was given to understand that this scheme is expected to help the pensioners in availing healthcare facilities. The Committee would like the Department to examine the performance of this Scheme and take corrective measures if found short on any account.
93. The Committee's attention was also drawn towards the hardships the beneficiaries have to face in getting their bills reimbursed which reflect that the Departments initiative to streamline reimbursement of claims have not yet yielded the desired results.
94. The Committee, accordingly, suggests that the Department should once again review the online bill submission and 16 O.A. No. 182/2021 approval process so that the online bills submitted by the hospitals can be approved by the bill clearing agency and then the hospitals should submit the bills as this will minimize the reconciliation/ disputes and reduce bill payment cycle. The Committee also suggests that the department should once again review the reimbursement process and make it simpler and transparent in view of the concerns put forth by the beneficiaries. Besides, the department should ensure that the claim adalats meant for settling pending claims are held regularly.
95. The Committee further recommends that since, one Bill Clearing Agency is not able to clear all the bills in time, the Department should appoint more agencies and specify the time period within which the bills have to be cleared."
3.8 Based on above Report, an Office Memorandum (O.M.) was issued on 15.07.2014 by the Ministry of Health and Family Welfare, Govt. of India, which is reproduced as under:-
"OFFICE MEMORANDUM Subject: Relaxation of procedures to be followed in considering request for medical reimbursement claims in respect of CS (MA) beneficiaries.
Ministry of Heath & Family Welfare received several representations from CGHS beneficiaries for issue of guidelines to be followed in considering requests for relaxation of procedures in considering requests for medical reimbursement over and above the approved rates. The matte was examined by the Ministry and Office Memorandum No.4- 18/2005-C&P {Vol-I Pt.(1)} datd the 20th February, 2009 was issued prescribing the procedures and guidelines to be followed for consideration of requests received from CGHS beneficiaries seeking reimbursement of expenditure incurred on medical treatment over and above the approved rates. The requirement of essentially certificate in respect of CGHS beneficiaries was also done away with.
However, no such guidelines were issued under CS(MA) Rules. In this regard Department - related Parliamentary Standing Committee on Health and Family Welfare in the seventy first report impressed upon the Department to immediately address this issue and extend same facilities to those covered under CS (MA) Rules and to issue a fresh circular clarifying the procedures in this regard and dispelling 17 O.A. No. 182/2021 misgivings, if any. Ministry was also in receipt of representation from several quarters in this regard.
2. The matter has been examined in consultation with Dte.GHS and it has been decided to revise the guidelines for reimbursement by the competent authority to issue guidelines under CS (MA), on similar pattern as under CGHS as per the following:
(1) The matter has been decided to do away with the procedure for verification of bills and issue of essentiality certificate by the treating doctor and the Medical Superintendent of the hospital. Ministries/Authorities concerned may verify and check the authenticity of the claims on the basis of the prescription slip and the diagnostic report submitted by the Government servant. In the event of any doubt, the concerned Ministry/Authority can always get verification done from the hospital concerned. (2) It is clarified that essentiality certificate/counter signature of treating doctor in a hospital would not, henceforth, be necessary. However, essentiality certificate would be required when the treatment is taken from an AMA on OPD basis. (3) All cases involving requests for relaxation of rules for reimbursement of full expenditure will henceforth be referred to the Technical Standing Committee, to be chaired by the DGHS/Spl.DGHS and Specialists of concerned subject as members. Addl DDG (MG-Section), Dte.GHS shall be member secretary for organizing the meetings of Technical Standing Committee. If Technical Standing Committee recommends the relaxation of rules for permitting full reimbursement of expenditure incurred by the beneficiary, the full reimbursement may be allowed by the Secretary (Health & Family Welfare) in consultation with IFD. A check list for consideration of requests for reimbursement in excess of the approved rates may include:
a. The treatment was obtained in a private hospital not empanelled under CS(MA)/ CGHS under emergency and the patient was admitted by other when the beneficiary was unconscious or severely incapacitated and was hospitalized for a prolonged period;
b. The treatment was obtained in a private hospital not empanelled under CS(MA)/ CGHS under emergency and was admitted for prolonged period for treatment of Head injury, Coma, Septicemia, Multi-organ failure, etc; c. Treatment was obtained in a private hospital not empanelled under CS(MA)/ CGHS under emergency for treatment of advanced malignancy;
d. Treatment was taken in a private hospital not empanelled under CS(MA)/ CGHS under emergency in higher type of accommodation as rooms as per his/he entitlement was not available during the period;18 O.A. No. 182/2021
e. Treatment was taken in higher type of accommodation under specific conditions for isolation of patients to avoid contacting infections;
f. Treatment was obtained in private hospital not empanelled under CS(MA)/ CGHS under emergency while on official tour to another city;
g. Treatment was obtained in a private hospital not empanelled under CS(MA)/ CGHS under emergency when there is a strike in Govt. hospitals' h. Approval for air-fare with or without attendant on the advice of treating doctor for treatment in another city even though he is not eligible for air travel/treatment facilities are available in city of residence and i. Any other special circumstances.
