Central Administrative Tribunal - Delhi
V.B. Jain vs Chief Executive Officer on 25 July, 2013
CENTRAL ADMINISTRATIVE TRIBUNAL PRINCIPAL BENCH, NEW DELHI O.A. No. 2954/2012 Reserved on : 22.05.2013 Pronounced on :25.07.2013 HONBLE MR. V. AJAY KUMAR, MEMBER (J) V.B. Jain, Retd. Chief Engineer, Delhi Jal Board, A-99, Sector-41, Noida, U.P.-210301. .. Applicant (By Advocate : Shri Ajay Kumar Chopra) Versus Chief Executive Officer, Delhi Jal Board, Govt. of NCT of Delhi, Varunalya Phase-II, Karol Bagh, New Delhi-110005. .. Respondent (By Advocate : Shri Manish Kumar) O R D E R
By V. Ajay Kumar, Member(J) The applicant retired as a Chief Engineer (Civil) from Delhi Jal Board (DJB) on 30.09.2005. He is governed by Central Government Health Scheme [CGHS]/Central Services (Medical Attendance) Rules, 1944 [(CS(MA) Rules] and is entitled for reimbursement of medical expenses in accordance with such Rules and Notifications/Circulars/Office Memorandums issued thereunder in terms of DJB Resolution No.227 dated 07.05.1999. He is also holder of medical insurance policies which were subscribed by him from his own sources.
2. It is submitted that when the wife of the applicant was diagnosed with malignant Cancer, she was medically treated in Indraprastha Appollo Hospital, Rockland Hospital and Pushpanjali Corslay Hospital and that she finally succumbed to the disease and died on 24.11.2009. In connection with the said treatment, the applicant incurred a total medical expenditure of Rs.12,93,036/-.
3. In terms of Office Memorandum dated 19.02.2009 (Annexure `B), the beneficiaries under CGHS and CS(MA) Rules, 1944 (who have subscribed to medi claim policy from an Insurance agency) were permitted to claim reimbursement of the medical expenditure from both the sources, i.e., Insurance Agency and CGHS and Ministries/Departments as the case may be. However, this benefit was subject to the condition that the beneficiary will first claim reimbursement from the Insurance Agency and then from the CGHS or Ministry/Department concerned, and that the total amount reimbursed by the two organizations, does not exceed the total expenditure incurred by the beneficiary.
4. The applicant initially made a claim for reimbursement of the medical expenditure with the Insurance Company at the first instance, as required under Annexure `B OM, and the Insurance Company has reimbursed an amount of Rs.6,83,479/- leaving a balance of Rs.6,09,558/-. Thereafter, he made the claim for reimbursement for the balance amount out of the total amount of Rs.12,93,037/- to the Respondent-Delhi Jal Board. However, the Respondent-DJB reimbursed only Rs.4,54,422/- again leaving a balance of Rs.1,55,136/-. Aggrieved by the action of the respondent-DJB, in not reimbursing the full medical expenses incurred by the applicant, he has filed the present OA.
5. The respondents filed a counter along with a detailed status report indicating the particulars of the medical claim made by the applicant and the reimbursement thereon. The respondents in their counter stated that out of the total claim of Rs.12,93,037/- of the applicant, a total amount of Rs.11,37,901/- [Rs.6,83,479/- was reimbursed by the Insurance Company and an amount of Rs.4,54,422/- was reimbursed by the Delhi Jal Board] was paid to the applicant as against the admissible amount of Rs.8,02,963/-. Even the status report annexed to the counter also supports the counter averments.
6. Heard Shri Ajay Kumar Chopra, the learned counsel for the applicant and Shri Manish Kumar, the learned counsel for the respondents and also perused the pleadings on record.
7. It is the contention of the respondents that as per the OM dated 19.02.2009 (Annexure `B), the total amount reimbursable from both the sources, i.e., Insurance and the respondent Department, should not exceed the package rates prescribed under the CGHS for the particular treatment. They further submit that though the admissible amount as per the CGHS rates is only Rs.8,02,963 out of the total claim of Rs.12,93,037, the Medical Screening Committee of the respondent-Delhi Jal Board reimbursed more amount than the admissible amount on humanitarian grounds by treating the applicants case as a special case, in view of the attendant circumstances, and hence, the applicant is not entitled for any further amount either under the said OM or under any other Rule. The learned counsel for the respondents has placed reliance on the Judgment of the Honble Supreme Court in State of Punjab and Others v. Ram Lubhaya Bagga,(1998) 4 SCC 117.
8. Per contra, the applicant though not denying the aforesaid condition, but submits that since he got his wife treated in the aforesaid Hospitals after due approval from the respondents, and hence, he is entitled for full reimbursement of the medical expenditure incurred by him.
9. In a catena of cases various courts have laid down the following general principles for reimbursement of medical expenses incurred by government servants, who undergo treatment in private hospitals:
It is now settled law that right to health is integral to right to life.
A welfare State like India is bound to provide the basic requirements of its citizens. Health care facility is an integral part of the same and the CGHS has been established for the benefit of the Central Government employees. Even retired Government employees should not be left out of the purview of medical care.
