Central Administrative Tribunal - Mumbai
Subhash Chandra Shivprasad Bajaj vs M/O Railways on 4 June, 2018
1. OA No.134/2016 CENTRAL ADMINISTRATIVE TRIBUNAL MUMBAI BENCH, CAMP AT NAGPUR.
ORIGINAL APPLICATION No.134/2016.
Dated this Monday the 4" day of June, 2018 CORAM: HON'BLE SHRI ARVIND J. ROHEE , MEMBER (J) Subhash Chandra Shivprasad Bajaj, Age 70 years, 15-A, Ex. Supdtt Typing, F.A. & C.A.O. (Admn), Central Railway, Mumbai CST.
R/at 15-A, Pandrinath Nagar, Jamner Road, | Bhusawal- 425201. wae Applicant.
( By Advocate Shri Vicky A. Nagrani) VERSUS
1. The Union of India Through the General Manager Central Railway, CSTM, Mumbai-1.
2. Divisional Financial Manager Central Railway, Bhusawal Division, Bhusawal-425201,
3. F.A.& CAO, Mumbai Central Railway, CSTM, Mumbai-1.
4, Chief Medical Director, Central Railway, CSTM, Mumbai-1l.
9. Chief Medical Superintendent, Central Railway Hospital, Bhusawal Division, Bhuswal-425201, wae Respondents (By Advocate Shri V.S. Masurkar) yo (eA E Sae oes 2 QA No. 134/2016 ORDER _ The applicant Superintendent Railway, CST Mumbai respondent No.4, under Section 19 Tribunals Act, 1985 reliefs:-
"2 (A) for the from examining the aside impugned 13.05.2015 ; who Typing, approached of retired as FA&CAO, Central while working under this Tribunal the Administrative seeking the following This Hon'ble Tribunal may graciously be pleased to records respondent same, cail of the case and after quash set orders dated with all consequential benefits.
(B) This further be the respondents applicant Rs.3, 63, 630/-
towards medical interest 13.08.2015.
@12% (C} Costs of be provided for.
(D} Any Hon'ble pleased to reimbursement expenses other Tribunal may direct to pay to the amount of and 25,541/-
of alongwith p.a. w.e.f, the application and further orders as this Hon'ble Tribunal deems fit in circumstances passed."
2. The applicant, superannuation on Retired Employees Vv of the 30.11.2005, the and be nature case after retirement on opted for Liberalized Health Scheme Se Eee a eens 3 OA No.134/2016 (RELHS) floated by Railways. After retirement, the applicant started residing at his native place Bhusawal in Jalgaon District. The applicant being member of RELHS, the amount is being regularly deducted from his monthly pension.
3. On 14.02.2015, the applicant had been to Jalgaon to attend some religious function. He suddenly fell ill since started suffering uneasiness and severe pain in chest and back coupled with giddiness, breathlessness and sweating. He was, therefore, immediately taken to the nearest private hospital i.e. Orchid Hospital at Jalgaon by his son. On his examination, the applicant was advised to undergo Coronary Angiography which was done on emergency basis in the said hospital, in which almost 95% biockage in the arteries was detected. The doctor who attended the applicant advised to shift him immediately for undergoing Cardio Thoracic and Vascular surgery (By pass surgery) at Pune. The applicant was, therefore, immediately shifted to Deenanath Mangeshkar Super Multispeciality Hospital and Research Centre at Pune in 4 OA No. 134/2016 Ambulance where he was admitted and on the next date i.e. 17.02.2015. By-pass surgery was undertaken. The applicant was discharged from the said hospital on 04.03.2015. He incurred Rs.3,63,630/- at Deenanath Mangeshkar Hospital for the treatment of surgery and Rs.25,541/- for carrying investigations at Orchid Hospital, Jalgaon.
4. The applicant then submitted the application in the prescribed format on 31.05.2015 to the respondent No.5 claiming reimbursement of the aforesaid expenses incurred by him, by annexing all the relevant medical papers, vouchers etc. However, by the impugned order dated 13.08.2015 (Annexure A-1), the respondent NO.3 rejected the claim on the ground that at does not fulfill the requirement of essentiality for treatment in a private health care facility. Hence, the present OA.
5. The impugned order of rejection has been Challenged mainly on the ground that the applicant was admitted under emergency in a private hospital, where he has undergone the By-pass surgery and hence, he is entitled to 5 OA No. 134/2016 reimbursement of all the expenses incurred he being the REHLS beneficiary. However, it was wrongly rejected on the ground that the applicant does not fulfill the requirement of essentiality for treatment in a private hospital. It is also stated that since 95% blockage in artery was revealed, there was imminent threat to his life and hence he was required to be admitted in a private hospital. It is stated that pensioners should not be deprived of medical facilities in their old age, when they require them most. The OA is, therefore, liable to be allowed by quashing the impugned order of rejection of claim for medical reimbursement.
