Telangana High Court
The Union Of India vs M S Viswanatham on 12 September, 2024
Author: Abhinand Kumar Shavili
Bench: Abhinand Kumar Shavili
HON'BLE SRI JUSTICE ABHINAND KUMAR SHAVILI
AND
HON'BLE SRI JUSTICE LAXMI NARAYANA ALISHETTY
WRIT PETITION No.23080 of 2024
ORDER:(per Hon'ble Sri Justice Laxmi Narayana Alishetty) This Writ Petition is filed assailing the order dated 05.04.2024 passed by the Central Administrative Tribunal, Hyderabad Bench, Hyderabad, in O.A.No.569 of 2023.
2. Heard Sri Akhilesh, learned counsel representing Sri Gadi Praveen Kumar, learned Deputy Solicitor General of India, appearing for the petitioners and Ms. Anitha Swain, learned counsel for the respondent.
3. In nut shell, the facts of the case are that the respondent is a retired employee of Atomic Mineral Directorate for Exploration and Research Department (AMD), which is a Department of Atomic Energy (DAE). He is a life member of Contributory Health Service Scheme (for brevity 'CHSS). That on 24.04.2021, on being affected with Covid-19 Virus, he was unable to breathe and his condition became serious and as such, he got admitted in a non- panel hospital viz., Sreshta Sri Kamala Hospital, Dilsukhnagar, Hyderabad, since all the panel hospitals refused to admit him due to non-availability of beds. He was treated in ICU for nine days 2 AKS,J & LNA, J W.P.No.23080 of 2024 and one day in General ward and was discharged on 03.05.2021 and thereafter, he was under home isolation and quarantine for 45 days. Subsequently, on 26.07.2021, he submitted medical claim for reimbursement of Rs.5,71,224/- incurred towards his treatment to petitioner No.2 and on 27.08.2021, petitioner No.2 called for evidence from the respondent regarding intimation of his admission in a non-panel hospital to the Medical Division of DAE, to which, the respondent submitted an explanation through mail on 31.08.2021 requesting to condone the delay. However, the same was not considered and the AMD issued order dated 12.01.2022 rejecting the claim of the respondent. Though the respondent made several representations and also got issued legal notice seeking to condone the delay, the petitioners have not responded to the same. Hence, the respondent approached the Tribunal by filing the present O.A. and the Tribunal vide impugned order dated 05.04.2024 directed the petitioners herein to reimburse the full medical claim to the respondent within a period of four weeks from the date of the said order. Challenging the said order of the Tribunal, the present Writ Petition is filed.
4. Learned counsel for the petitioners contended that CHSS was introduced in DAE in the year 1962 with an objective to 3 AKS,J & LNA, J W.P.No.23080 of 2024 provide medical facilities to employees, both serving and retired, and their eligible family members as per the terms of the said Scheme. At Hyderabad, the CHSS is being administered by Chief Executive, Nuclear Fuel Complex (NFC), Hyderabad, which is a Unit of DAE. Under the CHSS, various facilities like Authorized Medical Officers, Specialists, Hospitals, Clinical Laboratories, etc., are recognized in the station where the CHSS is being operated and payment towards treatment availed by the beneficiaries are borne directly by the Department based on the approved rates as per the Memorandum of Understanding (MoU) entered between the panel hospitals/diagnostic centers by NFC. The CHSS also provides for receiving medical attendance and treatment from any private medical practitioner or hospital during medical emergency and the reimbursement in such cases will be subject to the prescribed conditions under the CHSS to the extent admissible in terms of charges, etc., prescribed thereunder.
5. Learned counsel further contended that as per Rule 15.4 of CHSS, the beneficiary under the said Scheme should intimate to the Medical Division of DAE regarding emergency treatment availed by either for himself/herself or for the members of his/her family registered under the scheme as early as possible and in any 4 AKS,J & LNA, J W.P.No.23080 of 2024 case, within four days from the date of commencement of treatment. In the instant case, the respondent failed to comply with the said Rule and after lapse of more than three months from the date of admission in the hospital, i.e., on 25.07.2021, he sought for reimbursement of medical claim, therefore, the petitioners have rightly disallowed his claim.
6. Learned counsel for the petitioners further contended that the Tribunal erred in not taking note of the said Rule and allowed the O.A. filed by the respondent by assigning improper reasons and therefore, he prayed to set aside the impugned order dated 05.04.2022 and to pass appropriate orders.
7. Per contra, learned counsel for the respondent contended that the Tribunal taking into consideration the totality of circumstances, the conditions prevailing during Covid-19 pandemic vis-à-vis the non-availability of beds in hospital, etc., and the plight of the respondent being affected with Covid-19, has rightly allowed the O.A., which warrants no interference by this Court.
