Central Administrative Tribunal - Delhi
Shri B.L. Sharma vs Municipal Corporation Of Delhi on 12 December, 2011
CENTRAL ADMINISTRATIVE TRIBUNAL PRINCIPAL BENCH OA No.942 of 2011 New Delhi this the 12th day of December, 2011 Honble Dr. Dharam Paul Sharma, Member (J) Shri B.L. Sharma, S/o Late Shri Bhikeem Lal Sharma, R/o D-16, Mansarovar Park, Shahdara, Delhi. .... Applicant ( By Advocate Shri Rajeev Sharma ) VERSUS 1. Municipal Corporation of Delhi, Through its Commissioner, Dr. S.P. Mukherjee Civic Centre, J.L. Marg, New Delhi. 2. The Commissioner, Municipal Corporation of Delhi, Dr. S.P. Mukherjee Civic Centre, J.L. Marg, New Delhi. .. Respondents ( By Advocate Shri Ravi Kant Jain ) O R D E R
The applicant is working with the respondents Corporation as Assistant Engineer and in that capacity he is entitled to medical treatment/reimbursement under MCD Rules. MCD is having 37-38 hospitals within the territory of Delhi and MCD employees are required to have treatment in MCD hospitals. However, in case facility/treatment is not available as required by an employee in these hospitals, a list of hospitals approved for such treatment for which medical reimbursement is permissible. In 2009, the applicant has developed pains in his legs for which he consulted Swami Daya Nand Hospital of the respondents Corporation. Doctor in that hospital examined the applicant, namely Dr. Harpreet, who advised the applicant to have Colour Doppler X-ray. Upon examination of report of Colour Doppler X-ray, the doctor attending the applicant opined that the applicant required surgery of vascular vein which was not available in any of the hospitals of the Corporation. The applicant claims that this is also heart related surgery as these veins allow blood to go to the heart. The doctor of the respondents Corporation referred the case of the applicant to MDC approved centre for vascular vein surgery. The applicant picked up a list of private hospitals approved by the respondents Corporation and found at serial No.1 Escorts Heart Institute & Research Centre Ltd., (for short Escorts Heard Institute), Okhla Road, New Delhi for Specialised Cardiological services, including cardio-thoracic surgery and diagnostic purposes (laboratory, MRI, CT scan, USG, Colour Doppler, X-ray). The applicant, who had earlier got done Colour Doppler X-ray is not claiming reimbursement of expenses incurred by him towards X-ray of his legs. On 26.10.2009, the applicant visited the Escorts Heard Institute where one Doctor Ashok Gupta approved to undertake surgery of the applicant by Endoverous lasser surgery and accordingly, admitted the applicant on 2.11.2009. The operation of the applicant was conducted on 4.11.2009 and he was discharged on 5.11.2009. The total payment of Rs.74,623/- was made by the applicant to the said Escorts Heard Institute. Details of which are Rs.60,000/- on 2.11.2009, Rs.10,000/- on 3.11.2009 and Rs.4623/- on 5.11.2009. The actual cost of operation of the applicant came to Rs.70,301/-. The excess payment made by the applicant was, therefore, refunded to the applicant. On 19.11.2009, the application for reimbursement of Rs.70,301/- was made by the applicant. On 10.12.2009, the respondents have asked to applicant to furnish certain papers along with his application. On 16.12.2009, the applicant annexed necessary papers with his application. The applicants claim was, however, rejected on the ground that Escorts Heard Institute is on panel for Cardiolosis Surgery and not for vascular surgery. The applicant inquired about the hospitals on the panel of the corporation approved for vascular surgery undergone by the applicant but of no avail. On the request of the applicant his case was re-considered by the Expert Committee. This too rejected the applicants claim on 4.2.2010. The applicant then moved to Deputy Commissioner. From the official noting in this regard, it is seen that the applicants case was recommended for reimbursement since required treatment was not available in the hospitals of the Corporation, a copy of the extracts of this noting is at Annexure III, which reads as follows:-
As discussed, the list of recognized Private Hospital for approved by the MCD for beneficiaries of municipal employees is attached on page 28/C to 32/C. On go through this list, there is no specified private hospital under recognized list by the MCD, where only such facility for Endovendous Laser Surgery are available. The Escorts Heart Institute & Research Centre Ltd., Okhla Road, New Delhi is in the panel of MCD recognized private hospital. After advising of the treating Dr./Specialist of Swami Daya Nand Hospital Shri B.L. Sharma, ASW-I/SH-N have take the medical facility from Escorts Heart Institute & Research Centre Ltd., Okhla Road, New Delhi.
