JAMMU AND KASHMIR AND LADAKH HIGH COURT
Tashi Rabstan, Sindhu Sharma, JJ.
Union Territory of J&K & Ors. – Appellants
Versus
Sudesh Kumar Raina – Respondent
LPA No.15 of 2021
Decided On : 06-09-2022
Medical Reimbursement - Emergency Medical Treatment - The court held that the government servant is not altogether barred from seeking medical treatment in a hospital outside the state, provided there is an emergency and it is certified by the competent authority. The court emphasized that the rules should not be interpreted to operate harshly in medical treatment cases and that genuine emergency situations should be considered for reimbursement.
Fact of the Case:
The respondent sought reimbursement for medical treatment of his son at a hospital outside the state, which was rejected by the appellants citing violation of prescribed procedure.
Finding of the Court:
The court found that the treatment received by the patient was genuine and that it was under an emergent situation the respondent had to get his son treated at the hospital outside the state. The court emphasized that the rules should not be interpreted to operate harshly in medical treatment cases.
Issues: The main issue was whether the respondent was entitled to reimbursement for medical treatment of his son at a hospital outside the state, considering the violation of prescribed procedure.
Ratio Decidendi: The court held that the government servant is not altogether barred from seeking medical treatment in a hospital outside the state, provided there is an emergency and it is certified by the competent authority. The court emphasized that genuine emergency situations should be considered for reimbursement.
Final Decision: The appeal was dismissed, and the court found no merit in the appeal.
JUDGMENT
Tashi, J. - This Letters Patent Appeal is directed against the judgment dated 23.07.2019 delivered by the learned Single Bench in SWP No.911/2014, whereby the learned Single Judge while allowing the writ petition directed the respondents, appellants herein, to settle the medical reimbursement claim of writ petitioner, respondent herein, and disburse him the claim along with interest at the rate of 6% per annum to be paid with effect from 25.02.2014 till it is actually paid.
2. Today, when the matter was taken up for hearing, none appeared on behalf of respondent. On the last date of hearing, i.e., 29.07.2022 it was specifically observed by the Court that if the learned counsel for respondent fails to appear on the next date of hearing, the matter would be considered on merits in his absence.
3. Accordingly, matter was taken up today; heard learned counsel appearing for appellants and perused the file.
4. The contention of learned counsel for appellants is that it was incumbent upon the respondent to have referral of his son from the competent medical authority of the State. Since the respondent had failed to comply with the prescribed procedure, as such his case for reimbursement of his medical claim came to be rejected. It was further contended that the son of respondent had already been suffering from the same problem a year ago; as such the respondent could have easily got a referral from the J&K State Medical Authorities. The further contention of learned counsel for appellants is that in terms of Rule 6 of J&K Civil Services (Medical Attendance and Allowance) Rule, 1990, neither the respondent nor his family was temporarily residing outside the State in Delhi nor they have got the requisite certificate from the Directorate Health Services, as such, on this score too, the respondent is not entitled to for reimbursement of medical claim.
5. Admittedly, the medical reimbursement claim of the respondent came to be rejected owing to the fact that the treatment of the minor son of respondent from Sir Ganga Ram Hospital at Delhi was in violation of Circular dated 06.07.2011 issued by the Finance Department, which provided that if a person takes treatment outside the State on its (his) own without referral from the prescribed competent Medical Authority of the State, it shall be presumed to have been done on his own in violation of the prescribed procedure.
6. A perusal of the appeal reveals that the appellants have themselves admitted that when the son of respondent was operated at Sir Ganga Ram Hospital, New Delhi on 12.11.2012, he, as per the medical record, was already suffering from the same problem a year ago and had been admitted in Government Medical College, Jammu; meaning thereby the appellants cannot question the genuineness or emergent situation of the son of respondent. Otherwise too, the Medical Reimbursement Verification Committee of the Directorate of Health Services had also observed that the treatment received by the patient was genuine. Further, Director Agriculture in his recommendation had clearly indicated that the treatment of the son of respondent at Sir Ganga Ram Hospital was due to sudden illness of his son, Director Agriculture, thus, recommended that the case of respondent be settled under Rule 8 of the Rules of 1990. Even the appellants herein in their objections to the writ petition have not denied the genuineness of the claim of respondent nor did they deny that it was under an emergent situation the respondent had to get his son treated at Sir Ganga Ram Hospitaln New Delhi, but have justified the rejection on the strength of Circular dated 6.7.2011. The appellants have failed to understand that apart from the power of the Government to relax the rigors of the Rules in appropriate cases, in terms of Rule 8(ii) of the Rules, the medical treatment by Government servant in a hospital outside the State, is not altogether barred. The Government servant is, however, liable to demonstrate that there was
Government servants are not altogether barred from seeking medical treatment in a hospital outside the state, provided there is an emergency and it is certified by the competent authority.
Government employees are entitled to medical facilities, and reimbursement cannot be denied solely based on treatment in non-recognized hospitals.
Medical reimbursement cannot be denied solely for treatment in non-empanelled hospital if genuine and emergent, per Art.21.
The main legal point established in the judgment is the need for a humane and flexible approach in applying the J&K Civil Services (Medical Attendance-cum-Allowance) Rules, 1990, especially in cases ....
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 principles of administrative fairness mandate that decisions impacting individuals' rights must be reasoned, and arbitrary rejections are unsustainable under the law.
Medical reimbursement for treatment in a non-recognized hospital/private hospital must be made to the extent permissible under relevant Rules/Scheme/Policy.
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.
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