IN THE HIGH COURT OF KERALA AT ERNAKULAM PRESENT : THE HONOURABLE MR. JUSTICE M.N.KRISHNAN WEDNESDAY, THE 27TH AUGUST 2008 / 5TH BHADRA 1930 Ins.APP.No. 60 of 2007(F) ----------------------------- IC.3/2002 of ESI COURT,IDUKKI .................... APPELLANT/2ND RESPONDENT IN IC ------------------------------------------- THE DIRECTOR OF INSURANCE MEDICAL SERVICE, THYCAUD, THIRUVANANTHAPURAM. BY SR. GOVERNMENT PLEADER SRI. V.P.K. MOHANAN. RESPONDENTS: PETITIONER & 1ST RESPONDENT IN IC ---------------------------------------------------------------- 1. JAMES P.GEORGE, PANTHACKLE HOUSE, KARUMPALAMATTAM, VADEMETTAM, THODUPUZHA, IDUKKI DISTRICT. 2. THE REGIONAL DIRECTOR, ESI CORPORATION THRISSUR. BY ADV. SRI.A.V.XAVIER FOR R1 SMT.THUSHARA JAMES FOR R1 SRI.P.SANKARANKUTTY NAIR, SC, ESI CORPN FOR R2 THIS INSURANCE APPEALS HAVING BEEN FINALLY HEARD ON 27/08/2008, THE COURT ON THE SAME DAY PASSED THE FOLLOWING: M.N. KRISHNAN, J. = = = = = = = = = = = = = = INS.APPEAL NO. 60 OF 2007 = = = = = = = = = = = = = = = Dated this the 27th day of August, 2008. J U D G M E N T This appeal is preferred against the order of the Employees Insurance Court, Idukki in I.C.3/02. The applicant before the Court was a Bureau Chief of the Deepika Daily News Paper, Thodupuzha. On 14.6.97, while he was going to the office he felt severe chest pain and was admitted in the nearby Mount Seenai Hospital, Thodupuzha. He was in the intensive care unit for 13 days and thereafter he was taken to the Medical College Hospital, Kottayam. Dr.Rajan Manjooran, Cardiologist, according to the applicant, referred him to Malar Hospital at Adayar where angiogram was taken at once and on medical advice had also undergone a bye-pass surgery and thereafter was discharged from the hospital on 3.10.97. He has claimed medical bills under the provisions of the E.S.I. Act. As per the provisions of the E.S.I. Act, i.e., Ss.56 to 58 an insured person or a member of his family whose condition requires medical treatment and Ins. Appeal 60 OF 2007 -:2:- attendance are entitled to receive the medical benefits. U/s 58 the State Government shall provide for insured persons and their families in the State reasonable medical, surgical and obstetric treatment. As per the E.S.I. Regulations, 96A, the claims for reimbursement of expenses incurred in respect of medical treatment of insured person and his family may be accepted in circumstances and subject to such conditions as the Corporation by general or special order specify. So the Regulation 96A envisages a special order by Employees State Insurance Authorities. On the basis of the same there is E.S.I. Medical Manual and 3.30 of the said E.S.I. Medical Manual deals with the reimbursement of expenses incurred in respect of medical treatment under Regulation 96A. In part A the full authority is bestowed with the State Government concerned to reimburse the expenditure in respect of the medical treatment of insured person and his family. Also, under heading B, the State Government has to keep in view the following points while considering the cases of reimbursement of expenditure on medical ground and clause Ins. Appeal 60 OF 2007 -:3:- C deals with a list of types of cases for which reimbursement is permitted and clause 8 reads as follows. “Serious cases of accident/illness where a beneficiary was admitted directly at a private hospital or in a non- recognized hospital where admission in a hospital recognized under the scheme would have seriously jeopardized his health like sudden heart attacks, fracture of spine, cerebral haemorrhage etc.” Learned Government Pleader would contend materials are lacking to prove what is contemplated in clause 8 referred to above. Along with the proof affidavit the claimant has produced documents which would show that he was admitted initially in the Mount Seenai Hospital and as per the certificate dated 10.7.97 it was mentioned that he should undergo further examination by a cardiologist. On 26.8.97 some investigation has been done for him from the Medical College Hospital, Kottayam. It is the case of the applicant that he was referred to the Malar Hospital by Dr.Rajan Manjooran. A document produced from Malar Heart Foundations would reveal regarding the reference done by Ins. Appeal 60 OF 2007 -:4:- Dr.Rajan Manjooran and he was admitted for diagnostic coronary angiography on 22.9.97. Therefore, surgery was done on 24.9.97 and he was discharged on 3.10.97. By a letter dated 3.10.97 Dr. V.V. Bashy of the Malar Hospital had thanked Dr.Rajan Joseph Manjooran of the Medical College Hospital, Kottayam and has intimated about the successful surgery he had undergone. The contention raised by the learned counsel for the Government Pleader is to the effect that there is delay and there was no necessity to go to Madras for such a treatment. From the materials available, it can be seen that to start with that he was treated in a local hospital from where he was referred to the Medical College Hospital and who in turn had sent him to Malar Hospital for angiogram and it is seen that immediately after the angiogram on the 2nd day he had undergone a heart surgery. So there is force in the contention of the claimant that the surgery became inevitable and it was done in order to save his life and therefore he could not take prior sanction of the Government or any other authorities for undergoing Ins. Appeal 60 OF 2007 -:5:- treatment in a hospital outside the State. The records available conclusively reveal that he was in a very bad condition and unless surgical intervention was done it would have resulted in serious consequences. The Delhi High Court in the decision reported in Narendra Pal Singh v. Union of India (1999 II CLR 904) held that rejection of medical reimbursement claim on technical ground is not proper. It was a case where a Central Government retired employee had to be operated emergently for heart disease and his claim was rejected on the ground that prior sanction was not obtained. The Delhi High Court took the view that the health and survival was the prime matter, nobody would have waited for getting sanction for undergoing such surgery and in the fitness of things the Government should have granted ex-post facto sanction. The said decision applies in all force to this case on hand as well. Here, when the entire medical records are ready and the background is analysed it can be seen that angiogram became inevitable and surgery was done on the advice of doctors immediately and certainly the Ins. Appeal 60 OF 2007 -:6:- applicant could not have waited for getting the sanction of authorities or the Government as the case may be. The purport and intention behind all these rules is only to prevent misuse of these rules and each case has to be weighed and considered on the backdrop and the circumstances available in that case. In this case I am convinced that there was existing circumstances which comes within the ambit of clause 8 referred to above and therefore the claimant is entitled to get the amount of reimbursement from the authorities. So far as the quantification is concerned if there is any sustainable objection that may be brought to his notice and the amount be disbursed to him which is permissible to him as expeditiously as possible. The appeal is disposed of accordingly. M.N. KRISHNAN, JUDGE. ul/-