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Case Number

C.W.P No. 509/98

Advocates

Mr. Panna Lal Syngal, Mr. Bodhisatva Acharya, Advocates for Petitioner.
Mr. Ashok Bhasin, Advocate for Respondents.

Judges

C.M Nayar, J.

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Smart Summary

Structured Summary of the Opinion (C.M. Nayar, J.)

Factual and Procedural Background

This petition challenges the respondents' Order dated 4 December 1997 (Annexure-E) issued by the Government of India, Office of the Additional Director, Central Government Health Scheme (CGHS), which rejected the petitioner's claim for reimbursement of medical expenses. The petitioner sought a writ of certiorari to quash that order and a writ of mandamus directing reimbursement of Rs. 93,870/- together with interest at 24% from the date of discharge (22 February 1996) to the date of payment.

Relevant facts stated in the opinion: the petitioner, a retired Assistant Engineer (Mechanical) who retired on 31 July 1988 from Security Paper Mill, Hoshangabad, was admitted to Mayo Hospital, Vadodara, for severe chest pain. Coronary angiography was performed on 12 February 1996. He underwent Coronary Artery Bypass Grafting (CABG) on 14 February 1996 for triple vessel ischemic heart disease and was discharged on 22 February 1996. A hospital certificate dated 29 February 1996 (Annexure-C) certified that the operation was performed in an emergency.

The petitioner incurred total expenses of Rs. 93,870/-. He submitted a reimbursement claim to respondent no. 3, which was declined on the ground that treatment was taken in a non-CGHS covered area. An affidavit of Dr. P.K. Baliar Singh (Joint Director (R&H), CGHS) was filed stating that, per the CGHS scheme (para 17(iii)), reimbursement for pensioners is limited to areas covered by the scheme and that no reimbursement is to be made for treatment at places not covered unless specifically authorised by the Ministry of Health.

Legal Issues Presented

Whether the Order dated 4 December 1997 rejecting the petitioner's claim for reimbursement should be quashed.
Whether a pensioner who receives emergency medical treatment in a non-CGHS covered area without prior sanction is entitled to reimbursement (or to ex-post facto sanction) under the applicable CGHS rules and established law.
Whether the respondents were obliged to give cogent reasons or cite rules/regulations to deny the petitioner's claim taken in an emergency situation.

Arguments of the Parties

Petitioner's Arguments

The petitioner underwent an emergency CABG procedure on 14 February 1996 and was discharged on 22 February 1996; the hospital certificate (29/02/1996) confirms the emergency nature of the treatment.
Because the treatment was taken in an emergency, prior sanction was not feasible or required; the petitioner seeks reimbursement of Rs. 93,870/- (the actual amount incurred).
The petitioner has not claimed interest for the withheld payment (the learned counsel stated this fairly before the court).

Respondents' (Government/CGHS) Position

The respondents declined reimbursement because the treatment was taken in a non-CGHS covered area.
As per the affidavit of Dr. P.K. Baliar Singh, the CGHS scheme (cited as ANNEXURE R-1) provides in para 17(iii) that reimbursement for pensioners is limited to areas covered by the scheme and that no reimbursement shall be made when pensioners take treatment at places not covered by the scheme unless specifically authorised by the Ministry of Health.

Table of Precedents Cited

Precedent	Rule or Principle Cited For	Application by the Court
Surjit Singh v. State of Punjab and others, AIR 1996 Supreme Court 1388	That a person has the right to take steps for self-preservation and need not wait for prior governmental sanction in life-threatening situations; reimbursement may be allowed for urgent treatment taken outside the government system when necessary.	The court relied on paragraph 11 of Surjit Singh to support the proposition that the petitioner had the right to seek immediate treatment in an emergency without prior sanction and that such circumstances justify reimbursement or ex-post facto consideration.
State of Punjab & Ors. v. Mohinder Singh Chawla etc., JT 1997 (1) S.C. 416	That when the government recognises particular private hospitals for specialised treatments, reimbursement for expenses incurred in such hospitals (including room rent) is part of the medical expenditure; ex-post facto sanction can be granted and actual expenses are to be considered.	The court reproduced paragraphs 9–11 from the judgment and used them to illustrate that recognised institutions for specialised treatment justify reimbursement of actual expenses and to support the position that the State should not refuse reimbursement on technical grounds where emergency specialised treatment was required.

