Central Administrative Tribunal - Jodhpur
Bannu Ram vs M/O Defence on 23 August, 2022
1
CENTRAL ADMINISTRATIVE TRIBUNAL
JODHPUR BENCH, JODHPUR
Original Application No. 290/00284/2020
Reserved on : 04.08.2022
Pronounced on: 23rd August, 2022
CORAM
HON'BLE MRS. JASMINE AHMED, MEMBER (J)
Bannu Ram S/o Late Shri Ram Lal aged about 53 years, R/o House
No. 37 Sainik Puri, Khasra No. 109, Digadi Kalan, Jodhpur-342010.
Presently working on the post of HS-II in the office of GE (Army)
Central, Multan Lines, Jodhpur.
.......Applicant
By Advocate: Mr. S.K. Malik.
Versus
1. Union of India through the Secretary, Ministry of Defence,
Raksha Bhawan, New Delhi-110001.
2. The Garrison Engineer (Army), Central, Multan Lines, Jodhpur-
342010.
3. The Senior Accounts Officer (Medical Section) Office of the
AAO (SC) Opposite Military Hospital, Rasala Road, Jodhpur-
342008.
........Respondents
By Advocate: Mr K.S. Yadav.
ORDER
Per Hon'ble Mrs. Jasmine Ahmed, Member (J) The genesis of the case as stated by learned counsel for the applicant is that despite the applicant undergoing treatment for Peripheral Vascular Disease (Heart Disease) in the Medipulse Hospital, Jodhpur, which is recognized for treatment of Central Government Employee and their family members under Central Services (Medical Attendance) Rules, 1944, as well as CGHS, the just claim of the applicant has been denied by the respondents and the applicant has 2 been forced to approach this Tribunal for reimbursement of his claim for treatment taken in an emergent condition where his life was under
threat. The applicant has approached this Tribunal seeking quashing of rejection memo dated 21.10.2020 (Annex. A/1) issued by the respondent No. 3 and directing the respondents to reimburse the medical claim of the applicant amounting to Rs 84,275/- with an interest @ 9% p.a. and he is also seeking costs for causing undue harassment to him.
2. For better understanding of the case, the brief facts are that on 04.06.2017, the applicant in an emergent health condition (Unconscious) admitted to Medipulse Hospital, Jodhpur by his relatives. The treating doctors there diagnosed that the applicant is suffering from Peripheral Vascular Disease (Heart Disease) for which the applicant undergone procedure of PTA + Stenting to Left CIA and the applicant discharged from the hospital on 06.06.2017. Thereafter, the applicant submitted a medical claim of Rs 84,275/- in prescribed format alongwith necessary documents for reimbursement on 25.07.2017 to respondent No. 2. The respondent No. 2 forwarded the same to respondent No. 3 on 26.07.2017 for reimbursement of the same. The real trauma and harassment of the applicant commenced thereafter.
3. The respondent No. 3 returned the medical bill of the applicant 'unactioned' vide letter dated 05/07.09.2017 (Annex. A/3) for the following reasons, which reads as under :
"(1) Post fact sanction has not been found enclosed. (2) Statement of case duly indicating the circumstances under which prior permission has not been taken from the HOD/Head of Office.
(3) As per G.O.I., Ministry of Health and Family Welfare OM No. 1967/2013/DEL/CGHS/D52 - CGHS dated 10.12.2015, the Heads of Office should not be below the rank of Joint Secretary to the Govt. of India."3
Thereafter, respondent No. 2 made statement of case on 25.03.2019 (Annex. A/4) in respect of the applicant and ex-post facto sanction of Chief Engineer (NF), CWE (Army) Jodhpur has been accorded. The ex- post facto sanction dated 29.03.2019 (Annex. A/5) as well as statement of case by the immediate controlling officers of the applicant duly recognizes the medical emergency. However, the medical reimbursement claim of the applicant forwarded by respondent No. 2 has again been returned by the Accounts Officer of AAO (SC) Jodhpur vide letter dated 12.04.2019 (Annex. A/6) for the reasons quoted hereunder :
1. Bill/invoice not authenticated by the doctor.
2. CGHS code not mentioned in final bill by the recognized hospital.
3. The hospital is in front of AIIMS, which is Govt hospital. Why treatment was not preferred in this Govt. hospital.
4. As per prevailing orders medical bills should be resubmitted with proper reply/requirement of rejections with 45 days of rejection there for reasons for resubmitting the claim after elapse of 02 years should also be submitted.
