Emergency medical treatment in non-empanelled hospitals entitles retirees to full reimbursement under CHSS, overriding procedural formalities.

ORDER

PER HON‟BLE MRS. SHALINI MISRA, ADMINISTRATIVE MEMBER

The applicant has filed this OA seeking the following relief:

“To declare the action of the respondents in not processing to pay the balance amount of Rs.2,32,111/- (Rupees Two lakh, thirty two thousand, one hundred and eleven only) out of total expenditure of Rs.4,47,040/- medical expenditure incurred by him treated under medical emergency for survival of his life after the accident is highly illegal, arbitrary and violation of the Constitution as well as statutory obligation and Articles 14, 21 of the Constitution of India, and the Rules issued under the proviso to Articles 309 and direct the respondents (1) to pay the pending medical claim a sum of Rs.2,32,111/- along with future appropriate interest within a reasonable time to be fixed by this Tribunal; (ii) by an appropriate order or direction, the applicant may kindly be awarded the compensation of Rs.50,000/- as cost of harassment caused to him by the respondents; (iii) any other appropriate order or direction, which this Tribunal may deem fit, just and proper in the facts and circumstances of the case.”

2. The brief facts of the case, according to the applicant, are that he is a retired employee of Atomic Mineral Directorate for Exploration and Research Department (AMD), which is under the Department of Atomic Energy (DAE), who worked under the 3^rd respondent and life member of CHSS (Central Health Service Scheme), vide No.249201. On 16.05.2021 at around 7.30 AM, he met with an accident at Bollaram road while on the way to Temple on his bike, a Trolley Auto, carrying full load of vegetables, hit him, due to which he sustained head and multiple injury and lost consciousness. In an emergency situation, he was admitted by the passer-by in M/s Srikara Hospital, Kompally, Hyderabad, which is a non-panel hospital, on 16.05.2021. He was having a blood clot in his head and multiple fractures in Rib and Pelvic and further a surgery was performed on him. He was treated in the said hospital in ICU from 16.05.2021 to 02.06.2021. In the meanwhile, his son was also affected with Corona and none are there to help him. On discharge on 2.06.2021, he was issued bill for a sum of Rs.2,79,650 for head and chest treatment and for pelvic surgery, he was charged Rs.1,67,390/- totalling Rs.4,47,040/-. After discharge from the hospital, he submitted his medical claim with all necessary documents along with representation explaining the delay in submission of bill to the authority of AMD, Begumpet, Hyderabad on 14.06.2021 for reimbursement of Rs.4,47,040/-. His stay in hospital for 19 days was charged day to day basis expenditure, which was to be paid immediately by his family members by taking loan and spending his savings of past 30 years of service for better treatment in time to save his life. His medical bill was forwarded by the authority to the Sub Committee on 20.07.2021. The respondents asked him to submit few more documents, which was submitted by him on 10.03.2022 and 0804.2022. Surprisingly, the department has credited an amount of Rs.2,14,929/- to applicant‟s bank account on 27.04.2022 without any intimation and there was no mention why the applicant was not paid the balance amount of medical bill i.e., Rs.2,32,111/-. The applicant requested several times to the department the reasons for non-payment of balance amount, which was not reply till date. Hence, he issued a legal notice on 20.09.2023, which was not acted by the respondents.

3. The applicant has further submitted that even though more than a year has lapsed, the respondent