C.W.P.No.8684 of 2009 -1- IN THE HIGH COURT OF PUNJAB AND HARYANA AT CHANDIGARH C.W.P.No.8684 of 2009 Date of Decision:- 19.01.2010 Naunihal Singh ....Petitioner(s) vs. The Union of India and others ....Respondent(s) *** CORAM:- HON'BLE MR.JUSTICE AUGUSTINE GEORGE MASIH *** Present:- Mr.R.D.Bawa, Advocate, for the petitioner. Mr.Brijeshwar Kanwar, Central Govt.Standing Counsel for the respondents. *** AUGUSTINE GEORGE MASIH, J. The present writ petition has been filed by the petitioner who retired from General Reserve Engineering Force (hereinafter referred to as 'the GREF'), a Border Roads Organization as an Assistant Administrative Officer on 30.4.2002, clamouring for medical reimbursement amounting to Rs.4,50,379/- and to quash order dated 6.5.2009 (Annexure P-10) as he suffered some breathing problem on the fateful day. The petitioner was operated upon for implant of Automatic Intra Cardiac Defibrillator (hereinafter referred to as AICD) on 2.4.2009. The petitioner being registered with the Dispensary of Central Government Health Scheme, Sector 34, Chandigarh, therefore, became eligible for free treatment/reimbursement of medical expenses. Accordingly, he after his discharge submitted an application dated 15.4.2009 to the Additional Director, Central Government Health Scheme, (Ministry of Health and Family Welfare), Government of India, Sector 34, Chandigarh-respondent C.W.P.No.8684 of 2009 -2- No.2 for reimbursement of the expenses incurred by him i.e. Rs.4,50,379/- as operation charges and Rs.34,357/- for the follow up treatment, the total amount being Rs.4,84,736/-. The claim of the petitioner for reimbursement has been rejected by respondent No.2 vide letter dated 6.5.2009 (Annexure P-10) on the basis of an opinion given by Government Specialist of Post Graduate Institute of Medical Education and Research, Chandigarh (hereinafter referred to as 'the PGIMER') to the effect that in the light of the Central Government Health Scheme (for short CGHS), the discharge summary of Sh.Naunihal Singh (petitioner) i.e. the beneficiary, does not suggest that ICD insertion was an emergency as ICD is usually a planned procedure and it appeared to be a planned procedure and not an emergency case. It is this rejection letter dated 6.5.2009 (Annexure P-10) which is under challenge in the present writ petition. Counsel for the petitioner submits that the petitioner being entitled to reimbursement of medical expenses incurred by him on the operation for AICD implantation and the follow up treatment, he could not have been denied the same. The petitioner is also entitled to get treatment from a private hospital, apart from availing medical facilities in any of the Central Government/State Government hospitals and the hospitals recognized by the State Government/CGHS Rules/CS (MA) Rules, 1994, as well as hospitals fully funded by either Central Government or the State Government. It has not been disputed that the petitioner was admitted in Fortis Hospital for operation in emergency on 1.4.2009 and was operated upon for AICD implantation on 2.4.2009. Although Fortis is not a recognised hospital like Mukat Hospital in Chandigarh and Silver Oaks Hospital in Mohali but it was an emergency, which fact has been certified C.W.P.No.8684 of 2009 -3- by the doctor who had operated upon him as is apparent from the certificate issued by him dated 4.4.2009 (Annexure P-5). The discharge summary also supports the claim of the petitioner. It is the contention of counsel for the petitioner that the petitioner along with his family was going towards Ludhiana on 1.4.2009 (F.N.) to meet his relatives and on the way when they reached Kharar, he suddenly felt breathing trouble and, therefore, it was decided to return back. His health was deteriorating and in these circumstances, the family of the petitioner decided to stop at Mohali and they approached Fortis Hospital in emergency where the doctors advised immediate operation leading to the admission of the petitioner in Fortis Hospital followed by an operation for implant of AICD on 2.4.2009. He contends that the opinion given by the doctor of the PGIMER would not be justified as the doctor who is attending a patient is the best Judge with regard to the factum of emergency and as to what treatment and procedure would be suitable for the patient. He, on this basis, submits that