8. In the case on hand, the respondent stated that on being affected with Covid-19 severely, he approached Gandhi Hospital, Osmania Hospital and Yashoda Hospital, Hyderabad, for getting admitted for treatment, however, due to non-availability of beds, he 5 AKS,J & LNA, J W.P.No.23080 of 2024 had no other option except to rush to a hospital where he can get admission for treatment. In normal course, a reasonably prudent person would have acted only in such a manner.
9. Further, after discharge from the hospital on 03.05.2021, the respondent was under home isolation and quarantine for 45 days, as mandated by the Government and also the doctors, obviously, to prevent further infection of Covid-19 to others. Later, on 26.07.2021 he submitted medical claim for reimbursement of the expenses incurred by him for treatment. But, the petitioners declined to allow his medical claim on the ground that he failed to comply with Rule 15.4 of the CHSS.
10. Here, it is apposite to note Rule 15.4 of CHSS, which is reproduced hereunder, for better appreciation of the case:-
"The employee/beneficiary concerned should report the emergency treatment availed of either for himself/herself or for the members of his/her family registered under the scheme as early as possible and in any case within 4 days from the date of the commencement of the treatment to the Medical officer of the Dispensary where the employee should thereafter act on the direction if any given to him /her by the medical officer filling (sic failing) which no reimbursement will be allowed. In exceptional circumstances, the above condition may be waived or 6 AKS,J & LNA, J W.P.No.23080 of 2024 delay in reporting condoned by the Head, Medical Division, BARC."
11. In the instant case, the respondent being affected with Covid-19 got admitted in a non-panelled hospital for treatment, obviously, due to non-availability of beds in panel hospitals and after remaining in quarantine for 45 days, he submitted medical claim for reimbursement to the petitioners herein. Therefore, the case of the respondent falls under the exceptional circumstances, as was enumerated in Rule-15.4 of the CHSS and hence, the condition of intimating about admission of the respondent in non-panel hospital for treatment to the Medical Division of DAE within four days from the date of his admission can be waived and the delay can be condoned by the authority concerned.
12. The CHSS being a beneficiary scheme for the employees, either serving or retired, should be enforced and the medical claims should be reimbursed taking the true spirit of the said Scheme. This approach is totally missing on the part of the petitioners herein in considering the medical claim of the respondent for reimbursement.
13. Further, from a perusal of the impugned order, this Court finds that the Tribunal has rightly appreciated the case of the respondent, the circumstances/situations prevailing during Covid-
7 AKS,J & LNA, J W.P.No.23080 of 2024 19 pandemic, particularly the medical support and infrastructure at the relevant time.
14. That apart, even as per the petitioners herein, the CHSS Rules will be constantly reviewed and updated by DAE through its CHSS Review Committee and it was last revised in the year 1998. But, surprisingly, when the pandemic broke and the people were affected very seriously, the CHSS Review Committee has not taken any steps for revision of CHSS Rules, to give aid to its employees, either serving or retired, who were affected and combating with Covid-19 virus.
15. In the instant case, it is not expected that the respondent, who was affected with Covid-19 severely or his family members, being in nervous and grief, shall necessarily intimate about admission of the respondent in a non-panel hospital for treatment immediately to the Medical Division of DAE. The petitioners cannot curtail the benefit of CHSS to the respondent merely on that ground, which defeats the very purpose and objective of CHSS. In the impugned order, the Tribunal has also rightly observed so and allowed the O.A. in favour of the respondent.
8 AKS,J & LNA, J W.P.No.23080 of 2024
16. The Tribunal has also referred to the judgment of the Hon'ble Apex Court in Shiva Kant Jha Vs. Union of India 1, wherein it is held that a person cannot be deprived of reimbursement solely on the ground that the said hospital was not included in the Government Order. It is further observed as under:-
"...The real test must be the factum of treatment. Before any medical claim is honoured, the authorities are bound to ensure as to whether the claimant had actually taken treatment and the treatment is supported by records duly certified by Doctors/Hospitals concerned. Once, it is established, the claim cannot be denied on technical grounds."
17. The facts of the above case and the facts of the present case being similar, the law laid down in the aforesaid case squarely applies to the instant case. Therefore, the action of the petitioners in denying the claim of reimbursement of the respondent on the ground that he did not intimate about his admission in a non-panel hospital within four days of his admission to the Medical Division of DAE is untenable and deprecated.
18. For the foregoing reasons and apropos the grounds raised in the affidavit, the contentions put forth by the learned counsel for the both the parties, this Court has no hesitation to hold that the 1 (2018) 16 SCC 187 9 AKS,J & LNA, J W.P.No.23080 of 2024 action of the petitioners herein in rejecting the claim of the respondent for reimbursement is illegal and arbitrary. Hence, this Writ Petition fails and is liable to be dismissed.
19. Accordingly, the Writ Petition is dismissed. No costs.
20. As a sequel, the miscellaneous petitions pending, if any, shall stand closed.
_______________________________ ABHINAND KUMAR SHAVILI, J ___________________________________ LAXMI NARAYANA ALISHETTY, J Dated:10.09.2024 dr