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HIGH COURT OF JUDICATURE FOR RAJASTHAN AT JODHPUR
Kuldeep Mathur, J.
Ibrahim Khan – Appellant
Versus
Rajasthan State Road Transport Corporation & Ors. – Respondents
S.B. Civil Writ Petition No. 1388/2015
Decided On : 16-09-2022
Reimbursement - Medical Claim - The court held that even in cases where the treatment of an employee has been taken in a non-recognized hospital, the medical reimbursement has to be made at the rate that may be applicable for similar treatment in recognized government hospitals. The petitioner is entitled to the reimbursement of his medical claims to the extent as permissible in terms of Regulations, 2011.
Fact of the Case:
The petitioner sought reimbursement for medical expenses incurred for treatment at a private hospital, which was rejected by the competent authority. The petitioner argued that the treatment was for a life-threatening disease and should be reimbursed.
Finding of the Court:
The court found that the petitioner is entitled to reimbursement of medical claims to the extent permissible in terms of Regulations, 2011, despite the treatment being undertaken at a non-recognized hospital.
Issues: The main issue was whether the petitioner was entitled to reimbursement for medical expenses incurred at a non-recognized hospital for a life-threatening disease.
Ratio Decidendi: The court relied on previous judgments to establish that even in cases where treatment is taken in a non-recognized hospital, medical reimbursement has to be made at the rate applicable for similar treatment in recognized government hospitals.
Final Decision: The court allowed the writ petition and directed the respondent authorities to reimburse the medical claim of the petitioner to the extent permissible in terms of Regulations, 2011, within three weeks from the date of the order, with an additional interest of 6% per annum.
JUDGMENT
Kuldeep Mathur, J. - The petitioner has preferred this writ petition assailing the order dated 19.08.2014 (Annex.-5), whereby the competent authority i.e. respondent No. 2 returned the application dated 04.04.2014 for reimbursement of the medical claim of Rs. 1,75,697/- even after submission of all medical bills.
2. The case of the petitioner is that he suffered severe chest pain on 06.04.2013, whereupon he was taken to the nearest hospital at Nimbaheda. On the advice of treating Doctors and upon the opinion of Cardiologist, he was taken to CIMS Hospital Private Limited at Ahmedabad for treatment. The treating Doctors of CIMS Hospital Private Limited conducted an operation for removing blockage in the heart of petitioner. The petitioner was subsequently discharged from the hospital on 09.04.2013. The petitioner thereafter raised a medical claim of Rs. 1,75,697/- for reimbursement but the same was rejected vide order dated 19.08.2014 on the ground that treatment undertaken by the petitioner was not from a recognized hospital or referral hospital.
3. Learned counsel for the respondents vehemently submitted that once petitioner has underwent treatment from a private Hospital which is not an empanelled/approved/referral hospital, he would not be entitled for the reimbursement of the amount claimed and therefore, the bills submitted by the petitioner were rightly rejected/returned back to him.
4. Heard learned counsel for the parties.
5. The regulation 9.(3) of the RSRTC Medical Attendance Regulations, 2011 (hereinafter referred to as 'Regulations, 2011), which reads as under:-
"9.(3) If a Corporation Employee undertakes indoor treatment of life threatening disease like kidney, heart and some sudden accident, in a private hospital outside the State Without reference in case of emergent circumstances. Corporation may allow reimbursement of the medical expenses incurred upto the cost of treatment, that would have been incurred and the treatment been taken in SMS Hospital, Jaipur and if facility of that treatment is not available in SMS Hospital, Jaipur upto the cost of treatment at AIIMS, New Delhi, upon such emergent circumstances being explained satisfactorily. No Travelling Allowances shall be admissible in such cases.
Provided that if the total expenditure on medical attendance and treatment as per the provisions of sub regulation (2) is more than Rs. 5 lacs then the Head of Office will refer the case to the Principal of Medical College to constitute a Medical Board to ascertain the genuineness of the claim. The reimbursement on this account shall be governed as per opinion of the Medical Board and the excess claim, if any, shall be disallowed."
6. From perusal of aforesaid regulation, it is clear that in case an employee had taken indoor treatment of life threatening disease like kidney, heart and some sudden accident, in a private hospital outside the State without reference in case of emergent circumstances, the Corporation may allow reimbursement of the medical expenses incurred up to the cost of treatment that would have been incurred and had the treatment been taken in SMS Hospital, Jaipur.
7. Admittedly, the petitioner in the emergent circumstances has undergone an operation at CIMS Hospital Private Limited at Ahmedabad and was discharged on 09.04.2013.
8. In Rama Prasad Sharma v. State of Rajasthan & Ors.; S.B.C.W.P. No. 7469/2016, the coordinate Bench of this Court 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."
9. In State of Rajasthan & Ors. v. Tikam Chand Maloo; D.B.S.A.W. No. 1124/2015, the Division Bench of this Court held as under:
"it is obvious that this Court took view that in emergent situation, if the Govt. employee took treatment outside the State that too in unrecognized hospit
Even in cases where treatment is taken in a non-recognized hospital, medical reimbursement has to be made at the rate applicable for similar treatment in recognized government hospitals.
Medical reimbursement for treatment in a non-recognized hospital/private hospital must be made to the extent permissible under relevant Rules/Scheme/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....
The main legal point established in the judgment is that claims for reimbursement of medical expenses should be considered in accordance with the provisions of the Rajasthan Civil Services (Medical A....
Government employees are entitled to medical facilities, and reimbursement cannot be denied solely based on treatment in non-recognized hospitals.
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 ....
Government employees are entitled to medical reimbursement for treatment in non-recognized hospitals at applicable rates for similar treatments in recognized hospitals.
Government employees are entitled to medical reimbursement for emergency treatments, regardless of the treatment location, as long as proper documentation is provided.
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