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2003 Supreme(Mad) 1125
High Court of Judicature at Madras
THE HONOURABLE MR. JUSTICE K.P.SIVASUBRAMANIAM
E.V.Kumar - Appellant
Versus
The Union of India, rep.by the Ministry of Health and Family Welfare & Others - Respondents
Writ Petition No.10392 of 1996 and WMP.No.13753 of 1996
Decided On : 28 July 2003
The entitlement of a government servant to full medical reimbursement as per the Central Services (Medical Attendance) Rules, and the absence of provision for the government to fix any ceiling/package deal for medical expenses.
Headnote:
Medical Reimbursement - Coronary Bypass Surgery - Central Services (Medical Attendance) Rules - Rule 6
Fact of the Case:
The petitioner, a former judge, sought reimbursement for coronary bypass surgery expenses incurred at a private hospital. The government sanctioned a lower amount than claimed by the petitioner, citing package rates and deal arrangements with private hospitals.
Finding of the Court:
The court found that the petitioner was entitled to the full claimed amount as there was no provision in the rules for the government to fix any ceiling/package deal. The court also ordered the respondents to pay the balance amount with interest at the rate of 12% per annum.
Issues: Dispute over the sanctioned amount for medical reimbursement and the validity of package rates and deal arrangements with private hospitals.
Ratio Decidendi: The court held that the petitioner was entitled to the full claimed amount as there was no provision in the rules for the government to fix any ceiling/package deal. The court also relied on precedents to support the entitlement of the petitioner to the full amount and the awarding of interest on the balance amount.
Final Decision: The writ petition was ordered in favor of the petitioner, and the respondents were directed to pay the balance amount with interest at the rate of 12% per annum.
The petitioner, the former Additional District and Sessions Judge of Karaikal, Pondicherry has sought for a writ of certiorarified mandamus to call for the records relating to the order of the second respondent in G.O.Rt.No.573/95-LD dated 13.12.1995, to quash the same and to direct the respondents to reimburse to the petitioner, the actual amount of expenditure incurred by the petitioner for taking treatment of undergoing Coronary by-pass surgery in the Apollo Hospitals, Madras as certified by the Chief Cardio Thoracic Surgeon of the said hospital, after deducting the medical advance granted by the second respondent under G.O.Rt.No.288/95-LD dated 05.06.1995.
2. In view of the undisputed facts, it is not necessary to deal with the factual contentions raised by the petitioner. Admittedly, the petitioner underwent coronary by-pass surgery in Apollo Hospitals, Madras and the Hospital is also duly authorised by the Pondicherry Government as one of the private hospitals recognised for coronary by-pass surgery, namely Annexure-I of the Office Memorandum dated 20.07.1994.
3. It is also not disputed before me that the provision of Central services (Medical Attendance) Rules are applicable to the case of the petitioner herein.
Rule 6, of the Medical Attendance Rules is as follows:
"6.(1) A Government servant shall be entitled, free of charge, to treatment --
(a) in such Government hospital at or near the place where he falls ill as can in the opinion of the authorised medical attendance provide the necessary and suitable treatment; or
(b) if there is no such hospital as is referred to in sub-clause (a) in such hospital other than a Government hospital at or near the place as can in the opinion of the authorised medical attendant, provide the necessary and suitable treatment.
(2) Where a Government servant is entitled under sub-rule(1), free of charge, to treatment in hospital, any amount paid by him on account of such treatment shall, on production of a certificate in writing by the authorised medical attendant in this behalf, be reimbursed to him by the Central Government:
Provided that the controlling officer shall reject any claim if he is not satisfied with its genuineness on facts and circumstances of each case, after giving an opportunity to the claimant of being heard in the matter. While doing so, the controlling officer shall communicate to the claimant the reasons, in brief, for rejecting the claim and the claimant may submit an appeal to the Central Government within a period of forty-five days of the date of receipt of the order rejecting the claim."
4. Perusal of the above mentioned Rule says that it is open to the Government servant who is entitled to be treated in a hospital other than Government Hospital, if such hospital as referred to in Sub-Clause(a) is not available, he can get treatment in a hospital other than Government Hospital at or near the place as can in the opinion of the authorised medical attendant, provide the necessary and suitable treatment. Therefore, there is no dispute over the fact that the petitioner was entitled to be treated at Apollo Hospitals, Madras and there is no dispute over the said fact.
5. The dispute in the present case is that as against the total claim of Rs.1,44,019/-, the Government has sanctioned a total sum of Rs.99,500/-. According to the Government, the package rate/deal arrangement with the private hospitals and the rate of coronary by-pass surgery for all private hospitals in respect of private ward was Rs.89,000/- and Rs.10,500/- which was charged for Angiography test was reasonable. It was also certified that the rate of Rs.89,000/- charged by the Apollo Hospitals, Madras was also reasonable. Therefore, a total sum of Rs.99,500/- was paid and reimbursed to the petitioner.
6. It is further stated that the Government of India already recognised the package deal arrangement with the Private Hospitals and the rate for CAG/CABG and other investigations would be regulated on
