Mr.Anshuman v. AYODHYA PRASAD

Judgment

1. This petition has been filed, challenging the Order dated

13.02.2025 passed by the learned Central Administrative Tribunal, Principal Bench, New Delhi (hereinafter referred to as, ‘Tribunal’) in O.A. No. 2154/2023, titled Ayodhya Prasad v. Union of India & Anr., filed by the respondent herein, whereby the learned Tribunal allowed the O.A. with the following directions:

“4.4 For the reasons explained hereinabove, the OA is allowed. Respondents are directed to the balance amount of Rs. reimburse 3,53,718/- to the applicant within a period of six weeks from the date of receipt of a certified copy of this order. No order as to costs.” Signature Not Verified W.P.(C) 13418/2025 Signed By:RENUKA NEGI Signing Date:27.09.2025 14:42:30 FACTS OF THE CASE 2. In a nutshell, the background of the case is that the respondent initially joined the Banaras Locomotive Works, Varanasi on

12.07.1966. Thereafter, he worked on different posts and eventually superannuated on 31.01.2004 from the Railway Service as Office Superintendent-II. 3. The respondent had opted for the Retired Employees Liberalized Health Scheme (RELHS) and was allotted RELHS Card No. 2469. 4. Between 28.04.2021 and 19.05.2021, while the respondent was in Ahmedabad, he was admitted in Apollo Hospital, Gandhinagar, Gujarat, for the treatment of COVID-19. For his treatment, the respondent had paid a total bill of Rs.7,46,657/-. 5. The respondent claimed from the Banaras Locomotive Works, medical reimbursement for his treatment expenses. However, he was only reimbursed an amount of Rs.3,92,939/-. 6. Aggrieved of the non-reimbursement of the remaining amount, the respondent submitted a Review Application dated 28.04.2022 to the petitioner no.2. The same was rejected by a Letter dated

18.05.2022, stating the following: Municipal Corporation “Ahmedabad issued a rate chart administration has according to which you have been reimbursed for the isolation, ICU and ward charges as per ceiling rates per day as mentioned which have been reimbursed to you in addition to some medicines, diagnostics and dialysis as prescribed by such rate chart. The said to you reimbursement has been made Signature Not Verified W.P.(C) 13418/2025 Signed By:RENUKA NEGI Signing Date:27.09.2025 14:42:30 accordingly. Therefore, currently no reimbursement claim is pending. ”

7. The respondent preferred an appeal and representations against the decision of non-reimbursement of the remaining amount. The same were rejected, with the final rejection being on 05.12.2022. 8. 9. Aggrieved thereby, the respondent filed the above O.A. The learned Tribunal, relying on the decision of the Supreme Court in Shiv Kant Jha v. Union of India, 2018 SCC OnLine SC 370, and of this Court in Union of India & Anr. v. Shri Joginder Singh, 2023:DHC:3138-DB allowed the O.A. with the above-quoted directions. SUBMISSIONS OF THE LEARNED COUNSEL FOR THE PETITIONERS

10. The learned counsel for the petitioners submitted that as per the provisions of the Railway Board and the policy on the subject, the bill of the respondent was settled on the basis of the rates prescribed by the Ahmadabad Municipal Corporation. He submits that the claim of the respondent had been processed in light of the applicable regulations and rates defined by the local body, and the bill of the respondent was reimbursed to the extent approved by the Railway Board vide Letter dated 18.02.2022. 11. He contended that as per the Railway Board’s letter No. 2011/H/6-4/Policy-I dated 24.09.2013, in cases of emergency treatment, the General Manager is authorised sanction reimbursement up to Rs.5 Lakhs for treatment taken in private non- recognised hospitals, and without any financial ceiling limit for Signature Not Verified W.P.(C) 13418/2025 Signed By:RENUKA NEGI Signing Date:27.09.2025 14:42:30 Government Hospitals including Autonomous body hospitals. He submitted that a reimbursement claim is examined as per the existing rules and regulations by the Office of Principal Chief Medical Officer, and once the concerned office processes the reimbursement claim, the case is put up before the competent authority for sanctioning of the reimbursement amount. He submits that pertinently, the claimed amount is not the criterion for putting up the case before the higher authorities. 12. He further submitted that the reimbursement claim of the respondent was considered sympathetically in accordance with the existing rules and regulations. He submitted that as per the provisions contained in Railway Board’s Letter No. 2005/H/6-4/Policy-II dated