6. The respondents vide reply dated 25.04.2016 resisted the OA in which all the adverse averments, contentions and grounds raised therein are denied. It is stated that the applicant on his own accord went to Pune and had undergone By-pass surgery there on 17.02.2015. it is stated that had the applicant visited CMS, Bhusawal, he would have been referred to empanelled hospital INDO American Hospital in Jalgaon itself for taking RN ES ON Ten 6 OA No. 134/2016 the necessary treatment. However, the applicant, without reference of CMS, Bhusawal, voluntarily got himself admitted in a private hospital at Pune and, hence the expenses incurred cannot be said to be in furtherance of getting emergent treatment. The claim is, therefore rightly regretted and consequently the OA is liable to be dismissed.
7. It is stated that after scrutinizing the documents submitted by the applicant alongwith his application for medical reimbursement, no emergency was proved necessitating treatment in a private hospital and for not consulting Railway doctor at Bhusawal, which was necessary as per the Railway Rules, before getting himself admitted in a private hospital.
&. It is stated that the applicant was admitted in a private hospital at Jalgaon on 14.02.2015 at 11.06 am when he complained of severe back pain and he was admitted for CAG (Coronary Angio Graphy). No treatment for any heart attack was given. His vitals were Stable. No thrombolytic treatment was given and immediately CAG was done. Its report i ei cine 7 OA No. 134/2016 suggested significant triple vessel disease and CABG was advised. No emergency is stated in the said report. The applicant was discharged from the sald hospital on 15.02.2015 at 5.30 pm. It is stated that the applicant could, undertake nine hours road journey to go to Pune and, as such, he could have very well come to Bhusawal which was just 29 Kms away from Jalgaon, to consult Railway Hospital for reference to Private Hospital. It is stated that Railway has a tie-up with Indo- American Heart Institute, Jalgaon where all Railway patients are referred for necessary treatment, where heart surgeries and procedures are done.
3, It is stated that 2 D-echo was done on 16.02.2015 which suggested no abnormality and there was no emergency as such. The applicant has not given reasons as to why he did not consult Railway hospital before a decision was taken to shift to Private Hospital at Pune.
10. It is stated that Retired Railway servants are entitled to avail medical facilities under RELHS at Regional Railway Hospitals but not in private hospitals, EES SPSS GEE 8 OA No. {34/2016 except when referred by the competent authorities of Railway hospital as per rules. Since the same has not been done in the present case, the OA is liable to be dismissed.
11. It is stated that reimbursement of expenses incurred for treatment in private hospital can be allowed only if it is proved that it was emergency and essential for patient at the given moment. In other words, planned and non-emergent cases are not agreed upon. In this behalf, reliance is placed on Railway Board's letter dated 31.01.2007 (Annexure R-1). The OA is, therefore, liable to be dismissed since no emergency was proved.
12. On 04.04.2018 when the matter was taken up, heard Shri Vicky Nagrani, learned Advocate for the applicant and the reply arguments of Shri V.S. Masurkar, learned Advocate for the respondents.
13. I have carefully gone through the entire case record including the pleadings of the parties and documents produced on record. Findings
14. The only controversy involved for iii a oe 9 OA No. 134/2016 resolution of this Tribunal in the present OA is whether the impugned order rejecting applicant's claim for medical reimbursement is liable to be set aside being illegal, improper ox incorrect on the grounds alleged by the applicant.
15. It is not disputed that the applicant is retired Central Government (Railway) employee and he opted for RELHS which is floated by Railways for the benefit of its serving and retired employees. For the Central Government servants working in other departments, Central Government Health Scheme is applicable to them for serving as well as retired employees on deduction of prescribed charges so that they can get medical treatment free of cost from the CGHS wellness centres available at a particular station. Further, claim for medical reimbursement is governed by the provisions of Central Services (Medical Attendant) Rules, 1944,
16. It 1s obvious that if the medical facility ais not available at the RELHS hospitals or CGHS wellness centres, the employees can be referred to the notified 10 OA No. 134/2016 private hospitals for getting the treatment and charges are reimbursed as per the 'rates prescribed. There is also a provision for getting medical treatment, if required to be undertaken in emergency situations in any other private hospital after satisfying certain conditions.
