Anda Ram vs State And Ors
2022 Latest Caselaw 11552 Raj

HIGH COURT OF JUDICATURE FOR RAJASTHAN AT JODHPUR S.B. Civil Writ Petition No. 1464/2016

Anda Ram S/o Shri Bhura Ram, aged about 41 years, R/o Village Bogasani, Post Nimbol Via Balunda, Tehsil-Jaitaran, District Pali (Rajasthan).

----Petitioner Versus

1. The State of Rajasthan, through the Principal Secretary to the Government, Government of Rajasthan, Jaipur.

2. The Director, State Insurance & Provident Funds Department, Beema Bhawan, Bani Park, Jaipur.

3. The Good Health TPA Services, Plot No.49, Nagarjuna Hills, Panjagutta, Hyderabad-500 082.

4. The Manager, Insurance Ombudsman Office, 2/2-A, Universal Insurance Building, Asif Ali Road, New Delhi- 110 002.

----Respondents

For Petitioner(s) : Mr. Ram Niwas Choudhary. For Respondent(s) : Mr. Sandeep Shah, AAG, Sr. Advocate-cum-AAG, assisted by Mr. Lakshya Pagariya.

HON'BLE MR. JUSTICE KULDEEP MATHUR Order

16/09/2022

The present writ petition has been filed by the petitioner

with the prayer for reimbursement of the medical claims qua the

treatment of the petitioner's wife pertaining to severe spinal

problems.

Briefly stated facts of the case are that petitioner's wife

suffered severe problems in the spine and was taken to Goyal

Hospital, Jodhpur in precarious condition in an emergent situation.

After examination of the patient, the petitioner was advised by the

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treating Doctor to take his wife to Ahmedabad as the Hospital did

not possess adequate facilities for treatment. The wife remained

hospitalized from 30.10.2014 to 04.11.2014 and for treatment of

the petitioner's wife, a sum of Rs.1,09,031/- was incurred. The

petitioner applied for reimbursement of the medical bills covered

under the Medi-claim Policy before the respondent-authorities,

who returned the same on the ground that the hospital, where the

petitioner's wife availed treatment does not find place in the list of

empanelled hospitals approved by the State Government.

The petitioner being aggrieved by the denial of medical

claim, approached this Court by way of S.B.C.W. No.11348/2015

(Anda Ram v. State of Rajasthan & Ors.). The Coordinate Bench of

this Court vide order dated 05.10.2015, observed that the

petitioner has remedy to approach the Insurance Ombudsman

Office located nearest to the petitioner. The petition was dismissed

as withdrawn with liberty to approach the appropriate authority.

In pursuance of order dated 05.10.2015, the petitioner

approached the appropriate authority through representation

dated 03.11.2015 for the reimbursement of medical claim but to

no avail. Aggrieved by this, the petitioner has filed the present

writ petition.

Learned counsel for the petitioner submitted that Smt.

Dhariya was suffering from spinal problem. The treatment whereof

was not available in Goyal Hospital, Jodhpur and therefore, in the

critical condition on the advice of the treating Doctors, she was

taken to Stavya Spine Hospital & Research Institute, Ahmedabad

for spinal surgery, which was essential. He further submitted that

denial of reimbursement of the medical bills deserves to be

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declared illegal and arbitrary by this Court. Reliance was placed on

a judgment of this Court in Raghuveer Sharma v. State of

Rajasthan & Ors. reported in (2007 WLC (Raj.) UC 516, in

the aforesaid case, the Court has held as under:-

"prime consideration in case of grave emergency, which comes in the mind of family is to save the life of patient and at that point of time whatever hospital comes to their mind and considered just is felt as the best because emergency knows no law and no procedure and when human life is at stake in such situation ultimately responsibility of State cannot be washed out. Technicalities of Rules and Regulations under the Scheme are not required to be followed just in a mechanical manner so as to frustrate very purpose of the Scheme because a person having put in his whole life in the service of the State till attains age of superannuation always require human considerations."

Per contra, learned counsel for the respondents, submitted

that the case of the petitioner is not covered under clause 6.3 of

the Medi-claim policy, 2014-15. The treatment in a non-

empanelled private hospital can be taken only in case of grave

urgency viz life threatening disease like kidney or heart ailments

and accidents. It was further submitted that according to policy in

vogue, emergency certificate of treating doctor establishing

emergent situation is necessary for making any claim for

reimbursement in a private hospital. The claim of the petitioner

was rejected for non compliance of the terms and conditions of

Medi-claim policy.

A coordinate Bench of this Court in the case of Mool Singh

Vs. the State of Rajasthan & Ors. in S.B. Civil Writ Petition

(4 of 5) [CW-1464/2016]

No.5592/2018 vide order dated 09.09.2022 pleased to held

as under:-

"The medical claim qua the said amount was raised before the respondent Department but the same was rejected on the ground that the petitioner has not shown any emergent situation wherein his wife was required to be treated in the private hospital i.e. SAL Ahmedabad.

In Surjit Singh Vs. State of Punjab and Ors. reported in AIR 1996 SC 1388, decided on 31.01.1996, the Hon'ble Apex Court held as under:-

"10. ........... ............ In such an urgency one cannot sit at home and think in a cool and calm atmosphere for getting medical treatment at a particular hospital or wait for admission in some Government medical institute. In such a situation, decision has to be taken forthwith by the person or his attendants if precious life has to be saved.

We share the views afore-expressed"

In Rama Prasad Sharma Vs. State of Rajasthan & Ors.; S.B.C.W.P. No.7469/2016, decided on 21.01.2022, passed by this Court, it was held as under:-

"............ It is now a settled position of law that even in cases where the treatment of an employee has been taken in non-recognized hospital the medical reimbursement has to be made at the rate that may be applicable for similar treatment in the recognized government hospitals."

In view of the ratio as laid down in the above mentioned judgments, it is a law settled that even if some medical treatment is undertaken in a private or unrecognized hospital, the department is under an obligation to reimburse the amount to the extent permissible under the Rules governing the same. In the present case, the Rules governing the medical reimbursement are Rajasthan Civil Services (Medical

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Attendance) Rules, 2013 (hereinafter referred to as 'the Rules of 2013')."

In the light of aforesaid enunciation of law by this Court and

facts of the case, this Court has no hesitation in coming to the

conclusion that the respondent-department is under an obligation

to reimburse the amount to the petitioner for the treatment

underwent by his wife in a private or unrecognized hospital, to the

extent permissible under the Rules / Policy governing the same.

The hyper technical ground cannot supersede the object of Medi-

claim policies i.e. to provide shield against increasing medical

costs due to hospitalization in severe illness. The claim cannot be

merely rejected on these hyper technical grounds when the

treatment is not disputed by the respondent-department.

The present writ petition is therefore, allowed. The

respondents authorities are directed to reimburse the expenditure

incurred by the petitioner in treatment of his wife at Stavya Spine

Hospital & Research Institute, Ahmedabad for spinal surgery, to

the extent it is permissible for treatment in a private or

unrecognized hospital. The necessary exercise shall be completed

by the respondent department within a period of two months from

the date of this order. It is further ordered that in case the claim

of the petitioner is not settled within aforesaid period, the same

shall carry an interest @ 6% per annum.

(KULDEEP MATHUR),J

7-Prashant/-

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