Rajasthan High Court - Jodhpur

Smt. Manorma Asopa vs State Of Rajasthan on 17 October, 2022

Bench: Kuldeep Mathur

HIGH COURT OF JUDICATURE FOR RAJASTHAN AT JODHPUR S.B. Civil Writ Petition No. 16339/2018

Smt. Manorma Asopa W/o Shri S.n. Asopa, Aged About 77 Years, Retried Vice Principal, Diet Vidhya Shala, Jodhpur, Aged 77 Years, Now Residing At Vyas Haveli, Sumer Market, Dhan Mandi, And Jodhpur

----Petitioner Versus

1. State Of Rajasthan, Through The Member Secretary And Director, Rajasthan Pensioners Medical Fund, Secretariat, Jaipur

2. The District Health Benefit Empowered Committee, Through Its President The District Collector Jodhpur

3. The Board Of Trustee, Constituted For The Administration Of Scheme For Grant Medical Concession To The State Govt Pensioners, State Of Rajasthan, Jaipur

4. The Treasury Officer (Rural), Jodhpur

----Respondents

For Petitioner(s) : Mr. Hem Raj Soni Mr. Narottam Soni For Respondent(s) : Mr. Anil Kumar Gaur, AAG

HON'BLE MR. JUSTICE KULDEEP MATHUR

Order

17/10/2022

The present writ petition has been filed with a prayer for

reimbursement of the medical bills qua the treatment taken by the

petitioner in a private hospital.

Brief facts of the case are that the petitioner while in

Mumbai, for some family function in the month of September,

2016 in emergent condition, underwent a surgical treatment for

Uterus Vaginal Prolapse and Cystoretocele as indoor patient at

Lilavati Hospital. The petitioner remained hospitalised from

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11.09.2016 to 15.09.2016. The total expenditure incurred in the

above-mentioned treatment was Rs.1,95,723/-. The petitioner

submitted medical bills to the respondents for reimbursement as

per the provisions of Rajasthan Civil Services (Medical Attendance)

Rules, 2013 (hereinafter referred to as 'the Rules of 2013') and

Rajasthan State Pensioners' Concession Scheme, 2014

(hereinafter referred to as 'the Scheme of 2014'). The

respondents reimbursed only Rs.17,087/- qua the treatment taken

in Lilavati Hospital against the medical bills submitted for

Rs.1,95,723/-.

Learned counsel for the petitioner submitted that since the

treatment was undertaken in emergent situation, the entire

expenditure incurred in the treatment ought to have been

reimbursed by the respondents. It was further submitted that if,

the medical bills submitted for reimbursement exceeded the

prescribed ceiling limit for Treasury Officer (Rural) Jodhpur, the

matter ought to have been sent for consideration of District Health

Benefit Empowered Committee. It was further submitted that the

petitioner should have been reimbursed under the heads viz.,

medicines, drugs, anesthesia and room charges etc. as per the

Rules of 2013. For strengthening aforesaid contentions, reliance

was placed on judgments rendered by this Court in the cases of

Srigopal Guchiya v. the State of Rajasthan and Ors.

(S.B.C.W. No.9975/2018) and Neena Thakkar v. State of

Rajasthan (D.B. C.W. No.5049/2015).

Per contra, learned counsel for the respondents submitted

that the petitioner had been reimbursed qua the treatment taken

in accordance with the governing rules. It was further submitted

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that the petitioner underwent treatment in a private hospital, and

therefore, claim could only be reimbursed to the extent prescribed

under the Rules of 2013.

Heard learned counsel for the parties and perused the

material available on record.

Admittedly, the petitioner underwent medical treatment in a

private hospital and the claim qua the same had been partially

admitted by the respondents.

The Hon'ble Apex Court in the case of State of Rajasthan

Vs. Mahesh Kumar Sharma reported in (2011) 4 SCC 257

while relying upon the judgment passed in Ram Lubhaya

Bagga's case (supra) held as under:

"In the instant case, the Government has formulated necessary rules permitting the reimbursement of medical expenses in certain situations and upto a certain limit. The Government has been reimbursing the necessary expenditure as permitted by the rules uniformly. It will, therefore, not be proper for a Government employee or for his relatives to claim reimbursement of medical expenses otherwise than what was provided in the Rules 9."

