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The petitioner applied for reimbursement under the Cashless Health Insurance Scheme, namely, Punjab Government Employees and Pensioners Health Insurance Scheme (PGEPHIS), which had been launched by the Government of Punjab vide notification dated 20.10.2015 (Annexure P-1). Since the medical expenses incurred by the petitioner were not reimbursed, the petitioner was constrained to serve a legal notice dated 27.11.2017 (Annexure P-6) upon the respondents including respondent No.4.

In reply to the said legal notice dated 27.11.2017 (Annexure P-6), respondent No.4 replied through its counsel vide reply letter dated 04.01.2018 (Annexure P-8) that the claim of the petitioner could not be entertained, as the petitioner had not submitted the treatment record and the bills within 30 days from the date of discharge of the patient from the hospital.

Learned counsel for the petitioner submitted that the Punjab Government Employees and Pensioners Health Insurance Scheme (PGEPHIS) annexed as Annexure P-1 had been framed so as to cover all those, who would have been entitled under the State Services (Medical Attendant Rules) [CS(MA)] Rules, 1940 (hereinafter to be referred as 'the Rules') and that the premium of the main member (employee) as well as dependent/s towards PGEPHIS was to be paid by the State Government.

| attest to the accuracy and authenticity of this document CWP-8278-2018 (O&M) -3- VIMAL KUMAR 2023.08.01 19:44 It has been submitted that while under the said 1940 Rules, a period of 6 months is provided for making a claim for reimbursement in respect of medical treatment taken by an employee or by any of his/her dependent, the Insurance Company has somehow chosen to prescribe a period of 30 days only, which is on the lesser side and is rather a device to deprive a government employee or his/her dependent/s of reimbursement even in genuine cases as in many cases it may not be possible for the employees to collect all the requisite documents within a period of 30 days.

It has further been submitted that the State Services (Medical Attendant Rules) [CS(MA)] Rules, 1940 are in the nature of a beneficial legislation, but the employees are being deprived of availing benefits of such welfare legislation by introduction of PGEPHIS and that as a matter of fact the said scheme virtually failed and was withdrawn vide letter dated 28.12.2016 (Annexure P-2) i.e. after about 1 year of its induction.

It has further been submitted that in the instant case the petitioner had applied for reimbursement of the medical claim on 24.04.2017 i.e. after about 4 % months of discharge of petitioner's daughter from hospital, which is in any case less than 6 months prescribed under 1940 Rules. It has also been submitted that respondent No.4 -- Insurance Company in any case can only be said to have indemnified the claims made against the State and that the State cannot escape from his liability to reimburse the medical claim in case the Insurance Company does not come forward for the same.

| attest to the accuracy and authenticity of this document CWP-8278-2018 (O&M) -4-

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12. VIMAL KUMAR 2023.08.01 19:44 Although respondent No.4 -- Insurance Company had been duly served, but has not come forward to contest the petition and was accordingly proceeded against ex parte vide order dated 19.07.2019. Respondents No.1 to 3/State has, however, filed its reply submitting that once the petitioner had opted to chose PGEPHIS, he would be bound by all the conditions prescribed under the said Scheme and that the State cannot be held responsible or liable in any manner in respect of the reimbursement of the medical claim. It has further been submitted that the State in any case had taken all the necessary steps for processing the claim of the petitioner and had forwarded the petitioner's case for reimbursement to the Insurance Company and it is the Insurance Company, which had rejected the claim, as would be evident from the impugned reply dated 04.01.2018 (Annexure P-8).