Court's Reasoning and Analysis

The court's analysis proceeded in the following steps, based solely on the material in the opinion:

Emergency treatment: The court accepted that the petitioner suffered a bona fide and serious cardiac ailment requiring urgent treatment (angiography on 12 February 1996 and emergency CABG on 14 February 1996). The hospital certificate dated 29 February 1996 corroborated that the operation was emergency surgery.
Prior sanction not required in emergency: The court held that the law does not require prior permission where survival of the person is the prime consideration. Waiting for prior sanction in such a situation may imperil life.
Ex-post facto sanction is available: The court noted that it is open to the Government to grant ex-post facto sanction subject to verification of the claim; and decline to entertain the Government's technical objection where the petitioner had taken emergency treatment.
Reliance on precedents: The court relied on the decisions in Surjit Singh v. State of Punjab and State of Punjab v. Mohinder Singh Chawla to support the principles that (a) a person can take steps for self-preservation without prior governmental permission in emergencies, and (b) where specialised treatment is required and an authorised hospital exists, reimbursement of expenses is due and refusal on technical grounds is not tenable.
Assessment of respondents' reasons: The court found that the respondents gave no cogent grounds nor cited applicable rules/regulations to justify denial beyond a bald statement that the treatment was in a non-CGHS area and that the scheme generally limits reimbursement to covered areas. The court held these reasons inadequate in view of the emergency nature of the treatment and settled legal principles.
Remedy and quantification: The learned counsel for the petitioner stated that no interest was being claimed; thus the court confined relief to reimbursement of the actual amount incurred and costs.

Holding and Implications

Holding:

The petition is allowed and the Rule is made absolute.

Direct consequences and orders (as stated in the opinion):

The respondents are directed to disburse Rs. 93,870/- to the petitioner within four weeks from the date of the order.
The petitioner is awarded costs quantified at Rs. 10,000/-.
The petitioner has fairly stated that he is not claiming interest for the period during which the payment was withheld; accordingly, interest was not awarded.

Implications:

The decision affirms that emergency medical treatment taken by a pensioner in a non-covered area cannot be denied reimbursement on purely technical grounds when prior sanction was not feasible; ex-post facto sanction and reimbursement are appropriate in such circumstances.
The court noted that the law on this point is settled and therefore the opinion follows existing principles; the judgment enforces the application of those principles to the facts rather than announcing a new legal principle.

This summary reflects only the information contained in the provided opinion and does not add, infer, or assume facts or legal positions beyond those expressly set out in the text.

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Narendra Pal Singh v. Union Of India' Ors.

C.M Nayar, J. (Oral)— This petition is directed against the respondents for issuance of a writ in the nature of certiorari for quashing the Order dated 4th December, 1997 made by the Government of India, Office of the Additional Director, Central Government Health Scheme (Annexure-E to the petition) rejecting the case of the petitioner for reimbursement of the medical claim. The petitioner has further prayed for a writ of mandamus commanding the respondents to reimburse him the amount of Rs. 93,870/- with interest at the rate of 24% from the date of discharge from hospital i.e 22nd February, 1996 to the date of payment. The petitioner retired on 31st July, 1988 as Assistant Engineer(Mechanical) from Government of India, Security Paper Mill, Hoshangabad, M.P-461005. He was admitted in Mayo Hospital Savli Road, Harni, Vadodara-390022 due to severe Chest Pain and Coronary Angiography was conducted on 12th February, 1996. The relevant report is filed as Annexure-A to the writ petition. The petitioner was operated for Coronary Artery By-pass, Grafting (CABG) as per diagnosis-Tripple Vessel Disease (Ischemic Heart Disease) on 14th February, 1996 and he was discharged on 22nd February, 1996. It is stated that the petitioner had to undergo the aforesaid operation in an emergent situation and the requisite certificate dated 29th February, 1996 issued from Mayo Hospital is filed as Annexure-C to the writ petition which reads as follows:—

“Mayo Hospital

(Promoted by GIL Hospitals Ltd.)

Regd. Office: Savli Road, Harni, Vadodara-390022, India

Phone: 451818/559139.

Telex: 0175-6400 MAYO IN Fax: 0265-452249

Gram: MAYOHOSP

Date: 29/02/96.

