Retired government employees residing in non-CGHS areas must subscribe to CGHS to be eligible for medical reimbursement; mere residency does not confer entitlement.

ORDER 

Per: Justice Sunil Thomas, Judicial Member -

The applicant retired as a Junior Engineer (Civil), from the Andaman Public Works Department. After retirement, he settled in North Paravur in Ernakulam District. According to the applicant, that area did not fall under the Central Government Health Scheme (CGHS for short) and the nearest CGHS covered city was Trivandrum, which was at a distance of 225 kilometres. He claimed that, accordingly, CS(MA) Rules 1944 applied to him. He opted for Fixed Medical Allowance (FMA for short) in lieu of CGHS. Kochi which was the nearest city about 30 kilometres away from his place of residence, was brought under the coverage of CGHS, after a CGHS Welfare Centre was started at Kadavanthra, Kochi in 2020. However, he continued to stay in the non- CGHS covered area.

2. On 7.5.2022, the 24 year old son of the applicant, who was studying in Bangalore, sustained severe head injuries when the two wheeler in which he was riding as a pillion rider skid. He fell down and sustained severe head injuries. He claimed to have sustained, acute brain damage also. According to the applicant, the diagnosis report showed that the son sustained ‘severe traumatic brain injury, left temporal EDH and thin Acute SDH with Mass effect and Uncal Herination Left clavicle fracture’. He was discharged after prolonged treatment, evidenced by Annexure A-2, the Discharge Summary. Annexure A-3 medical bill for a sum of Rs.18,07,596/- was submitted. According to the applicant, as per the Office Memorandum No.4-24/96-c&p/CGHS/CGHS(P) issued by the Government of India, Ministry/department of Health and Family Welfare dated 31.5.2007, the age limit for dependent children of Government servant and pensioners for availing medical facilities under the CGHS and Central Services (MA) Rules, 1944, was fixed as the age till he starts earning or attains the age of 25 years. The said O.M was produced as Annexure A-4.

3. Further, as per O.M No.4-24/96-c&p/CGHS/CGHS(P) issued by the Government of India, Ministry/Department of Health & Family Welfare dated 25.2.2009, it was clarified that married son is excluded from the criteria for dependent children of Government servant and pensioners for availing medical facilities under the CGHS and CS(MA) Rules, 1944, even if the age of the son was below 25 years. The O.M was produced as Annexure A-5. Annexures A-6, A-7 and A-8 were produced to show the date of birth of the applicant, that he was unmarried and that he was a student in a College at Bangalore.

4. The applicant submitted Annexure A-9 claim dated 21.7.2022 seeking medical reimbursement of medical bills under CGHS. It was rejected by Annexure A-10, on the ground that Government servant who are not registered under any CGHS scheme and are drawing FMA are eligible for medical claim till the date of retirement and hence, his claim was not admissible.

5. Aggrieved by the above, the applicant has approached this Tribunal seeking the following reliefs:

“(i) Set aside Annexure A-10.

(ii) Issue directions to the respondents to pay the full reimbursement amounting of Rs.18,07,596/- (Rupees Eighteen Lakhs Seven Thousand Five Hundred and Seventy Six) as per the medical bills submitted by