The medical claim of the applicant again agitated by the respondent No. 2 before respondent No. 3 and Medical Branch of AAO (SC) Jodhpur thereafter vide letter dated 07.11.2019 (Annex. R/1) advised the respondent No. 2 as under :
"Please refer this office letter no. cited under reference. In this connection, it is intimated that, PCDA (SC) Pune, after consultation with Additional Director CGHS Pune, has cleared that "outer pouch of the coronary stent pocket with the sticker with details should be attached in the original for claim"
Therefore it is advised that, the subject cited claim may be processed accordingly."
Thereafter, the medical claim of the applicant again resubmitted by the respondent No. 2 by issuing waiver certificate (page 43) on the basis of certificate issued by the Medipulse Hospital dated 14.12.2019 (page 4
42), the handwritten portion duly stamped by the Medipulse Hospital dated 15.07.2020 reads as under :
"Patient Banu Ram admitted here for Peripheral Angioplasty dt
04.06.2017 and discharged on 06.06.2017 and taken treatment for Angioplasty- Stunting.
Kindly consider this letter, its been long for patient admission, we are not able to find the sticker on pouches-kindly pass the patient Bill as per CGHS norms - we are very sorry to tell you that the pouches are not found as its very old case - we are not able to find the pouches - please consider."
The controlling Officer, i.e. Lt. Col (Garrison Engineer - respondent No. 2) also issued a waiver certificate, which reads as under
:
"Certified that MES-195210 Sh. Bannu Ram, P/Ftr HS-II was actually incurred the expenditure on account of coronary stent during his treatment in Medipulse Hospital, Jodhpur. The outer pouch of the coronary stent packet with the sticker with details has been lost and recommended for wear and tear."
Thereafter, the claim of the applicant again returned by respondent No. 3 on 05.02.2020 and the order impugned dated 21.10.2020 (Annex. A/1) reads as under :
I. The Medical bill with the above reference is returned herewith by for the following reasons :
1) Others
1.Reply to this office letter no. R0293MDB741 dated 05/02/2020 is not admitted in audit.
2.The outer pouch of the stent along with the sticker on which details of the stent are printed has to be enclosed with the medical claim.
3. You are requested to resubmit the claim only after enclosing required documents as per objections raised in absence of the required documents claim is not supposed to be submitted to obviate the situation of re rejecting the claim which not only indulges unproductive correspondence but vanishes the man hours of task holder(s) also.5
II. The claim may be resubmitted after complying with the audit requirements. In case of re-submission, please quote the Dak Id No R0293MDB148 on top of the forwarding letter.
4. Learned counsel for the applicant submitted that the applicant despite taking treatment from an empanelled hospital under the rules, the respondents created unnecessary hurdle in releasing legitimate medical claim of the applicant. The genuineness of the claim of the applicant has never been questioned and his controlling officers were satisfied that the applicant has actually been undergone treatment, it is the respondent No. 3 who on one or other pretext neither rejected nor sanctioned the claim of the applicant. The applicant submitted his claim to the respondents on 25.07.2017 and thereafter each time his claim has been returned/rejected on one ground or another. In return memo dated 05/07/09.2017 (Annex. A/3) & 12.04.2019 (Annex. A/6), the requirement "Outer pouch of the coronary stent pocket with the Sticker with details" has not been mentioned and it was added later on. On such objection raised at a later stage and issuance of certificate by the controlling officer as well as Medipulse Hospital that due to being old case, the outer pouch is not traceable, yet respondent No. 3 not considered allowing the genuine case of the applicant. Learned counsel for the applicant vehemently states that respondent No. 3 is an audit authority and not the controlling officer. The respondent No. 3 pointed out the requirement of outer pouch at a later stage for harassing the applicant. He thus prays that the respondent No. 3 may kindly be directed to pass the medical claim of the applicant with interest and heavy costs may be imposed on the respondent No. 3 for undue harassment of the applicant. In support of his arguments, learned counsel for the applicant relied upon the following judgments of Hon'ble Supreme Court :
(i) Surjit Singh Vs State of Punjab & Ors, (1996) 2 SCC 336.
(ii) State of Punjab & Ors Vs Mohinder Singh Chawla & Ors, (1997) 2 SCC 83.6
(iii) Suman Rakheja Vs State of Haryana & Anr, 2006 SCC (L&S) 890.
5. Per contra, learned counsel for the respondents states that the respondents have acted as per rules as the applicant has not been able to provide "Outer pouch of the coronary stent pocket with the Sticker with details", hence, his claim could not be admitted and reimbursed. It is the main and only contention of learned counsel for the respondents that the applicant should have attached the outer pouch alongwith the medical bill failing which the respondents are not in a position to release any claim towards medical reimbursement. He further states that the respondents have attached OM dated 31.10.2011 (Annex R/3) and 2102.2013, wherein it has clearly been mentioned that batch number of invoice and outer pouches of the stent has to be submitted for reimbursement. He thus states that the respondents including respondent No. 3 is well within the rules while returning the medical claim of the applicant and action of the respondents is just and legal.
