Allowed¶29

Uma Goel v. Govt. of NCT of Delhi & Anr.

Delhi HC17 Jan 2025W.P.(C)/15154/2022

Case brief

AI extract

What is this about?

W.P.(C) 15154/2022, Uma Goel v. Govt. of NCT of Delhi & Anr., decided 17.01.2025 by Sachin Datta, J. (Delhi High Court). Keywords: DGEHS medical reimbursement; empanelled hospitals list; Indraprastha Apollo Hospital empanelled for urology; 'primary consultant' in discharge summary cannot defeat reimbursement claim; emergent admission during Covid-19 pandemic (14.03.2021–25.03.2021); urological procedure by urologist Dr. Rajesh Taneja; balance Rs.4,13,366.03 directed to be released; no interest or damages; order limited to peculiar facts.

What did the court decide?

Petition allowed; respondent no.1 directed to release the remainder sum of Rs.4,13,366.03/- to the petitioner in terms of the extant policy; no interest or further damages granted. ¶29

Uma Goel Vs Govt. of NCT of Delhi & Anr. — Delhi HC (2025) — LawSathi Research

What the court decided

AI extract

Outcome

Petition allowed; respondent no.1 directed to release the remainder sum of Rs.4,13,366.03/- to the petitioner in terms of the extant policy; no interest or further damages granted.

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Issue for consideration

Whether the petitioner is entitled to full medical reimbursement of Rs.5,11,779/- under the DGEHS for the emergent urological treatment of her dependent father-in-law at the respondent no.2 hospital (empanelled for urology), notwithstanding that the discharge summary described a specialist in 'Respiratory Medicine, Critical Care & Sleep Medicine' as the 'primary consultant' +1 more

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Court's answer

The respondent's justification for denying full reimbursement on the ground that the opening page of the discharge summary disclosed a doctor specializing in 'Respiratory Medicine, Critical Care & Sleep Medicine' as the 'primary consultant' does not commend itself to the Court.

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Ratio / Principle

The manner of preparing the discharge summary is not in the hands of the concerned patient; the reason why a particular doctor was mentioned as 'primary consultant' is unknown to the petitioner and is an internal matter of the hospital, possibly dictated by factors such as relative seniority of consulting doctors.

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Key takeaways

The primary reason for admission in the respondent no.2 hospital was a urological condition, and it is undisputed that the respondent no.2 hospital is duly empanelled for urology; the invasive procedure was also performed by a urologist.ratio¶22
There is no rationale for denying reimbursement to the petitioner of the medical bills submitted by her to respondent no.1.ratio¶26
During the admission period (14.03.2021–25.03.2021) the Covid-19 pandemic was raging; the Court found nothing amiss in a doctor well versed in Respiratory Medicine examining and tending to the patient as part of the treatment protocol, and any secondary issue bearing on the urological procedure necessarily had to be attended/pre-empted.

Detailed headnote1 paragraphs

Delhi High Court (Sachin Datta, J.) allowed a writ petition assailing partial allowance of a DGEHS medical reimbursement claim. The petitioner's dependent father-in-law was admitted in emergent circumstances (14.03.2021–25.03.2021) to a hospital specifically empanelled under DGEHS for urology, where a urologist performed an invasive procedure for his urological condition; the claim of Rs.5,11,779/- was allowed only to Rs.98,413/- on the ground that the discharge summary named a 'Respiratory Medicine, Critical Care & Sleep Medicine' specialist as the 'primary consultant'. Held: preparation of the discharge summary and naming of a 'primary consultant' are internal matters of the hospital beyond the patient's control; the primary reason for admission was the urological condition; with the Covid-19 pandemic raging during the admission period, attendance by a respiratory medicine doctor formed part of the treatment protocol; there was no rationale for denying reimbursement. Respondent no.1 was directed to release the remainder of Rs.4,13,366.03/- in terms of the extant policy; no interest or damages were awarded, and the order was expressly confined to the peculiar facts of the case.

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$~7

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IN THE HIGH COURT OF DELHI AT NEW DELHI

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- W.P.(C) 15154/2022 UMA GOEL .....Petitioner Through: Mr. Nitin Goel, Adv. versus

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GOVT. OF NCT OF DELHI & ANR. .....Respondents Through: Ms. Avnish Ahlawat, SC, Mr. Nitish Kumar singh and Ms. Laavanya Kaushik, Advs.

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CORAM:

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HON'BLE MR. JUSTICE SACHIN DATTA

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O R D E R % 17.01.2025

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The present petition has been filed by the petitioner assailing the letter dated 21.07.2022, issued by the respondent no.1 whereby the petitioner’s medical reimbursement claim has been allowed only to the amount of Rs.98,413/- instead of Rs.5,11,779/-, submitted by the petitioner.

