Mr. Nitin Goel, Adv v. GOVT. OF NCT OF DELHI ANR

Judgment

1. dated 21.07.2022, issued by the respondent no.1 whereby the petitioner’s medical reimbursement claim has been allowed only to the amount of Rs.98,413/- instead of Rs.5,11,779/-, submitted by the petitioner. 2. It is submitted that the petitioner is covered under Delhi Government Employees Health Scheme (DGEHS) of the respondent no.1. The father-in- law of the petitioner (dependent upon the petitioner) underwent medical treatment at the respondent no.2 hospital for a urological condition. 3. The father-in-law of the petitioner initially visited the Narmada hospital, Sikandara, Agra where he got initial treatment. Since the requisite treatment could not be given to him in the said hospital, he came to Delhi and visited Lal Bahadur Shastri Hospital, Delhi. The said hospital recommended the patient to visit the urologist department in a bigger hospital. Consequently, the father-in-law of the petitioner went to AIIMS, W.P.(C) 15154/2022 This is a digitally signed order.

The authenticity of the order can be re-verified from Delhi High Court Order Portal by scanning the QR code shown above. The Order is downloaded from the DHC Server on 28/01/2025 at 14:28:36 New Delhi. However, under emergent circumstances, he was admitted to the respondent no.2 hospital on 14.03.2021, where an invasive procedure / surgery was performed on him. He was discharged from the hospital on

25.03.2021. It was in respect of the treatment / procedure undergone by the father-in-law of the petitioner during the period 14.03.2021 – 25.03.2021 at the respondent no.2 hospital that a medical claim to the tune of Rs.5,11,779/- was submitted. The same ultimately led to the impugned letter being issued whereby only a part of the claim amount was released to the petitioner. 4. Learned counsel for the petitioner draws attention to the list of DGEHS empanelled hospitals. It is emphasized that the respondent no.2 hospital is very much a part of the said list. The relevant entry in the said list is extracted hereunder: 136 3. Indraprastha Apollo Hospital, Mathura Road, Sarita Vihar, New Delhi 76 NABH/NABL Accredited Radiological Investigations & Nuclear Medicines, Laparoscopic Surgery, Dialysis, Urology, Organ Transplant Liver), Lithotripsy, Joint Replacement, Radiation Therapy, Cardiology, Vascular Cardiothoracic surgery. (Renal, &

5. Attention is drawn by learned counsel for the petitioner to the fact that the respondent no.2 hospital is specifically empanelled for ‘urology’. It is pointed out that the hospitalization and consequent claim for reimbursement is on account of a urological condition of the father-in-law of the petitioner, for which he was admitted in emergent circumstances in respondent no.2 hospital. Learned counsel on behalf of the petitioner also draws attention to W.P.(C) 15154/2022 This is a digitally signed order. The authenticity of the order can be re-verified from Delhi High Court Order Portal by scanning the QR code shown above. The Order is downloaded from the DHC Server on 28/01/2025 at 14:28:36 the discharge summary issued by the respondent no.2 hospital which records the history of urological condition of the patient and also clearly mentions the procedure that was performed on him. He specifically draws attention to the invasive procedure/ surgery performed by Dr. Rajesh Taneja, a doctor in the urology department of the respondent no.2 hospital. 6. It transpires that while in the respondent no. 2 hospital, the father-in- law of the petitioner was also examined by doctors from other streams / departments, who had to visit him as a part of standard operating procedure. However, it is apparent that the primary reason for admission in the respondent no.2 hospital was on account of a urological condition. It is undisputed that for urology, the respondent no.2 hospital is duly empanelled. 7. Learned counsel for the respondent seeks to justify the denial of full reimbursement on the basis that the opening page of the discharge summary discloses that a doctor specializing in ‘Respiratory Medicine, Critical Care & Sleep Medicine’ was referred to as the “primary consultant”. The said submission does not commend itself to this Court. 8. The manner of preparing the discharge summary is not in the hands of the concerned patient. Also, the reason which impelled the hospital to mention any the name of any particular doctor as a “primary consultant” is unknown to the petitioner, and is an internal matter of the hospital. The same could be dictated by a variety of factors, including the relative seniority of the consulting doctors who have examined the patient. What is crucial is that it is apparent from the history of the patient, as recorded in the very same discharge summary, that it was on account of the urological condition of the concerned patient that he was constrained to admit himself in the respondent no.2 hospital. The invasive procedure that he underwent was also performed W.P.(C) 15154/2022 This is a digitally signed order. The authenticity of the order can be re-verified from Delhi High Court Order Portal by scanning the QR code shown above. The Order is downloaded from the DHC Server on 28/01/2025 at 14:28:36 by a urologist. In the circumstances, there is no rationale for denying reimbursement to the petitioner of the medical bills submitted by him to the respondent no.1. 9. It is also noticed that the admission of the father-in-law of the petitioner was during the period 14.03.2021 to 25.03.2021. It is the matter of common knowledge that during the said period, the Covid-19 pandemic was raging and this Court finds nothing amiss in a doctor well versed with ‘Respiratory Medicine’ examining and tending to the patient, as part of the treatment protocol. Moreover, any secondary issue that would have a bearing on the urological procedure to be performed on the patient, was necessarily required to be attended / pre-empted. 10. 11. The respondent no.1 is directed to release the remainder sum of In the circumstances, the present petition is allowed. Rs.4,13,366.03/- to the petitioner in terms of the extant policy. 12. In the facts and circumstances of the case, this Court is not inclined to grant any interest or any further damages to the petitioner. 13. It is made clear that this order has been passed in the peculiar facts and circumstances of the case. JANUARY 17, 2025/cl SACHIN DATTA, J W.P.(C) 15154/2022 This is a digitally signed order. The authenticity of the order can be re-verified from Delhi High Court Order Portal by scanning the QR code shown above. The Order is downloaded from the DHC Server on 28/01/2025 at 14:28:36