Central Administrative Tribunal - Bangalore
N Uma vs Employees Providend Fund Organisation ... on 22 April, 2024
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OA.No.170/00002/2022/CAT/BANGALORE
CENTRAL ADMINISTRATIVE TRIBUNAL
BANGALORE BENCH, BENGALURU
ORIGINAL APPLICATION NO.170/00002/2022
ORDER RESERVED ON 16.04.2024
DATE OF ORDER: 22.04.2024
CORAM:
HON'BLE MRS. JUSTICE S. SUJATHA, MEMBER (J)
HON'BLE MR. RAKESH KUMAR GUPTA, MEMBER (A)
Smt. N. Uma
W/o Late C.K. Gundappa S.S. (Retd),
(O/o the Regional Provident Fund Commissioner,
Bangalore), 67 years,
No. 4447, 3rd Cross, 17th Main,
Vijayanagara, II Stage,
Mysore 570 017 .... Applicant
(By Ms. Latha S.H., Advocate)
Vs.
1. The Regional Provident Fund Commissioner-II,
Sub Regional Office,
Employees Provident Fund Organisation,
2nd Stage, Gayathripura, Mysore 570 019
2. The Regional Provident Fund Commissioner-I
"Bhavishya Nidhi Bhavan"
High Lands, Sylva Road,
Mangalore 575 002
3. The Additional Central Provident Fund Commissioner,
(Karnataka & Goa), "Bhavishyanidhi Enclave",
No. 13, R.M. Roy Road, Bangalore 560 025
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OA.No.170/00002/2022/CAT/BANGALORE
4. The Secretary,
Ministry of Labour,
Union of India, Shramshakthi Bhavan,
Rajaji Marg, New Delhi 110 001 ...Respondents
(By Ms. Shwetha Anand, Advocate - through video conference)
ORDER
PER: JUSTICE S. SUJATHA, MEMBER (J)
This application is filed by the applicant under Section 19 of the Administrative Tribunals Act, 1985 seeking the following reliefs:
"(a) Direct the respondents, while quashing impugned order at Ann-12 as arbitrary, unjust, unfair and against the Hon'ble Supreme Court of India to regulate the medical reimbursement claim as per Rule 6 of CS (MA) Rules 1944 and thus order to pay the entire medical reimbursement amount of after deducing the amount of Rs. 1,47,167/- (Rupees one lakh forty seven thousand one hundred sixty seven only) and Rs. 3,10,634/- (Rupees three lakhs ten thousand six hundred thirty four only) which was paid as against Rs. 8,02,100/-.
(b) Awarding 12% interest per annum on the amount withhold/delayed payment in the interest of justice.
(c) Award cost of this litigation.
(d) Award compensation for mental agony and harassment undergone at the hands of the respondents at her evening age.
And 3 OA.No.170/00002/2022/CAT/BANGALORE
(e) Pass any other order or direction as deemed fit by this Hon'ble Tribunal in the interest of justice and equity."
2. Briefly stated the facts as narrated by the applicant are that the applicant is the wife of late C.K. Gundappa, a retired employee of the Employees Provident Fund Organisation (EPFO), Bengaluru. The retired employees of the EPFO were covered under the medical facilities of Oriental Insurance Co. Ltd. prior to 23.10.2006. The proposal placed before the Executive Committee under the Chairmanship of the then Secretary to the Government, Ministry of Labour and Employment for switching over from the Mediclaim Policy to Central Services (Medical Attendance) Rules, 1944 ('Rules' for short) had been approved in its 55th meeting held on 24.07.2006. Accordingly, the retired employees of EPFO were brought under the Rules with effect from 24.10.2006 for indoor treatment and thus the erstwhile Oriental Scheme was ceased on the expiry of its term, i.e., on 23.10.2006. This decision was communicated inter alia to all retired employees vide letter dated 06.11.2006, which is detailed as the pensioners EPFO along with their eligible members of family were brought under the purview of the Rules with effect from 24.10.2006 for indoor treatment 4 OA.No.170/00002/2022/CAT/BANGALORE including the treatment for specialised diseases and the claim shall be regulated for reimbursement under the Rules.
