- Bookmark
- Share
- CaseIQ
V.B. Jain v. Chief Executive Officer
Concise Analytical Summary of the Opinion (V. Ajay Kumar, Member (J))
Factual and Procedural Background
The applicant is a retired Chief Engineer (Civil) of the Delhi Jal Board (DJB), having retired on 30.09.2005. He was governed by the Central Government Health Scheme / Central Services (Medical Attendance) Rules, 1944 (CGHS / CS(MA) Rules) and entitled to reimbursement of medical expenses in accordance with those Rules and related notifications/circulars/memoranda, as adopted by DJB Resolution No.227 dated 07.05.1999. The applicant also held private medical insurance policies purchased from his own funds.
The applicant's wife was diagnosed with malignant cancer and was treated at Indraprastha Apollo Hospital, Rockland Hospital and Pushpanjali Corslay Hospital. She died on 24.11.2009. The opinion contains two closely similar figures for the total medical expenditure incurred: Rs.12,93,036/- (Paragraph 2) and Rs.12,93,037/- (Paragraphs 3 & 4). The applicant first claimed under his insurance; subsequently he sought reimbursement of the remaining amount from the respondent (DJB). After partial reimbursements by the Insurance Company and by DJB, the applicant filed the present Original Application (OA) aggrieved at not receiving full reimbursement.
Procedurally: the respondents filed a counter and status report; the matter was heard with counsel for both sides and the record was considered by the bench (V. Ajay Kumar, Member (J)).
Legal Issues Presented
- Whether the applicant is entitled to full reimbursement of medical expenses incurred in approved private hospitals despite CGHS package rates being lower than the actual bills.
- Whether the Office Memorandum dated 19.02.2009 (allowing claim from both insurer and CGHS/Department provided the total does not exceed expenditure) and the CGHS package rates restrict the respondent from reimbursing the balance where the private hospital was approved and/or the Department had granted approval.
- Whether the ratio in State of Punjab & Ors. v. Ram Lubhaya Bagga (1998) 4 SCC 117 precludes full reimbursement in a case where the Government/Department itself recommended or approved treatment at a private/approved specialty hospital.
Arguments of the Parties
Applicant's Arguments
- The applicant does not dispute the condition in the Office Memorandum requiring first claim from the insurer, but contends that he obtained the respondents' approval for his wife's treatment in the named hospitals.
- Because the treatment was obtained with the respondents' approval, he claims entitlement to full reimbursement of medical expenditure paid by him.
Respondents' Arguments
- Relying on the Office Memorandum dated 19.02.2009, the respondents contend that total reimbursement from both the Insurance Agency and the Department should not exceed the package rates prescribed under CGHS for the particular treatment.
- They state that the admissible amount as per CGHS package rates in this case is Rs.8,02,963/-, whereas the applicant's total claimed amount was approx. Rs.12.93 lakh. The respondents assert that they, in fact, paid more than the admissible package amount on humanitarian grounds treating the matter as a special case.
- The respondents placed reliance on State of Punjab & Ors. v. Ram Lubhaya Bagga (1998) 4 SCC 117 to support their position.
