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HIGH COURT OF JUDICATURE FOR RAJASTHAN AT JODHPUR
Kuldeep Mathur, J.
Pramila Tak – Appellant
Versus
State Of Rajasthan & Ors. – Respondents
S.B. Civil Writ Petition No. 11726/2016
Decided On : 23-09-2022
Medical Reimbursement - Emergency Treatment in Non-Empanelled Hospital - The court held that in cases of grave emergency, the responsibility of the state cannot be washed out, and technicalities of rules and regulations under the scheme are not required to be followed in a mechanical manner to frustrate the purpose of the scheme. The respondent-department is obligated to reimburse the amount for treatment in a private or unrecognized hospital in emergent situations, as long as the treatment undertaken has not been disputed.
Fact of the Case:
The petitioner's husband was admitted to a hospital due to severe chest pain and was later referred to another hospital where he passed away. The petitioner applied for reimbursement of medical bills, but it was rejected on the grounds of treatment in a non-empanelled hospital and lack of emergency certificate from treating doctors.
Finding of the Court:
The court found that the petitioner's husband had been taken to a private hospital due to emergent circumstances, and reimbursement cannot be rejected solely on the ground of the hospital not being empanelled or the absence of a certificate justifying emergency for availing treatment.
Issues: The issues revolved around the rejection of medical bill reimbursement due to treatment in a non-empanelled hospital and the absence of an emergency certificate from treating doctors.
Ratio Decidendi: The court emphasized that in cases of grave emergency, the responsibility of the state cannot be washed out, and technicalities of rules and regulations under the scheme are not required to be followed in a mechanical manner to frustrate the purpose of the scheme. It also cited previous judgments to support the obligation of the respondent-department to reimburse the amount for treatment in a private or unrecognized hospital in emergent situations.
Final Decision: The present writ petition was allowed, and the respondent authorities were directed to reimburse the expenditure incurred by the petitioner in the treatment of her husband at a private or unrecognized hospital in an emergent situation. The respondent department was given a period of two months to complete the necessary exercise, and in case the claim was not settled within the specified period, it would carry an interest of 6% per annum. No order as to costs was given.
JUDGMENT
Kuldeep Mathur, J. - Briefly stated facts of the case are that the petitioner's husband was admitted in Krishna Super Speciality Hospital, Jodhpur due to severe chest pain. The treating doctors looking at the severity of case, referred him to Apollo Hospital, Ahmedabad, where he passed away on 08.09.2015 while taking treatment.
2. The petitioner applied for reimbursement of medical bills before the respondent-authorities amounting toRs.9,80,992/-. The bills were returned with an assertion that the petitioner's husband availed treatment in a non-empanelled hospital and has also not annexed the certificate of the treating doctor, showcasing emergent situation for availing treatment in a non-empanelled/private hospital.
3. Learned counsel for the petitioner submitted that petitioner's husband had been taken to a private hospital due to emergent circumstances therefore, reimbursement cannot be rejected solely on the ground that the hospital was not an empanelled one or the certificate of treating doctors justifying emergency for availing treatment was not annexed. Reliance was placed on a judgment of this Court in the case of Raghuveer Sharma v. State of Rajasthan & Ors. reported in (2007 WLC (Raj.) UC 516, in which it was held as under:-
"prime consideration in case of grave emergency, which comes in the mind of family is to save the life of patient and at that point of time whatever hospital comes to their mind and considered just is felt as the best because emergency knows no law and no procedure and when human life is at stake in such situation ultimately responsibility of State cannot be washed out. Technicalities of Rules and Regulations under the Scheme are not required to be followed just in a mechanical manner so as to frustrate very purpose of the Scheme because a person having put in his whole life in the service of the State till attains age of superannuation always require human considerations."
4. Per contra, learned counsel for the respondents submitted that the treatment in a non-empanelled/private hospital can be taken in case of grave urgency viz. life threatening disease like kidney or heart ailments and accidents. It was further submitted that according to the rules/policy in vogue, emergency certificate of treating doctor establishing emergent situation is necessary for making any claim for reimbursement in a private hospital.
5. A co-ordinate Bench of this Court in the case of Mool Singh v. the State of Rajasthan & Ors. in S.B.CWP No. 5592/2018 vide order dated 09.09.2022 was pleased to held as under:-
"The medical claim qua the said amount was raised before the respondent Department but the same was rejected on the ground that the petitioner has not shown any emergent situation wherein his wife was required to be treated in the private hospital i.e. SAL Ahmedabad.
In Surjit Singh v. State of Punjab and Ors. reported in AIR 1996 SC 1388, decided on 31.01.1996, the Hon'ble Apex Court held as under:-
"10........................ In such an urgency one cannot sit at home and think in a cool and calm atmosphere for getting medical treatment at a particular hospital or wait for admission in some Government medical institute. In such a situation, decision has to be taken forthwith by the person or his attendants if precious life has to be saved. We share the views afore-expressed"
6. In Rama Prasad Sharma v. State of Rajasthan & Ors.; S.B.C.W.P. No. 7469/2016, decided on 21.01.2022, passed by this Court, it was held as under:-
"............ It is now a settled position of law that even in cases where the treatment of an employee has been taken in non-recognized hospital the medical reimbursement has to be made at the rate that may be applicable for similar treatment in the recognized government hospitals."
7. In the light of aforesaid enunciation of law, the respondent-department is under an obligation to reimburse the amount to the petitioner for the treatment underwent by her husband in a private or unrecognized hosp
In cases of grave emergency, the responsibility of the state cannot be washed out, and technicalities of rules and regulations under the scheme are not required to be followed in a mechanical manner ....
The obligation of the department to reimburse medical treatment in a private or unrecognized hospital as per the applicable Rules, despite technicalities of the Medi-claim policy.
The main legal point established is that the department is obligated to reimburse the amount for medical treatment undertaken in a private or unrecognized hospital, to the extent permissible under th....
Medical reimbursement for treatment in a non-recognized hospital/private hospital must be made to the extent permissible under relevant Rules/Scheme/Policy.
The right to medical aid is fundamental under Article 21, and reimbursement for treatment at private hospitals during emergencies cannot be denied, upholding the principles of fairness and timely adm....
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