PER: HON’BLE JUSTICE SANGITA DHINGRA SEHGAL, PRESIDENT

1. The facts of the case as per the District Commission record are:

"The complainant is a retired employee of Central Govt. from the Income Tax department. He was issued CGHS card No. 87601 of which he and his wife were beneficiaries. The complainant was entitled for semi-private ward in the Central Govt.'s recognized private hospitals. The case of the complainant is that on 28.03.2009 his wife was admitted in Max hospital in emergency as at that time dispensary no. 71 to which the card pertains was closed. His wife was discharged on 20.04.2009. The complainant spent an amount of Rs. 8,33,685/- on the treatment of his wife and submitted the bill for reimbursement with OP-2. The complainant enquired from OP-2 several times but did not get any response and after a lapse of more than five months the complainant received a letter from OP-2 wherein his claim was rejected on false and frivolous grounds that emergency is not justified on the day of admission. It is submitted that officials of OP-2 waited for five months in the hope of getting something for reimbursing the claim but since they did not get anything from the complainant hence the claim was rejected.

The complaint No. 266/10 was filed on 06.05.2010 before this Forum. On the same day another complaint No. 265/10 was also filed as the wife of the complainant was again admitted in the same hospital on 25.04.2009. The complainant spent an amount of Rs. 10,57,488.83 on the treatment of his wife. The claim was rejected on the ground that there was no emergency on the day of treatment. It is stated in the complaint that the claim was rejected as the illegal gratification was not paid by the complainant to the officials of OP-2. Terming the action of OP as deficiency in service, the present complaint has been filed whereby the complainant has prayed for reimbursement of Rs. 10,57,488.83 with interest and also sought compensation and litigation expenses.

2. The District Commission after taking into consideration the material available on record passed the order dated 29.08.2018, whereby it held as under:

"It is submitted by Ld. Counsel for the complainant that the complainant took his wife to CGHS dispensary No. 71 which was closed. Since it was a case of emergency, therefore, the complainant took his wife to OP-1 i.e. Max Hospital.

The fact of the matter is that both these matters were referred to the expert committee of the Safdarjung Hospital to find out whether there was any case of emergency and as per the opinion of the hospital, it was not a case of emergency. This Forum cannot sit over the opinion of the Safdarjung Hospital.

Even otherwise we have gone through the discharge summary and as per that on first occasion, the wife of the complainant was admitted on 28.03.2009 and was discharged on 20.04.2009 and discharge summary shows that wife of the complainant was admitted with the complaints of six months history of abdominal bloating and 1 month history of decreased appetite, vomiting, frothy urine, decreased urine output. She was admitted in emergency. The question is that she was suffering form abdominal pain for the last six months with one month history of decreased appetite, vomiting, frothy urine and decreased urine output. The complainant has not placed anything on record to show that his wife has taken treatment anywhere. It is significant to note that Max hospital was not on the panel of the CGHS. It was a private unrecognized hospital and treatment can be taken in private hospital only in case of emergency. No emergency is made out as per opinion of Safdarjung Hospital. It was submitted by Ld. counsel for the complainant that the wife of the complainant was taken to Max Hospital because they were residing at Kishan Garh, Vasant Kunj, New Delhi and Max Hospital was close to their residence. It is not correct. The nearest hospital was Fortis Hospital which is at distance of 1 km from the house of the complainant. As per Google map, the distance of Max Hospital is around 8 kms from Vasant Kunj and likewise the distance of Safdarjung Hospital is about 8 kms from Vasant Kunj. The complainant should have taken his wife to Safdarjung Hospital but he has not taken her there rather he took his wife to a private unrecognized hospital and as per the opinion of Safdarjung Hospital it was not a case of medical emergency.

On second occasion the wife of the complainant was taken to Max Hospital on 25.04.2009 and discharged on 19.04.2009 on the request of the attendant of the patient. Due to personal reason the patient was transferred in AIIMS. It was a case of renal failure. Second time she was taken to the hospital with complaints of sudden jerky movements of the whole body with drowsiness and severe headache. She was discharged on 19.05.2009. Again the matter was referred to the Safdarjung Hospital and as per opinion of the Safdarjung Hospital, it was not a case of emergency.

As per the report of the Safdarjung Hospital, it was not a case of emergency and, therefore, there was no reason for taking the patient to the unrecognized private hospital for treatment. We have already stated that the Safdarjung/AIIMS were at same distance. The complainant could have easily taken his wife to government hospital. Since as per the report of the Safdarjung Hospital, it was not a case of emergency hence OP was justified in rejecting the claim. No case of deficiency in service is made out against CPs. Hence the complaints are dismissed."