TO WHOMSOEVER IT MAY CONCERN

This is to certify that Mr. N.P Singh was admitted with chest pain on 12/02/96 after which angio was done as he had continuous pain & in view of severe tripple vessel disease he had to be operated on 14/02/96 in emergency. He had an uneventful post operative course.

Thanking you,

Dr. Rajesh Desai

Cardialthoracic Surgeon.”

The petitioner incurred a total expenditure of Rs. 93,870/-. The petitioner submitted his medical reimbursement claim to respondent no. 3 but the said respondent has declined to reimburse on the ground that the treatment was taken in a non-C.G.H.S covered area. The affidavit filed by Dr. P.K Baliar Singh, Joint Director (R&H), Central Government Health Scheme, New Delhi has been filed to deny the claim of the petitioner. Paragraph 5 of the said affidavit reads as follows:—

“5. That his claim has been considered by the concerned authorities and was regretted since he had taken the treatment in non-CGHS covered area and as per Central Government Health Scheme orders and instructions issued by Government of India, Ministry of Health and Family Planning (Department of Health) a pensioner is not entitled to the facilities of reimbursement. The respondent is filing said scheme alongwith this affidavit. The relevant provision in the present case is on page 40 of the said scheme. As per para 17(iii) of the said scheme (Reimbursement) shall in the case of pensioners be limited to areas covered by the scheme. No reimbursement shall be made when pensioners and members of their families take medical treatment at a place not covered by the scheme unless specifically authorised by the Ministry of Health. Copy of the said scheme is being filed as ANNEXURE R-1.”

The petitioner has admittedly suffered the ailment and required urgent and immediate treatment in an emergency. The pleaof the Government that he has not taken prior sanction for treatment in non-C.G.H.S Hospital is clearly erroneous and cannot be entertained. Moreover, the law does not require that prior permission has to be taken in such situation where the survival of the person is the prime consideration. It is always open for the Government to grant ex-post facto sanction subject to verification of the claim which has not been denied in the present case. Reference may be made to the judgment of the Supreme Court reported as Surjit Singh v. State of Punjab and others AIR 1996 Supreme Court 1388. Paragraph 11 of the judgment reads as follows:—

“11. The appellant therefore had the right to take steps in self preservation. He did not have to stand in queue before the Medical Board, the manning and assembling of which, bare-facedly, makes its meetings difficult to happen. The appellant also did not have to stand in queue in the government hospital of AIIMS and could go elsewhere to an alternate hospital as per policy. When the State itself has brought the Escorts on the recognised list, it is futile for it to contend that the appellant could in no event have gone to the Escorts and his claim cannot on that basis be allowed, on suppositions. We think to the contrary. In the facts and circumstances, had the appellant remained in India, he could have gone to the Escorts like many others did, to save his life. But instead he has done that in London incurring considerable expense. The doctors causing his operation there are presumed to have done so as one essential and timely. On that hypothesis, it is fair and just that the respondents pay to the appellant, the rates admissible as per Escorts. The claim of the appellant having been found valid, the question posed at the outset is answered in the affirmative. Of course the sum of Rs. 40,000/- already paid to the appellant would have to be adjusted in computation. Since the appellant did not have his claim dealt with in the High Court in the manner it has been projected now in this Court, we do not grant him any interest for the intervening period, even though prayed for. Let the difference be paid to the appellant within two months positively. The appeal is accordingly allowed. There need be no order as to costs.”

Similar reference may be made to the judgment reported as State of Punjab & Ors. v. Mohinder Singh Chawla etc. JT 1997 (1) S.C 416. Paragraphs 9, 10 and 11 may be reproduced as follows:—

“9. While the respondent was a Government servant, he had developed sudden coronory ailment. After required angiography and other reports of tripple vessets disease was diagnosed in CMC Hospital, Ludhiana and he was recommended by the said hospital to go over to Escorts Hearts Institute, New Delhi for urgent treatment. On its basis, the respondent had the treatment. The Medical Board granted by its proceedings dated January 12, 1969, ex-post facto sanction for treatment with one attendant. The appellant had granted reimbursement of a sum of Rs. 1,03,267/- less the rent paid for the room in the hospital for the period of stay. It is the Government's stand that the reimbursement could be allowed as per rates charged by All India Institute of Medical Sciences. Accordingly, a sum of Rs. 20,000/- paid as rent was deducted. When the respondent filed the writ petition, the High Court by judgment dated April 12, 1996 in CWP No. 16570/95, the Division bench allowed the writ petition. Thus, this appeal by special leave.

