Central Administrative Tribunal - Delhi
Rajinder Singh Meena vs Union Of India Through on 30 November, 2009
CENTRAL ADMINISTRATIVE TRIBUNAL PRINCIPAL BENCH OA NO.2270/2008 New Delhi this the 30th day of November, 2009. HONBLE MRS. MEERA CHHIBBER, MEMBER (J) HONBLE MR. SHAILENDRA PANDEY, MEMBER (A) Rajinder Singh Meena S/o Shri Bani Singh Working as Account Assistant In the office of Sr. D.F.M., Delhi Division R/o 260-A, Indira Enclave, Sector-21D, Faridabad (Har) Applicant (By Advocate Shri Yogesh Sharma) VERSUS 1. Union of India through the General Manager, Northern Railway, Baroda House, New Delhi. 2. The Chief Medical Director, Northern Railway, Baroda House, New Delhi. 3. The Chief Medical Superintendent, Northern Railway, Divisional Hospital, Delhi 4. The Chairman, Railway Board, Rail Bhawan, New Delhi. Respondents By Advocate: Shri R.L. Dhawan. ORDER (ORAL) Mrs. Meera Chhibber, Honble Member (J):
Applicant has filed this OA as he has been reimbursed an amount of Rs.47,532/- only out of the total amount claimed, i.e., Rs. 1,38,399/-. Rest of the amount has been denied, according to the applicant, in an arbitrary manner. He has thus prayed that he be paid balance of Rs.90,867/- with interest at the rate of 18%. He has also challenged para (II)( c) of the Railway Board Policy/Circular dated 31.1.2007.
2. The brief facts, as stated by the applicant, are that on 8.6.2007 while going to his residence by motorcycle, he met with an accident with serious head injury, fracture and other multiple injuries. Since applicants level of consciousness was very low, he was taken to the Escorts Hospital by the public, which was nearest hospital from the place of accident. The applicant was bleeding from left ear, was having head injury and was having very low blood pressure. On investigation, it was found that he was having massive collection of blood in his abdomen due to the injury in the spleen, therefore, an emergency operation was done on 9.6.2007 and post operatively, 6 units of blood were transfused. He was finally discharged on 15.6.2007 from the hospital. A total amount of Rs.1,38,399/- was paid by the applicant before his discharge from the Escorts Hospital.
3. Since applicant was taken to the Escorts Hospital in an emergency by the public, he claimed the amount of Rs.1,38,399/- by way of medical reimbursement. However, respondents sanctioned only an amount of Rs.35,830/- vide letter dated 29.6.2007. Subsequently, some more amount was sanctioned and the applicant was paid Rs.47,532/-. The remaining amount was not paid to him on the ground that this was a non-referred case, therefore, full medical claim was not admissible. Being aggrieved, applicant filed OA No. 1422/2008 which was disposed of on 11.7.2008 with a direction to the respondents to decide the claim of the applicant by passing a reasoned and speaking order. Pursuant to the said directions, respondents have issued order dated 14.8.2008 rejecting the claim of the applicant in view of the guidelines dated 31.1.2007. It is in these circumstances, that applicant has filed the present OA.
4. It is submitted by the counsel for the applicant that no details have been given to the applicant as to which payments have been accepted and which payments have been rejected and on which count. Once the applicant was treated in an emergency due to a road accident, there is no justification to deny the full amount. Counsel for the applicant relied on the following judgments:-
(i) Shri Venkarai Srinivasan Raghavan Vs. the Union of India and others reported in 2006 (3) ATC 414.
(ii) Prithvi Nath Chopra (Shri) Vs. Union of India and Another reported in 2004 III AD (Delhi) 569.
(iii) Balram Sharma Vs. Union of India and Another reported in 154 (2008) DLT 463 (DB).
(iv) Milap Singh Vs. Union of India and Another reported in 2004 V AD (DELHI) 529.
(v) C.B. Gupta Vs. U.O.I. & Another decided on 7.12.2006 (OA No. 1116/2006).
(vi) S.P. Kapur Vs. U.O.I. & Others reported in 2000 (1) ATJ 654.