¶9

It is submitted that the petitioner is covered under Delhi Government Employees Health Scheme (DGEHS) of the respondent no.1. The father-inlaw of the petitioner (dependent upon the petitioner) underwent medical treatment at the respondent no.2 hospital for a urological condition.

¶10

The father-in-law of the petitioner initially visited the Narmada hospital, Sikandara, Agra where he got initial treatment. Since the requisite treatment could not be given to him in the said hospital, he came to Delhi and visited Lal Bahadur Shastri Hospital, Delhi. The said hospital recommended the patient to visit the urologist department in a bigger hospital. Consequently, the father-in-law of the petitioner went to AIIMS,

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Page 1 of 4

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W.P.(C) 15154/2022

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This is a digitally signed order. The authenticity of the order can be re-verified from Delhi High Court Order Portal by scanning the QR code shown above. The Order is downloaded from the DHC Server on 28/01/2025 at 14:28:36

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New Delhi. However, under emergent circumstances, he was admitted to the respondent no.2 hospital on 14.03.2021, where an invasive procedure / surgery was performed on him. He was discharged from the hospital on 25.03.2021. It was in respect of the treatment / procedure undergone by the father-in-law of the petitioner during the period 14.03.2021 – 25.03.2021 at the respondent no.2 hospital that a medical claim to the tune of Rs.5,11,779/- was submitted. The same ultimately led to the impugned letter being issued whereby only a part of the claim amount was released to the petitioner.

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Learned counsel for the petitioner draws attention to the list of DGEHS empanelled hospitals. It is emphasized that the respondent no.2 hospital is very much a part of the said list. The relevant entry in the said list is extracted hereunder:

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3. Indraprastha	NABH/NABL	Radiological Investigations &
Apollo	Accredited	Nuclear Medicines, Laparoscopic
Hospital,		Surgery, Dialysis, Urology, Organ
Mathura Road,		Transplant (Renal, Liver),
Sarita Vihar,		Lithotripsy, Joint Replacement,
New Delhi 76		Radiation Therapy, Cardiology,
		Cardiothoracic & Vascular
		surgery.

¶17

Attention is drawn by learned counsel for the petitioner to the fact that the respondent no.2 hospital is specifically empanelled for ‘ urology’ . It is pointed out that the hospitalization and consequent claim for reimbursement is on account of a urological condition of the father-in-law of the petitioner, for which he was admitted in emergent circumstances in respondent no.2 hospital. Learned counsel on behalf of the petitioner also draws attention to

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W.P.(C) 15154/2022

the discharge summary issued by the respondent no.2 hospital which records the history of urological condition of the patient and also clearly mentions the procedure that was performed on him. He specifically draws attention to the invasive procedure/ surgery performed by Dr. Rajesh Taneja, a doctor in the urology department of the respondent no.2 hospital.

¶22

It transpires that while in the respondent no. 2 hospital, the father-inlaw of the petitioner was also examined by doctors from other streams / departments, who had to visit him as a part of standard operating procedure. However, it is apparent that the primary reason for admission in the respondent no.2 hospital was on account of a urological condition. It is undisputed that for urology, the respondent no.2 hospital is duly empanelled. 7. Learned counsel for the respondent seeks to justify the denial of full reimbursement on the basis that the opening page of the discharge summary discloses that a doctor specializing in ‘ Respiratory Medicine, Critical Care & Sleep Medicine ’ was referred to as the “primary consultant”. The said submission does not commend itself to this Court. 8. The manner of preparing the discharge summary is not in the hands of the concerned patient. Also, the reason which impelled the hospital to mention any the name of any particular doctor as a “primary consultant” is unknown to the petitioner, and is an internal matter of the hospital. The same could be dictated by a variety of factors, including the relative seniority of the consulting doctors who have examined the patient. What is crucial is that it is apparent from the history of the patient, as recorded in the very same discharge summary, that it was on account of the urological condition of the concerned patient that he was constrained to admit himself in the respondent no.2 hospital. The invasive procedure that he underwent was also performed

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W.P.(C) 15154/2022

by a urologist. In the circumstances, there is no rationale for denying reimbursement to the petitioner of the medical bills submitted by him to the respondent no.1.

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It is also noticed that the admission of the father-in-law of the petitioner was during the period 14.03.2021 to 25.03.2021. It is the matter of common knowledge that during the said period, the Covid-19 pandemic was raging and this Court finds nothing amiss in a doctor well versed with ‘ Respiratory Medicine’ examining and tending to the patient, as part of the treatment protocol. Moreover, any secondary issue that would have a bearing on the urological procedure to be performed on the patient, was necessarily required to be attended / pre-empted.

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