2. Thereupon another Expert Committee was constituted but the case of the applicant was again rejected. The minutes of this Committee have been referred to earlier in this order, a copy of which is at Annexure A-I. The legality and correctness of this is being challenged by the applicant on the grounds taken in Para 5 of the Application. It has been contended by the applicant that as on date treatment/facility, which is required by the applicant, is not available in any of the hospitals of the respondents Corporation. He was recommended the prescribed surgery by the doctors of the Corporations hospital. The applicant has taken treatment as per his entitlement and in accordance with the list which is not in dispute in the present case. The only objection is that he has taken treatment from a wrong hospital whose name, though in the list of approved hospital was not approved for the particular surgery undergone by the applicant.
3. Opposing the applicants claim, the respondents in their counter reply reiterated the grounds on which the applicants claim has been rejected. It has thus been submitted that the doctor of the respondents Corporation has referred the case of the applicant to approved centre for varicose vein surgery. Varicose vein surgery is a vascular surgery for which Delhi Heart & Lung Institute and R.L.K.C. Hospital & Heart Institute are approved. Since he has taken treatment at Escorts Heard Institute, which was not a recognized hospital for the vascular vein surgery though its name is in the list of approved private hospitals for different purposes. The respondents have also taken a preliminary objection to the effect that the Application is being bad for non-joinder of necessary party as the Chair person of the Committee who rejected his claim has not been impleaded as a party. Further as per Circular No.Addl. MHO[M]/2007/1352 dated 1.8.2007, MCD employees are extended medical facilities in recognized private hospitals as per CGHS approved rates only if they have been referred except in cases of emergency. The applicant was diagnosed as a case of Bilateral Varicose Vein and had neither taken the treatment i.e. vascular surgery in the recognized hospital by the respondents for that purpose nor it was a case of emergency and, therefore, the applicant is not entitled for reimbursement. ]
4. The applicant has filed his rejoinder stating that no details have been furnished as to when the Chair person rejected his claim which would warrant his impleadment. Furthermore, the circular referred to by the respondents in support of their objection does not oust the claim of the applicant for his claiming reimbursement at the CGHS rates.
5. At the hearing learned counsel for the applicant submitted that the rates for Escorts Heard Institute as well as the other two hospitals, namely, Delhi Heart & Lung Institute and R.L.K.C. Hospital & Heart Institute are the same. It has further been submitted that rates charged by all these Hospitals are at par with CGHS rates. The names of all these three hospitals clearly indicate that they are heart hospitals. The learned counsel for the applicant strongly contended that the applicant is an Engineer and is not well versed with the intricacies of the medical science. In the list of approved hospitals, name of Escorts appears at Serial No.1. A plain reading of the entry clearly indicates that Escorts Heart Institute & Research Centre Ltd., Okhla Road, New Delhi is running special services, including cardio-thoracic surgery and diagnostic purposes. The Escorts is a specialized institution running special services. The treatment including is indicative of the fact that diseases mentioned therein are not exhaustive. The applicant is being under the bonafide impression the special services rendered by the Escorts hospital, including surgery he has undertaken. The applicant has filed a copy of detailed bill by means of additional affidavit wherefrom it is seen that Vascular is a specialized wing of Escorts hospital. The applicants consulting doctor has been Dr. Ashok Gupta, specialized in Vascular. It has further been seen that the bill clearly indicates that the applicant has been charged at the CGHS rates. That being so, there is no justification for rejection of the claim of the applicant for medical reimbursement to which he is otherwise legally entitled.
6. The learned counsel for the respondents reiterated the averments made in the counter affidavit. It has thus been contended that although Escorts Hospital is a recognized hospital by the respondents Corporation but it is recognized only for the diseases mentioned in the list as at Annexure A-II. Therefore, Escorts hospital is not recognized for vascular vein surgery which the applicant has undertaken.
7. I have given my careful consideration to the respective submissions made by both the parties. I have carefully perused the records of the case.