Further in the case of State of Karnataka and Ors. Vs. R.

Vivekananda Swamy and Ors. reported in AIR 2008 SC 2080,

Hon'ble the Supreme Court held as under :

"18. In view of the aforementioned settled principles of law there cannot be any doubt that the Rules regarding reimbursement of medical claim of an employee when he obtains treatment from a hospital of his choice can be made limited. Such a rule furthermore having been framed under the proviso to Article 309 of the Constitution of India constitutes conditions of service in terms whereof on the one hand the employee would be granted the facility of medical aid free of cost from the recognized government hospitals and on the

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other he, at his option, may get himself treated from other recognized hospitals/institutions subject of course to the conditions that the reimbursement by the State therefore would be limited."

In view of the enunciation of law by Hon'ble the Supreme

Court, reimbursement of medical bills submitted by an employee

can be restricted to the extent prescribed under the rules in force.

An argument was advanced by the learned counsel for the

petitioner that in case, the medical bills submitted by the

petitioner exceeded the prescribed ceiling limit available to the

Treasury Officer (Rural) then the matter ought to have been

referred for consideration of the District Health Benefit Empowered

Committee.

The Rule 4 and 5 of the Scheme of 2014 are reproduced

below for ready reference:-

"4. Medical Attendance and Treatment:

A pensioner and his family shall be provided free medical attendance and treatment as admissible to State Government servant under Rules 6, 7, 8, 9(1), 10, 11, 14, 17 and 19 of Rajasthan Civil Services (Medical Attendance) Rules, 2013 subject to following limits:

(a) Allopathic drugs, medicines, vaccines, sera, other therapeutic substances not ordinarily available in Government Hospitals free of charge can be taken from medical shop/store recognised for the Scheme in case of outdoor treatment up to the cost ceiling given below:

           Category of Pensioner Amount          of    cost
                                    ceiling

(i) Pensioners below the Rs. 10,000/- per annum age of 75 years

(ii) Pensioners who have Rs. 20,000/- per annum attained the age of 75 years and above

Provided that medicines to the indoor patient shall be made available irrespective of the cost ceiling.

(b) The District Collector is authorised to reimburse the test charges (Pathological, Bacteriological,

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Radiological and other tests) up to Rs. 5000/ per annum in each case. The test charges shall be reimbursable if NAC from the Government hospital has been obtained or charges paid in Government hospital, if any.

Provided that for the tests above Rs.5000/- may also be sanctioned by District Collector concerned as per rates approved by the Finance Department. Note: The pensioner/family pensioner shall be eligible for the free accommodation in Government Hospitals on the basis of last pay drawn by Government Servant at the time of retirement or on the date of death while in service, as the case may be. The class of free accommodation and reimbursement in present scheme shall be as APPENDIX XV of RCS (MA) Rules, 2013. The Government Servant retired on Contributory Provident Fund benefits shall also be entitled for free accommodation in Government Hospitals on the basis of pay last drawn by them Immediately before retirement. This facility shall be subject to, availability of accommodation in Government Hospitals. The provisions regarding entitlement of free accommodation in Government Hospitals from time to time before present scheme has also been compiled and appended as PMF-8.

5. Relaxation in cost celling under Para 4:

(1) District Collector may extend the cost ceiling of medicines under Para 4 up to Rs. 50,000/- per annum in all deserving cases and in respect of treatment of Cancer, Kidney failure and Renal disease up to the limit of Rs. 1,00,000/- per annum subject to proposals being approved by a District Committee consisting of the following:

1 District Collector President 2 A representative of the District Pensioners' Samaj Member 3 Principal Medical Officer / Chief Medical & Health Officer/ Superintendent of the Government Hospital of the District (any one of them) Member 4 Treasury Officer Member Secretary Note: The District Collector may obtain second medical opinion after scrutiny of the case where felt necessary.

(2) Board of Trustees may grant further relaxation in cases of severe and persistent diseases upon recommendation of the District Committee (after obtaining medical option) in deserving cases."