3. Aggrieved by the aforesaid judgment of the District Commission dated 29.08.2018, the Appellant has preferred the present Appeal contending that the District Commission has erred in rejecting the genuine claim of medical expenses borne by the Appellant on the ground that no medical emergency occasioned at the time when the Appellant's wife was hospitalized to Max Super Speciality Hospital, Saket on 28.03.2009. Secondly, it is contended by the Appellant that the Central Govt. employees are entitled for reimbursement of the treatment expenses taken from non-penal hospitals and the patient is entitled to get reimbursement from CGHS. To support his contention, the Appellant had relied upon the Hon'ble Supreme Court precedent in writ petition (civil) no. 694 of 2015. Pressing the aforesaid contentions, the Appellant prayed for setting aside the impugned judgment of the District Commission.

4. The Respondent No. 1 has filed the reply to the present Appeal and stated that no allegation has been made against the answering Respondent in the present case and it has been wrongly impleaded as party in the present matter. The Respondent no. 1 also submitted that neither medical negligence nor deficiency of service on the part of Respondent no. 1 has been established in the present case. Pressing the aforesaid submission, the counsel for the Respondent no. 1 has prayed for the dismissal of the present Appeal.

5. The Respondent No. 2 has also filed its reply to the present Appeal and has stated therein that as per CGHS guidelines prevailing at the time, treatment expenses at non-empanelled private hospitals is admissible for reimbursement, only in the event of emergencies. Secondly, it is submitted that the opinion of experts is essential to justify the medical emergency based on the clinical records of the patient and in the present case, the committee of experts at Safdarjung Hospital opined that based on the patient's clinical condition, medical emergency in the present case was not justified for either of the two admissions. Hence, claim of the Appellant is not admissible as per the expert report. Lastly, counsel for the Respondent no. 2 submitted that, however, in the light of recent precedents delivered in similar cases and considering the fact that the patient eventually succumbed to her illness, reimbursement can be considered as per Central Government Health Scheme (CGHS) rates.

6. The Appellant has filed rejoinder to the reply filed by the Respondent no. 1 and has placed the reliance therein upon Shiva Kant Jha Vs Union of India, Writ Petition (Civil) No. 694 of 2015 stating that the claim for reimbursement of the expenses borne in the treatment of Appellant's wife cannot be rejected merely on technical grounds.

7. We have perused the material available on record and heard the parties at length.

8. The main question for consideration before us is whether the District Commission erred in rejecting the claim of the Appellant.

9. To resolve this issue, we deem it appropriate to refer to the in-house procedure to be followed in dealing with the claims under CGHS which is provided for the nature of claims pending in respect of card holders. The detailed procedure which is followed for the purpose of medical reimbursement claims of CGHS beneficiaries have been set out in Circular dated 14.11.2011 and further supplemented by the instructions dated 11.12.2012. The steps included in the aforementioned procedure are referenced below:

"Procedure for Medical Reimbursement Claim (MRC) in Central Government Health Scheme (CGHS)

(a) The patient or beneficiary has to approach the in-charge of the wellness centre where he/she is registered.

(b) That after getting all the documents required for MRC from the beneficiary, CMO in-charge submits the same online to CMO (R&H) of the respective Zonal Office and also send one hard copy through official dak to the respective Zonal Office CMO (R&H) who process the MRC as per CGHS rates.

(c) The CMO (R&H) processes the MRC as per CGHS Rates. If CGHS rates are not available, reimbursement is considered at AIIMS rates. And if AIIMS rates are also not available, the reimbursement is made as per actual rates.

(d) The CMO (R&H) gets the approval of Additional Director (AD) of the respective Zonal Office for the MRC. Then approved amount of MRC is sent as bill to the Pay & Accounts Office (PAO) CGHS Rajinder Nagar.

(e) Pay & Accounts Office credits the approve amount of MRC in the account of beneficiary through Electronic Clearing System (ECS)."

The procedure of appeal/remedy in CGHS regarding MRC is given hereunder:-

"(a) If the beneficiary is not satisfied with the claim, he can request in writing to the Competent Authority in CGHS. The request is then forwarded to the higher authority by the respective Zonal Office for consideration.

(b) If the higher authority considers it necessary to have the opinion of the specialist of concerned speciality, a Special Technical Committee (STC) meeting is held.

(c) On the basis of the recommendation of the Special Technical Committee, the approval of the competent authority is taken and the approved amount is paid to the beneficiary by PAO."