the order dated 6.5.2009 (Annexure P-10) passed by respondent No.2 cannot be sustained and deserves to be set aside. In support of the contention that the petitioner is entitled to reimbursement of the expenses incurred by him on his treatment at the Fortis Hospital, counsel has relied upon the judgments in the cases of Mohinder Singh vs. Union of India and others, 2008(2) SCT 239 and Madhu Sharma vs. The Principal, Kendriya Vidyalaya, Sector 31, Chandigarh, 1998(4)S.C.T. 30. In any case, counsel submits that if the petitioner is not entitled to the reimbursement of the actual expenses incurred by him in an unrecognized hospital i.e. Fortis Hospital, then also he would be entitled to reimbursement of medical expenses at the rates equivalent to the amount as admissible for treatment in Mukat C.W.P.No.8684 of 2009 -4- Hospital and Silver Oaks Hospital which are duly recognized hospitals by the respondents. In support of his contention, he has relied upon a decision in the case of Darshan Singh Rai vs. Union of India, 2008(2) SCT 242. On the other hand, counsel for the respondents has contended that under the CGHS, reimbursement for treatment taken from the private unrecognized hospitals is not permissible unless it is a case of emergency or the treatment has been recommended by the Incharge, Medical Officer, CGHS, which claim again is subject to certain conditions. The case of the petitioner was neither recommended by the Incharge, Medical Officer, CGHS nor it was opined in the report of the expert of the PGIMER dated 29.4.2009 (Annexure R-1) that the ICD insertion was a case of emergency. In a case of medical emergency, the beneficiary may go directly to the private recognized/Govt. referred hospital and submit a medical reimbursement claim. Ordinarily, treatment can be taken from such recognized hospitals after the specialist of the CGHS/Govt.hospital recommends and the In-charge, Medical Officer, CGHS, makes a reference for it. Counsel, on this basis, contends that none of the conditions, which are required to be fulfilled for being entitled to reimbursement of the expenses incurred by the petitioner from the private unrecognized hospital, having been fulfilled by the petitioner, the rejection of his case for reimbursement vide letter dated 6.5.2009 (Annexure P-10) is in accordance with law and, therefore, deserves to be sustained. I have heard counsel for the parties and have gone through the records of the case. It is not in dispute that the petitioner is registered with the Dispensary of the Central Government Health Scheme and, therefore, is eligible to free treatment/reimbursement of medical expenses under the C.W.P.No.8684 of 2009 -5- Scheme for claiming benefit under the CGHS and, therefore, the requirements as envisaged therein need to be complied with. The basic requirement is that the beneficiary must avail of all the medical facilities in any of the Central Government, State Government hospitals and hospitals recognized by the State Government, CGHS Rules, CS (MA) Rules, 1944 as well as hospitals fully funded by either Central Government or the State Government subject to the condition that he will be reimbursed the medical expenses at the rates fixed by the Government under the CGHS Rules/CS (MA) Rules, 1944 or the actual expenditure, if permission is 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 the CGHS in the 18 CGHS covered cities. This finds mention in the letter dated 28.3.2000. What is permitted as per this letter is the reimbursement of the expenses which are incurred from the Central Government and State Government hospitals and hospitals which are fully funded by the Central Government or the State Government besides the private hospitals recognized by the Central Government/State Government under the CGHS / CS (MA) Rules, 1944. An exception finds mention in the letter dated 18.3.1992 (Annexure R-2) wherein it has been provided that in case the treatment had been taken in private unrecognized hospital in an emergency by the beneficiaries, their claim could be entertained subject to certain conditions as mentioned therein. Therefore, for being entitled to get benefit of the CGHS, the requirement for reimbursement of expenses incurred towards treatment in private unrecognized hospital is that there should have been an emergency situation when the treatment was taken