The argument advanced although looks superficially

attractive but from the perusal of the Scheme of 2014, it becomes

clear that the ceiling cost of medicines can be extended by the

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aforesaid committee only in cases where annual cost of allopathic

drugs, medicines, vaccines, sera, other therapeutic substances

exceed the cost limit prescribed under Rule 4 of the Scheme,

2014. The District Health Benefit Empowered Committee does not

posses powers to enhance the limit of the expenditure incurred for

a treatment taken in a private hospital.

The respondents in the reply dated 07.09.2018 to the legal

notice dated 22.06.2018, served upon them by the petitioner

informed the break-up of the amount sanctioned in favour of the

petitioner qua the treatment taken in private hospital. The relevant

portion of the reply is reproduced below:-

"3. बिन्दु सं . 4 से 7 में आपकी पक्षकार श्रीमती मनोरमा दे वी आसोपा के इलाज पर हुये व्यय राशि रू 1,95,723 /- (एक लाख पचानवे हजार सात सौ तेईस मात्र) के विरूद्ध पारित राशि 17,087/- (अक्षरे सत्रह हजार सतासी रूपये ) का भुगतान करने का जवाब राजस्थान सिविल सेवा (चिकित्सा परिचर्या) नियम, 2013 एवं राजस्थान स्टे ट पें शनर्स चिकित्सा रियायत योजना, 2014 के अनुसार विन्दुवार निम्नानुसार है • राजस्थान सिविल सेवा (चिकित्सा परिचर्या) नियम, 2013 के नियमो में बहिरं ग के रोगी के रूप में कराये गये उपचार क पुनर्भरण के संबंध में किसी प्रकार का कोई प्रावधान वर्णित नहीं होने के कारण आप द्वारा प्रस्तुत चिकित्सा व्यय दावा सूची में दिनां क 08.09.2016 एवं 22.09.2016 के बीजकों की राशि का पुनर्भरण दे य नहीं है ।

• बीजक सं . आरक्यू 2016274251 दिनां क 12.09.2016 में Consumable article है जिनका पुनर्भरण नियमानुसार दे व नही है ।

• बीजक सं . 11/16/010977 दिनां क 15.09.2016 के अवलोकन करने पर इसका भुगतान निम्नानुसार किया गया: • Accommodation Charges योजना 2014 के PMF8 चार्ट तथा नियम, 2013 के परिशिष्ट XV अनु सार @600/- के अनुसार भुगतान किया गया।

• ऑपरे शन थियेटर चालेंज का भुगतान नियम, 2013 के परिशिष्ट XIII के अनुसार 40% of actual expenditure subject to maximum of Rs. 3000/- के अनुसार अधिकतम 3000 / - का भुगतान किया गया है ।

• एनिस्थिसिया फीस चार्जेज का भुगतान नियम 2013 के परिशिष्ट XIII के अनुसार 40% of actual expenditure subject to maximum of Rs.

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3000/- के अनुसार अधिकतम 3000 / - का भुगतान किया गया है ।

• डॉक्टर विजिट चार्जेज का भुगतान नियम, 2013 के परिशिष्ट XIII के अनुसार 400/- प्रतिदिन के अनुसार 1200/- का भुगतान किया गया।

• उपचार के दौरान की गई समस्त जाँ चो का भुगतान परिशिष्ट XVI के अनुसार किया गया है ।

• उपचार के दौरान औषधि का भुगतान परिशिष्ट XIII के अनुसार पुनर्भरण योग्य औषधि 6404 का 50 प्रतिशत राशि रु 3202/ किया गया है ।"

From the perusal of the aforesaid portion of the reply, it is clear

that reimbursement in favour of the petitioner qua medicines,

drugs, anesthesia and room charges etc. for the treatment

undertaken by the petitioner had been made to the extent

permissible for treatment taken in a private/unrecognized hospital as

per the Rules of 2013 and Scheme of 2014.

This court has carefully perused the judgments cited by learned

counsel for the petitioner. In the considered opinion of this Court,

since justification for partial reimbursement of the medical bills by

making deductions in conformity with the Rules of 2013 and Scheme

of 2014 has been provided by the respondents, the judgments cited

are of no help to the petitioner.