CW 6849/08 //1// In the High Court of Judicature for Rajasthan Jaipur Bench ** Civil Writ Petition No.6849/2008 Jacob Oommen Versus State & (2) Ors. Date of Order ::: 18/08/2010 Hon'ble Mr. Justice Ajay Rastogi Mr. LM Bhardwaj, for petitioner Ms Sunita Satyarthi, Addl.Govt. Counsel for State Instant petition has been filed with the grievance that medical expenses incurred by petitioner for treatment undertaken in Santokba Durlabhji Hospital, Jaipur are not being reimbursed by respondents, despite being member of Rajasthan State Pensioner Medical Concession Scheme; however, declined vide order dt. 27/03/2008 on the premise that Santokba Durlabhji Hospital is not an approved hospital from the Government. Petitioner was a Government servant and while holding the post of Upper Division Clerk in Department of ESI Dispensary No.1, Alwar retired from service and is a member of Raj. State Pensioner's Medical Concessional Scheme. Case set up by petitioner is that being a critical cardiac patient, had undergone treatment of heart disease in Department of Cardiology, SMS Hospital Jaipur where, he was advised on 19/04/2007 for CTMT & other medical investigations; and upon diagnosis, finally advised him for Bye-pass Surgery for heart CW 6849/08 //2// disease but gave date of operation in October, 2007 (after three months) as is evident from his prescription (Ann.1). It has also been averred that when petitioner went to his native place at Kochi (Kerala) in June, 2007, he had a severe cardiac attack – as a result of which he got himself admitted in Medical Trust Hospital, Kochi where coronary angiography test was held as is evident from medical reports (Ann.2). Accordingly, the petitioner was shifted to Jaipur and his family members got him admitted in Santokba Durlabhji Memorial Hospital Jaipur in a critical state of his condition as he had a severe chest pain and on having found in tremendous distress on 25th July, 2007, was admitted in intensive care unit and his angiography report revealed coronary artery disease, Triple Vessel Disease (LAD 90%, LCX, RCA 80%) about critical stenosis of LAD, for which ultimately on expert medical opinion, he was advised to get coronary artery byepass surgery conducted as is evident from certificate (Ann.3) and discharged from Hospital on 08/08/2007 incurred medical expenses of treatment (supra) to the tune Rs.1,42,127=18p. and claimed for reimbursement, which was declined vide letter dt.27/03/2008 (Ann.3). Indisputably, petitioner is entitled for reimbursement of medical expenses/treatment CW 6849/08 //3// under Pensioner's Medical Concession Scheme. Counsel submits that because of emergent & critical situation of petitioner, his family members took him to Intensive Care Unit of Santokba Durlabhiji Hospital where immediately coronary Artery byepass surgery operation was conducted in order to save his life, which resulted in incurring expenses as per medical bills claimed for reimbursement submitted to respondents; as such in light of Pensioner's Medical Scheme, medical bills are required to be reimbursed in his favour and very rejection of bills for reimbursement on the premise that SDM Hospital is not a Government recognized/ approved hospital, cannot be sustainable under law. However, Counsel for respondents submits that since petitioner has not been operated in recognized hospital, is not entitled for medical reimbursement and placed reliance upon DB decision in State of Rajasthan Vs. Mithulal Gupta (Special Appeal (Writ) 858/07 decided on 24/03/08 (Per Hon. R.M.Lodha, J.). I have considered contentions of both the parties and with their assistance, pondered over material on record. This fact remain undisputed that the petitioner was firstly taken to SMS Hospital in a critical condition, but surgery operation date was given of three CW 6849/08 //4// months later and in the meantime, his condition became deteriorated, ultimately he was shifted to SDM Hospital (supra) in an emergent situation, and was operated for coronary artery bye-pass surgery having triple vessel disease as is evident from certificate (Ann.3). In State Vs. Mithulal Gupta (supra) this Court while dealing with such like controversy and taking note of Para 4E of Pensioners' Medical Scheme, observed ad infra: “11. The Counsel for the respondent then submitted that in any case the petitioner was entitled to the reimbursement to the extent of Rs.1,20,000/- as per the then existing rule 4B. Rule 4B provides the scale of assistance to the extent of 80% of hospital expenses or Rs. 1,20,000/- which is less in the case of bye-pass surgery if the treatment is taken in a Government hospital within the State of Rajasthan. The petitioner did not choose to avail of the specialised treatment in SMS Medical College and Hospital although angiography was done there but instead without any reference from that hospital went to Escort Hospital, New Delhi on his own. Having not chosen to have the specialisted treatment in a Government hospital within the State of Rajasthan, the scale of assistance provided in the para 4B of the Rules for treatment in such hospitals cannot be applied. The CW 6849/08 //5// case of petitioner is covered by para 4E of the Scheme and according to that provision, scale of assistance is limited to Rs.44,000/- being 80% of general award charges of All India Institute of medical Sciences, New Delhi.” In instant case, the petitioner took treatment from a hospital in State of Rajasthan, which is not recognised & approved hospital by the Government. Paras 4A of Pensioner medical scheme take note of treatment of disease not available in Government Hospital in the State of Rajasthan and so also para 4B is in respect of specialised treatment taken in Government hospital within State of Rajasthan. Para 4G deals with treatment of disease other than heart ailment in recognised hospital outside the State being entitled to AIIMS as per rates prescribed therein. No provision has been brought to the notice of this Court in regard to cases where treatment of heart ailment has been undertaken by a member of pensioners medical scheme from a hospital within State of Rajasthan which is not a recognized hospital. At the same time, Para 4-E of the Scheme, deals with treatment undertaken by member of the Scheme from a hospital/institution not recognised by Govt. Thus, this Court considers it proper that in such cases, where the member has taken treatment from a hospital which is CW 6849/08 //6// not recognised by Government within State of Rajasthan shall also be entitled to claim reimbursement under para 4-E of the Scheme. It has also been brought to the notice of this Court that vide notification No.F.6(4) FD(Rules)/2003 dt.15/02/2010, the State Government included three hospitals as “approved Hospitals” as defined in Rule 3(7) of Rajasthan Civil Services (Medical Attendance) Rules, 2008 in the Appendix I thereof, - 1. Santokba Durlabhji Memorial Hospital, Jaipur; 2. SK Soni Hospital, Jaipur 3. Geesibai Memorial Mittal Hospital & Research Centre, Ajmer In view of what has been observed above, instant petitioner is entitled for reimbursement of medical bills furnished by him, in terms of Rule 4-E of the Scheme. Consequently the writ petition succeeds and is hereby allowed. Order dt.27/03/2008 (Ann.5) is quashed & set aside. Respondents are directed to make payment of medical bills raised in terms of Rule 4E of the Scheme with interest @ 9% p.a., from the date of presentation of bills till actual payment. The respondents may ensure compliance of this order within three months. No order as to costs. (Ajay Rastogi), J. K.Khatri/p.6/ 6849CW2008Aug18MedRmb.doc