17. In the present case, the applicant has admittedly secured medical treatment in private hospitals firstly at Jalgaon and thereafter at Pune. Both the aforesaid hospitals namely Orchid Hospital, Jalgaon and Deenanath Mangeshkar Super Multispeciality Hospital and Research Centre, Pune are not notified hospitals under the said RELHS by the Railways.
18. It is not disputed that the applicant has undergone the angiography and thereafter he was advised to undergo the By-pass surgery, since in some artery, 95% blockages were found. The applicant placed reliance on the certificate dated 27.05.2015 (Annexure A-5) issued by Pune hospital where he was admitted on 16.02.2015, which according to him having .
been issued for emergency medical treatment, 11 OA No.134/2016 he is entitled to reimbursement of full amount incurred by him towards medical treatment. The said certificate reads as under:-
"Date: 27.05.2015 TO WHOMSOEVER IT MAY CONCERN EMERGENCY ADMISSION CERTIFICATE THIS IS TO CERTIFY THAT MR/SMT Bajaj] Subhas Chandra Shivprasad WHO IS UNDER THE TREATMENT OF DR Jagtap Ranjit FOR Coronary Artery Disease DM, HTN, went CABG IS/WAS ADMITTED IN DEENANATH MANGESHKAR HOSPITAL ON 16.02.2015.
RENCE THIS CERTIFICATE OF EMERGENCY ADMISSION.
C.M.O. L.M.M.EF'S DEENANATH mANGESHKAR HOSPITAL Erandwane, Near Himali Society, Pune 411 004."
19. It is not disputed that prior to admission at Pune hospital, the applicant has undergone some investigations viz. CAG at Jalgaon Hospital. Tt is stated by the respondents that at Jalgaon, Indo American Hospital for treatment of heart disease is available, which is the empanelled hospital for Railways employees and as such the 12 OA No.134/2016 applicant should have approached the said hospital since he is member of RELHS. He failed to do so. It is also obvious from record that the applicant did not get himself referred by the Railway Hospital Bhusawal either to any empanelled or other private hospital. He started residing at Bhusawal after retirement and straight way went to Pune at a distance of about 450 kms for getting himself admitted in non-empanelled private hospital there for further treatment. The applicant has undergone By pass surgery on 17.02.2015. There is nothing on record to show that after admission for investigations at Jalgaon hospital or for medical treatment at Pune hospital, the applicant had taken any steps to give written intimation to Railway hospital of Bhusawal, to which he was attached for receiving the medical facility.
20. As such, it is obvious that the applicant suo-moto and without bothering to intimate the Railway Hospital Bhusawal regarding his ailment got himself admitted as &@ private patient in both the hospitals at Jalgaon and Pune since there is nothing in the 13 OA No. 134/2016 medical certificates or documents produced by the applicant from those hospitals to _ show that he was referred by Railway hospital, Bhusawal or by empanelled Indo-American Hospital Jalgaon to Pune hospital for By-pass surgery. Not only this, it 1s pointed out by learned Advocate for the respondents that when the applicant was admitted in Orchid hospital Jalgaon on 14.02.2015 at 11.06 am _ since started feeling uneasy with chest pain, the admission certificate only states that the applicant complained of severe back pain and he was admitted for CAG. The discharge certificate also does not state any other complaints. It is also stated that his vitals were stable and no treatment on suffering heart attack was given to the applicant there. In the facts and circumstances of the case, learned Advocate for the respondents submitted that it cannot be said that there was any emergency as such in the real sense for getting the applicant admitted in private hospital without reference from Railway Hospital for heart treatment. Simply because the admission certificate issued by Pune , Va iii ia a ae 7 14 OA No.134/2016 hospital styled as "Emergency Admission Certificate", it cannot be said that the applicant's condition was so critical that it Was not possible or that there was imminent danger to his life if not treated immediately. There is also nothing on record to show from the symptoms noted at Jalgaon hospital or Pune hospital that the applicant has suffered from heart stroke and it was necessary to undertake By-pass Surgery urgently. Normally after undergoing coronary angiography in which blockages are located, the angioplasty is undertaken with stent implantation to overcome the biockages to ensure smooth blood supply to heart. However, the hospital at Jalgaon did not undertake angioplasty and straight way Coronary Artery By pass Grafting (CABG) was advised. This being so, this Tribunal finds substantial force in the contentions of the learned Advocate for the respondents that it was not in fact the case of acute emergency, necessitating admission in private hospital.
