IN THE HIGH COURT OF KERALA AT ERNAKULAM PRESENT : THE HONOURABLE MR. JUSTICE K.S.RADHAKRISHNAN & THE HONOURABLE MR. JUSTICE T.R.RAMACHANDRAN NAIR TUESDAY, THE 13TH NOVEMBER 2007 / 22ND KARTHIKA 1929 MFA.No. 349 of 2002(B) ---------------------- IC.87/1999 of EMPLOYEES INSURANCE COURT, ALAPPUZHA .................... APPELLANT: ------------------ M.K.PRABHAKARAN, MADATHETHUKUDY HOUSE, CHELAMATTOM, OKKAL P.O., PIN-683 550. BY ADV. SRI.A.X. XAVIER SRI.JOLLY JOHN RESPONDENTS: ---------------------- 1. EMPLOYEES STATE INSURANCE CORPORATION, PANCHADEEP BHAVAN, NORTH SWARAJ ROUND,TRICHUR-20, REPRESENTED BY ITS REGIONAL DIRECTOR 2. THE DIRECTOR OF INSURANCE MEDICAL SERVICE, TRIVANDRUM 3. DR.N.S.SUNIL, M.B.B.S.,M.D.(GEN MED) REG:NO.13525, ESI HOSPITAL,ERNAKULAM,KOCHI-18. 4. THE MEDICAL OFFICER, ESI DISPENSARY, PERUMBAVOOR, 683 542. BY GOVERNMENT PLEADER SRI.P.SANKARANKUTTY NAIR THIS MISC. FIRST APPEAL HAVING BEEN FINALLY HEARD ON 13/11/2007, THE COURT ON THE SAME DAY DELIVERED THE FOLLOWING: -: 2 :- J U D G M E N T IN VIEW OF THE ORDER IN CMP.No.1845/2002 THE APPEAL IS ALSO DISMISSED. Sd/- K.S.Radhakrishnan, Judge. 13-11-2007. Sd/- T.R.Ramachandran Nair, Judge. ( true copy ) P.S. TO JUDGE. Kvs/- J.B. Koshy & Thomas P.Joseph, JJ. -------------------------------------- M.F.A. No.349 of 2002 --------------------------------------- Dated this the 17th day of November, 2008 Judgment Koshy,J. Appellant was an employee covered under the Employees' State Insurance Act (for short 'the Act'). He developed heart disease. He is entitled to free medical treatment as per the scheme made under the Act. Both employee as well as the employer contributes and the employee is insured under the ESI Scheme. The ESI Act is a social security legislation. Not only the members, but the family members are also entitled to get free medical treatment. Appellant was being treated in ESI Hospital, Perumbavoor for heart ailment. On 15.12.1997, when he felt chest pain, uneasiness and discomfort due to the heart disease, he went to the ESI Hospital where he was getting treatment and some medicines were prescribed. There was no facility for any further treatment and he was rushed to the Medical Trust by his relatives and it was diagnosed as advanced heart disease requiring a By-pass surgery. During the year 1997, in none of the ESI hospitals in the State of Kerala or in any of the Hospitals in Ernakulam, there was M.F.A. No. 349 /2002 2 provision for by-pass surgery and he was referred to Malar Hospital, Chennai, an operation was conducted on 23.12.1997 and finally he was discharged on 1.1.1998. He continued treatment there upto 3.1.1998. It was noticed in the ECG that there were two blocks, one of 90% and another of 100% and he escaped only because of the type of treatment he received. When he felt severe chest pain, he was rushed to the hospital and formal concurrence from the ESI hospital was not obtained. It is an admitted fact that there was no provision for by-pass surgery at that time in none of the ESI hospitals in the State. When his claim was refused, he approached the E.I. Court. It is true that during the pendency of the case, Government wrote letter to furnish the details, but, that was not given as the case was pending. The E.I. Court after considering the matter made the following relief: "It is declared that the applicant is entitled to get reimbursement of cost of medicines and cost of medicines and cost of bye-pass surgery as admissible in accordance with the Government norms with regard to or availing treatment from the Malar Hospital, Chennai. The applicant shall present his claim in the prescribed manner for the above as early as possible before the 4th respondent Medical Officer. He shall scrutinise the claim with regard to the above items and pass the papers to D.I.M.S. who shall arrange payment within three months from the date of receipt of the same M.F.A. No. 349 /2002 3 failing which the sanctioned amount will carry interest at the rate of 12% thereafter." It was also observed that operation charge shall be paid at Government rates applicable to the Government employees. Here, appellant is an insured employee. He as well as the employer pays for the treatment and he is entitled to complete reimbursement of expenses incurred including the surgery charges etc. and it cannot be limited to Government rates applicable to Government employees. Of course, Government will get reimbursement from the ESI Corporation. In these set of facts, we direct the appellant to file all the bills and documents to the Government. He can get back the documents filed before the EI court and the Government shall verify and grant reimbursement after checking up the genuineness of the bills. He may approach fourth respondent who, in turn, shall pass all the genuine bills after verifying the same. The appeal is allowed to the above extent. J.B.Koshy Judge Thomas P. Joseph Judge M.F.A. No. 349 /2002 4 vaa M.F.A. No. 349 /2002 5 J.B. KOSHY AND THOMAS P.JOSEPH,JJ. ------------------------------------- M.F.A.No.349/2002 ------------------------------------- Judgment Date:17th November,2008