Dismissed

Satheesh Kumar R., v. Union of India

Kerala HC18 Dec 2020OP (CAT)/194/2020

Case brief

AI extract

What is this about?

Challenging the rejection of his claim for full medical reimbursement under CGHS, the petitioner argued entitlement based on new government guidelines for treatment in private unrecognized hospitals. The Court dismissed the petition, directing the petitioner to submit a detailed representation to the respondents to determine the claim type.

What did the court decide?

Petition dismissed; petitioner permitted to submit detailed representation on claim within two weeks for respondents to take appropriate action.

Satheesh Kumar R., Vs Union of India — Service and Employment | Kerala HC (2020)

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IN THE HIGH COURT OF KERALA AT ERNAKULAM

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PRESENT

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THE HONOURABLE MR.JUSTICE A.M.SHAFFIQUE

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THE HONOURABLE MR. JUSTICE GOPINATH P.

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FRIDAY, THE 18TH DAY OF DECEMBER 2020 / 27TH AGRAHAYANA, 1942

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OP (CAT).No.194 OF 2020

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AGAINST THE ORDERS DATED 29.07.2020 AND 25.02.2020 IN R.A.NO.4/2020 AND OA 119/2019 RESPECTIVELY OF CENTRAL ADMINISTRATIVE TRIBUNAL,ERNAKULAM BENCH

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PETITIONER/:

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SATHEESH KUMAR R., AGED 60 YEARS S/O. N. RAGHAVA PANICKER(LATE), MTS RMS, TRIVANDRUM DIVISION, THIRUVALLA, RESIDING AT SREESADHANAM, MATHILBHAGAM, THIRUVALLA – 689 101.

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BY ADVS. SRI.SAJITH KUMAR V. SRI.A.V.VIVEK SHRI.GODWIN JOSEPH SMT.APARNA CHANDRAN

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RESPONDENTS:

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1 UNION OF INDIA REPRESENTED BY THE SECRETARY TO THE GOVERNMENT, DEPARTMENT OF POSTS, MINISTRY OF COMMUNICATIONS, GOVERNMENT OF INDIA, NEW DELHI – 110 001.

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2 THE CHIEF POSTMASTER GENERAL, KERALA CIRCLE, TRIVANDRUM – 695 033,

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3 THE SUPERINTENDENT, RMS TV DIVISION, THIRUVANANTHAPURAM – 695 001.

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4 THE SUB RECORD OFFICER, RMS, T.V DIVISION THIRUVALLA – 689 101.

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R1-4 BY ADV. SHRI.P.VIJAYAKUMAR, ASG OF INDIA

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THIS OP (CAT) HAVING COME UP FOR ADMISSION ON 18.12.2020, THE COURT ON THE SAME DAY DELIVERED THE FOLLOWING:

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OP (CAT).No.194 OF 2020

JUDGMENT

Shaffique, J

The original petition has been filed by the petitioner challenging an order dated 25.02.2020 in O.A.No.119/2019. The petitioner challenged the action taken on behalf of the respondents in rejecting his claim for full medical reimbursement. The Tribunal observed that, the petitioner is entitled to get all medical expenses as per CGHS rate. The petitioner filed review, which also came to be dismissed. The contention urged by the learned counsel appearing for the petitioner is that as per O.M. dated 22.05.2018 and 06.06.2018 (Exts.P7 and P8) of the Govenment of India, Ministry of Health and Family Welfare, Department of Health & Family Welfare, new guidelines had been formulated, by which, certain category of persons who had obtained treatment in private unrecognised hospitals under emergency and was admitted for prolonged period for treatment of Head Injury, Coma, Septicemia, Multi-organ failure, etc., are entitled for full reimbursement.

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For easy reference we may refer to the said O.M. dated

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06.06.2018 especially clause 2(a) which reads as under :

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2.Full reimbursement case/Cases for relaxation of Rules

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OP (CAT).No.194 OF 2020

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As per the new guidelines they fall into two categories

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(a) Full reimbursement-Non-HPC (Non-High Power Committee) Cases

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(b) Full reimbursement -HPC (High Power Committee) Cases

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a)Full reimbursement-Non-HPC cases

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The following cases fall under this category;

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i. Treatment was obtained in a private unrecognized hospital under emergency and the patient was admitted by others when the beneficiary was unconscious or severely incapacitated and was hospitalized for a prolonged period.

