1. The applicant, in this case, Shri D.L. Lulla, comes up to this Tribunal seeking the declaration that he is entitled for reimbursement of medical expenses of Rs. 97,481/- as claimed by him and for a declaration that the rejection of the claim by the respondents vide letters dated 9.11.1999 and 27.11.1999 being illegal and arbitrary, these letters are liable to be set aside. Directions for payment of the aforesaid claim along with 12% interest from 1.10.1998 is also sought.
2. The facts of the case, as brought forth by the applicant, are that he retired from government service from 31.1.1988 and that even before his retirement he was taking treatment for problems of chronic blood pressure, diabetes and heart problem from Jagjivan Ram Hospital (J.R.Hospital) of Western Railway. He states that he had his first heart attack in March, 1987 and further again in January, 1996 and on both occasions had got admitted to the aforesaid Jagjivan Ram Hospital.
Details of his grave problems on admission in 1996 are set out in the O.A.3. The Applicant then moves on to his medical problems in February, 1998 where a number of tests were recommended by the said Jagjivan Ram Hospital. Further developments of Angiography and other tests are described, making a point that ECG indicated that his valves were blocked more than 70 to 90%. He states that he had decided not to go in for an operation, but to resort to medication, and had been regularly visiting the Jagjivan Ram Hospital. Also that he is a member of the RELHS Scheme of the Railways for reimbursement of the medical expenses incurred for serving and retired employees of the Railway.
4. The applicant further states that he had another heart attack at his residence on 11.5.1998, when he became unconscious. His wife, of 70 years age, with the help of neighbours, rushed him to Hinduja Hospital, where his Angiography was done, and that after some tests he was operated upon, some three days later, on 14.5.1998 to clear the blocks of the arteries. The applicant further states that he was billed for Rs. 96,681/- and discharged from the Hospital. His case for medical claim had been forwarded to medical board. Thereafter, the applicant submitted the necessary details in the prescribed form and had annexed all the bills and certificates which were necessary for the approval of his claim and the same was approved by the Chief Medical Superintendent. However, his claims are rejected by the aforesaid impugned letter/s. It is with such grievance that the applicant approaches this Tribunal, seeking the relief as described above.
5. The respondents have filed a written statement in reply, resisting the claims of the applicant. It is accepted that the applicant was an old patient of chronic heart disease since 1984 and was admitted to J.R. Hospital on 24.3.1987, 10.1.1996, 11.1.1996 and 11.2.1998. As per rules, the Railway Hospital directs such cases (in which medical attendance is required in other hospitals) to recognised hospitals, having tie-up with the Railways. It is then stated that the Jagjivan Ram Hospital does not have facilities for doing angiography or by-pass operations, and that patients who are to undergo the said operation are referred to other hospitals having tie-up with the Railway Hospital. In fact it is stated that the applicant was once referred for one test to the Tata Hospital.
6. The stand importantly taken is that the applicant has himself taken the decision not to go in for an operation and as such has availed the medical facility on his heart attack in question as per his requirements. It is alleged that this is an admitted position and thus the stand taken in the challenged letters/orders in letter dated 9.11.1999 is sought to be substantiated. At this juncture it is advisable to reproduce the letter dated 9.11.1999 (Exhibit - 'A') under challenge : Kindly refer to your letters dated 30th June, 99; 31st Aug., 99; 29th Sept., 99; etc. addressed to the then Minister of State for Railways (Shri Ram Naik), undersigned has been directed to state 'that it is seen from the records that you had undergone an elective and planned operation in a private hospital of your choice without the element of emergency as there was a gap of two months from the date of the angiography (i.e. on 14.3.98) and date on which CABG was done (i.e. on 14.5.98). There was sufficient time for you to consult the Railway doctor i.e. the Authorised Medical Attendant when it was known to you through angioplasty that the CABG was inevitable. Thus your case does not deserve any special consideration." 7. The stand thus taken by the respondents is that the patient should have reported to the Railway Hospital for being referred to the recognised hospital for the purpose i.e. Bombay Hospital which is having the required medical facilities to treat such cases. This has references to the illness in May, 1998 and it is specifically averred by the respondents that there was enough time for attending Railway hospital earlier on, from 14.3.1998, when the investigations revealed that an operation was required. It is stated elsewhere in the written statement, inter alia, that by using the context of emergency one cannot avoid the procedure established rules. As such the admission in May, 1988 being on emergency basis is disputed.
8. I have seen all papers in the case, including rejoinder and additional statement of reply. I have also heard the arguments raised by the learned Counsel on both sides.
9. The learned Counsel for the applicant, Shri Ramamurthy, first took me over the facts of the case and made the point that on 11.5.1998 the applicant had a severe heart attack. This was a clear emergency situation as admittedly a very old man was first assisted by neighbours, and an aged wife who took him to the Hinduja Hospital. He importantly made the point that the fact that this was an emergency is clear because only three days later the doctor found it necessary to conducta major operation on him after full investigations/tests. Shri Ramamurthy stated that the doctors assessment should not be challenged, and that no doubts should be ascribed to the conduct of the applicant.
He strenuously reiterated the point regarding this being an emergency.
Arguing further Shri Ramamurthy stated that the Medical Superintendent, Jagjivan Ram Hospital, indeed had accepted the position and his case had been recommended for reimbursement of costs, as can be seen from the documents at page 29. The said document is a letter to the applicant from the FA & CAO to state that sanction was awaited from the Railway Board.