3. The applicant's husband late C.K. Gundappa was admitted on 03.04.2021 at Apollo BGS Hospital, Adichunchanagiri, Kuvempunagar, Mysore where he was diagnosed as "left hemispheric chronic SDH" and he was discharged on 04.04.2021 as per discharge summary dated 04.04.2021. Medical bill of Rs. 1,77,100/- was issued by the hospital with a direction to seek a review after one week. Again on 14.04.2021, the applicant's husband was admitted in the same hospital, where he was diagnosed as "left hemispheric acute on chronic SDH S/P craniotomy - lower respiratory tract infection with sepsis - ischemic heart disease - hypertension. Medical bills claiming charges of Rs. 6,25,000/- was issued by the Apollo BGS Hospital. It transpires that the applicant submitted two medical bills along with the discharge summary to the Respondent No. 1 for reimbursement but the Respondent No. 1 has reimbursed Rs. 1,47,167/- against Rs. 1,77,100/- for the first bill and Rs. 3,10,634/- against Rs. 6,25,000/- for the second bill, which was directly credited to the applicant's Savings Bank Account No. 5 OA.No.170/00002/2022/CAT/BANGALORE 540063940476, SBI. The applicant submitted a representation dated 25.06.2021 seeking for reconsideration of the medical bills for reimbursement (Rs. 1,77,100/- dated 04.04.2021 and Rs. 6,25,000/- dated 21.04.2021). The said representation has been rejected by the Respondent No. 1, hence, this OA.
4. Learned counsel Ms. Latha S.H. representing the applicant submitted that the medical reimbursement claimed by the applicant - deceased retired employee's wife, though is governed by the Rules, has not been fully reimbursed. Withholding of an amount of Rs. 3,44,299/- by the respondents is arbitrary and against the Rules. There being no enabling provision to restrict or to fix ceiling on medical reimbursement bills under Rule 6 of the Rules, rejection of the claim of the applicant for reimbursement in full is unjustifiable. Learned counsel submits that another detailed representation dated Nil was submitted by the applicant seeking reimbursement of the balance amount of Rs. 3,44,299/- placing reliance on the judgment passed by the Hon'ble High Court of Karnataka in Writ Petition No. 8995/2013 dated 13.06.2013. (The Regional PF Commissioner-I and Ors. vs. C.K. Nagendra Prasad) and Writ Petition No. 33026/2015 (DD: 30.11.2015), 6 OA.No.170/00002/2022/CAT/BANGALORE Central Board of Trustees vs Manjunath Rao T., but the same has not fetched any positive response. Placing reliance on the judgment of the Hon'ble High Court of Karnataka in C.K. Nagendra Prasad, supra, and Manjunath Rao T, supra, learned counsel sought for the reliefs claimed.
5. Learned counsel Ms. Shwetha Anand representing the respondents submitted that the claim for reimbursement of the applicant's husband's medical expenses was to the extent of Rs.8,02,114/-. After scrutiny of the medical bills dated 29.04.2021 and 21.05.2021, the respondents released an amount of Rs.1,47,167/- and Rs. 3,10,634/- vide letter dated 07.05.2021 and 16.06.2021 respectively to the applicant which was regulated on the basis of the Rules issued by the Ministry of Health and Family Welfare, Government of India (CGHS package rates) applicable. Placing reliance on the Head Office Circular dated 16.06.2014 (Annexure-R8), OM dated 01.08.2013 and 29.09.2016 (Annexure- R10 and R11) respectively, learned counsel submitted that the applicant is entitled to medical reimbursement at the rates fixed by the Government under the CGHS Rules/CS (MA) Rules, 1944 or the actual expenditure incurred, whichever is less. Further placing 7 OA.No.170/00002/2022/CAT/BANGALORE reliance on the judgment of the Hon'ble Apex Court in the case of State of Punjab and Ors. Vs Ram Lubhaya Bagga reported in AIR (1998) SUPREME COURT 1703, learned counsel submitted that the respondents have reimbursed the entitled amount of the applicant as per latest CGHS rates. Justifying the decision of the respondents in restricting the reimbursement as per the CGHS rates, learned counsel seeks for the dismissal of the OA.