31.01.2007 and Letter No. 2021/H/28/Brief(Madhu) dated 18.05.2021 and in accordance with rates fixed by the Administration of the Ahmedabad Municipal Corporation, Gandhinagar, Gujarat vide Letter No. Dis/ERC/COVID-19/W.S.No2122/2020 dated 21.05.2020, the respondent’s request for reimbursement was processed as per the rates fixed by the concerned State Government, and all the amounts as per the ceiling rates had been reimbursed to the respondent. SUBMISSIONS OF THE LEARNED COUNSEL FOR THE RESPONDENT

13. On the other hand, the learned counsel for the respondent submitted that the respondent was suffering from COVID-19 and it was in an emergency, that he was admitted to the Apollo Hospital, Gandhinagar, Gujarat. He submitted that the factum of the medical condition of the respondent being emergent, his admission to the Signature Not Verified W.P.(C) 13418/2025 Signed By:RENUKA NEGI Signing Date:27.09.2025 14:42:30 hospital, and the treatment undertaken are not in dispute. He submitted that, therefore, he is entitled to reimbursement of the full amount paid by him to the hospital. 14. He further placed reliance on the decision of the Hon’ble Apex Court in Shiv Kant Jha v. Union of India(supra), wherein, in similar circumstances, the Apex Court not only granted relief but also directed the Ministry of Health and Family Welfare to issue guidelines on the subject. ANALYSIS AND FINDING

15. We have considered the submissions made by the learned counsels for the parties. 16. It is not in dispute that the respondent, a retired railway employee enrolled under RELHS, was admitted in Apollo Hospital, Gandhinagar, Gujarat, for the treatment of COVID-19 in an emergency situation. The total treatment cost was Rs.7,46,657/-, out of which only Rs.3,92,939/- has been reimbursed. The balance amount of Rs.3,53,718/- remains unreimbursed. 17. The primary issue for determination is whether the respondent is entitled to reimbursement of the full medical expenses incurred during emergency COVID-19 treatment. 18. It has been contended by the learned counsel for the petitioners that the reimbursement was correctly processed as per the Railway Board circulars and the rates prescribed by Ahmedabad Municipal Corporation. Furthermore, it has been contended that the General Manager’s powers are confined to sanctioning reimbursement as per Signature Not Verified W.P.(C) 13418/2025 Signed By:RENUKA NEGI Signing Date:27.09.2025 14:42:30 the Railway Board’s circulars. 19. We, however, are unable to agree with these contentions. The plea that reimbursement has already been made strictly as per the rates notified by the Ahmedabad Municipal Corporation cannot be sustained in the present factual matrix. Once it is undisputed that the respondent had to undergo treatment during a medical emergency, the rigidity of rate fixation or the confined sanctioning powers of the General Manager cannot stand in the way of full reimbursement. The responsibility of regulating or recovering from the concerned hospital any overcharged amount, lies with the government. The respondent in state of emergency is neither expected to nor can fight with the hospital authorities to charge amounts in accordance with the rates as may have been notified by the Municipal Authorities. If the hospital was bound by these rates and still overcharged the respondent in excess of these rates, the Municipal Authority or any other concerned authority must proceed against the hospital, however, the respondent cannot be penalised for the same. 20. Furthermore, the contention of the petitioners that the claim was ‘sympathetically considered’ equally misplaced. Medical reimbursement is not a matter of concession or charity but an enforceable right flowing from the employer’s duty in a welfare state. 21. The Supreme Court in Shiv Kant Jha v. Union of India (supra), has held as under: "17.It is a settled legal position that the government employee during his life time or after his retirement is entitled to get the benefit of the medical facilities and no fetters can be placed on his rights. It is acceptable to Signature Not Verified W.P.(C) 13418/2025 Signed By:RENUKA NEGI Signing Date:27.09.2025 14:42:30 common sense, that ultimate decision as to how a patient should be treated vests only with the doctor, who is well versed and expert both on academic qualification and experience gained. Very little scope is left to the patient or his relative to decide as to the manner in which the ailment should be treated. Speciality hospitals are established for treatment of specified ailments and services of doctors specialized in a discipline are availed by patients only to ensure proper, required and safe treatment. Can it be said that taking treatment in speciality hospital by itself would deprive a person to claim reimbursement solely on the ground that the said Hospital is not included in the government order. The right to medical claim cannot be denied merely because the name of the hospital is not included in the government order. The real test must be the factum of treatment. Before any medical claim is honoured, the authorities are bound to ensure as to whether the claimant had actually taken treatment and the factum of is supported by records duly treatment certified by doctors/hospitals concerned. Once, it is established, the claim cannot be denied on technical grounds. Clearly, in the present case, by taking a very inhuman approach, the officials of the CGHS have denied the grant of medical reimbursement in full to the petitioner forcing him to approach this Court. 18. This is hardly a satisfactory state of affairs. The relevant authorities are required to be more responsive and cannot in a mechanical manner deprive an employee of his legitimate The Central Government Health Scheme (CGHS) was propounded with a purpose of providing health the Central scheme Government employees so that they are not left without medical care after retirement. It was in furtherance of the object of a welfare State, which must provide for such medical care that the scheme was brought in force. In the facts reimbursement. facility Signature Not Verified W.P.(C) 13418/2025 Signed By:RENUKA NEGI Signing Date:27.09.2025 14:42:30 the person of the present case, it cannot be denied that the writ petitioner was admitted in the abovesaid hospitals in emergency conditions. Moreover, the law does not require that prior permission has to be taken in such situation where the the prime survival of consideration. The doctors did his operation and had implanted CRT-D device and have done so as one essential and timely. Though it is the claim of the respondent State that the rates were exorbitant whereas the rates charged for such facility shall be only at CGHS rates and that too after following a proper procedure given in the circulars issued on time to time by the Ministry concerned, it also cannot be denied that the petitioner was taken to hospital under emergency conditions for survival of his life which requirement was empanelled hospitals.” sanctions and treatment