(vii) Smt. Gouri Sengupta Vs. State of Assam reported in 2000 (1) ATJ 582.
(viii) Laxman Dass Vs. State of Haryana reported in 2001 (1) ATJ 466.
(ix) V.K. Gupta Vs. U.O.I. and Others reported in 97 (2002) DLT 337.
(x) M.G. Mahendru Vs. U.O.I. reported in 2001 DLT 59.
5. On the basis of the above judgments, counsel for the applicant submitted that he is entitled to get the full reimbursement of the amount. He further stated that clause (II) of the Railway Board circular dated 31.1.2007 is also arbitrary as the amounts spent on a patient in an emergency case cannot be restricted to the CGHS rates only. The respondents failed to appreciate the situation in which applicant was taken to Escorts Hospital.
6. Respondents on the other hand have opposed this OA. They have submitted that the amount of Rs.47532/- has been sanctioned on the basis of CGHS rates in terms of Railway Boards instructions dated 31.1.2007. They have also stated that the applicant was offered the opportunity to satisfy himself that the medical bill has been dealt with in accordance with the rules and instructions but without availing the said facility, he has rushed to the court, therefore, this OA is premature. They have thus prayed that the OA may be dismissed.
7. We have heard both the counsel and perused the pleadings as well.
8. In the counter-affidavit respondents had taken an objection that the Railway Board has not been impleaded even though is a necessary party because applicant has challenged instructions dated 31.1.2007 issued by the Railway Board. Applicant had filed MA No. No.2225/2009 for impleading Chairman, Railway Board as respondents which was allowed and the Chairman, Railway Board has also been impleaded as a party. However, when the matter was called out, Shri R.L. Dhawan gave a statement at the bar that no separate reply is required to be filed on behalf of the Chairman, Railway Board, therefore, matter was heard on the basis of pleadings which were available before us. Since respondents have referred to the letter dated 31.1.2007 issued by the Railway Board for rejecting the claim of the applicant, it would be relevant to quote the said letter:-
Subject: Reimbursement of medical expenses - Procedure of disposal.
(1) The cases to be considered for sanction of reimbursement claim.
As per extant rules, a railway beneficiary must report to Railway Medical Officer for his/her and dependents medical treatment. The authorized Medical Officer will make necessary arrangements for medical treatment through Railway Hospital/Government Hospital/Private Recognized Hospital. In exception situations, CMDs of Zonal Railways can obtain special permission from Railway Board for treatment in any Private Hospital on case to case basis. Hence, there is no scope available for any railway beneficiary to go to any private hospital himself/herself or their dependents on their own volition, except in case of real emergency situation.
Emergency shall mean any condition or symptom resulting from any cause, arising suddenly and if not treated at the early convenience, be detrimental to the health of the patient or will jeopardize the life of the patient. Some examples are - Road accidents, other types of accidents, acute heart attack, etc. Under such conditions, when the Railway beneficiary feels there is no scope of reporting to his/her authorized Railway Medical Officer and avails treatment in the nearest and suitable private Hospital, the reimbursement claims are to be processed for sanction, after the condition of the emergency is confirmed by the authorized Railway Medical Officer ex-post-facto.
In order to establish the emergency condition, following parameters are to be examined on record:-
Admission details :-
Date and time of admission.
Admitted through OPD service/emergency service.
Admitted to an ICU bed or general bed or cabin bed.
(b) Clinical findings at the time of admission. Following findings should be made available and critically evaluated:-
Pulse rate.
B.P. Level of consciousness.
Any convulsive feature.
Urine output.
Any other feature of shock.
Body temperature.
Extant of external wound.
Extant of active bleeding.
Extant of Chest pain or pain in other part(s) of the body.
(c) Types of medical treatment given immediately after admission:-
(i) List of emergency medicines used immediately after admission.
(ii) Type of surgical procedure done immediately after admission.
(II) Calculation of the amount of reimbursement to be sanctioned out of the claimed amount:-
Once the emergency is established beyond doubt, then the case should be further processed for calculating the amount/money to be sanctioned.
For that, following guidelines are given:-
(a) Treatment taken in Government Hospital - Full admissible amount should be recommended for sanction.
