Essentiality certificate not required for medical reimbursement per 2009 OM; authorities must verify treatment genuineness from records/hospital, not reject claims technically when factum undisputed, even for non-empanelled hospitals in renal failure cases.

ORDER

The applicant filed this OA under Section 19 of the Administrative Tribunals Act, 1985 for seeking relief of quashing and setting aside the order dated 5th April, 2022 and direction to the respondents to pay the remaining balance medical expenses to the tune of Rs.7,53,197/- with interest @18% per annum.

2. Applicant’s case in brief is that he had joined the department of Indian Council of Agricultural Research (ICAR), Central Institute of Fisheries Education (CIFE) (respondent No.3) on 16th May, 1984 as Hindi Translator.

3. In the month of September, 2017 the applicant was admitted to Kokilaben Ambani Hospital which is nearby the residence of the applicant. Both the kidneys of the applicant had failed because of which he was on dialysis. For performing kidney transplant surgery, the applicant had demanded Rs.8,00,000/- as medical advance by letter dated 16th October, 2017. The applicant was admitted for kidney transplant and was discharged from the hospital on 8th March, 2018. An advance of Rs.2,70,000/- was paid by respondent No.3 to the applicant. The applicant was admitted on 26th February, 2018 and was discharged on 8th March, 2018. The kidney donor, who was his wife Ms. Manorama Uniyal, was admitted in the hospital on 27th February, 2018 and was discharged on 4th March, 2018.

4. The applicant contends that he raised medical bill of Rs.14,52,788/- on 9th April, 2018 out of which the respondents granted medical expenses to the tune of Rs.6,99,591/-. It is the contention of the applicant that he was admitted in Kokilaben Ambani Hospital in emergency. Therefore, the entire bill of Rs.14,52,788/- ought to have been granted but the respondents granted medical bills to the tune of Rs.6,99,591/-. He is, therefore, claiming balance amount of Rs.7,53,197/-. He contends that the respondents did not grant the remaining amount as the applicant did not produce the emergency certificate and that the respondent No.3 had referred the case of the applicant to CGHS Mumbai as the claim was over and above the power conferred on respondent No.3 to sanction bills. It is contended that in reply to his RTI application, it was revealed that case of the applicant was discussed in the meeting of the Committee on 21st August, 2020 and the Committee unanimously decided to refer the case of the applicant to AS&DG, CGHS for clarification. That clarification is yet to be received. The respondents rejected the claim of the applicant partly as the applicant had not annexed the emergency certificate. He submitted that in terms of OM dated 20th February, 2009, essentiality certificate is not required to be obtained from the treating Doctor. Therefore, the rejection of the claim of the applicant is bad in law. He has, therefore, prayed for allowing the OA.

5. Respondents filed their reply. They contend that there was no emergency for the applicant to undergo surgery. Kidney transplant is not a multi organ failure and does not come within the scope of emergency in elective procedure. They contend that the bills of the applicant were placed before the Committee and the Committee has unanimously decided to seek clarification from CGHS in respect of the remaining balance amount to be paid to the applicant. They, therefore, prayed for dismissal of the application.

6. I have heard the le