6. We have carefully considered the submissions of the learned counsel appearing for the parties and perused the material on record.
7. The crucial point that arises for our consideration is, whether the claim for the medical reimbursement made by the applicant as per the CS (MA) Rules, 1944 could be restricted applying the CGHS Rules?
8. The medical reimbursement claim in the present case is regulated as per Rule 6 of the Rules, which reads thus:
"Rule 6 (1)- A Government servant shall be entitled, free of charge, to treatment-8
OA.No.170/00002/2022/CAT/BANGALORE
(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;
(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 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."
9. An identical issue was considered by the Division Bench of the Hon'ble High Court in C.K. Nagendra Prasad, supra, wherein reliance was placed on the Office Memorandum bearing No. S.14025/7/2000 MS dated 28.03.2000 by the respondents, the relevant portion of which is quoted hereunder for ready reference: 9
OA.No.170/00002/2022/CAT/BANGALORE "(6) Government employees/members of their families may take treatment from any hospital recognized under CGHS/State Government.--The issue for grant of permission for treatment of Central Government employees and the members of their family in any of the hospitals recognized by the State Government/CGHS Rules/CS (MA) Rules, 1944, had been under consideration of the Government for some time past. It has now been decided that the Central Government employees and the members of their families may be permitted to avail of medical facilities in any of the Central Government, State Government Hospitals and the hospitals recognized by the State Government/CGHS Rules/CS(MA) Rules, 1944, as well as the hospitals fully funded by either Central Government or the State Government subject to the condition that they will be reimbursed the medical expenditure at the rates fixed by the Government under the CGHS Rules/CS(MA) Rules, 1944 or the actual expenditure incurred, whichever is less. In other words, the permission can be granted by the Head of the Ministry/Department/Office to the Central Government employees/members of their families to obtain medical services from any of the private hospitals recognized under CGHS in the 18 CGHS covered cities also.
2. If the treatment for a particular disease/procedure is available in the same city where the Government servant is employed, he may be permitted to avail of the medical services in any other city of his choice but in such cases, he will not be eligible for sanction of T.A./D.A. In case the treatment for a particular disease/procedure is not available at the same station, the beneficiary will be eligible for sanction of TA of his entitled class for taking treatment in a different city
3. xxxxxxx
4. xxxxxxx."
10. Having considered the subject issue, in paragraphs 11 and 12 in C.K. Nagendra Prasad, supra, it has been held thus: 10
OA.No.170/00002/2022/CAT/BANGALORE
11. A perusal of Rule 6 indicates there is no fetter imposed unless rule itself is fixing any ceiling for the cost of the treatment and it contemplates reimbursement of the expenses incurred or paid by the employee in the opinion of the authorized medical attendant unless such treatment was necessary, etc. The restriction imposed which Mr. Hari Prasad has relied upon is as per the Office Memorandum of the year 2000.
12. The office memorandum cannot regulate the rules or restrict the operation of the rule. Rule 6 being a beneficial provision, we think it should be interpreted to give its full effect and not to restrict or to deprive of the benefits to the employee."