6. I have considered the rival contentions of learned counsel for the parties and carefully perused the material available on record.
7. It is undisputed that Medipulse Hospital, Jodhpur is an empanelled hospital for IPD treatment of Central Government employees under CGHS/CSMA Rules and the applicant was admitted in the said hospital in an emergent condition and took the treatment, which has been claimed in his medical reimbursement claim. Though no contention was raised regarding the fact as to whether the applicant is CGHS beneficiary or governed under CS (MA) Rules, 1944, but looking to the material available on record, the applicant appears to be a beneficiary under CS(MA) Rules. Be as it may, the only objection, in reply to the OA, raised by the respondents is that, in the hospital 7 certificate dated 14.12.2019, it is clearly stated that original stickers and outer pouch were given to the patient (applicant) but the same were not attached with the claim submitted by the applicant. This is the only contention opposing the OA put forth by learned counsel for the respondents during course of the arguments wherein he relied upon GOI, MoH&FW OM dated 21.02.2013 (Annex. R/4), the relevant paragraphs of the same reads as under :
"3. It is essential for the empanelled hospitals to quote the Batch number when a coronary/vascular stent of any type is implanted in the case of a CGHS/CS (MA) beneficiary and also enclose a copy of the relevant invoices pertaining to the procurement of the stents by the hospitals. In addition to this, the outer pouch of the Stent packet along with the sticker on it on which details of the stent are printed shall also be enclosed with the medical bill for claiming reimbursement from the Govt. In case of treatment from a private non-empanelled hospital, where the treatment was taken in an emergency, it is the responsibility of the beneficiary to obtain the batch number, invoice and outer pouches of the stent(s) before the submission of the medical claim to CGHS/ concerned department, as the case may be.
4. The empanelled hospital shall submit a self certified undertaking that the hospital has not charged the CGHS / CS (MA) beneficiary more than the rate at which the stent has been procured by the hospital and in case of any detection and establishment that the hospital has overcharged, the hospital shall be removed from the list of hospitals empanelled under CGHS without any further notice.
5. UTI-ITSL, while processing the hospital bills of coronary / vascular stents shall ensure that the hospitals have enclosed copies of the relevant invoices pertaining to the procurement of the stents by the hospitals and the outer pouch of the Stent packet along with the sticker on it on which details of the stent are printed and that the prescribed rates and the guidelines have been followed, before making provisional payments to the hospitals."
Para 03 of the aforesaid OM relied upon by learned counsel for the respondents makes it clear that it is the responsibility of the empanelled hospital to provide the outer pouch of the Stent packet along with the sticker on it , but in its certificate the Medipulse Hospital 8 itself has clearly stated that outer pouch is destroyed/not traceable being old case.
8. The Hon'ble Supreme Court, Hon'ble High Courts and Tribunals have time and again pronounced their views in catena of judgments that genuine medical claim of an employee in an emergent medical condition cannot be denied irrespective of the fact whether treatment is taken in the private hospital/govt. hospital. In this particular case, the applicant has ticked all the boxes right as he underwent his treatment in an empanelled hospital in an emergent condition requiring no relaxation under the rules as the empanelled hospital are in with MoUs with the Government of India for treatment of their employees. Under Rule 6 of CS (MA) Rules, 1944, the applicant is entitled for free of charge treatment of his illness and genuineness of his medical claim is also not in question. Yet, the respondent No. 3 surprisingly raised objections in a fragmented manner and lastly, the claim of the applicant has been returned by respondent No. 3 for want of 'Pouch', which sought by respondents No. 3 at a later stage in his series of observation memos. In my considered view, the technicalities laid down while formulating a policy are meant for judging the veracity of a claim and the technicalities or formalities coupled with insensitivity of the concerned officers should not be allowed to stand in the way of a valid medical reimbursement claim for indoor medical treatment in an empanelled hospital which is in MoU with the Government. The veracity of applicant undergoing treatment is not in question but his claim is not being reimbursed for want of production of a 'Pouch' that too which is the responsibility of the empanelled hospital as per document attached by the respondents themselves. Accordingly, the applicant is entitled for reimbursement of his medical claim without insistence on production of 'Pouch' and Rejection Memo dated 21.10.2020 (Annex. A/1) issued by respondent No. 3 is quashed and set aside.