2i. The above position is corroborated with the certificate dated 27.05.2015 issued by Pune hospital which nowhere states that there 15 OA No. 134/2016 was any sort of emergency and on the contrary it states that the applicant was admitted as a routine patient and he was operated for CABG. The entire text of the said medical certificate is reproduced here for ready reference:-
"MEDICAL CERTIFICATE Patient Name:Mr. Bajaj Subhaschandra MRD# : 638886 SHIVPRASAD Age: 69Y 3M 11D sex: Male Visit Code: IP0001 Date:10.03.2015 TO WHOMSOEVER IT MAY CONCERN This is to certify that Mr. Bajaj Subhaschandra Shivprasad was admitted in this hospital on 16.02.2015 as a routine patient and was suffering from K/C/O CAD, DM, HTN and was under care of Dr. Ranjit Jagtap and Dr. Amit Walimbe, He was operated for Coronary Artery bypass Graft-CABG on 17.02.2015.
He was discharged on 04.03.2015.
He is advised regular medicines and periodic follow up and assessment.
ee a 16 OA No. 134/2016 Signature:
Name of the Dr. Ranjit Jagtap Reg. No. :48973."
22. During the course of arguments, learned Advocate for the respondents relied upon the communication dated 31.01.2007 (Annexure R-1) issued by Railway Board to all the General Managers styled as 'reimbursement of medical expenses ~ procedure of disposal'. It clearly states that to provide medical treatment, the Indian Railway Health Care Delivery System has 121 Railway Hospitals and 586 Railway Health Units established All Over India. In addition to this, all Government Hospitals and more than 115 private hospitals all over the country have been recognised to provide necessary medical treatment to Railway beneficiaries. The said communication also describes "emergency" in the following words:-
"Emergency" shall mean any condition or Symptom resulting from any cause, arising suddeniy and if not treated at the early convenience, be detrimental to the health of the patient or will jeopardize the list of the patient. Some examples are Road accidents, other types of accidents, acute heart attack etc. Under such conditions, when the Railway beneficiary feels that there is no scope of reporting I ES Sea i7 OA No.134/2016 to his/her authorized Railway Medical Officer and avails treatment in the nearest and suitable private hospital reimbursement claims are to be processed for sanction, after the condition of the emergency iS con...... by the authorized Railway medical officer ex-postfacto."
23. In order to establish the emergency condition, certain parameters are also laid down therein to be examined by the Medical Officer of Railway hospitals before declaring that there was an emergency. For calculation of the amount of reimbursement to be sanctioned out of the claimed amount, the following guidelines are prescribed:-
"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) - Preatment taken in Govt. Hospital ~ Full admissible amount be recommended for sanction.
Db) 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 a 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 Govt. Health Scheme) approved rates are to be recommended/ processed as an upper dimit for Si ee ae a i8 OA No.134/2016 sanction."
24, It is obvious from record that on submission of the application for copies of reimbursement alongwith the medical case papers, it was examined by the Medical Officer of Railway Hospital and then it was found that it was not a case of emergency. It can safely be said that medical expert is the best person to take a rational decision and this Tribunal is not expected nor empowered to review it. As such, it will have to be relied upon, unless countered by other side by producing reliable evidence in rebuttal. The same has not been done in the present case.
25. It is also obvious that the applicant has taken medical treatment in a non- recognised private hospital, although there WaS no accute emergency as such and further the applicant failed to give any intimation to the Railway Hospital, Bhusawal to which he was attached after he was admitted in the hospital at Pune and till he submitted the claim for medical reimbursement. However the applicant will be entitled to reimbursement of the expenses incurred by him at CGHS approved i aw 19 OA No, 134/2016 rates and not as claimed by him.
26. During the course of arguments, learned Advocate for the applicant relied on Central Services (Medical Attendant) Rules, 1944, Reliance on the decision rendered by Jaipur Bench of Central Administrative Tribunal in OA No.517/2012 decided on 04.12.2012 is also placed. It is stated that the applicant is entitled to get full reimbursement since he was required to take a medical treatment under emergency in a private hospital in order to save his life. However, perusal of the aforesaid judgment revealed that the applicant therein was a postal employee and after his retirement he operated his right eye and implant of the lens on 01.10.2011. He took treatment in a recognized hospital, at Sharda Nursing Home, Jaipur which is specialized hospital for Ophthalmology. He thereafter submitted medical bills amounting to Rs.12,294.74 to respondent No.3 on 15.12.2011. Vide impugned letter dated 01.05.2012, the respondents informed the applicant that the treatment was taken after superannuation and, therefore, the medical bills cannot be 20 OA No. 134/2016 reimbursed. It was also stated that Central Services (Medical Attendant) Rules, 1944 are not applicable upon the retired Government officials and that the postal department was not adopted CGHS Scheme. The aforesaid contentions were overruled and since treatment was taken in a recognized hospital, the reimbursement at CGHS rates was only allowed.
