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2024 Supreme(Telangana) 442
IN THE HIGH COURT FOR THE STATE OF TELANGANA AT HYDERABAD
ABHINAND KUMAR SHAVILI, LAXMI NARAYANA ALISHETTY, JJ.
The Union of India – Appellant
Versus
M S Viswanatham – Respondent
Writ Petition No.23080 of 2024
Decided on : 10-09-2024
Advocate Appeared:
For the Appellant : GADI PRAVEEN KUMAR Dy. SOLICITOR GEN. OF INDIA
For the Respondent: ANITA SWAIN
IMPORTANT POINT
IMPORTANT POINT
Medical reimbursement claims cannot be denied solely on technical grounds when treatment is substantiated, especially under exceptional circumstances like a pandemic.
Headnote:
(A) Contributory Health Service Scheme (CHSS) – Rule 15.4 – Medical reimbursement – Respondent, a retired employee, denied reimbursement for treatment in a non-panel hospital due to late intimation – Tribunal directed reimbursement considering exceptional circumstances during Covid-19 pandemic – Petitioners' rejection deemed illegal and arbitrary. (Paras 3, 11, 12, 16, 18)
(B) Medical Claims – The denial of reimbursement based solely on technical grounds, without considering the actual treatment received, is impermissible. (Paras 16, 18)
Facts of the case: The respondent, affected by Covid-19, was admitted to a non-panel hospital due to unavailability of beds in panel hospitals and later sought reimbursement for his medical expenses. The petitioners rejected the claim citing late intimation as per CHSS Rule 15.4.
Findings of Court: The Tribunal's order to reimburse the respondent's medical claim was upheld, emphasizing the need for flexibility in emergency situations. The petitioners' actions were found to be arbitrary.
Issues: Whether the late intimation of hospital admission justifies the denial of medical reimbursement under CHSS Rule 15.4.
Ratio Decidendi: The court held that the exceptional circumstances during the pandemic warranted a waiver of the late intimation requirement, reinforcing that reimbursement should not be denied on technical grounds when treatment is substantiated.
Result: Writ Petition dismissed.
ORDER:
(per Hon’ble Sri Justice Laxmi Narayana Alishetty)
This Writ Petition is filed assailing the order dated 05.04.2024 passed by the Central Administrative Tribunal, Hyderabad Bench, Hyderabad, in O.A.No.569 of 2023.
2. Heard Sri Akhilesh, learned counsel representing Sri Gadi Praveen Kumar, learned Deputy Solicitor General of India, appearing for the petitioners and Ms. Anitha Swain, learned counsel for the respondent.
3. In nut shell, the facts of the case are that the respondent is a retired employee of Atomic Mineral Directorate for Exploration and Research Department (AMD), which is a Department of Atomic Energy (DAE). He is a life member of Contributory Health Service Scheme (for brevity ‘CHSS). That on 24.04.2021, on being affected with Covid-19 Virus, he was unable to breathe and his condition became serious and as such, he got admitted in a non-panel hospital viz., Sreshta Sri Kamala Hospital, Dilsukhnagar, Hyderabad, since all the panel hospitals refused to admit him due to non-availability of beds. He was treated in ICU for nine days and one day in General ward and was discharged on 03.05.2021 and thereafter, he was under home isolation and quarantine for 45 days. Subsequently, on 26.07.2021, he submitted medical claim for reimbursement of Rs.5,71,224/- incurred towards his treatment to petitioner No.2 and on 27.08.2021, petitioner No.2 called for evidence from the respondent regarding intimation of his admission in a non-panel hospital to the Medical Division of DAE, to which, the respondent submitted an explanation through mail on 31.08.2021 requesting to condone the delay. However, the same was not considered and the AMD issued order dated 12.01.2022 rejecting the claim of the respondent. Though the respondent made several representations and also got issued legal notice seeking to condone the delay, the petitioners have not responded to the same. Hence, the respondent approached the Tribunal by filing the present O.A. and the Tribunal vide impugned order dated 05.04.2024 directed the petitioners herein to reimburse the full medical claim to the respondent within a period of four weeks from the date of the said order. Challenging the said order of the Tribunal, the present Writ Petition is filed.
4. Learned counsel for the petitioners contended that CHSS was introduced in DAE in the year 1962 with an objective to provide medical facilities to employees, both serving and retired, and their eligible family members as per the terms of the said Scheme. At Hyderabad, the CHSS is being administered by Chief Executive, Nuclear Fuel Complex (NFC), Hyderabad, which is a Unit of DAE. Under the CHSS, various facilities like Authorized Medical Officers, Specialists, Hospitals, Clinical Laboratories, etc., are recognized in the station where the CHSS is being operated and payment towards treatment availed by the beneficiaries are borne directly by the Department based on the approved rates as per the Memorandum of Understanding (MoU) entered between the panel hospitals/diagnostic centers by NFC. The CHSS also provides for receiving medical attendance and treatment from any private medical practitioner or hospital during medical emergency and the reimbursement in such cases will be subject to the prescribed conditions under the CHSS to the extent admissible in terms of charges, etc., prescribed thereunder.
5. Learned counsel further contended that as per Rule 15.4 of CHSS, the beneficiary under the said Scheme should intimate to the Medical Division of DAE regarding emergency treatment availed by either for himself/herself or for the members of his/her family registered under the scheme as early as possible and in any case, within four days from the date of commencement of treatment. In the instant case, the respondent failed to comply with the said Rule and after lapse of more than three months from the date of admission in the hospital, i.e., on 25.07.2021, he sought for reimbursement of medical claim, therefore, the petitione
