Kerala High Court
Tribunal vs The Central Provident Fund ... on 7 April, 2017
Author: V Shircy
Bench: P.R.Ramachandra Menon, V Shircy
CR
IN THE HIGH COURT OF KERALA AT ERNAKULAM
PRESENT:
THE HONOURABLE MR.JUSTICE P.R.RAMACHANDRA MENON
&
THE HONOURABLE MRS. JUSTICE SHIRCY V.
FRIDAY, THE 19TH DAY OF JANUARY 2018 / 29TH POUSHA, 1939
OP (CAT).No. 167 of 2017
AGAINST ORDER IN O.A. NO.740/2015 DATED 7.4.2017 OF THE CENTRAL ADMINISTRATIVE
TRIBUNAL, ERNAKULAM BENCH
PETITIONER(S)/RESPONDENTS 2,3 & 4 IN O.A.
1 THE CENTRAL PROVIDENT FUND COMMISSIONER,
EMPLOYEES PROVIDENT FUND ORGANISATION,
HEAD OFFICE, 14 BHIKAIJI CAMA PLACE,
NEW DELHI-110066
2 THE REGIONAL PROVIDENT FUND COMMISSIONER -1,
EMPLOYEES PROVIDENT FUND ORGANISATION,
REGIONAL OFFICE, THIRUVANANTHAPURAM-695004
3 THE ACCOUNTS OFFICER,
EMPLOYEES PROVIDENT FUND ORGANISATION,
REGIONAL OFFICE, THIRUVANANTHAPURAM-695004
BY ADVS.SRI.N.N.SUGUNAPALAN (SR.)
SMT.T.N.GIRIJA, SC,EPF ORGANISATION
RESPONDENTS/APPLICANT & 1ST RESPONDENT IN O.A.:
1. N.SATHEESAN,
AGED 63 YEARS, S/O.P.NARAYANAN, RETIRED APFC,
RESIDING AT CRA 3A, SREECHITHIRA LANE,
VANCHIYOOR, THIRUVANANTHAPURAM
2. UNION OF INDIA,
REPRESENTED BY THE SECRETARY,
MINISTRY OF LABOUR & EMPLOYMENT,
GOVERNMENT OF INDIA, SHRAM SHAKTI BHAVAN,
RAFFI MARGH, NEW DELHI-110001
R2 BY ADV. SRI.A.R.GANGADAS, CGC
R1 BY ADV. DR.K.P.SATHEESAN (SR.)
R1 BY ADV. SRI.P.MOHANDAS (ERNAKULAM)
R1 BY ADV. SRI.S.VIBHEESHANAN
R1 BY ADV. SRI.K.SUDHINKUMAR
R1 BY ADV. SRI.MUHAMMED IBRAHIM ABDUL SAMAD
R2 BY SRI.N.NAGARESH, ASSISTANT SOLICITOR GENERAL
THIS OP (CAT) HAVING BEEN FINALLY HEARD ON 31.10.2017,
THE COURT ON 19.01.2018 DELIVERED THE FOLLOWING:
OP (CAT).No. 167 of 2017 (Z)
APPENDIX
PETITIONER(S)' EXHIBITS
EXHIBIT P1 ORIGINAL APPLICATION
EXHIBIT P2 REPLY STATEMENT FILED BY THE RESPONDENTS 2,3, &
4
EXHIBIT P3 TRUE COPY OF THE REJOINDER FILED BY THE
APPLICANT
EXHIBIT P4 TRUE COPY OF THE ORDER DATED 7.4.2017 IN O.A.NO.740
OF 2015
RESPONDENTS' EXTS:
R1A COPY OF THE ORDER DT. 21.4.2015 IN OA NO. 334/2014 OF THE CAT BANGALORE
BENCH
R1B COPY OF THE JUDGMENT DATED 30.11.2015 IN WP(C) nO.33026/2015 OF HE HIGH
COURT OF KARNATAKA.