10. From the aforementioned guidelines, it is to be noted that claims for reimbursement are cleared only when the required essentials are met by the beneficiary of the scheme. It is to be noted that opinion of an expert is an essential condition to be met when a beneficiary approach a private non-empanelled hospital for treatment.

11. In the present case, the report of Expert Committee at Safdarjung Hospital opines that the patient had no medical emergency and had certain symptoms since a while even before the patient was admitted to the Respondent No. 1 hospital on the first occasion i.e. 28.03.2009. On the other hand, the Appellant has placed on record the certificate issued by Dr. Alka Bhasin under whose supervision the patient was kept during her first visit according to whom, the Appellant's wife was admitted to the Respondent no. 1 hospital in emergency situation and needed immediate treatment at that time.

12. It seems to us that where there is a conflict between the opinion of two experts, the Court should generally accept the evidence of the expert whose evidence is corroborated by direct evidence of the case, which according to the court is reliable. Therefore, we are of the view that the certificate issued by Dr. Alka Bhasin needs to be relied upon as she was the one under whose direct supervision, the Appellant's wife was admitted and Dr. Alka Bhasin was in a position to witness the patient's suffering and symptoms at the time of admission.

13. Further, the Appellant has submitted that at the first instance he made an endeavour to approach the Dispensary No. -71 which was closed. It was only after that he approached the Respondent No. 1 hospital. The Commission is of the opinion that in the event of exigency and crisis, the usual state of mind of the person accompanying the patient is to rush to any hospital where quality treatment is assured. The case of the Appellant in the present matter seems no different. It is plausible that the Appellant couldn't think of any other recourse in such crucial situation when the life of his wife was at stake, and took her to a hospital where quality treatment was assured. It is to be noted further that the Appellant is a senior citizen and cannot be expected to search for an empanelled hospital at the very moment when his wife's life was at stake and he is himself subject to infirmity on account of old age. The appellant practiced reasonable diligence at his end in making an endeavour to go to the Dispensary no. 71 but the same was closed. We are of the opinion that in such critical situation, neither reasonable prudent person can be expected to waste time in searching for an empanelled hospital nor any ordinary prudence man would do so.

14. Additionally, the Respondent No. 2 has submitted that CGHS is largely a health welfare scheme and it is the duty of the Government to provide healthcare but to the limit the resources permit. We find substance in the submission of the Respondent No. 2. Though Appellant has placed the reliance upon the decision of Hon'ble Supreme Court in Shiva Kant Jha Vs Union of India, Writ Petition (Civil) No. 694 of 2015, it is to be noted that the Hon'ble Apex Court in the said precedent has made an observation that the relief granted was confined to the said case only and cannot be applied in general sense. Therefore, the said dicta cannot be applied generally in every case and the reimbursement of the claim depends upon the facts & circumstances of each and every case.

15. Further, on perusal of record, we find that the Respondent No. 2 has submitted its willingness to reimburse the claim as per the CGHS rates as mentioned in its reply as well as in the order dated 13.02.2023. Moreover, the calculation sheets have also been filed by the Respondent no. 2 in order to reimburse the amount of Rs. 5,89,747/- against the bill of Rs. 8,33,685/- and Rs. 6,49,565/- against the bill of Rs. 10,44,695/- after scrutinizing the medical bills provided by the Appellant. The Respondent no. 2 also submitted that said admitted amount is calculated as per the CGHS rates. Furthermore, we find that the Appellant never disputed the assessed amount through his pleadings.

16. Therefore, in view of the same and as per the facts and circumstances of the present case, we direct the Respondent no. 2 to disburse the said assessed or admitted claim in favour of the Appellant within a period of 30 days from the date of present judgment.

17. Further, in case, if the Respondent no. 2 fails to reimburse the amount mentioned in para 15, on or before 29.04.2023, the entire amount shall be refunded by the Respondent no. 2 along with simple interest @ 9% p.a. calculated from 29.03.2023 (being the date of present judgment) till the actual realisation of the amount.

18. Accordingly, we set aside the judgment dated 29.08.2018 passed by the District Commission (Udyog Sadan C-22 & 23, Institutional Area, New Delhi -110016 and the present Appeal is partly allowed.

19. Application(s) pending, if any, stand disposed of in terms of the aforesaid Judgment.

20. A copy of this judgment be provided to all the parties free of cost as mandated by the Consumer Protection Regulations, 2005. The judgment be uploaded forthwith on the website of the Commission for the perusal of the parties.

21. File be consigned to record room along with a copy of this Judgment.