99. The applicant has prayed for a direction for payment of interest on his medical reimbursement claim from the date of its submission, as well as prayed for costs for causing undue harassment to him. Here, I must note that the respondent No. 2 is the controlling authority of the applicant and the respondent No. 3 is the pre-audit authority. I concede that a medical claim has to be supported by a proper supporting documents, to enable the competent authority to sanction the same. At the same time, the controlling officers also must not act in a mechanical manner. It appears from perusal of series of observations/objections raised by the office of respondent No. 3 that they were acting in a negative manner, anyhow, not allowing the medical reimbursement to the applicant for one reason or another. The observation memo dated 05/07.09.2017 (Annex. A/3) issued by the respondent No. 3 contains the objection why prior permission has not been taken from the HoD/H.O.O. and further qualifying that Head of Office should not be less than the level of Joint Secretary to the Govt. of India for the medical claim of a H.S.-II. In my considered view, the focus of local audit authority should have only been to the extent of scrutinizing the medical reimbursement claim to the effect whether the hospital or the applicant has claimed more money than permitted under the rules for the treatment taken by the applicant. When the medical reimbursement claim of the applicant has again been submitted to the office of respondent No. 3, the office of respondent No. 3 on 12.04.2019 (Annex. A/6) raised one of the observation/objection that when AIIMS is opposite of Medipulse Hospital, Jodhpur then why the applicant has not been admitted in AIIMS. Had this issue been at all valid for the consideration, it is the jurisdiction of office of respondent No. 2 to consider the same. Though empanelment of private hospital by the Government itself for treatment of its employees does not at all suggests that it bars an employee to undergo treatment in empanelled hospital if it is nearer to 10 a Govt. hospital. Here, I am fortified in my view that respondent No. 3 is adamant not to allow the medical reimbursement claim of the applicant for reasons best known to him. I am unable to understand that when an employee can prefer in patient treatment either in empanelled hospital or govt. hospital for a procedure, then which rule allowed the audit authority to raise such observation. If this question, if at all to be put, it can best be put by the controlling officer/office of the applicant but respondent No. 3 went on overdrive in a mechanical way to suggest that aim of the Govt. is to disallow the reimbursement to its employee for their treatment in a private empanelled hospital. I am unable to understand that if it is the aim then why would Govt. will empanel such hospitals for treatment of their employees? In the present context, it would be relevant to refer to the Hon'ble Supreme Court's decision in Surjit Singh v. State of Punjab, (1996) 2 SCC 336. In that case, an employee with the Punjab Police force fell ill while in London, and had a bye-pass surgery, which cost around Rs. 3 lakhs. On his return to India, he claimed reimbursement. The government refused. During litigation, however, it was stated that the government was willing to pay the expenses for the bye-pass surgery to the extent of the cost of such treatment at AIIMS (Rs. 40,000/). The High Court accepted this proposal, and directed the payment of the money. Aggrieved of this order, the State Government approached the Supreme Court. The Court found that according to the State Government's own policy, there was a list of diseases for which specialized treatment was unavailable in Punjab government hospitals, but available in certain private hospitals. Those hospitals were "recognized" by the government for the purposes of treatment. One listed treatment was open-heart surgery, for which the relevant private hospital was Escorts, at Delhi. Consequently, the Court held that the reimbursement is due to him. The Court invoked Article 21, and then cited a Punjab & Haryana High Court opinion, stating that:
11"we cannot loose sight of factual situation in the AIIMS New Delhi i.e. with respect to the number of patients received there for heart problems. In such an urgency one cannot sit at home and think in a cool and calm atmosphere for getting medical treatment at a particular hospital or wait for admission in some Government medical institute. In such a situation, decision has to be taken forthwith by the person or his attendants if precious life has to be saved"
The Court further noted:
"the appellant therefore had the right to take steps in self preservation, He did not have to stand in queue before the Medical Board the manning and assembling of which, bare-facedly, makes its meetings difficult to happen. The appellant also did not have to stand in queue in the government hospital of AIIMS and could go elsewhere to an alternate hospital as per policy. When the State itself has brought the Escorts on the recognised list, it is futile for it to contend that the appellant could in no event have gone to the Escorts and his claim cannot on that basis be allowed, on suppositions. We think to the contrary. In the facts and circumstances, had the appellant remained in India, he could have gone to the Escorts like many others did, to save his life. But instead he has done that in London incurring considerable expense. The doctors causing his operation there are presumed to have done so as one essential and timely. On that hypothesis, it is fair and just that the respondents pay to the appellant the rates admissible as per Escorts"
10. It is important to note that the Court expressly remained agnostic on the question of whether or not this was a case of emergency. The Court held that "since... [the Appellant] has now brought down his claim to the rates prevalent in the Escorts in place of that of AIIMS, further reference to emergency treatment etc. would not be necessary. It would hypothetically have to be assumed that the appellant was in India, had not subjected himself to Medical Board examination, and had gone on his own to the Escorts and got himself operated upon for Bye-Pass Surgery." The logic of the Surjit Singh (supra) decision seems to be that a Government policy which provides a procedure for treatment and reimbursement in cases of certain ailments creates a 12 threshold entitlement for its employees (flowing from Article 21). If the applicant runs up a bill higher than that contemplated by the Policy, because he goes to a hospital not on the official list - then while the Government is not obligated to reimburse him the full cost of his treatment, it is nevertheless obligated to provide him the amount of reimbursement contemplated in the policy, for that particular ailment. In Surjit Singh (supra), the applicant underwent a treatment that was specifically referred to in the Policy, but not at a listed hospital. The Court's answer was not to deprive him of reimbursement altogether, but to allow reimbursement to the extent that the Policy contemplated.
