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2013 Supreme(Del) 1734
DELHI HIGH COURT
V.K.Jain, J.
P.S Bist - Appellant
Versus
UOI and Ors. - Resopndent
W.P.(C) 2320/2011
Decided On : 25-10-2013
For the Petitioner: Mr R.K. Saini, Adv.
For the Respondent: Ms. Sapna Chauhan, Adv.
In emergency conditions, CGHS card holders are entitled to reimbursement at the rates prescribed by CGHS for hospitals at par with the hospital where the treatment is taken, irrespective of empanelment status.
Headnote:
CGHS - Medical Reimbursement - OM dated 07.09.2001, OM dated 17.8.2010 - MCA bifurcation aneurysm, SAH due to ruptured Right MCA with right temporal hematoma - Writ petition seeking reimbursement of medical bill - Reimbursement at package rates for non-empanelled hospital in emergency condition
Fact of the Case:
The petitioner, a retired Government servant, sought reimbursement for medical expenses incurred at a non-empanelled hospital in an emergency condition. The respondent approved only a partial reimbursement based on CGHS rates, leading to the petitioner filing a writ petition.
Finding of the Court:
The court directed the respondent to accept the petitioner's claim based on the rates fixed for an empanelled hospital at par with the non-empanelled hospital where the treatment was received. The court acknowledged the emergency condition and ordered further payment to the petitioner.
Issues: Reimbursement of medical expenses at non-empanelled hospital in emergency condition, Application of CGHS rates for approved hospitals
Ratio Decidendi: In emergency conditions, a government servant holding a CGHS card is entitled to reimbursement at the rates prescribed by CGHS for hospitals at par with the hospital where the treatment is taken, regardless of empanelment status.
Final Decision: The writ petition was disposed of with a direction to the respondent to accept the petitioner's claim based on the rates fixed for an empanelled hospital at par with the non-empanelled hospital where the treatment was received. Further payment was ordered to be made to the petitioner within eight weeks.
The petitioner before this Court is a retired Government servant entitled to benefits of Central Government Health Scheme (CGHS). The case of the petitioner, as set out in the writ petition, is that on 08.03.2008, he along with his wife was going to Sarojini Nagar to meet his daughter, who was staying there and on way to Sarojini Nagar when he reached near Saket, he felt uneasy, had severe pain in the head and was taken by his wife to the nearby Max Super Speciality Hospital, Saket, where he was admitted in emergency. An MRI Angiogram of the petitioner was done, which revealed MCA bifurcation aneurysm with mild tortuousity of the aortic rash. The petitioner was diagnosed as SAH due to ruptured Right MCA with right temporal hematoma. The petitioner was operated upon in the aforesaid hospital and was discharged on 13.03.2008. The petitioner paid a sum of Rs. 2,10,638.98/- to the aforesaid hospital for his treatment during the aforesaid period.
2. On discharge from the hospital, the petitioner submitted a bill to CGHS Dispensary at Sarojini Nagar, seeking reimbursement of the expenses incurred by him. The claim of the petitioner, however, was accepted only to the extent of Rs 61,145/-, which according to the respondent, was the CGHS rate approved for treatment taken by the petitioner. The petitioner made a representation to the Additional Director of CGHS against the limited reimbursement made to him. The said representation, however, yielded no result which constrained the petitioner to file this writ petition seeking the following relief:-
(a) A writ, order or direction in the nature of certiorari calling for the records of the case for perusal;
(b) A writ, order or direction in the nature of certiorari quashing the action of the respondent in refusing to reimburse to the petitioner whole of the medical bill of Rs. 2,10,638/- by way of medical reimbursement, being illegal, arbitrary, discriminatory and unjust and in violation of the Rules, Regulations and the principles of equity, justice and good conscience;
(c) A writ, order or direction in the nature of a writ of mandamus directing the respondent to forthwith reimburse to the petitioner the remaining amount of the medical bill i.e. Rs. 2,10,638/- minus Rs. 61,145/-.
(d) A writ, order or direction in the nature of a writ of mandamus directing the respondent to pay the cost of this petition to the petitioner.”
3. In their counter-affidavit, the respondents have stated that the Ministry of Health and Family Welfare has approved the rate list vide OM dated 07.09.2001 to settle the medical claim in respect of CGHS beneficiaries. Such package rate is a lump sum cost of inpatient treatment or Diagnostic procedure for which a patient has been referred by Compete Authority or CGHS to Hospital or Diagnostic Centre and includes all charges pertaining to a particular treatment/procedure including, accommodation charges, ICU/ICCI charges, monitoring charges, procedural charges/Surgeon’s fee, cost of disposable, surgical charges and cost of medicine used during hospitalization, related routine investigations, physiotherapy charges etc. It is further stated in the counter-affidavit that the petitioner chose to go to Max Super Speciality Hospital though he could have gone to AIIMS/Safdarjung Hospital, which was much closure. It would be pertinent to note that Max Super Speciality Hospital is not a hospital empanelled by CGHS.
4. A similar issue came up for consideration of this Court in W.P.(C) No. 5576/2012 titled Jai Pal Aggarwal vs. Union of India, decided on 30.08.2013 and the following view was taken:-
4. Clause 10 of MH & FW, OM No. S.11011/23/2009-CGHS D.H/Hospital, Cell (Part-I), dt. 17.8.2010 reads as under:
10. In case of treatment taken in emergency in any non-empanelled private hospitals, reimbursement shall be considered by competent authority at CGHS prescribed packages/ rates only.
Vide OM of even number dated 13.9.2010, CGHS clarified as under:
2. After the