R1C COPY OF THE ORDER OF THE HON'BLE SUPREME COURT IN SPECIAL LEAVE TO APPEAL
(CIVIL) 9294/2016 DT. 29.06.2016.
KS.
TRUE COPY
P.S. TO JUDGE
C.R.
P. R. RAMACHANDRA MENON & SHIRCY V.,JJ.
==============================
O.P.(CAT) No. 167 of 2017
==============================
Dated this the 19th day of January, 2018
JUDGMENT
Shircy V., J.
Ext.P4 verdict dated 11th April 2017 rendered by the Central Administrative Tribunal, Ernakulam Bench in O.A 740/2015 is under challenge at the instance of the respondents in the Original Application.
2. The brief facts involved in this Application are as follows: The applicant joined service in the year 1972 in the Employees Provident Fund Office ('EPFO' for short ) and retired as Assistant Provident Fund Commissioner on 31.10.2011. As per an order dated 6.11.2006, the benefit under Civil Service (Medical Attendants) Rules, 1944, ('CS (MA) Rules' for short) was extended to the retired OPCAT 167/2017 2 employees of the Provident Fund Office with effect from 24.10.2006. As such the employees and their family members are eligible for medical reimbursement. The wife of the applicant had undergone treatment on various spells incurring considerable amount but the full amount spent by him was not reimbursed. The details of the actual amount incurred for treatment and the amount reimbursed are furnished in the Tabular form as follows:
Sl.No. Date of Amount claimed Amount paid claim 1 12/10/12 Rs.28,157/- Rs.12,300/- 2 19/12/13 Rs.1,50,420/- Rs.1,22,000/- 3 28/04/15 Rs.48,349/- Rs.12,300/- 4 08/06/15 Rs.24,214/- Rs.7,213/-
3. As the entire amount claimed was not sanctioned by the authority, he submitted a representation as Annexure-
A2 with Annexure A1, as a similar claim was allowed by the Central Administrative Tribunal, Bangalore but, it was rejected stating that the claim raised by him was deviating from CS (MA) Rules. He never raised any claim deviating OPCAT 167/2017 3 from the Rules. Hence, the O.A. was filed with the following reliefs:
"i) to set aside Annexure-A3 letter
No.KR/Adm,1(7)/Medical/2015 dated 29.07.2015
issued by the 4th respondent as it is illegal and void.
ii) to issue an order or direction to the 3rd respondent to reimburse the balance amount on the medical bills out of the total claim to the applicant with interest from the respective due dates till the date of payments,
iii) to declare that the applicant is entitled for full reimbursement of the medical bills as provided under rule 6 of CS(MA) Rules, 1944.
iv) To issue such other order or direction as this Hon'ble Tribunal may be deem fit and proper in the facts and circumstances of the case''
4. The respondents /petitioners admitted that all the Central Government employees and their family members are entitled to avail medical facilities in any of the Central Government/State Government Hospitals and in the Hospitals recognized by the State Government, subject to the condition that the actual expenditure incurred or the medical expenditure at the rate fixed by the Government OPCAT 167/2017 4 whichever is less. It was contended that, though all facilities are available at the Medical College Hospital, Trivandrum, she had undergone cataract operation in a private hospital of applicant's choice, against the Rules. For implantation of pace maker(the second claim), he claimed an amount of Rs.1,50,420/-, though the hospital where the treatment was undertaken was not a recognized hospital. But considering the emergency situation and the ceiling prescribed under CS (MA) Rules, a sum of Rs.1,22,000/- was granted. The third claim was also for cataract operation of right eye of his wife and for the same, a sum of Rs.12,300/- has been granted and for the last claim of Rs.24,214/- for treatment in NIMS Hospital, Neyyattinkara, a sum of Rs.7213/- was granted as the hospital has now empanelled to undertake treatment with the facility of reimbursement.