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ii. Treatment was obtained in a private unrecognized hospital under emergency and was admitted for prolonged period for treatment of Head Injury, Coma, Septicemia, Multi-organ failure, etc.

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iii. Treatment was obtained in a private unrecognized hospital under emergency for treatment of advanced malignancy.

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iv. Treatment was taken under emergency in higher type of accommodation as rooms as per his/her entitlement are not available during that period.

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v. Treatment was taken in higher type of accommodation under specific conditions for isolation of patients to avoid contacting infections.

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vi. Treatment was obtained in a private unrecognized hospital under emergency when there is a strike in Govt.hospitals.

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vii. Treatment was obtained in a private unrecognized hospital under emergency while on official tour to non-CGHS covered area.

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Although the new OM has not mentioned about STC recommendation, it is advisable to have expert

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OP (CAT).No.194 OF 2020

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Committee meetings under the Chairperson of Addl.DGHS (as in the case of earlier STC meetings) in respect of item Nos.i),ii),iii) and v) before arriving at a decision.

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The conditions mentioned at Nos.iv),vi)and vii) are administrative in nature and do not require meetings of expert committees and may be recommended by Addl.Director, if conditions are satisfied.

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In Delhi the expert committee meetings shall be organized by respective CMO(R&H) and by AD(R&H) in case of claims of serving employees of Delhi. Such meetings in respect of other cities shall be organized by Sr.CMO in the office of Addl.DDG (HQ).

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The requests for full reimbursement as examined by Additional Director (HQ)/Addl.DDG(HQ), in consultation with expert committee meetings, wherever deemed necessary and recommended for full reimbursement shall be submitted to Director, CGHS and concurrence of IFD may be obtained after approval of AS&DG, CGHS before the seeking the approval of Secretary for reimbursement in excess of CGHS rates.

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If the above criteria are not satisfied (including the regrets by expert committees) the requests may be regretted by Addl.Director of concerned City, with a covering letter explaining the reasons and referring to the concerned OM.

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In case there is a representation to consider as a special case then only it may be placed before the High Power Committee.

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Addl.Directors shall prepare a self-contained note giving details of case and submit the files with relevant documents to Director, CGHS though AD(HQ)/Addl.DDG(HQ)

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OP (CAT).No.194 OF 2020

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If the proposal is approved by AS&DG,CGHS, concurrence of IFD and approval of Secretary, Health & Family Welfare and solicited for reimbursement in excess of approved rates.

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According to the learned counsel, the case of the petitioner comes under clause 2 (a) (i) and (ii), in which event, the petitioner's claim is required to be considered by an expert committee under the Chairperson of Addl.DGHS. According to the petitioner, there was no necessity for the matter to be referred to the High Power Committee as his claim does not come under clause 2(b) of the said O.M.

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We also heared the learned ASG, who submits that unless a representation is received in the manner prescribed under the aforesaid OM, it may not be possible for the competent Authority to consider the said representation and refer the matter to the appropriate Authority. The learned ASG submits that it might also be a case involving reference to the High Power Committee as well as the Ministry of Health and Family Welfare.

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Be that as it may, unless a representation on the basis of the OM is submitted by the petitioner; it may not be possible for the competent Authority to decide on whether it is a Non-HPC case or HPC case. If it is a Non-HPC case,

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OP (CAT).No.194 OF 2020

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necessarily the competent Authority will be the expert committee in terms of OM under clause 2(a) and if it is a HPC case, it will have to be placed before the High Power Committee. It is for the competent Authority to decide whether it should be placed before the expert committee or the High Power Committee as the case may be. We are not expressing any opinion in that regard.

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In the result, the original petition is disposed of in modification of the order passed by the Tribunal permitting the petitioner to submit a detailed representation regarding his claim based on Exts.P7 and P8, within a period of two weeks from today and on receipt of the said representation, the respondents shall take appropriate action, in accordance with law, as expeditiously as possible.

Sd/-

A.M.SHAFFIQUE, JUDGE

sd/-

GOPINATH P., JUDGE

AMV/21/12/2020

OP (CAT).No.194 OF 2020

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APPENDIX

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PETITIONER'S/S EXHIBITS:

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EXHIBIT P1 A TRUE COPY OF THE O.A NO.119/2019 DATED 20.02.2019 SUBMITTED BY THE PETITIONER.

