Medical Claims cannot be denied only because hospital not mentioned in Govt order: HC

Jammu: Reiterating the observations made by the Supreme Court, the High court of Jammu and Kashmir and Ladakh recently clarified that an employee of the Government cannot be denied reimbursement solely on the ground that he/she has taken treatment in a speciality hospital by himself/herself which was not at all recognized or approved by the State or not included in the Government order.

With this, the HC bench comprising of Justice Wasim Sadiq Nargal provided relief to a late employee of Bharat Sanchar Nigam Limited (BSNL) at Kupwara, Kashmir. Although the employee had been admitted at the Government Medical College and Hospital, Jammu, he had later been taken to Apollo Hospital and AIIMS, New Delhi.

In a relief order, the Court observed, "It also goes without saying that the amount of medical reimbursement is constitutional obligation towards sufferer which is a beneficial legislation in a welfare State for its employees, therefore, the rules and instructions formulated should be construed liberally in favour of the employees for granting them the relief rather than to adopt the wooden attitude to deprive the person of his/her dues."

The plea has been filed by the wife and the children of the deceased BSNL employee. Back in October, 2009, the concerned employee became seriously ill while he was on duty and following this, he had been shifted to GMC, Jammu. However, since his health condition continued to deteriorate, he had been shifted to Apollo Hospital, New Delhi in the Emergency Wing.

After conducting necessary tests, the patient was diagnosed as suffering from blood cancer. Since the family of the patient did not have enough resources to get him treated in the Apollo Hospital, New Delhi, he was once again shifted to All India Institute of Medical Sciences (AIIMS), New Delhi in a serious condition. After being admitted at the Emergency Wing, the patient got referred to the Oncology Department of the Institute. However, the petitioners claimed that at AIIMS, the response of the doctors towards the patient was not good and therefore, left with no other alternative, the patient was shifted back to Apollo Hospital, New Delhi for Chemotherapy.

The petitioners submitted that despite various representations before the concerned Department, Minister for Communication and Information Technology and also to the General Manager, Bharat Sanchar Nigam Limited (BSNL), J&K Circle, seeking medical reimbursement of the patient with all the details i.e. medical diagnosis, medical bills, etc. they were not provided with the reimbursement.

On the other hand, the concerned authorities claimed that as per the Policy Guidelines regarding Compassionate Appointment, there should be 55 or more net points for consideration by the Corporate Office High Power Committee for compassionate grounds but the petitioners scored 31 points only and as a result, the claim of the petitioners was rejected.

Apart from this, the authorities also submitted a compliance report and claimed that the Apollo Hospital officials expressed inability to give details regarding the admission of the concerned BSNL employee because the case was too old. 

After considering the contentions from both the sides, the HC bench noted that the admittedly, the deceased BSNL employee had undergone treatment for blood cancer from Apollo Hospital as is evident from the medical bills annexed with the petition. Further, the petitioners' counsel submitted that few of the medical bills must have been missing keeping in view the fact that the age of the widow as she may not have kept all the medical bills.

In this context, the HC bench also took note of a Scheme formulated for medical policy for BSNL employees known as "BSNL Employees Medical Reimbursement Policy" which came into force on 24.02.2003 and Clause 1.5 of the aforesaid Scheme specifically mentioned that all serving and retired employees of BSNL including deputationists would be eligible under this Scheme.

Clause 1.5 of the concerned Scheme mentions:

"All serving and retired employees of BSNL including deputationists will be eligible for this scheme. However, the employees in order to avail of this scheme have to opt for this scheme whereby they will not be allowed the facility under CGHS Scheme. The employees opting for this scheme, can avail of Domiciliary treatment either from P & T dispensaries or from any Registered Medical Practitioners (RMPs) depending on their option to be exercised while registering for this scheme. The employees opting for this scheme will be eligible for Indoor treatment as per this scheme."