and expenses C.W.P.No.8684 of 2009 -6- incurred. The petitioner was admitted on 1.4.2009 and operated upon on 2.4.2009 for the AICD implant. A certificate has been issued by the Fortis Hospital dated 4.4.2009 stating therein that the AICD implantation was carried out under emergency circumstances. As per the Rules for reimbursement, the matter was referred by the competent authority- respondent No.2 vide letter dated 2.4.2009 to sanction reimbursement to the Specialist for obtaining the opinion locally as was required vide letter dated 26.5.2005 (Annexure R-4) issued by the Director General of Health Services. The whole case was referred to Dr.Rajeev Mahajan, Assistant Professor, Department of Cardiology, PGIMER, Chandigarh for his opinion. His opinion dated 29.4.2009 has been placed on record as Annexure R-1 the relevant portion whereof reads as follows:- “The discharge summary of Sh.Naunihal Singh, CGHS, Chandigarh beneficiary does not suggest that ICD insertion was an emergency. No documented VT ECGs are enclosed. Moreover, if the patient is having ventricular tachycardia storm, ICD on an emergency basis is not indicated and patient would need drugs and possibly Radiogrequency ablation. ICD is usually a planned procedure and from the discharge summary, it appears planned and not an emergency.” A perusal of the above expert opinion clearly spells out that there was no emergency and it was a planned procedure which has been projected as an emergency. A person for being entitled to get the benefit under a particular scheme, must fulfil the requirement of the Scheme as envisaged therein. It is not the case of the petitioner that the expert opinion C.W.P.No.8684 of 2009 -7- given by the doctor of the PGIMER, Chandigarh, is either biased or without any basis. The requirement of obtaining the opinion of the Government Specialist locally is mandated by the letter dated 26.5.2005 (Annexure R- 4). On going through the case history and the documents attached therewith for claiming reimbursement, the Expert has given his opinion which is fully justified and there is no reason as to why the same should not be accepted. It is well known these days as to how the private hospitals proceed to show each case as an emergency as these hospitals are run primarily on commercial lines. The opinion given by the Expert clearly suggests that the operation which was performed upon the petitioner was a planned procedure and not a case of emergency. That being so, the conditions as mandated, for being entitled to claim reimbursement under the CGHS, having not been fulfilled, the rejection of the claim of the petitioner vide letter dated 6.5.2009 (Annexure P-10) by respondent No.2 is fully justified and in accordance with law. The judgments relied upon by the counsel for the petitioner would not be applicable to the facts and circumstances of the present case. In the case of Mohinder Singh (supra), the issue involved was as to whether a person who was availing of fixed medical allowance per month under the Rules, would be entitled to reimbursement of medical expenses incurred by him during his treatment in a private hospital. In the case of Madhu Sharma (supra), the question was with regard to the amount to which an employee would be entitled to towards reimbursement. It was not a case where the petitioner had been held ineligible for reimbursement. Therefore, both these judgments would not be of help to the case of the petitioner. C.W.P.No.8684 of 2009 -8- As regards the contention of the counsel for the petitioner that the petitioner would be entitled to at least the amount to which he would have been entitled to, had he been operated upon and taken treatment from a private recognized hospital, the same deserves to be simply noticed and rejected for the reason that since the petitioner is not entitled to the reimbursement of the expenses incurred by him as he does not fulfil the requirement for claiming such reimbursement as per CGHS, the question of determination of the amount to which he would be entitled to does not arise. The judgment in the case of Darshan Singh Rai (supra) would not be applicable to the facts of the present case. In view of the above, finding no merit in the present petition, the same stands dismissed. January 19, 2010 ( AUGUSTINE GEORGE MASIH ) poonam JUDGE Whether referred to Reporters Yes/No