27. It is thus obvious that facility of medical treatment can be availed by the retired employee also subject to certain conditions. It is obvious that the facts of the present case are different. However, considering the fact that the applicant was required to take the medical treatment for heart disease, it will be just and proper to Sanction the medical reimbursement at CGHS rates only as stated and discussed in preceding para, although applicant took treatment in unrecognized private hospital.
28, This Tribunal also came across a recent decision rendered by Hon'ble Supreme Court in Writ Petition No.694/2015, Shiva Kant Jha Vs. Union of India and Others aecided on 13.04.2018, in which the petitioner was the En a ee eee 21 OA No. 134/2016 CGHS beneficiary (Retired Pensioner) having a CGHS Card valid for whole life for medical treatment in private ward. He submitted two sets of medical bills under CGHS for reimbursement on account of his treatment done in November, 2013 in the Forties Escorts Hospital, New Delhi for Rs.9,86,343/- for his cardiac ailment involving the implant of CRT-D device and two sets of bill amounting to Rs.3,98,097/- for his treatment at Jaslok Hospital, Mumbai for cerebral stroke and paralytic attack were submitted. The first bill was considered by the Technical Standing Committee in May, 2014 and the claim was rejected without informing the petitioner of the reasons for rejection. However, the case was again considered by the Standing Committee on 10.07.2014 and was rejected on the ground that CRT-D implant was not required.
29, Aggrieved by the above decision, the petitioner filed a representation before the secretary, Ministry of Health & Family Welfare. The said representation was again considered by the Standing Committee on 15.01.2015 and was rejected for the reason Ci ae iii na 22 OA No.134/2016 that prior approval for such device implant was not sought. Again, in fourth attempt, the petitioner approached the Director General of the CGHS. After presenting the memorial to the said authority, the Government credited the amount of Rs.4,90,000/- in the petitioner's bank account. However, he was never heard on any point nor any speaking order was ever communicated.
30. In the peculiar facts of the aforesaid | case, the reimbursement was allowed holding that the claim cannot be denied on technical ground. It is also held that the relevant authorities are required to be more responsive and cannot in a mechanical manner deprive an employee of his legitimate reimbursement. Asserting the purpose of establishing Central Government Health Scheme, it is stated that it was propounded with the purpose of providing health facility to the Central Government employees so that they are not left without medical care after retirement. It is held that it was in furtherance of the object of a welfare State, which must provide for such medical care that the scheme was brought in 23 OA No, 134/2016 force. Further in paragraph No.15 of judgment zt is held as under:-
"In the present view of the matter we are of the considered opinion that the CGHS is responsible for taking care of healthcare needs and well being of the central government employees and pensioners. in the facts and circumstances of the case, we are of opinion that the treatment of the petitioner in non-empanelled hospital was genuine because there was no option left with him at the relevant time. We, therefore, direct the respondent-State to pay the balance amount of Rs.4,99,555/- to the writ petitioner. We also make it clear that the said decision is confined to this case only."
31. It is thus obvious that the decision rendered in the aforesaid case cannot be treated as a president for others, since it was made clear that the aforesaid decision is confined to the said case only. In view of above, no relief can be granted to the applicant based on the aforesaid decision, except that he is entitled to get medical reimbursement at CGHS prescribed rates.
32. In the result, this Tribunal does not find any force in the contentions of the applicant that he is entitled to get full amount incurred by him towards medical treatment for heart disease in a non recognized private hospital without being Se eae 24 OA No.134/2016 referred by Railway Hospital. However, as stated earlier, it will be just and proper to allow reimbursement of the amount incurred by him in both the hospitals at Jalgaon and Pune at CGHS prescribed rates only.
33. The OA is, therefore, partly allowed in above terms. The respondents are directed to calculate the amount of medical expenses incurred by the applicant for its reimbursement at CGHS prescribed rates.
34. The above excise shall be done within a period of four weeks from the date of receipt of certified copy of this order and the amount so settled shall be disbursed to the applicant within two weeks thereafter.
35. In the facts and circumstances of the case, the parties are however directed to bear their respective cost of this OA.
36. Registry is directed to forward certified copy of this order to both the parties for taking appropriate steps in the matter. AY ee ty ver Place: Mumbai. (Arvind J. Rohee) Date : 04.06.2018. Member (J).
ma.