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ANNEXURE A1	A TRUE COPY OF T	HE ORDER
	NO.B1/MR/SATHEESH KUMAR	DATED
	10.01.2019 ISSUED BY RESPONDENT.	THE 3RD
ANNEXURE A2	A TRUE COPY OF THE RELEVAN THE MEDICAL BILL IN THE	T PAGES OF PRESCRIBED
	FORMAT SUBMITTED TO RESPONDENT.	THE 3RD
ANNEXURE A3	A TRUE COPY OF THE OP TICK OF THE PRIMARY HEALT KOTTANGAL.	ET NO.19205 H CENTRE,
ANNEXURE A4	A TRUE COPY OF THE CERTIFICATE DATED 17.03.2 BY THE PUSHPAGIRI HOSPITAL.	EMERGENCY 018 ISSUED
ANNEXURE A5	A TRUE COPY OF THE CERTIFI 25.04.2018 ALONG WITH SUMMARY.	CATE DATED DISCHARGE
ANNEXURE A6	A TRUE COPY OF THE RELEVAN THE MEDICAL BILL SUBMITTED RESPONDENT IS PRODUCED.	T PAGES OF TO THE 3RD
ANNEXURE A7	A TRUE COPY OF THE REP DATED 20.03.2018 SUBMITTE APPLICANT TO THE 3RD RESPO WITH ITS TRANSLATION.	RESENTATION D BY THE NDENT ALONG
ANNEXURE A8	A REPRESENTATION DATED SUBMITTED BY THE APPLICANT RESPONDENT.	19.12.2018 TO THE 3RD
EXHIBIT P2	A TRUE COPY OF THE REPLY DATED 03.10.2019 FILED RESPONDENTS.	STATEMENT BY THE
ANNEXURE R1	A TRUE COPY OF THE RULE 12 RULES, 1944.	OF CS (MA)
ANNEXURE R2	A TRUE COPY OF THE GOV	ERNMENT OF
	KERALA CIRCULAR NO.2462	3/G2/2012/H

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OP (CAT).No.194 OF 2020

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AND FWD DATED 11.07.2012 ANNEXURE R3 A TRUE COPY OF THE CHECKLIST ISSUED BY THE 3RD RESPONDENT VIDE OFFICE LETTER NO.B1/MR/R SATHEESH KUMAR DATED 01.08.2018. ANNEXURE R4 A TRUE COPY OF RULE 5 OF APPENDIX VIII OF CS (MA) RULES, 1944 ANNEXURE R5 A TRUE COPY OF THE MOH AND FW OM NO.S 14025/14/2012-MS DATED 11.06.2013. ANNEXURE R6 A TRUE COPY OF THE SANCTION MEMO NO. B1/MR/R SATHEESH KUMAR DATED 15.07.2019. EXHIBIT P3 A TRUE COPY OF THE REJOINDER DATED 03.01.2020 FILED BY THE PETITIONER. EXHIBIT P4 A TRUE COPY OF THE ORDER DATED 25.02.2020 IN OA NO.119/2019 OF THE CENTRAL ADMINISTRATIVE TRIBUNAL, ERNAKULAM BENCH. EXHIBIT P5 A TRUE COPY OF THE RA NO.4/2020 DATED 19.03.2020 FILED BY THE PETITIONER. ANNEXURE RA1 A TRUE COPY OF THE ORDER OF THE HON'BLE TRIBUNAL IN OA 119/2010 DATED 25.02.2020 AND TYPED COPY. EXHIBIT P6 A TRUE COPY OF THE ORDER DATED 29.07.2020 IN RA NO.4/2020 OF THE HON'BLE CENTRAL ADMINISTRATIVE TRIBUNAL, ERNAKULAM BENCH AND TYPED COPY. EXHIBIT P7 A TRUE COPY OF THE OM.NO.Z.15025/51/2018/DIR/CGHS/EHS DATED 22/05/2018 ISSUED ON BEHALF OF THE 1ST RESPONDENT. EXHIBIT P8 A TRUE COPY OF THE O.M.NO.Z.15025/51/2018/DIR/CGHS/EHS DATED 06/06/2018 ISUED ON BEHALF OF THE 1ST RESPONDENT. RESPONDENTS EXHIBITS : NIL TRUE COPY P.A.TO JUDGE

Satheesh Kumar R., v. Union of India

Case brief

What is this about?

What did the court decide?

Satheesh Kumar R., v. Union of India

Case brief

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What did the court decide?

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