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2006 Supreme(Del) 6
High Court Of Delhi
PAMELA BHANDARI - Appellant
Versus
GAS AUTHORITY OF INDIA LTD - Respondent
Decided On : 01/02/2006
The main legal point established is that the reasonableness of medical procedures and reimbursement claims should be evaluated based on the available options and adherence to medical rules and regulations.
Headnote:
GAIL - Medical Reimbursement Dispute - Medical Attendance Rules 5.3, 6.3, 6.4.7, 6.4.10 - The court found that the demand of GAIL for reimbursement of Rs. 4,46,170 for angioplasty procedure was unreasonable and arbitrary. However, the denial of the claim for Rs. 1,23,200 towards the cost of injections was found to be in accordance with the rules.
Fact of the Case:
The petitioner, an IRS Officer, sought relief from GAIL for the expenditure incurred for her husband's angioplasty treatment and medication costs. GAIL disallowed the claims, leading to a legal dispute.
Finding of the Court:
The court found GAIL's demand for reimbursement of Rs. 4,46,170 for angioplasty procedure to be unreasonable and arbitrary. However, the denial of the claim for Rs. 1,23,200 towards the cost of injections was found to be in accordance with the rules.
Issues: The issues involved were the reasonableness of GAIL's refusal to reimburse the angioplasty cost and the denial of the claim for medication costs.
Ratio Decidendi: The court held that the angioplasty procedure was a reasonable option available to the patient and the demand for reimbursement was unreasonable. However, the denial of the claim for medication costs was in accordance with the rules requiring supporting documents.
Final Decision: The court quashed GAIL's demand for reimbursement of Rs. 4,46,170 and directed GAIL to pay Rs. 2,81,980 to the petitioner with interest. The writ petition was allowed to this extent.
( 1 ) IN these proceedings, under Article 226 of the Constitution of India the relief claimed is the setting aside of a decision by respondent, (hereinafter called gail ) dated 28th December 1999 disallowing the petitioners expenditure incurred for the angioplasty treatment of her husband and consequential directions that claims in the sum of Rs. 4,46,170/- and rs. 1,23,200/- respectively be granted. The other directions sought sought is for remitting the pay revision arrears and other claims of the petitioner along with appropriate interest.
( 2 ) THE petitioner, an Indian Revenue Services (IRS) Officer was deputed to gail as its Chief Vigilance Officer for the period from June 1997 to July 2000. Sometime during this period, her husband, Shri. Anil Bhandari was diagnosed for serious coronory disease, chest pain and he underwent coronary angiography on 1. 4. 1999. He had undergone an angioplasty procedure about 10 years earlier in 1989. This time the diagnosis/ the recommendation after evaluation of angiogram was Myocardial revascularisation/cabg ). The report was examined by dy. CMO (Deputy Chief Medical Officer) of GAIL, Dr. S. K. Saboo who referred the patient to Dr. Seth at Escort Heart Institute for necessary assessment on 5. 4. 1999. The petitioner requested for sanction which was given by the letter dated 6. 4. 99 on behalf of GAIL. On the same day patient was examined by Dr. Seth in the Escort Hospital. The diagnosis of Dr. Seth recorded ?ptca + Stent. RCA and LLAD ROTA + Stent LCX?. ? The patient was advised to be admitted as soon as possible.
( 3 ) MR. Bhandari was admitted in the Escort Heard Institute and Research centre, admittedly a referral institute as far as GAIL is concerned on 15. 9. 1999. He underwent ?ptca+stent to Stent + Stent ; Om -1 + PTCA ; LCX LAD and ROTA ; Stent RCA on 16. 4. 1999, (hereinafter referred to as angioplasty procedure ). On 19. 4. 1999 he underwent a further angioplasty procedure.
( 4 ) IT is claimed that all the blockages were removed and the patient was recovering; and was scheduled for discharge on 22/23. 4. 1999. He however developed fever resulting in further investigation on 24th April 1999, which revealed an infection. In a subsequent angiogram it was discovered that he had a pseudo- aneurysm in one of the arteries, a rare complication, and a life threatening situation. It is alleged that patient was advised to undergo a by pass surgery which was performed on 4. 5. 1999. Mr. Bhandari was eventually discharged on 8. 6. 1999 after 15 days of hospitalization. On 9. 6. 1999 the bills were directly sent by the hospital to GAIL. The necessary payments were also released.
( 5 ) IT is claimed that on all relevant and material times when patient was under treatment, Dr. Saboo of GAIL was apprised of the latest development and he had confirmed that Dr. Seth was reliable doctor. During the period from 6. 5. 1999 to 3. 6. 1999 the doctors at the Escort has advised administering of primaxin injection every six hours. It is claimed that this injection was not available with the hospital and the petitioner had to procure it urgently. Being an imported drug and readily not available off the shelf, the petitioner managed to procure them with some difficulty in small lots. It is alleged that average cost of the injection was about Rs. 1100/- and the petitioner had spent an aggregate of Rs. 1,23,200/- on these injections. The petitioner relied on a certificate issued on 8. 6. 1999 by the Escort Hospital that Primaxin injection was administered to the patient every six hours between 6. 5. 1999 to 3. 6. 1999 and they were essential for his treatment and recovery. By the letters dated 21. 10. 1999 and 28. 12. 1999 impugned in these proceedings, the GAIL has taken position that in the absence of any vouchers or bills regarding purchase of the injections it is not possible to reimburse the amount claimed and also that an amount of Rs. 4,46,170/- being total expenditure for the an