Table of Precedents Cited
| Precedent | Rule or Principle Cited For | Application by the Court |
|---|---|---|
| State of Punjab & Ors. v. Ram Lubhaya Bagga, (1998) 4 SCC 117 | Referred to by respondents as supporting limits on allowance-related governmental liabilities (cited by respondents). | The court reviewed how Bagga has been considered in subsequent cases and concluded that Bagga's ratio does not operate against full reimbursement where treatment is in a government-approved private hospital or recommended by government hospitals. The court therefore rejected respondents' reliance on Bagga to deny balance reimbursement. |
| K.P. Singh v. Union of India & Ors., 2001 (10) SCC 167 | Listed among authorities establishing principles in favour of reimbursement and the State's obligation regarding medical treatment of government servants. | Used as part of the body of case law supporting the proposition that government must bear expenditure when treatment is required at an approved specialized hospital. |
| State of Punjab & Ors. v. Mohinder Singh Chawla, JT 1997 (1) SC 416 | Listed among authorities on reimbursement of medical expenses and interpretation of government obligations. | Relied upon (as part of the judicial corpus) to support the view that package rates cannot be the sole determinant when approved hospitals charge higher sums and government hospitals recommend treatment elsewhere. |
| J.C. Sindhwani v. Union of India & Anr., 2005 (124) DLT 513 | Cited for the proposition that the Government is not necessarily bound to disburse only package rates and that full reimbursement may be ordered. | The court cited Sindhwani approvingly to support awarding full or fuller reimbursement notwithstanding package rates; Sindhwani is treated as a precedent rejecting strict reliance on package limits. |
| J.K. Saxena v. Govt. of NCT of Delhi, WP(C) No. 5015/2003 (decided 16.12.2004) | Included in the list of cases addressing reimbursement of medical expenses for government servants treated in private hospitals. | Counted among authorities reinforcing that where treatment is approved/recommended and exigent, full reimbursement follows; relied on generically in the court's reasoning. |
| Prithvi Nath Chopra v. Union of India & Anr., 2004 (111) DLT 190 | Listed as supporting full reimbursement despite package rates, and considering Bagga in that light. | Used as part of the cluster of decisions that have directed full payment even when actual charges exceed older package rates. |
| V.K. Gupta v. Union of India & Anr., 2002 (97) DLT 337 | Cited among cases that rejected package-rate-only defenses and directed fuller reimbursement. | The court referred to V.K. Gupta as part of precedent reinforcing that the Government must reimburse actual expenses in approved circumstances. |
| M.G. Mahindru v. Union of India & Anr., 2001 (92) DLT 59 | Explicitly discussed in the opinion for holding that where a government hospital recommends treatment at an approved specialty private hospital, respondents must reimburse the total amount paid by the patient. | The court relied on Mahindru to show that when the Government (or its hospital) recommends treatment at an approved private specialty hospital denial of full reimbursement is contrary to granting medical facilities; Mahindru was used to distinguish Bagga and to support full payment. |
| Narendra Pal Singh v. Union of India & Ors., 1999 (79) DLT 358 | Listed among authorities dealing with reimbursement of medical expenses of government servants in private hospitals. | Included among the collected authorities that underpin the court's approach to reimbursement issues. |
| L.P. Sharma v. Union of India & Ors., 2004 (2) ATJ 492 | One of the cases cited in support of the broader principles favouring reimbursement where appropriate. | Part of the jurisprudential basis the court relied upon to hold package rates are not sacrosanct where treatment is approved. |
| Sh. S.R. Jha v. Union of India & Ors., 2003 (2) ATJ 168 | Included among decisions addressing the entitlement to reimbursement of medical expenses. | Counted in the body of case law referenced to sustain the court's approach favouring reimbursement beyond outdated package rates. |
| Shri Bhagwan Singh v. Union of India & Ors., 2002 (1) ATJ 226 | Listed with other authorities concerning reimbursement principles. | Relied upon collectively to show judicial trend in favor of reimbursing medical expenses in appropriate cases involving approved hospitals and recommendations. |
Court's Reasoning and Analysis
The court proceeded by reviewing the factual record (claims and reimbursements), the Office Memorandum dated 19.02.2009 and the arguments advanced by both sides. The respondents' position was that the OM and CGHS package rates limit the total amount reimbursable from insurance plus Department to the package rates, and that the Department had already paid an amount in excess of admissible package rates on humanitarian grounds. The applicant's position was that treatment had been taken with the respondents' approval and therefore full reimbursement was due.