10. It is contended for the State that though the Government had granted ex-post facto sanction through the Medical Board and permitted the patient to undergo treatment outside the State with the policy, for reimbursement of medical expenses incurred and the medical treatment taken in the Hospital to the Government servant/pensioners or dependents, as per rules, the Government has imposed a condition to pay room rent at the rates charged by the AIIMS for stay in the hospital. The reimbursement will be given at those rates. The Government, therefore, is not obliged to pay the actual expenses incurred by the patient while taking the treatment as inpatient in the hospital, for rent.

11. We are unable to agree with the stand taken by the Government. It is seen that the Government had decided in the proceedings dated October 8, 1991 to reimburse the medical expenditure incurred by the Punjab Government employees/pensioners and dependents on treatment taken abroad in private hospital. It is stated in paragraphs 2 and 3 that the Government has prepared a list of those diseases for which the specialised treatment is not available in Punjab Government Hospitals but it is available in certain identified private hospitals, both within and outside the States. It was, therefore decided to recognise these hospitals for treatment of the diseases mentioned against their names in the enclosed list for the Punjab Government employees/pensioners and their dependents. The terms and conditions contained in the letter under reference would remain applicable. The Government can, however, revise the list in future. The name of the disease for which the treatment is not available in Punjab Government hospitals is shown as Open Heart Surgery and the name of the private hospital is shown as Escorts Heart Institute, New Delhi as one. of the approved hospital/institution. Thus, for open heart surgery or heart disease the Escort Heart Institute is authorised and recognised institution by the Government of Punjab. Consequently, when the patient was admitted and had taken the treatment in the hospital and had incurred the expenditure towards room charges, inevitably the consequential rent paid for the room during his stay is integral part of his expenditure incurred for the treatment. Consequently the Government is required to reimburse the expenditure incurred for the period during which the patient stayed in the approved hospital for treatment. It is incongruous that while the patient is admitted to undergo treatment and he is refused the reimbursement of the actual expenditure incurred towards room rent and is given the expenditure of the room rent chargeable in another institute whereat he had not actually undergone treatment. Under these circumstances, the contention of the State Government is obviously untenable and incongruous. We hold that the High Court was right in giving the direction for reimbursement of a sum of Rs. 20,000/- incurred by the respondent towards the room rent for his stay while undergoing treatment in Escorts Heart Institute, New Delhi.”

The law is, therefore, well settled that right to health is an integral part to life and the Government has constitutional obligation to provide the health facilities to its employees or retired employees and in case an employee requires a specialised treatment in an approved hospital it is the duty of the Government to bear or reimburse the expenses. The petitioner in this case had to be operated in an emergency as he suffered a heart problem and in case he had waited for a prior sanction he might not have survived. Therefore, in this situation it is the duty of the Government to grant ex-post facto sanction and not deny the claim of the petitioner on technical and flimsy grounds. Firstly the Government does not give any proper reasoning to deny the claim of the petitioner in its communication dated 4th December, 1997 and secondly the affidavit of Dr. P.K Baliar Singh merely states that since the petitioner had taken the treatment in non-C.G.H.S covered area and as per Central Government Health Scheme Orders and instructions as issued by the Government, a pensioner is not entitled to the facilities of reimbursement. These reasons cannot be appreciated in view of the settled position that the petitioner is entitled to take recourse to an emergency treatment in any area if the circumstances and the nature of disease so warrant.

No cogent grounds nor any rules/regulations have been cited to deny the relief to the petitioner. The petition is, therefore, liable to succeed. The learned counsel for the petitioner has fairly stated that the petitioner is not claiming any interest for the payment which has since been withheld.

In view of the above, the present petition is allowed. Rule is made absolute. The respondents shall disburse the amount of Rs. 93,870/- to the petitioner within four weeks from today. The petitioner is also entitled to costs which are quantified at Rs. 10,000/-.

Narendra Pal Singh v. Union Of India' Ors.

Structured Summary of the Opinion (C.M. Nayar, J.)

Factual and Procedural Background

Legal Issues Presented

Arguments of the Parties

Petitioner's Arguments

Respondents' (Government/CGHS) Position

Table of Precedents Cited

Court's Reasoning and Analysis

Holding and Implications

Narendra Pal Singh v. Union Of India' Ors.

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