Full medical reimbursement mandatory for genuine emergency treatment in empanelled hospitals, regardless of CGHS rates.

ORDER

(As per Ms. Shalini Misra, Administrative Member)

The applicant filed the OA seeking the following relief:

“…to set aside and quash the letter No. G/MDF.34/II-dt. 31.12.2023 by directing the Respondents to pay the remaining amount Rs.4,04,474/- (Rs. Four Lakh Four Thousand and Seventy Four only) with interest @ 24% per annum till the date of realization of the amount … ”

2. The facts of the case are that the applicant joined the service of Railways on 24.06.1971 and retired voluntarily on 30.04.1993. He was admitted in Yashoda Hospital, Secunderabad, which is an empanelled hospital, in emergency situation as he felt severe breathlessness and he became unconsciousness. The applicant was diagnosed with “hinipneumonia hyperglycemia with neuroglycopenia” which is life threatening and therefore, it was essential to take treatment duly paying an amount of Rs.4,91,001/- towards hospital charges and spent Rs.11,282/- for purchase of the prescribed medicines totaling to Rs.5,02,283/-. Out of the said amount incurred by him, an amount of Rs.97,809/- was only reimbursed to him. Being aggrieved, the applicant earlier filed OA No. 315/2023, which was disposed of by this Tribunal on 06.12.2023, with certain directions. Despite the same, the respondents once again rejected his claim vide the impugned order. Therefore, the applicant, who is aged 89 years, had to once again knock the doors of this Tribunal.

3. Upon notice, the respondents entered their appearance and filed a reply statement opposing the OA. It is admitted by the respondents that the applicant had taken treatment during the period mentioned in the OA at Yashoda Hospital, Secunderabad. The hospital charged very high amount to his patients comparing with Central Government Health Scheme rates and all the reimbursement claims are disposed and settled as per CGHS rates. The applicant incurred an amount of Rs.5,02,283/- towards the treatment he had taken which includes medicine charges. When he submitted the application claiming the said amount, the claim has been scrutinized as per the Central Government Health Scheme rates and submitted to Accounts Department in Guntakal Division on 05.11.2023 for finance concurrence of Rs.1,14,902/-. However, the said amount was further reduced to Rs.97,809/- as per the advice of the Accounts Department. After receiving the said amount, the applicant is demanding 100% reimbursement of claim amount which is against the rules of CGH Scheme. It is not possible to reimburse 100% of claimed amount as per the CGHS rates which is statutory to sanction medical reimbursement of the retired Railway servants. If as per the contention of the applicant, the amount claimed by him is cleared, this will open gates and become precedent to similar other reimbursement cases which have been paid under CGHS guidelines/policies and rates and is against rules and will cause irreparable loss and heavy financial implications to the Railway Administration. Thus, the respondents prayed for dismissal of the OA.

4. It is submitted by the learned counsel for the applicant that denial of the claim is contrary to law settled by the Hon’ble Supreme Court as well as the very health scheme formulated by the Government. Learned counsel for the applicant further submitted that despite clear directions given by this Tribunal, the respondents have passed the impugned rejection order without proper reasoning.

5. On the other hand, learned counsel for the respondents submitted that, the applicant had already been reimbursed the amount as admissible under CGHS rates and no further amount is reimbu