Prem Mahalwal vs Govt. Of Nct Of Delhi & Others
2009 Latest Caselaw 3405 Del

*         IN THE HIGH COURT OF DELHI AT NEW DELHI

+         W.P.(C) 3145/2008

    PREM MAHALWAL                        ..... Petitioner
                        Through    Mr. Ankit Jain, Adv.

                 versus


    GOVT. OF NCT OF DELHI & ORS             ..... Respondent
                    Through     Ms. Zubeda Begum, Adv.

    CORAM:
    HON'BLE MR. JUSTICE SANJIV KHANNA

1. Whether Reporters of local papers may be
  allowed to see the judgment?
  2. To be referred to the Reporter or not ?
  3. Whether the judgment should be reported
  in the Digest ?

                              ORDER

% 27.08.2009

1. The petitioner, Ms. Prem Mahalwal seeks reimbursement of the

medical treatment bills from the Government of NCT of Delhi. She

suffered a stroke in April, 2006 and was referred to the Nephrology

Department, Rockland Hospital, a private recognized hospital, by the

Chief Medical Officer (CMO), Directorate of Health Service, Government

of NCT of Delhi. The petitioner has placed on record the reference

W.P.(C) 3145/2008 Page 1 certificate issued by the CMO dated 19th April, 2006. The petitioner

claims that the said reference certificate is valid and binding on the

respondents as the CMO is the authorized medical attendant (AMA) for

referral purposes. In this regard, counsel for the parties have drawn my

attention to the clause 10 (ii) of the office memorandum dated 25th

October, 2007, which reads as under:-

"ii. The authorized medical attendant (AMA) for referral pruposes will be the CMO/MO Incharge of the dispensary/hospital where the beneficiary is attached."

2. The respondent have stated that the reference was made in

April, 2006 i.e. before office memorandum dated 25th October, 2007 and

on the relevant date reference from Head of the Department was

required. Even if this is correct, in the present case, undisputedly

reference was made by the doctor employed by the respondents. It was

equally the responsibility of the respondents to ensure that reference

was made after following the prescribed procedure. Moreover the

doctor concerned should have asked and warned the petitioner to

follow the procedure. Technicalities should not come in way when it is

accepted that treatment in a private recognized hospital was required.

W.P.(C) 3145/2008 Page 2

3. The petitioner has asked for reimbursement of three bills of Rs.

13,839.90/-, Rs. 20887.40/- and Rs. 31,689.90/- for the periods May

2006 to December, 2006, January 2007 to June 2007 and July 2007 to

November, 2007, respectively. These bills pertain to OPD treatment in

Rockland Hospital. The respondents did not reimburse the said bills

relying upon clause 10 (A) of the office memorandum dated 25th

October, 2007. The said clause reads as under:-

             "A. OPD        Treatment     in   nonemergent
             conditions:
       i.    OPD specialist treatment in private recognized

hospitals of the choice of the beneficiary shall be available on the advice of the concerned AMA for a period not exceeding six months in each instance. Any OPD treatment in private hospitals not recognized/empanelled under the scheme shall not be admissible for reimbursement."

4. As noticed above, the petitioner was asked to approach a

private recognized hospital by the CMO vide his recommendation dated

19th April, 2006. Thereafter, she has been taking treatment in the

Rockland Hospital. No doubt clause 10 (A) requires

recommendation/advice of the concerned AMA after period of 6

months at each instance, but the question is whether reimbursement

should be denied, when otherwise specialist treatment in a private

W.P.(C) 3145/2008 Page 3 recognized hospital was required and necessary. As noticed above, the

office memorandum was issued on 25th October, 2007 i.e. after

recommendation/advice for treatment at the private recognized

hospital was already given. Approval if justified and was required can be

given subsequently and expost facto. Reimbursement of medical

expenses, which was necessary and required, should not be rejected on

technical grounds unless there is an express prohibition. A liberal

approach is required. Clause 10 (A) prohibits reimbursement of

expenses/bills of private non-recognized or un-empanelled hospitals.