(b) Treatment taken in Recognized Private Hospital for an ailment for which it is recognized Rate as approved by Railway should be processed for sanction.
(c) Treatment taken in Recognized Private Hospital but for an ailment for which it is not recognized or treatment taken in a non-recognized Private Hospital, Reimbursement should be made at the CGHS rates of that city or nearest city. CGHS (Central Government Health Scheme) approved rates are to be recommended/processed as an upper limit for sanction.
9. It is correct that in letter dated 31.12007 it has been stated that the claims of employees for reimbursement, who meet with an accident and are treated at the private hospitals, in an emergency is to be processed as per the CGHS rates but respondents failed to appreciate that the railway employee was almost unconscious and was taken to the Escorts Hospital for treatment by the public meaning thereby he was not in a condition to decide where he should be taken for treatment. Admittedly, due to the accident applicant had suffered serious head injuries and other multiple injuries with fracture etc. and was bleeding from the ear. On investigation the hospital found mass collection of blood in his abdomen, therefore, he had to be operated to remove the spleen. All these facts clearly show that the applicant was taken to the Escorts Hospital in an emergency which fact is admitted by the respondents. It is also clear that he had not gone to the Escorts Hospital on his own volition. In these circumstances while processing the case for medical reimbursement it has to be kept in mind that when a person is injured so badly in the road accident that he is to be carried by the public, they would naturally go to the nearest hospital which is available from the site of the accident. This aspect has completely been ignored by the respondents at the time of processing the case of applicant for medical reimbursement. After all, had the applicant been in a position to decide which hospital should he be taken to, probably the stand of the respondents could be right to reimburse only as per CGHS rates because then he would have gone out of his own volition. But here we are dealing with a situation where applicant had met with a very serious accident resulting in head injuries and other multiple injuries. He had to be operated immediately and even blood had to be transfused. His level of consciousness was also very low. In these circumstances it cannot be insisted that he should have gone to a recognized hospital because timely treatment is most important when it is a question of life and death and any prudent person would take the victim of a serious accident to the nearest hospital, where he can be attended to immediately.
10. In the instant case applicant was taken to the Escorts Hospital by the public in a very grave situation when applicant was seriously injured. It is also relevant to note that at the time of discharge, it was mentioned that the applicant had to be admitted in ICU as he had persistent low blood pressure despite fluid replacement. It is also mentioned therein that in post operative period, 6 units of whole blood was transfused. It is also mentioned in the discharge slip that he was admitted with Grade II Splenic injury with fracture left clavicle and head injury. The certificate of the Escorts Hospital shows that on investigation it was found that the applicant was having massive collection of blood in his abdomen with injury in spleen, therefore, an emergency operation had to be conducted for removal of spleen. These facts clearly show that applicant was admitted to the Escorts Hospital in a serious condition of emergency.
11. The question, therefore is, if a person has been treated in a Private Hospital, in these circumstances, whether it would be justified to reimburse him only the rates which are available in CGHS that too without specifying and deny him the full medical reimbursement. At this juncture it would be relevant to refer to the judgment of Honble Supreme Court in the case of Suman Rakheja Vs. State of Haryana and Another reported in 2004 (13) SCC 563 wherein it was held that in case of emergency even in a private non-recognised hospital, the Government servant is entitled not only to 100% medical expenses at the AIIMS rates but also 75% of the expenditure in excess theretoo.
12. Moreover, as per para 648 of Indian Railway Medical Manual also, in case of medical reimbursement claims above Rs.30,000/- case should be referred to Railway Board. We are sure Railway Board has ample powers to relax the instructions in a genuine case, therefore, this case is remitted to the Railway Board for taking appropriate decision in view of the facts as explained above within a period of 3 months from the date of receipt of a copy of this order. It is made clear that applicant would not be entitled to any interest in view of the judgment of Honble Supreme Court in the case of Om Prakash Gargi Vs. State of Punjab reported in 1997 (1) ATJ SC 372.
13. With above direction, OA stands disposed of. No costs.
(SHAILENDRA PANDEY) (MRS.MEERA CHHIBBER) MEMBER (A) MEMBER(J) Rakesh