The entitlement of employees to reimbursement based on the prevailing policy and the obligation of the Corporation to provide reimbursement in accordance with the policy, even if the treatment was undertaken at a non-recognized hospital.

S. Ravindra Bhat, J.

1. The North Delhi Municipal Corporation [hereafter “the Corporation”] has approached the Court under Articles 226 of the Constitution, assailing an order of the Central Administrative Tribunal (CAT) dated 16th December, 2013. The CAT directed the Corporation to reimburse the medical expenses of the Respondent, its employee [hereafter "the Applicant"], who had undergone a surgery in a private, non-empanelled hospital.

2. The Corporation provides medical facilities to its employees under the C.S. (MA) Rules of 1944 [hereafter “the Rules”]. Under these Rules, employees can undertake treatment at recognized or empanelled Government hospitals, or private hospitals if recommended to do so by an authorized medical officer. In cases of emergency, prior authorization is inessential. In 2006, the Corporation amended the Rules, extending cases in which unauthorized medical treatment at private hospitals could be undertaken, to “real emergencies, accidents and other deserving cases.”

3. In March 2010, the Applicant was advised by a doctor at Gangaram Hospital to undergo a cardiac evaluation. Consequently, he went to Indraprastha Apollo Hospital, and underwent a bypass surgery. In June 2010, his representation for reimbursement of medical expenses was rejected by the Expert Committee set up by the Corporation to look into such claims. The Applicant then obtained an Emergency Certificate from the Hospital, and made a second representation. This too was rejected.

4. The Applicant approached the CAT. In August 2011, the CAT issued an order directing the Expert Committee to consider the Applicant’s claims, while limiting them to the Central Government Health Service’s (hereafter “CGHS”) prescribed rates. In December 2011, the Committee did so, and rejected the claim once again.

5. In 2013, the Applicant filed another application before the CAT. The CAT decided in his favour, and directed the Corporation to reimburse the medical expenses, as limited by CGHS rates. This order is questioned in these proceedings.

6. It was pointed out before the CAT that the Corporation’s Expert Committee decided the question of reimbursement on the ground that the Applicant had planned his surgery and that the hospital was miles away from his residence; if the case was one of real emergency, there were several hospitals near the vicinity of his house. In its first rejection of the Applicant’s claim, the Experts Committee's remarks include “planned procedure; unrecognized centre; no emergency – not recommended.” In its third – and final – rejection of the Applicant’s representation, the Committee has stated that “treatment taken from Apollo Hospital in emergency ward does not mean that he was having any emergency situation… Expert Committee is of the view that after having a coronary angiography done from Sir Ganga Ram Hospital and a By-Pass Surgery from Apollo Hospital Sh. Rajinder Sharma opted for a planned procedure from an unrecognized hospital hence his claim cannot be recommended for reimbursement by the expert committee."

This claim is repeated on many occasions.

7. The CAT overturned the decision of the Expert Committee. Its order, requiring the Corporation to reimburse the Respondent was based on two grounds. The CAT found, on fact that the Respondent’s situation was one of emergency. Independently of that, the CAT also held that:

"7. As can be seen from the observations of the Committee, the claim of the applicant for reimbursement is not found tenable because the procedure of bypass surgery from Indraprastha Apollo Hospitals opted by the applicant was a planned procedure and instead of undergoing such procedure from a hospital, which is not recognized by the MCD, he could have very well gone to AIIMS, J. B. Pant Hospital and Dr. R.M.L. Hospital.

8. It is true that being at Chandni Chowk, the applicant could have been taken to any of the nearby hospitals, which were also recognized by the MCD. However, in the admission slip, it is