10. Learned Counsel Mr. Ramamurthy also sought to spend some time in arguing the point made about applicant's earlier decision not to go in for an operation. He argued that this cannot be allowed to go against the applicant's claim which was brought about in the circumstances described. He referred to the package deal through which certain amounts were payable on reference to tie-up hospitals viz. Bombay Hospital and even stated that the amount of the claim could be restricted to the eligible amount in the tie-up hospital if that was less. Shri Ramamurthy concluded by saying that the factual position, papers etc, were nowhere in dispute.
11. Arguing the case on behalf of the respondents, their learned Counsel Mr. V.S. Masurkar first made the point that the Railway policy regarding reimbursement had not been assailed, and the only point that the Tribunal could look into was whether the claim being made within the rules and the Tribunal had to reach its conclusion within the limits of judicial review. He also made the point that the relief plaimed being limited to the limits envisaged in package deal/rules of tie-up hospital have not been specifically claimed as relief in the O.A.12. Mr. Masurkar then stated that the order at page 19 is a detailed order giving reasons, and is in the nature of a speaking order, even though the action is administrative action and not a statutory appeal being decided. He emphasised the point that there was no violation of rules.
13. In fact, the specific point made by the learned Counsel Mr.
Masurkar was that the case of the applicant was not an emergency. It was only being stated as such and hence the full payment which is allowed in cases of emergency could not be allowed. This was indeed a point of issue which needed to be decided i.e. where the applicant's case was one of medical emergency or otherwise, Mr. Masurkar stated.
Mr. Masurkar took me over to page 59 of respondents statement. He reiterated strenuously the argument taken in Para 4 and made the point that the Jagjivan Ram Hospital had not referred him to the private hospital where he underwent treatment. Also, that his plea that the test done was done outside in private hospital because it is not available in J.R. Hospital is not correct. He cited the judgment of the Hon'ble Apex Court in the matter of Union of India and Ors. v. Lt.
General Rajendra Singh Kadya and Anr., AIR 2000 SC 2513=2001(1) SU 354 (SC). (Mr. Ramamurthy nevertheless disputed its relevance).
14. After considering all facts of the case and the arguments advanced on behalf of both sides, I find that the crucial issue that indeed needs to be decided here is whether the operation and other treatment taken by the applicant from 12th May onwards would be said to constitute treatment taken in an emergent situation/emergency requirement of health. In fact the learned Counsel for the respondents also did agree to this aspect being the crucial aspect/issue around which the decision in the case would hinge. The main argument that is advanced against the applicant is that some time prior to this incident when the applicant had taken ill seriously he had been advised to undergo surgery which he admittedly decided against. This ground was streuously taken by Respondent. I am afraid I cannot take this argument to go against the applicant's case with reference to the decision regarding reimbursement and the crucial issue referred to above. The point regarding advise for operation for heart surgery was indeed made and is admitted fairly by the applicant. Does it mean that any illness which came to the applicant make his case for medical reimbursement weak only because he had taken a decision not to undergo surgery. In the crucial area of uncertainities in human life and more so the uncertainity of human health such kind of assumptions and arguments cannot be made. The fact of the matter is that the man had admittedly taken ill, and had even gone into some kind of unconscious state, These facts in the case are admitted on both sides and in fact it is the clarity with regard to facts that this case becomes simpler to decide.
Now having gone to the private hospital and it having been found that an operation was necessary after proper tests, it is clear that the illness and the need for an operation was indeed genuine. No one will let himself come to such a pass without genuine need just for claiming certain reimbursements. It is not a source of benefit or income to him but an amount rendered inescapably necessary.
15. It is true that normally one should go only to government hospitals but in regard to the decisions and moreso the heart surgery, it is admitted here that the government hospital in question viz. the Jagjivan Ram Hospital did not have in-house facilities for heart surgery or even angiography. The respondents have elaborately described that there is a referral system to a hospital i.e. Bombay Hospital, with which they have a tie-up. In fact, it is stated that the applicant should have gone to Jagjivan Ram Hospital from where he would have referred to Bombay Hospital and there would then have been a case for reimbursement. In an emergent situation like the one faced by the applicant and in the peculiar facts and circumstances of the case this is an unfair and unjustified stipulation to make. What has happened is that a situation of emergency of health has developed, and since all costs and charges are payable as per rules in an emergency, this case would also demand, in the interest of justice, that charges payable for treatment in emergency situations should be paid here also. We have seen the case of Lt. Gen. Rajendra Singh Kadyan (supra) and do not agree that the ratio there will apply to the present case. The objections of the nature taken on behalf of respondents-as set out in Para 11 above also do not merit any consideration.
16. In view of the discussions made above, it will be in the interest of justice that the charges incurred by the applicant in his treatment arising at the private hospital on and around 12th May, 1998 be reimbursed. Thus reimbursement will however be subject to the amount that would have been reimbursed to him, had he proceeded to the Hospital with whom the respondents state they have a tie-up viz, Bombay Hospital.
(a) The Applicant shall be paid the amount claimed by him as medical reimbursements. If the amounts admissible as per rates in the tie-up Hospital (Bombay Hospital) are less, then the claim/s will be limited to those amounts.
(c) The Respondents shall make the aforesaid payments within three months of the date of receipt of copy of this order, indicating briefly the item-wise amount paid for to the applicant. No interest will be payable.