5. Thereafter a counter affidavit was filed by the applicant and produced Ext.R1(a), true copy of the order of OPCAT 167/2017 5 the CAT, Bangalore Bench in O.A. No. 334/2014 and Ext.R1(b) the order of the High Court of Karnataka confirming Ext.R1(a) order. Ext.R1(c) is a copy of the order of the Supreme Court dismissing the Special Leave Petition filed against Ext. R1(b)resulting confirmation of the said order. The learned counsel for the applicant has submitted that by dismissal of the S.L.P by the Apex Court, the matter has now become final and the issue has been settled. Relying on these decisions, the learned counsel for the applicant would submit that the part payment effected by the respondents is not correct and he is entitled to get full reimbursement .
6. Admittedly, the retired employees of EPFO are granted the benefits of medical reimbursement with effect from 24.10.2016 as per an order dated 6.1.2006.
7. Before adverting to the rival contentions, it would be apt to refer to the relevant provisions of CS(MA)Rules. Treatment is defined in Rule 2(h) of the CS(MA)Rules, as OPCAT 167/2017 6 follows:
(h) "Treatment" means the use of all medical and surgical facilities available at the Government hospital in which the Government servant is treated and includes
(i) the employment of such pathological, bacteriological, radiological or other methods as are considered necessary by the authorized medical attendant.'' Rule 6 of the said rules is as follows:
" Rule 6 (1)- A Government servant shall be entitled, free of charge, to treatment(a) in such Government hospital at or near the place where he falls ill as can in the opinion of the authorised medical attendant provide the necessary and suitable treatment; or (b) if there is no such hospital as is referred to in sub- clause (a) in such hospital other than a Government hospital at or near the place as can in the opinion of the authorised medical attendant, provide the necessary and suitable treatment;
Rule 6(2)- Where a Government servant is entitled under sub-rule (1), free of charge, to treatment in a hospital, any amount paid by him on account of such treatment shall, on production of a certificate in writing by the authorised medical attendant in this behalf, be reimbursed to him by the Central OPCAT 167/2017 7 Government.
Provided that the Controlling Officer shall reject any claim if he is not satisfied with its genuineness on facts and circumstances of each case, after giving an opportunity to the claimant of being heard in the matter. While doing so, the Controlling Officer shall communicate to the claimant the reasons, in brief, for rejecting the claim and the claimant may submit an appeal to the Central Government within a period of forty-five days of the date of receipt of the order rejecting the claim."
8. It is significant to note that the respondents have not totally denied the claim raised by the applicant, but part payments have been effected for all the four claims scheduled in tabular form in the petition. During the pendency of this petition, as per an interim order of this Court dated 17.10.2017, the parties produced the Government Order dated 15.03.2001, which would show that the Government has given approval to SP Fort Hospital, Thiruvananthapuram (as Sl.No.35) along with some other hospitals for Thorasic Surgery and Orthopaedics to claim reimbursement facility for availing treatment if the patient is OPCAT 167/2017 8 referred by an authorised Medical Attendant. So also as per a Government Order issued by the Health and Family Welfare Department (dated 22.04.2013), NIMS Hospital Neyyattinkara is also empanelled as a recognized hospital where reimbursement facility is provided. The file regarding the reimbursement claim of the applicant has been produced by the department. On a perusal of this file, it is revealed that the patient was undergoing treatment in the cardiology department at SP Fort Hospital from 15.2.2011. She was referred to NIMS Hospital for implantation of pace maker by the Cardiologist of SP Fort Hospital as the instrument for implantation was not stocked/available at this hospital at that point of time. Therefore implantation of pace maker was done at NIMS Hospital, Neyyattinkara.
9. The main grievance projected by the applicant is that though he is entitled for reimbursement of the actual amount paid by him for treatment of his wife in various hospitals recognized by the Government to undertake OPCAT 167/2017 9 treatment of the employees entitled to get the benefit, it was illegally denied by the respondents. As mentioned above, the applicant has contended that as per Ext.R1(a) order, the Central Administrative Tribunal, Bangalore, has held that the employees have to be paid the actual amount spent for treatment as per CS(MA)Rules and by R1 (C) the issue involved therein has become final.