If the Government servant has suffered an ailment which requires treatment at a specialized approved hospital and, on reference, the Government servant has undergone such treatment therein, it is the duty of the State to bear the expenditure incurred by the Government Servant. Expenditure thus incurred requires to be reimbursed by the State to the employee.
The mismatch between the rates charged by the approved hospitals and the rates approved by the Government works always to the disadvantage of the patient. What was fair and reasonable in 1996 or 1999 or 2001, when the rates apparently had some nexus with the then (current) rates has ceased to be so.
The cost of medical treatment has been rising over a period of time and Government cannot deny the actual reimbursement from a Hospital recognized by it for treatment on the basis of applying the rates as per the orders issued previously. It would, therefore, be appropriate to update the approved rates on an annual or, at least, biennial basis.
It is not the duty of the citizen to ensure that recognized hospitals do not charge in excess of the package rates.
The Government was obliged to grant ex post facto sanction in case an employee requires a speciality treatment and there is a nature of emergency involved. In such a situation, treatment in a non-recognized hospital and non-observance of prescribed procedure and incurring expenditure in excess of CGHS package/approved rates have to be condoned.
[K.P. Singh v. Union of India & Ors., 2001 (10) SCC 167; State of Punjab & Ors. v. Mohinder Singh Chawla etc., JT 1997 (1) SC 416; J.C. Sindhwani v. Union of India & Anr., 2005 (124) DLT 513; J.K. Saxena v. Govt. of NCT of Delhi, WP(C) No. 5015/2003, decided on 16.12.2004; Prithvi Nath Chopra v. Union of India & Anr., 2004 (111) DLT 190; V.K. Gupta v. Union of India & Anr., 2002 (97) DLT 337; M.G. Mahindru v. Union of India & Anr., 2001 (92) DLT 59; Narendra Pal Singh v. Union of India & Ors., 1999 (79) DLT 358; L.P. Sharma v. Union of India & Ors., 2004 (2) ATJ 492; Sh. S.R. Jha v. Union of India & Ors., 2003 (2) ATJ 168; and Shri Bhagwan Singh v. Union of India & Ors., 2002 (1) ATJ 226.]
10. As regards the judgment of the Honble Supreme Court in State of Punjab & Ors. v. Ram Lubhaya Bagga etc. (supra), cited by the respondents, it has been considered in several of the judgments cited above. Thus, in the case of M.G. Mahindru v. Union of India & Anr. (supra) the following ruling was given:
There cannot be any dispute with regard to the ratio laid down by the Supreme Court in State of Punjab v. Ram Lubhaya Baggas case (supra). In that case the petitioner challenged the policy of the government with regard to fixation of allowances. In that case no recommendation was made by the CGHS for getting the treatment from a private hospital. As far as the case in hand is concerned, it is the Government Hospital, namely, RML Hospital which has recommended the case of the petitioner for a specialized treatment by a speciality hospital, which is on the approved list of CGHS. When the respondents themselves have recommended the case of the petitioner for getting treatment at a speciality hospital, to deny the benefit of giving full reimbursement would be contrary to the grant of medical facilities to a retired Government servant, if he cannot actually avail of the same. If the Government Hospital did not have the facility for giving treatment like the one which was required to be given to the petitioner, then it was an obligation on the part of the respondents to have reimbursed the total amount paid to the said hospital. Following the ratio laid down in the State of Punjab & Ors. v. Mohinder Singh Chawlas case (supra), I direct the respondents to reimburse the amount of Rs. 80,620/- to the petitioner within a period of four weeks.
11. Similarly, in the case of J.C. Sindhwani v. Union of India & Anr. (supra), it was held:
8. The issue of whether the Government is bound by the package rates and cannot disbursement amounts in excess of such approved rates has arisen for consideration; in V.K. Gupta v. Union of India, 97 (2002) DLT 337, M.G. Mahindru v. Union of India, 92 (2001) DLT 59; and P.N. Chopras case (supra) the Court expressly rejected similar defences and directed full reimbursement. In P.N. Chopras case, the decision in Ram Lubhaya Baggas case (supra) was considered; nevertheless a direction to make full payment was issued. I am in complete agreement with the reasoning in those cases.
12. Taking the totality of facts and circumstances into consideration and also taking into account the ratio of various judgments aforementioned, I arrive at the following findings on the core issues identified earlier:
The package rates fixed in the year 2001, not having been revised periodically, are not sacrosanct and cannot be the sole criteria for denying full reimbursement to the applicant, whose wife admittedly underwent the treatment in a private hospital, approved by the respondents.
The ratio of the judgment of the Honble Supreme Court in the case of State of Punjab & Ors. v. Ram Lubhaya Bagga (supra), as pointed out in the judgments of the Honble High Court of Delhi in the cases of M.G. Mahindru v. Union of India & Anr.(supra) and J.C. Sindhwani v. Union of India & Anr. (supra), is not against full reimbursement of medial expenses incurred in a private hospital approved by the Government.
13. In the circumstances and for the aforesaid reasons, the OA is allowed and the respondents are directed to reimburse the balance amount of Rs.1,55,136/- to the applicant within eight weeks from the date of receipt of a copy of this order. However, in the circumstances, the applicant is not entitled for any interest on the said amount. No order as to costs.
(V. Ajay Kumar) Member (J) /nsnrvak/