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Employee’s medical claim cannot be denied over non-empanelment of hospital

The Delhi High Court has ruled that the medical claim of a government employee for reimbursement of treatment undertaken in emergency should not be denied merely because the hospital was not empanelled with CGHS facility.

A division bench of Justice V. Kameswar Rao and Justice Anoop Kumar Mendiratta observed that the test would be to see whether the claimant had actually undertaken the treatment in emergent condition as advised and if the same is supported by record.

“Preservation of human life is of paramount importance. The State is under an obligation to ensure timely medical treatment to a person in need of such treatment and a negation of the same would be a violation of Article 21 of the Constitution of India. Administrative action should be just on test of fair play and reasonableness,” the court said.

The bench added that denial of such medical claim by the authorities only adds to the misery of the government servant by forcing such individual to “resort to courts.”

“Accordingly, keeping into consideration the constitutional values, the executive instructions need to be applied than rejecting the claim on technical ground of undertaking treatment in a non- empanelled hospital, since the CGHS/State is responsible to ensure proper medical treatment in an emergent condition and further cannot escape the liability, if the treatment undertaken is genuine. Any denial of claim by the authorities in such cases only adds to the misery of the Government servant by further forcing him to resort to Court of law,” the court said.

The bench made the observations while dismissing a plea moved by the Central Government challenging an order passed by Central Administrative Tribunal directing it to reimburse a retired pensioner employed as a Senior Carpenter with the government, for the balance amount incurred by him due to emergency medical treatment for “Trigeminal Neuralgic” in VIMHANS hospital which was not empaneled.

The pensioner was initially taken to Mata Chanan Devi Hospital wherein he was examined and advised further treatment at VIMHANS Hospital. His wife took him in emergency to VIMHANS Hospital wherein he underwent a surgery.

While the pensioner submitted medical bills amounting to Rs.2,60,000 as raised by VIMHANS for reimbursement along with the emergency certificate at CGHS Dispensary, he was reimbursed only an amount of Rs.31,556.

It was the case of the Union Government that the treatment was undertaken by pensioner at a non empaneled hospital at his own choice and thus, he was not entitled to reimbursement as per policy and Standing OMs. It was contended that if such relief is granted, it would open flood gates for other cases.

Noting that Trigeminal Neuralgia is a chronic pain condition affecting the trigeminal nerve in the face which carries the sensation from the face to the brain, the bench noted that the prescription issued by a Consultant Neurosurgeon of VIMHANS hospital stated that the pensioner was advised “Gamma Knife Radiosurgery” as “emergency treatment‟ apart from other treatment.

“Merely because the respondent was conscious, awake and oriented at time of admission at VIMHANS cannot lead to an inference that his claim of being admitted in emergency, is false,” the court said.

Dismissing Union Government’s plea, the bench said that it needs to be kept in perspective that the patient has a “little scope” to decide the nature of treatment and merely looks forward to an expert guidance or treatment for relieving him from immense pain and suffering.

“The patient in distress is not in a position to go against the specialist medical advice for surgery in emergency. Even assuming that in emergency, gamma knife surgery may not render an immediate relief as contended by learned counsel for the petitioners, but it is an established alternative medical treatment for trigeminal neuralgia as per literature,” the court said.

Taking note of the emergency certificate and the treatment papers filed by the pensioner, the court said that it cannot be said that his treatment was not taken in an emergent condition or that he should have deferred the immediate surgery as advised by the Specialist.

“For the foregoing reasons, we agree with the reasons and findings of the Tribunal. The writ petition is accordingly dismissed. No order as to costs. Pending application, if any, also stands disposed of,” the bench said. LiveLaw

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