8. Admittedly, Escorts is recognized for rendering special services including cardio-thoracic surgery and diagnostic purposes, the terms including is indicative of the fact that the diseases for which the Escorts Heart Institute is recognized by the respondents. If the diseases mentioned therein are only diseases for which Escorts Heart Institute has been recognized by the respondents, the use of words special services including are redundant and superfluous as the subject mentioned of diseases by itself would have been sufficient for the purpose. The learned counsel for the respondents was unable to specify as to what are those special services, which are being rendered by Escorts Heart Institute. The Escorts Heart Institute is a renowned Institute for cardiologic treatment. However, the treatment cardiology is not mentioned in the entry at Serial No.1 pertaining to Escorts Heart Institute. The respondents case is that R.L.K.C. Hospital & Heart Institute is recognized hospitals for the treatment which the applicant has undergone. In Serial No.16 against the name of the hospital diseases mentioned are Cardiology and Cardiothoracic Vascular Surgery. Cardiothoracic surgery mentioned at Serial No.1 pertaining to Escorts Heart Institute does not refer to Cardiothoracic vascular surgery. The omittion of the wor vascular in the case of Escorts Heart Institute vis-`-vis R.L. K.C. Hospital and Heart Institute in Entry 16 where Cardiothoracic vascular surgery is used gives rise to bonafide doubts as to whether two treatments referred the same treatment or really means the different treatments. As against this, entry 15 pertaining to Delhi Heart & Lung Institute referred Cardiology vascular Surgery without making any mention of cardiothoracic whereas the respondents stated that Delhi Heart & Lung Institute is recognized for treatment undertaken by the applicant. By necessary implication, they admit that cardiology vascular surgery is the same as that of cardiothoracic vascular surgery. There is indeed ambiguity writ large in the list of recognized private hospitals of MCD beneficiaries, especially with regard to treatment for which hospitals mentioned therein are particularly recognized by the respondents Corporation. There are indeed certain entries wherein certain hospitals are recognized for general purposes as well as certain specialized treatments. Once the hospitals are recognized for general purposes that would also include specialized treatment rendered by them as well. In such a case, it would not be proper to confine the recognition to the treatment specifically mentioned, including import such as general or special services. The respondents Corporation needs to have re-look in the matter to dispel these ambiguity causing avoidable inconvenience and litigations in its application. In such a scenario, the doctor and respondents hospitals advising treatment from the approved centre for the reason of it not been available in the Corporations hospitals should have mentioned the name of the approved recognized hospital for the recommended treatment rather than leaving it to be judged by an individual beneficiary/patient to the risk of choosing wrong approved hospital which might lead to denial of benefit of reimbursement of expenses incurred for such a treatment. In any case, Escorts Heart Institute confirmed in which the applicant has availed treatment on the one hand and two hospitals which the respondents claims are recognized by the respondents Corporation for the treatment undergone by the applicant are of Heart specialized institutes and hospitals. All of them are recognized in their own right and providing the treatment which has been availed by the applicant. All the three of them are charging the same rate at par with CGHS rates. The respondents under Scheme confined reimbursement of expenses as per the CGHS approved rates. There is nothing to show that the Escorts Heart Institute is not adequately equipped and competent as the other two institutes, namely, Delhi Heart & Lung Institute and R.L.K.C. Hospital & Heart Institute in the conduct of cardiothoracic vascular surgery. In any case, the official noting as at Annexure-III indicative of the merits of the applicants claim which would call for reimbursement of medical expenses incurred by the applicant even as a special case, particularly, in view of the fact that on going through list it was found that there is no specific private hospital under the recognized list of MCD, where only such facility for Endovendous Laser Surgery was available. As a matter of fact, Escorts Heart Institute was in the panel of MCD recognized private hospitals and the applicant has taken treatment from this institute after receiving advice of the doctor/specialist of Swamy Daya Nand Hospital. From this one can see that the applicant suffered from a disease for which he took treatement from MDC hospital itself, namely, Swami Daya Nand Hospital. In the opinion of consulting/specialist there attending the applicant in Swami Daya Nand Hospital that the applicant required surgical treatment which was not available in the MCD hospital and, therefore, advised the applicant to have it from any private recognized hospital and having availed necessary treatment, he was charged at the CGHS rates and is claiming reimbursement accordingly. Even if he had availed this treatment from any other private hospital in the approved list, the amount that could have been reimbursed the same, i.e., as per the approved CGHS rates. In these premises, I do not find any warrant or plausible reasons for the respondents to deny the claim of the applicant. I would have appreciated if the respondents, particularly, Members of the Expert Committee constituted by the respondents Corporation from time to time would have taken more pragmatic view in the matter. In any case, the MCD Corporation would do well to remove from the list with a view to remove difficulty experienced in the working over a period of time with a view to done away the unnecessary inconvenience to its intended beneficiaries and to avoid multiple litigations.
9. In the facts and circumstances of the case, I do not find any justification in the stand taken by the respondents to deny reimbursement of medical expenses incurred by the applicant. I would have allowed interest on the amount claimed by the applicant but for ambiguity and uncertainty in the operation of list of recognized hospitals, I therefore do not award interest as claimed by the applicant. However, I allow this OA to the extent that the impugned order dated 28.10.2010 is quashed and set aside and the respondents are directed to reimburse the expenses incurred by him towards his treatment in the light of the observations made above. The respondents are directed to make the payment within two months from the date of receipt of a certified copy of this order. If the reimbursement is not done within aforesaid period, the applicant is entitled to interest @ rate of 8% per annum from the date of expiry of two months of receipt of a certified copy of this order till the date of actual payment. No costs.
(Dr. Dharam Paul Sharma) Member (J) /ravi/