In emergency medical situations, full reimbursement of medical expenses is mandated regardless of any imposed ceiling limits, emphasizing the right to timely medical treatment.

JUDGMENT :

JYOTI SINGH, J.

1. This writ petition is preferred on behalf of the Petitioner laying a siege to order dated 10.11.2015 passed by the Respondent/State Trading Corporation of India Ltd. (‘STC’) rejecting the claim of the Petitioner for medical reimbursement to the tune of Rs.23,79,313/- on account of medical expenses incurred by him in Max Super Speciality Hospital, Saket, on the treatment of his wife who was hospitalized on 09.01.2012 in a serious condition for 21 days and expired on 31.01.2012.

2. Case of the Petitioner as set out in the writ petition is that Petitioner was employed with STC from 1966 and after serving for 31 years, retired in the year 1997. Respondent introduced a Voluntary Retirement Scheme (‘VRS’) on 09.04.1997, which provided that regular employees who had completed minimum 10 years of service in STC or 40 years of age, shall be eligible to seek voluntary retirement by making an application in writing through proper channel to the Competent Authority. VRS came into force w.e.f. 10.04.1997.

3. Clause 5 of VRS enumerated the benefits available under the Scheme which included Provident Fund and Gratuity as admissible, ex-gratia payment to the extent stipulated, travel expenses etc. As for medical benefits, it was provided that benefits as stipulated under STC (Retired Employees’) Medical Benefits Scheme, 1981 (‘Medical Scheme’) will be available, provided that the employee has rendered minimum of 15 years of service and provided further that he/she does not avail similar benefits from any other source.

4. On 04.05.2006, Respondent issued a Circular requiring retired officers to pay 5% of the in-patient treatment amount in empanelled hospitals and 95% was payable by the Respondent. Procedure for reimbursement was also laid down in the circular. On 16.01.2007, STC issued a circular giving a list of hospitals empanelled till further orders and this included Max Super Speciality Hospital, Saket. On 12.11.2010, based on a representation by the STC Ex-Employees’ Welfare Association, bringing forth that the Circular dated 04.05.2006 was contrary to the undertaking given by the STC, Chennai Office before the Madras High Court in W.P. 15314/2005, STC withdrew the Circular dated 04.05.2006 but issued another Circular dated 12.11.2010 imposing a ceiling limit/cap on the amount reimbursable towards indoor medical expenses. It was further provided that in case of major ailments such as cancer, kidney, heart ailments, paralysis, major accidents etc., treating hospitals will be allowed to exceed in their entitlements up to double the amount of the ceiling limit, with approval of the Competent Authority, on a case-to-case basis.

5. Petitioner’s wife was hospitalized in Max Super Speciality Hospital, Saket on 09.01.2012 in a serious condition for multiple organ failure due to severe sepsis. She was also suffering from chronic kidney disease (Stage-V) requiring haemodialysis thrice a week. She expired on 31.01.2012 in the hospital and bill to the tune of Rs.25,75,275/- was raised by the hospital.

6. In a Board meeting held on 09.11.2012, STC resolved to withdraw the ceiling limit on hospitalization expenses and it was decided that the employees who had retired prior to 01.01.2007 will be allowed medical expenses on hospitalization at actuals while to those who retired post 01.01.2007, an option will be given to avail medical expenses on hospitalization at actuals but without pensionary benefits or to avail pensionary benefits with proposed ceiling/slab on medical expenses on hospitalization, as per rules. The decision was prospective in operation. Another Circular was issued on 22.02.2013, in partial modification of the existing Medical Scheme, stipulating that employees who had retired on or before 25.11.2008 will be allowed indoor medical expenses on hospitalization at actuals, however, 5% of the total expenditure towards indoor treatment shall be borne by the retired employees as was in vogue prior to September, 2010.