11. In yet another decision in Manjunath Rao T., supra, the Division Bench of the Hon'ble High Court of Karnataka considering similar issue placing reliance on the judgment of C.K. Nagendra Prasad, supra, observed thus:
"7. As has been held by the Division Bench of this Court in W.P.No.8995/2013 (S-CAT) disposed of on 13.6.2013, mentioned supra, the Government servant is entitled to free of charge, treatment in hospital and any amount paid by him on account of such treatment shall, on production of a certificate in writing by the authorized medical attendant in this behalf, be reimbursed to him by the Central Government as per Rule 6 of the Rules. The Official Memorandum relied upon by the petitioner's counsel cannot restrict or deprive the benefits to the employee provided under Rule 6 of the Rules."11
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12. SLP CC No. 9294/2016 filed against the said order has been dismissed by the Hon'ble Apex Court vide order dated 29.06.2016. It is not in dispute but, on the other hand, it has been clearly admitted by the respondents in the reply statement that M/s Apollo BGS Hospital, Mysore is a recognised hospital under CGHS. However, placing reliance on the EPFO Head Office Circular dated 16.06.2014 (Annexure-R8), the respondents have rejected the claim of the applicant for full medical reimbursement or, in other words, restricted the reimbursement to the CGHS rates applicable. In terms of the said circular instructions dated 16.06.2014, in para 5, it is observed thus:
"5. Accordingly, Para 3 of the circular no. HRM- V12(2)2004/52960 dated 18/10/2006 may be read as "The claims shall be regulated for reimbursement subject to the rates/ceiling, terms and conditions prescribed under the CS (MA) Rules, 1944/CGHS/actual cost, whoever is lower and as per instructions of Govt. of India." This is in compliance of the detailed agenda approved by the 55th EC held on 24.07.2006 in which it was mentioned that the reimbursement of medical expenditure to the EPF Pensioners shall be restricted at the rates fixed by the Govt under CGHS Rules/CS (MA) Rules, 1944 of the actual expenditure incurred, whichever is less. Since we had only issued executive instructions to adopt the CS (MA) Rules and no notification was issued in official gazette.
However, in specific cases, based on distinguishable facts, a 12 OA.No.170/00002/2022/CAT/BANGALORE view can be taken on, case to case basis, as per the decisions of different courts in this regard."
13. The aforesaid circular instructions are similar to the instructions considered by the Division Bench of the Hon'ble High Court in C.K. Nagendra Prasad, supra, and Manjunath Rao T, supra. The Office Memorandum cannot regulate the statutory rules or restrict the operation of Rule 6 of the Rules. In the absence of any ceiling fixed for the cost of the treatment and reimbursement and the expenses incurred are paid by the employee, Rule 6 has to be given its full effect and cannot be restricted to deprive the benefits to the employee. Hence, no shelter can be taken by the respondents under the Office Memorandum dated 16.06.2014 to deny the benefits to the employee.
14. In Ram Lubhaya Bagga, supra, the question which came up for consideration is the entitlement towards the medical expenses of the Punjab Government employees and pensioners as per the relevant rules and as per the Government policies, not under Rule 6 of the Rules. Reimbursement of medical expenses under the Rules were not under consideration before the Hon'ble Apex Court, hence, the said judgment would be of little assistance to the 13 OA.No.170/00002/2022/CAT/BANGALORE respondents. As aforesaid, C.K. Nagendra Prasad, supra, and Manjunath Rao, supra, are squarely applicable to the facts of the present case. In the light of the said decisions, the impugned order (Annexure-A12) cannot be held to be sustainable. At the cost of repetition, we observe that in the absence of any restriction/limitation fixed under Rule 6 of the Rules, no restrictions could be imposed by issuing the Office Memorandum. No other ground is raised by the respondents for denial of the benefits to the applicant.
15. For the reasons aforesaid, we pass the following:
:ORDER:
1) The impugned order dated 08.07.2021 (Annexure-A12) issued by the Respondent No. 1 is set aside.
2) The respondents are directed to pay the balance amount of Rs. 3,44,299/- (Rupees Three Lakhs, Forty Four Thousand, Two Hundred and Ninety Nine Only) to the applicant in an expedite manner, in any event, within four weeks from the date of receipt of the certified copy of this order, failing which, the same shall carry interest at 14 OA.No.170/00002/2022/CAT/BANGALORE 12% p.a. on the delayed payment till the date of full payment.
3) OA stands allowed to the extent indicated above.
No order as to costs.
(RAKESH KUMAR GUPTA) (JUSTICE S. SUJATHA)
MEMBER (A) MEMBER (J)
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