There is no such express prohibition in case advise is not obtained every

six months. It will be appropriate for the respondents to examine the

case of the petitioner for post facto approval. While examining the case

of the petitioner for post facto approval, the respondents will keep in

mind the prescription, diagnostic reports and medical treatment, which

the petitioner had to undergo. The respondents will also keep in mind

the first prescription of the CMO dated 19th April, 2006 by which the

petitioner was referred to Nephrology Department, Rockland Hospital.

5. Another contention raised by the counsel for the respondents is

that the three bills mentioned above were submitted by the petitioner

W.P.(C) 3145/2008 Page 4 for reimbursement on 13th February, 2008. In this regard, she relies

upon the clause 8 of the Central Services (M.A.) Rules, which reads as

under:-

"(8) Bills to be preferred within three months.- It has been decided that final claims for reimbursement of medical expenses of Central Government servants in respect of a particular spell of illness should ordinarily be preferred within three months from the date of completion of treatment as show in the last Essentiality Certificate issued by the Authorized Medical Attendant/Medical Officer concerned. The controlling authorities shall also be empowered not to entertain a medical claim not preferred by a Central Government servant within three months of the completion of the treatment where they are not satisfied with the reasons put forth by the Government servant for late submission of the medical claim or where the claim prima facie is incomplete."

6. The said objection has not been raised by the respondents in

their counter affidavit. Clause 8 of the Central Services (M.A.) Rules

quoted above stipulates that the final claim for reimbursement of

medical expenses in case of a particular spell of illness should ordinarily

be preferred within three month from the date of completion of

treatment. Use of the word "ordinarily" shows that it is not mandatory

and the requirement is flexible. Further, the requirement is that the

W.P.(C) 3145/2008 Page 5 medical claim/bills should be submitted within three months from the

date of the completion of the treatment. In the present case, the

petitioner underwent treatment for a long period. The object and

purpose behind the said Central Services (M.A) Rule is to ensure that the

frivolous claims are not made and claims in genuine cases are dealt with

expeditiously and payments are made. Delay in submitting medical bills

for reimbursement is to the disadvantage of the person, who is entitled

to reimbursement.

7. Keeping all these aspects in mind, the respondents are directed

to examine the bills submitted by the petitioner for reimbursement and

if they are found to be genuine, correct and treatment was required and

necessary in the private recognized hospital, the petitioner should not

be denied reimbursement.

8. The last objection raised by the respondents is for

reimbursement of the injections Wepox. The reimbursement for the

said injections has been denied in view of the fact that the concerned

doctor had not recommended the said injections during the period 11th

July, 2007 to 6th September, 2007. The petitioner, however, has filed on

record the bill from the medical store dated 11th July, 2007 for purchase

W.P.(C) 3145/2008 Page 6 of the said injection for Rs. 4,660/- plus taxes. The bill has also been

verified by the Consultant Nephrologist, Rockland Hospital. There is

another bill dated 6th September, 2007 for Rs. 21,00/-. The said bill is

also verified by the Consultant Cardiologist, Rockland Hospital. The

petitioner has also filed on record photocopy of the out-patient card. As

per the said card, the petitioner was advised and recommended

administration of Wepox injection. The claim of the petitioner for

reimbursement for Wepox injections requires consideration by the

respondents. If required, the respondents are entitled to verify from the

concerned Doctor/ Hospital. Similarly, the respondent will also examine

the medical bills submitted by the petitioner for claiming

reimbursement with regard to diagnostic tests at Dr. Lal Path

Laboratory. It is a case of the petitioner that these diagnostic tests are

permitted and allowed under clause 6 of the notification dated 22nd July,

2004. The respondent will examine whether bills for diagnostic test from

Dr. Lal Path Laboratory are covered by the said clause.

9. With the aforesaid directions, the writ petition is disposed of.

The respondents will pass a speaking order dealing with the each aspect

on which the matter is remanded back to them, within a period of two

W.P.(C) 3145/2008 Page 7 months from the date copy of this order is made available to them. In

case any amount is found to be payable and due to the petitioner, the

same will be paid to the petitioner within a period of one month from

the date speaking order is passed. In case the petitioner is still

aggrieved, he will be entitled to ventilate his grievance in accordance

with law.

Dasti to the counsel for the parties.

SANJIV KHANNA, J.

AUGUST 27, 2009.

 NA/P




 W.P.(C) 3145/2008                                                    Page 8