Clause 2.2.0 states:

"An employee (including retired employee) and his/her dependants shall be entitled to the reimbursement of expenses at the approved rates at all hospitals recognized from time to time by the management. Till such time as approved rates in recognized hospitals are not notified by BSNL management, the reimbursement will be as per actual expenses basis. Entitlement under this clause will be separate and distinct from the ceiling amount prescribed in para 2.1.0 and 2.1.1 under domiciliary/outdoor treatment. All expenditure incurred in connection with the treatment will be reimbursable subject to a limit on the room rent which will be as per Annexure-I"

Referring to these clauses, the Court observed,

"From a bare perusal of the aforesaid Scheme, it is emphatically clear that by virtue of clause 2.2.0, an employee (including retired employee) and his/her dependants shall be entitled to reimbursement of expenses at the approved rates at all hospitals recognized from time to time by the management."

Further, the court noted that the concerned Scheme also provided for recognized hospitals/nursing homes and clause 2.2.2 provided that in emergency cases, the reimbursement would be allowed for treatment in non-recognized hospital with the approval of CGM for field office employees and concerned Director of BSNL Board for C.O employees. Clause 3.0 deals with the procedure for reimbursement of claim which inter alia provides that all claims of medical expenses shall be made in prescribed proforma supported by necessary bills, vouchers, certificates and prescriptions etc. and shall be subject to the procedure laid down by the management from time to time.

Therefore, taking note of the Scheme, the HC bench noted that the concerned authorities were under legal obligation for considering their claim for reimbursement of expenses.

"Thus, from a bare perusal of the aforesaid Scheme, it transpires that the respondents were under legal obligation qua the petitioners to consider their claim for reimbursement of expenses at the approved rates inconformity with the aforesaid BSNL Medical Reimbursement Scheme which has come into force w.e.f. 24.02.2003."

"While according consideration to the case of the petitioners, the respondents have to keep in mind that the technicality of the rules and regulations are not required to be followed just in a mechanical manner so as to frustrate the very purpose of the Scheme. Each case has to be examined on its own facts before taking any final decision. It goes without saying that to preserve health and medical aid in furtherance of the self preservation is a part of right of life as envisaged under Article 21 of the Constitution of India and in the present case, the petitioners are held entitled for medical reimbursement of their expenses," it added.

At this outset, the HC bench also referred to the Supreme Court order in the case of Shiv Kant Jha Vs. Union of India, where the top court bench had observed, "The right to medical claim cannot be denied merely because the name of the hospital is not included in the Government Order. The real test must be the factum of treatment. Before any medical claim is honoured, the authorities are bound to ensure as to whether the claimant had actually taken treatment and the factum of treatment is supported by records duly certified by Doctors/Hospitals concerned."

Referring to this, the Court noted,

"Even the Apex Court has been so liberal in medical reimbursement case and held that the employee could not be denied reimbursement solely on that ground in case an employee had taken treatment in speciality hospital by itself which was not at all recognized or approved by the State or not included in the Government order."

"Thus, there is no denial of the fact that under Article 21 of the Constitution of India provides for an obligation to bear the medical expenses of its employees while in service and also after having retired. The respondents on receipt of the aforesaid bills and various representations from time to time cannot deny to process the claim of the petitioners and the long delay in such like matters cannot be condoned on the part of the respondents," it noted.

The Court further observed, "Thus, in the light of the law laid down by the Hon'ble Supreme Court coupled with the BSNL Employees Medical Reimbursement Scheme, the respondents are under legal obligation to process the medical bills of the petitioners expeditiously and disburse the same."

Providing relief to the petitioners, the Court ruled, "Accordingly, the present writ petition is allowed and the respondents are directed to process the medical bills of the deceased and release the same in favour of the petitioners within a period of two months from the date the copy of this order is served upon respondents in respect of which all the bills required have already been submitted by the petitioners besides completing all the medical formalities."

To read the Court order, click on the link below.

https://medicaldialogues.in/pdf_upload/jammu-kashmir-hc-187241.pdf

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