10. In the instance case out of the four claims the major claim is for the implantation of pace maker at NIMS Heart Foundation Neyyattinkara. Though the claim was for a sum of Rs.1,50,420/-, only an amount of Rs.1,22,000/- was granted on the ground that the maximum ceiling of pace maker is Rs.1,15,500/-. The implantation of pace maker was, as referred by the cardiologist of SP Port Hospital, Thiruvananthapuram, which is a recognized hospital as it is empanelled in the list of recognized hospitals as per G.O. dated 15.03.2001 of the Health & Family Welfare Department. Hence, it is not proper to deny the OPCAT 167/2017 10 claim stating that NIMS Hospital was empanelled only in the year 2013. It is important to note that the respondents have not denied the claim but on the finding that maximum ceiling of pace maker is Rs.1,15,500/- refused reimbursement of the full amount. No such ceiling limit is seen prescribed under the Rules. Moreover, since part payment was effected, it is not legally correct to deny the actual amount spent on the ground that the amount claimed exceeded the ceiling limit and hence the applicant is entitled to get the full amount incurred for implantation of pace maker.
11. Though an amount of Rs.28,157/-was claimed for treatment for cataract operation undergone in Chaithanya Hospital, Trivandrum, the claim dated 12.10.2012 was not fully reimbursed as the operation was not performed in the nearby Government hospital. Of-course Chaithanya Hospital was empanelled to facilitate medical reimbursement benefits as per G.O dated 22.4.2013, (after the surgery). As part OPCAT 167/2017 11 payment was effected for the said claim, we deem it appropriate to direct reimbursement of the full amount. For the 3rd claim for cataract surgery also, part payment was effected. If the applicant was not entitled for reimbursement, part payment would not have been effected by the respondents. So there is no justification for denying the full amount claimed.
12. So also the last claim of Rs.24,214/- for reimbursement for treatment in connection with cardiac problem at NIMS Hospital, Neyyattinkara, was found admissible as by that time the hospital was empanelled for reimbursement for treatment under CS(MA) Rules. But for the same also only Rs.7200/- was granted stating that the ceiling limit would entitle for reimbursement, only for that much amount.
13. When treatment is afforded to those who are entitled to get reimbursement from the empanelled hospitals, no restriction can be imposed by effecting part OPCAT 167/2017 12 payments under CS(MA) Rules in the light of the decision of the Supreme Court in a similar matter, which has become final as per Ext.R1(c) dated 29.6.2016.
14. More importantly, Rule 6(1)(2) makes it clear that 'any amount 'paid by the Government Servant entitled under Rule (1) is eligible for reimbursement subject to the conditions enumerated therein. So also proviso to Rule 6 of CS(MA) Rules says that, only if the controlling officer is not satisfied with the genuineness on facts and circumstances of case, that too after affording an opportunity of being heard could deny the claim. Effecting part payment of the claim itself is a ground to presume that the genuineness of claim is not in dispute. No ceiling limit is also prescribed. The materials produced indicate that when there is no doubt regarding the genuineness of bills submitted for reimbursement, denial of a portion of the amount claimed asserting that there was deviation to the relevant Rules is quite unjustifiable and illegal.
OPCAT 167/2017 13
15. Therefore, the verdict of the Tribunal that the applicant is entitled for full reimbursement of the claim submitted by him for treatment of his wife under the provisions of Rule 6 of CS(MA)Rules warrants no interference. Disburse the balance amount due without any interest at the earliest, at any rate within a period of one month from the date of receipt of a copy of this judgment.
Dismissed.
Sd/-
P. R. RAMACHANDRA MENON JUDGE Sd/-
SHIRCY V. JUDGE ks.
True copy P.S. To Judge