The court then examined the relevant judicial authorities. It summarized a consistent line of decisions holding (in the court's words): that the right to health is integral to the right to life; CGHS exists to benefit Central Government employees; if a government hospital recommends specialized treatment in an approved private hospital, it is the duty of the State to bear the expense; and that package rates fixed earlier (e.g., in 2001) have not been periodically updated and therefore should not be treated as sacrosanct or as the sole criterion for denying actual reimbursement when an approved hospital treats the patient.
Regarding State of Punjab v. Ram Lubhaya Bagga (supra), the court noted that Bagga has been considered in subsequent decisions and that where the Government/its hospital itself recommends or approves treatment at an approved specialty hospital, the ratio in Bagga does not preclude full reimbursement. The court relied specifically on prior Delhi High Court authorities—particularly M.G. Mahindru and J.C. Sindhwani—which treated Bagga consistently with the view that recommendation/approval by a government hospital or authority supports full reimbursement.
Applying these principles to the record, the court concluded that the CGHS package rates from 2001 (which had not been revised periodically) could not be the sole basis to deny the applicant the remaining admissible reimbursement, especially as the treatment was in private hospitals approved by the respondents and earlier judicial precedents supported fuller reimbursement in such situations.
Holding and Implications
Holding: The Original Application is allowed. The court directed the respondents to reimburse the balance amount of Rs.1,55,136/- to the applicant within eight weeks from receipt of a copy of the order. The court further held that the applicant is not entitled to any interest on the said amount. There was no order as to costs.
DISPOSITION: The applicant's claim for the outstanding balance (Rs.1,55,136/-) was accepted and payment was ordered within eight weeks; no interest and no costs were awarded.
Implications: The decision applies existing precedents cited in the opinion to require reimbursement of the outstanding balance in the specific factual matrix (treatment in private hospitals approved by the respondents and prior approvals/recommendations). The opinion treats earlier CGHS package rates as insufficient, in themselves, to deny full reimbursement where other factors (approval/recommendation; judicial precedent) point towards making the employee whole. The court did not purport to lay down novel law; rather it applied and followed the cited line of authorities in directing payment in the particular case.
Note: All statements in this summary are drawn exclusively from the provided opinion text. Where the opinion contained two slightly differing figures for total medical expenditure (Rs.12,93,036/- and Rs.12,93,037/-), both values have been reported as presented in the source.
By V. Ajay Kumar, Member(J) The applicant retired as a Chief Engineer (Civil) from Delhi Jal Board (DJB) on 30.09.2005. He is governed by Central Government Health Scheme [CGHS]/Central Services (Medical Attendance) Rules, 1944 [(CS(MA) Rules] and is entitled for reimbursement of medical expenses in accordance with such Rules and Notifications/Circulars/Office Memorandums issued thereunder in terms of DJB Resolution No.227 dated 07.05.1999. He is also holder of medical insurance policies which were subscribed by him from his own sources.
2. It is submitted that when the wife of the applicant was diagnosed with malignant Cancer, she was medically treated in Indraprastha Appollo Hospital, Rockland Hospital and Pushpanjali Corslay Hospital and that she finally succumbed to the disease and died on 24.11.2009. In connection with the said treatment, the applicant incurred a total medical expenditure of Rs.12,93,036/-.
3. In terms of Office Memorandum dated 19.02.2009 (Annexure `B), the beneficiaries under CGHS and CS(MA) Rules, 1944 (who have subscribed to medi claim policy from an Insurance agency) were permitted to claim reimbursement of the medical expenditure from both the sources, i.e., Insurance Agency and CGHS and Ministries/Departments as the case may be. However, this benefit was subject to the condition that the beneficiary will first claim reimbursement from the Insurance Agency and then from the CGHS or Ministry/Department concerned, and that the total amount reimbursed by the two organizations, does not exceed the total expenditure incurred by the beneficiary.
