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.

JUDGMENT

Kuldeep Mathur, J. - The present writ petition has been filed by the petitioner with the prayer for reimbursement of the medical claims qua the treatment of the petitioner's wife pertaining to severe spinal problems.

2. Briefly stated facts of the case are that petitioner's wife suffered severe problems in the spine and was taken to Goyal Hospital, Jodhpur in precarious condition in an emergent situation. After examination of the patient, the petitioner was advised by the treating Doctor to take his wife to Ahmedabad as the Hospital did not possess adequate facilities for treatment. The wife remained hospitalized from 30.10.2014 to 04.11.2014 and for treatment of the petitioner's wife, a sum of Rs. 1,09,031/- was incurred. The petitioner applied for reimbursement of the medical bills covered under the Medi-claim Policy before the respondent-authorities, who returned the same on the ground that the hospital, where the petitioner's wife availed treatment does not find place in the list of empanelled hospitals approved by the State Government.

3. The petitioner being aggrieved by the denial of medical claim, approached this Court by way of S.B.C.W. No. 11348/2015 (Anda Ram v. State of Rajasthan & Ors.). The Coordinate Bench of this Court vide order dated 05.10.2015, observed that the petitioner has remedy to approach the Insurance Ombudsman Office located nearest to the petitioner. The petition was dismissed as withdrawn with liberty to approach the appropriate authority.

4. In pursuance of order dated 05.10.2015, the petitioner approached the appropriate authority through representation dated 03.11.2015 for the reimbursement of medical claim but to no avail. Aggrieved by this, the petitioner has filed the present writ petition.

5. Learned counsel for the petitioner submitted that Smt. Dhariya was suffering from spinal problem. The treatment whereof was not available in Goyal Hospital, Jodhpur and therefore, in the critical condition on the advice of the treating Doctors, she was taken to Stavya Spine Hospital & Research Institute, Ahmedabad for spinal surgery, which was essential. He further submitted that denial of reimbursement of the medical bills deserves to be declared illegal and arbitrary by this Court. Reliance was placed on a judgment of this Court in Raghuveer Sharma v. State of Rajasthan & Ors. reported in (2007 WLC (Raj.) UC 516, in the aforesaid case, the Court has 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."

6. Per contra, learned counsel for the respondents, submitted that the case of the petitioner is not covered under clause 6.3 of the Medi-claim policy, 2014-15. The treatment in a non-empanelled private hospital can be taken only in case of grave urgency viz. life threatening disease like kidney or heart ailments and accidents. It was further submitted that according to policy in vogue, emergency certificate of treating doctor establishing emergent situation is necessary for making any claim for reimbursement in a private hospital. The claim of the petitioner was rejected for non compliance of the terms and conditions of Medi-claim policy.

7. A coordinate Bench of this Court in the case of Mool Singh v. the State of Rajasthan & Ors. in S.B. Civil Writ Petition No. 5592/2018 vide order dated 09.09.2022 pleased to held as under:-

"The medical claim qua the said amount was