4. The Office Memorandum is issued with the concurrence of IFD vide Dy.No.C-695 dated 07.07.2014." The above O.M. was also circulated to Ministry of Railways. 3.9 In factual martix of present case, it is seen from the records that substantial medical reimbursement claim pertains to earlier Bill No. 18045757 dated 30.01.2019 to the tune of Rs.228970/-. The said Bill pertains to admission, i.e., 16.01.2019 and discharge of patient, i.e., 30.01.2019. 3.10 The Appellant Authorities rejected the claim only on the basis of subsequent admission of patient on 13.02.2019 for a period of two days ignoring the fact the patient was admitted based on earlier history and continuation of the same, which has been recorded in discharge certificate dated 13.02.2019 and the same reads as under:- 19 O.A. No. 182/2021
"History The patient was admitted with complaints of vertigo, constipation, and cough for 2 days.
Hospital Course The patient was admitted with above mentioned complaints. All relevant investigations were done and treated for same. Neurology reference was given in view of vertigo. Magnetic Resonance Image and Electroencephalogram advised. Respiratory Medicine reference in view of cough, Endocrinology reference was given in view of type-II diabetes mellitus and adviced followed. Gastroenterology reference was given in view of chronic constipation. Neurology reference was given in view of acute kidney injury. Patient's condition improved and is being discharged in hemodynamically stable."
3.11 It is also borne out from the records that the Bill No.18047756 dated 13.02.2019 was only to the tune of Rs. 37508/-. The policy dated 31.01.2007 itself postulates that "The issue of bringing in objectivity, consistency and transparency in disposal of reimbursement cases, where the treatment has been taken in emergency without consultation with the Authorized Medical Officer, has been under consideration of the Board.
The Railway Board after thorough review of the whole subject of reimbursement has taken the following decisions which are to be implemented with immediate effect. Any instructions on this subject as available in IRMM 2000 or any office order issued prior to this office order and will stand modified, accordingly."
20O.A. No. 182/2021 3.12 Furthermore, there is no explanation forthcoming from the Additional Chief Medical Officer in his report dated 24.06.2019 (page 16 of counter affidavit) and report dated 13.08.2019 (page 19 of counter affidavit) as to why he has left the admission details, i.e., "(A) (iii) Admitted to an ICU bed or general bed or cabin bed" blank, which is quite contrary to discharge summary dated 30.01.2019. There is no reason or justification to have ignored the same before arriving at conclusion.
3.13 The rejection the case of the applicant is based only on the ground that "the treatment taken by the patient was not an emergency in nature". These observations are perverse and irrational as well as contrary to letter and spirit of medical reimbursement policy. It cannot be expected from a model employer that once the patient is undergoing a proper treatment in a particular hospital under supervision of doctor, it would be imperative to seek reimbursement that patient ought and must have shifted to NRCH/NDLI or DH/DLI for treatment. There is no logic and rationality behind such medical opinion. The said finding ignores the fact mentioned in discharge summary dated 30.01.2019. The said finding is only based on a matter of choice. The 21 O.A. No. 182/2021 choice to switch over to NRCH/NDLI or DH/DLI in cases of medical treatment without any basis or logic, more so when the respondents' own doctor concurred and gave an emergency certificate. Thus, the rejection of claim is based on self assessment, surmises and conjectures. 3.14 What has also been ignored by the Competent Authority is that in the discharge summary it has been clearly mentioned "In case of emergency (cough, chest pain, nausea, vomiting, and onset of any new symptoms), please contact on Casualty - Phone No. 011-40777587, Ext. No. 5099 or call hospital ambulance at mobile no. 9910489495)" and also emergency certificate dated 16.01.2019 issued by doctor who treated the patient, as there are no allegations of fraud or forged certificate. The impugned office order(s) brushes aside its own policy in matter of deciding the claims as well as O.M. dated 15.07.2014.
4. CONCLUSION :-
In view of the above, the impugned orders dated 07.01.2021 and 04.10.2019 are quashed and set aside. The applicant is entitled to refund of a sum of Rs.2,32,204/- (First period), if any, and Rs.60,143/- (Second period), if any, subject to verification of bills, within a period of two months from the 22 O.A. No. 182/2021 date of receipt of a certified copy of this order, failing which the applicant shall be entitled to interest @ 6% after expiry of period of two months till the date of actual payment.
5. The OA is allowed in aforesaid terms.
No orders as to costs.
(Manish Garg) Member (J) /sm/