4. The applicant initially made a claim for reimbursement of the medical expenditure with the Insurance Company at the first instance, as required under Annexure `B OM, and the Insurance Company has reimbursed an amount of Rs.6,83,479/- leaving a balance of Rs.6,09,558/-. Thereafter, he made the claim for reimbursement for the balance amount out of the total amount of Rs.12,93,037/- to the Respondent-Delhi Jal Board. However, the Respondent-DJB reimbursed only Rs.4,54,422/- again leaving a balance of Rs.1,55,136/-. Aggrieved by the action of the respondent-DJB, in not reimbursing the full medical expenses incurred by the applicant, he has filed the present OA.
5. The respondents filed a counter along with a detailed status report indicating the particulars of the medical claim made by the applicant and the reimbursement thereon. The respondents in their counter stated that out of the total claim of Rs.12,93,037/- of the applicant, a total amount of Rs.11,37,901/- [Rs.6,83,479/- was reimbursed by the Insurance Company and an amount of Rs.4,54,422/- was reimbursed by the Delhi Jal Board] was paid to the applicant as against the admissible amount of Rs.8,02,963/-. Even the status report annexed to the counter also supports the counter averments.
6. Heard Shri Ajay Kumar Chopra, the learned counsel for the applicant and Shri Manish Kumar, the learned counsel for the respondents and also perused the pleadings on record.
7. It is the contention of the respondents that as per the OM dated 19.02.2009 (Annexure `B), the total amount reimbursable from both the sources, i.e., Insurance and the respondent Department, should not exceed the package rates prescribed under the CGHS for the particular treatment. They further submit that though the admissible amount as per the CGHS rates is only Rs.8,02,963 out of the total claim of Rs.12,93,037, the Medical Screening Committee of the respondent-Delhi Jal Board reimbursed more amount than the admissible amount on humanitarian grounds by treating the applicants case as a special case, in view of the attendant circumstances, and hence, the applicant is not entitled for any further amount either under the said OM or under any other Rule. The learned counsel for the respondents has placed reliance on the Judgment of the Honble Supreme Court in State of Punjab and Others v. Ram Lubhaya Bagga,(1998) 4 SCC 117.
8. Per contra, the applicant though not denying the aforesaid condition, but submits that since he got his wife treated in the aforesaid Hospitals after due approval from the respondents, and hence, he is entitled for full reimbursement of the medical expenditure incurred by him.
9. In a catena of cases various courts have laid down the following general principles for reimbursement of medical expenses incurred by government servants, who undergo treatment in private hospitals: It is now settled law that right to health is integral to right to life. A welfare State like India is bound to provide the basic requirements of its citizens. Health care facility is an integral part of the same and the CGHS has been established for the benefit of the Central Government employees. Even retired Government employees should not be left out of the purview of medical care. If the Government servant has suffered an ailment which requires treatment at a specialized approved hospital and, on reference, the Government servant has undergone such treatment therein, it is the duty of the State to bear the expenditure incurred by the Government Servant. Expenditure thus incurred requires to be reimbursed by the State to the employee. The mismatch between the rates charged by the approved hospitals and the rates approved by the Government works always to the disadvantage of the patient. What was fair and reasonable in 1996 or 1999 or 2001, when the rates apparently had some nexus with the then (current) rates has ceased to be so. The cost of medical treatment has been rising over a period of time and Government cannot deny the actual reimbursement from a Hospital recognized by it for treatment on the basis of applying the rates as per the orders issued previously. It would, therefore, be appropriate to update the approved rates on an annual or, at least, biennial basis. It is not the duty of the citizen to ensure that recognized hospitals do not charge in excess of the package rates. The Government was obliged to grant ex post facto sanction in case an employee requires a speciality treatment and there is a nature of emergency involved. In such a situation, treatment in a non-recognized hospital and non-observance of prescribed procedure and incurring expenditure in excess of CGHS package/approved rates have to be condoned. [K.P. Singh v. Union of India & Ors., 2001 (10) SCC 167; State of Punjab & Ors. v. Mohinder Singh Chawla etc., JT 1997 (1) SC 416; J.C. Sindhwani v. Union of India & Anr., 2005 (124) DLT 513; J.K. Saxena v. Govt. of NCT of Delhi, WP(C) No. 5015/2003, decided on 16.12.2004; Prithvi Nath Chopra v. Union of India & Anr., 2004 (111) DLT 190; V.K. Gupta v. Union of India & Anr., 2002 (97) DLT 337; M.G. Mahindru v. Union of India & Anr., 2001 (92) DLT 59; Narendra Pal Singh v. Union of India & Ors., 1999 (79) DLT 358; L.P. Sharma v. Union of India & Ors., 2004 (2) ATJ 492; Sh. S.R. Jha v. Union of India & Ors., 2003 (2) ATJ 168; and Shri Bhagwan Singh v. Union of India & Ors., 2002 (1) ATJ 226.]