22. This Court in Shri Joginder Singh (supra),has further held as under: “12. The medical claim treatment undertaken in emergency should not be denied for reimbursement merely because the hospital is not empanelled. The test remains whether the claimant had actually undertaken the treatment in emergent condition as advised and if supported by record. Preservation of human life is of paramount importance. The State is under an obligation to ensure timely medical treatment to a person in need of such treatment and a negation of the same would be a violation of Article 21 of the Constitution of India. Administrative action should be just on reasonableness. test of Accordingly, keeping into consideration the constitutional executive instructions need to be applied than rejecting the claim on technical ground of undertaking treatment in a non-empanelled hospital, since to ensure the CGHS/State fair play and is responsible values, Signature Not Verified W.P.(C) 13418/2025 Signed By:RENUKA NEGI Signing Date:27.09.2025 14:42:30 further cannot escape treatment undertaken proper medical treatment in an emergent condition and liability, genuine. Any denial of claim by the authorities in such cases only adds to the misery of the Government servant by further forcing him to resort to Court of law.”

23. More recently, in New Delhi Municipal Council v. Shakuntala Gupta, 2025:DHC:6775-DB, in similar facts and circumstances, where the respondent therein was being denied full reimbursement of her claim incurred during the treatment of COVID-19 in a hospital located in Greater Noida West on the ground that the Government of NCT of Delhi, had fixed the rates for COVID-related treatment to be charged by private hospitals in the NCT of Delhi, based on the national guidelines and reimbursement in excess of the said amount could not have been granted, held as under: “4. We are not impressed with the above submission. The claim of the respondent cannot be denied only because some hospital allegedly has charged more than what was fixed by the Government of NCT of Delhi. Whether the hospital has overcharged the respondent, is an issue to be taken up by the petitioner/relevant authority with that hospital. As far as the respondent is concerned, once it is not disputed that the respondent had to be admitted to the said hospital in a state of emergency, and had incurred expenses of the above amount, the same have to be reimbursed to the respondent.”

24. From the above, it is apparent that the respondent herein is entitled to claim the full reimbursement of the medical expenses incurred by him during emergency COVID-19 treatment at Apollo Hospital, Gandhinagar, Gujarat. Signature Not Verified W.P.(C) 13418/2025 Signed By:RENUKA NEGI Signing Date:27.09.2025 14:42:30

25. In view of the above facts and circumstances, we find no infirmity with the Impugned Order of the learned Tribunal. The petition is accordingly, dismissed. 26. The petitioners shall release the balance payment of the medical expenses to the respondent, along with interest at the rate of 8% per annum, within a period of eight weeks from today. 27. The petition, along with the pending application, is disposed of in the above terms. MADHU JAIN, J NAVIN CHAWLA, J. SEPTEMBER 26, 2025/k Signature Not Verified W.P.(C) 13418/2025 Signed By:RENUKA NEGI Signing Date:27.09.2025 14:42:30