Emergency medical treatments require reimbursement even if provided by non-empanelled facilities, prioritizing the necessity of treatment over technical compliance with prescribed rates.

ORDER :

1. Petitioners assail order, dated 23.02.2024, passed by the Central Administrative Tribunal, Hyderabad (for short “the Tribunal”), in O.A.No.020/0883/2021, by which, they were directed to reimburse balance medical claim to a tune of Rs.3,80,717/- to the respondent herein, incurred on account of medical treatment of his daughter.

2. Petitioners herein are respondents and respondent is claimant before the Tribunal. For the sake of convenience, they are referred to as “respondents” and “claimant” as arrayed before the Tribunal.

3. Claimant retired from service from the post of Senior Section Engineer (P.Way)/BTTR, South Central Railway, Vijayawada Division, on attaining age of superannuation on 31.03.2018. His dependent daughter, aged 24 years, as was suffering from severe left leg pain and unable to walk, was taken to private hospital at Nellore on 10.01.2019, upon diagnosing the seriousness and immediate medical treatment, she was referred to Vijaya Super Specialty Hospital at Chennai. She was immediately admitted in I.C.U. at aforesaid hospital on 10.01.2019 itself in view of emergency. After thorough diagnosis and evaluation of patient, the treating doctor diagnosed her illness “Acute Ischemia Left Lower Limb (Advanced) Thrombus in Infra Renal Aorta 100% Occluded Rirhr+Poplitel Arthery-100% occluded left superficial femoral artery raw area left leg famicial insulin resistance syndrome-? Type-3 autommune thyroid disease acromegaly etc.” Immediately, daughter of claimant has undergone surgery and was in hospital as inpatient from 10.01.2019 to 29.01.2019, for which claimant incurred expenditure of Rs.4,40,927/-. Claimant submitted application, dated 23.04.2019, for reimbursement of the same. The 5^th respondent, by letter, dated 05.08.2019, recommended to Senior DFM/BZA, for payment of Rs.1,81,266/- as per CGHS 2014 tariff, after evaluating the genuineness of the claim and consulting the Specialist regarding the condition of patient, who opined to be a case of emergency and treatment to be essential. Surprisingly, 5^th respondent has issued memorandum of sanction, dated 28.01.2021, for reduced amount of Rs.60,210/- as against aforesaid recommendation. Claimant immediately submitted representation, dated 23.03.2021, requesting the 5^th respondent to revise the sanction amount of reimbursement, which came to be rejected by proceedings, dated 23.08.2021, justifying the same to be in accordance with CGHS rates. Assailing the same, claimant preferred the O.A.No.020/0883/2021 before the Tribunal.

4. Respondents filed counter inter alia stating that the disease diagnosed to claimant’s daughter being very unusual, after extensive evaluation by the Endocrinologist, though the treatment offered was not included in CGHS surgical packages, considering physical condition of patient, 5^th respondent has made initial recommendation for an amount of Rs.1,81,266/- however, later the same has been revised having regard to the Railway Board letter No.2005/H/6- 4/Policy-II, dated 31.01.2007, which provided that for any treatment taken in non-recognized private hospital, the reimbursement should be not more than at the CGHS rates of that city or nearest city, therefore, the reimbursement was limited to CGHS package rates. It is also stated that Senior DFM/BZA, by letter, dated 04.09.2019, in response to the initial recommendation, has made remarks that the claim has to be considered with reference to CGHS package rates for surgical treatment, as claimant’s daughter undergone various types of surgical procedures, which necessitated revision of reimbursement.

5. The Tribunal, having considered aforesaid rival submissions, being satisfied that there is no issue with respect to the nature of treatment, the urgency in undergoing the same,, and entitlement of claimant for medical reimbursement, by placing reliance on the judgment of the Hon’ble Apex Court in Shiva Kant Jha v. Union of India , (2018) 16 SCC 187 , later followed by Delhi High Court in Unio