10. As regards the judgment of the Honble Supreme Court in State of Punjab & Ors. v. Ram Lubhaya Bagga etc. (supra), cited by the respondents, it has been considered in several of the judgments cited above. Thus, in the case of M.G. Mahindru v. Union of India & Anr. (supra) the following ruling was given: There cannot be any dispute with regard to the ratio laid down by the Supreme Court in State of Punjab v. Ram Lubhaya Baggas case (supra). In that case the petitioner challenged the policy of the government with regard to fixation of allowances. In that case no recommendation was made by the CGHS for getting the treatment from a private hospital. As far as the case in hand is concerned, it is the Government Hospital, namely, RML Hospital which has recommended the case of the petitioner for a specialized treatment by a speciality hospital, which is on the approved list of CGHS. When the respondents themselves have recommended the case of the petitioner for getting treatment at a speciality hospital, to deny the benefit of giving full reimbursement would be contrary to the grant of medical facilities to a retired Government servant, if he cannot actually avail of the same. If the Government Hospital did not have the facility for giving treatment like the one which was required to be given to the petitioner, then it was an obligation on the part of the respondents to have reimbursed the total amount paid to the said hospital. Following the ratio laid down in the State of Punjab & Ors. v. Mohinder Singh Chawlas case (supra), I direct the respondents to reimburse the amount of Rs. 80,620/- to the petitioner within a period of four weeks.
11. Similarly, in the case of J.C. Sindhwani v. Union of India & Anr. (supra), it was held: 8. The issue of whether the Government is bound by the package rates and cannot disbursement amounts in excess of such approved rates has arisen for consideration; in V.K. Gupta v. Union of India, 97 (2002) DLT 337, M.G. Mahindru v. Union of India, 92 (2001) DLT 59; and P.N. Chopras case (supra) the Court expressly rejected similar defences and directed full reimbursement. In P.N. Chopras case, the decision in Ram Lubhaya Baggas case (supra) was considered; nevertheless a direction to make full payment was issued. I am in complete agreement with the reasoning in those cases.
12. Taking the totality of facts and circumstances into consideration and also taking into account the ratio of various judgments aforementioned, I arrive at the following findings on the core issues identified earlier: The package rates fixed in the year 2001, not having been revised periodically, are not sacrosanct and cannot be the sole criteria for denying full reimbursement to the applicant, whose wife admittedly underwent the treatment in a private hospital, approved by the respondents. The ratio of the judgment of the Honble Supreme Court in the case of State of Punjab & Ors. v. Ram Lubhaya Bagga (supra), as pointed out in the judgments of the Honble High Court of Delhi in the cases of M.G. Mahindru v. Union of India & Anr.(supra) and J.C. Sindhwani v. Union of India & Anr. (supra), is not against full reimbursement of medial expenses incurred in a private hospital approved by the Government.
13. In the circumstances and for the aforesaid reasons, the OA is allowed and the respondents are directed to reimburse the balance amount of Rs.1,55,136/- to the applicant within eight weeks from the date of receipt of a copy of this order. However, in the circumstances, the applicant is not entitled for any interest on the said amount. No order as to costs. (V. Ajay Kumar) Member (J) /nsnrvak/
Alert