11. Interestingly, the medical reimbursement claim of the applicant has been submitted in the year July, 2017 and till 12.04.2019, the respondent No. 3 did not raise the issue of 'Pouch' till this time, which suggests that medical reimbursement bill of the applicant has not been properly scrutinized and rather, the respondent No. 3 was only interested in throwing it back 'unactioned'. It appears that when the applicant and consequently, respondent No. 2 again and again resubmitted the medical reimbursement bill of the applicant, at a later stage the respondent No. 3 raised the issue of submitting 'Pouch' with stickers of stunt implanted in the body of the applicant. Here also, I find that respondent No. 3 was adamant on not to pay even a single penny to the applicant, as non- submission of pouch by the applicant would only have disallowed him reimbursement of cost of stent but remaining medical reimbursement bill would still be admissible. Yet the respondent No. 3 did not inform to do so and returned the whole reimbursement bill.
12. While going through the records, it is also noted considering letter dated 07.11.2019, issued by the office of respondent No. 3 to respondent No. 2, that office of respondent No. 3 is acting in a manner with the office of respondent No. 2 as it is a subordinate office. Looking to the all observations memos and particularly, letter dated 07.11.2019 (Annex. R/2) annexed with the reply, I find that office of respondent No. 3 is using 13 indecent official language as the letter signed by the AO (Medical) officially 'advising' to respondent No. 2, and choice of use of word 'advise' without salutation gives a prima-facie foundation to make such observation while adjudicating this matter. Be as it may, the applicant alleged malafide intentions of respondent No. 3 but he did not allege the same to any particular person(s). However, looking to the entire facts and circumstances of the case and after examining the material available on record, it is clear that the there is administrative malice of office of respondent No. 3 for the office of respondent No. 2 and repeated rejection of medical claim of the applicant by the respondent No. 3 may either be for extraneous reasons or incompetence of respondent No. 3. This issue is for the higher offices of the respondent No. 2 and respondent No. 3 to ponder over, but it establishes one thing that during all these times, the applicant has been meted with undue harassment who is a heart patient also, entitled for medical reimbursement claim. The administrative apathy, to resolve the issue amicably led to avoidable delay. We are in the year 2022 and since 05 years have already been elapsed since the applicant undergone treatment. Although, monetary payment is not a substitute for the mental agony and anxiety caused to the applicant, on account of the procrastination and indecisiveness, but in the facts and circumstances of the case, the respondent No. 3 is directed to pay a cost of Rs 10,000/- (Ten thousand only).
13. Accordingly, impugned rejection memo dated 21.10.2020 issued by respondent No. 3 is quashed and set aside. The respondent No. 3 is directed to pass medical reimbursement bill of the applicant as per norms for reimbursement of medical expenses for treatment in an empanelled hospital, i.e. Medipulse Hospital, Jodhpur without insisting for 'Pouch', and shall also pay a cost of Rs 10,000/- with the medical reimbursement claim of the applicant additionally, within a period of two months from the date of pronouncement of this order. It is made clear that fixing of responsibility, if any, in the office of respondent No. 3, i.e. office of AAO 14 (SC) Jodhpur for imposition of cost, shall not be an impediment for payment of costs to the applicant alongwith his due medical reimbursement claim as ordered. Non-payment of medical reimbursement claim, as well as, costs to the applicant within 02 months shall entitle the applicant to claim interest @5% on his medical reimbursement claim as well as costs, from the date of submission of his medical bill in the office of respondent number 2 to till final payment of the same.
14. OA is accordingly allowed with costs.
(JASMINE AHMED) MEMBER (J) Ss