Mediclaim To A Govt Employee Should Not Be Disallowed Due To Non-Empanelment Of Hospital: Delhi HC
The Delhi High Court has ruled that mediclaim facility of a government employee should not be disallowed if the hospital was not empanelled under CGHS facility.
In brief, as per the facts noticed in O.A. No.4664/2018, the respondent retired as Senior Carpenter on March 30, 2016, and is a pensioner availing the CGHS facility. On November 03, 2017, the respondent fell unconscious and was taken to Mata Chanan Devi Hospital, Janak Puri, Delhi wherein he was examined in the Neurology Department and advised further treatment at Rancan Gamma Knife Centre-VIMHANS Hospital, Nehru Nagar, Delhi specializing in Neurosurgery cases. The wife of the respondent accordingly took him in an emergency to VIMHANS Hospital wherein the respondent underwent surgery on November 04, 2017, and was discharged on November 05, 2017.
Respondent thereafter submitted the medical bills amounting to Rs.2,60,000/- as raised by VIMHANS, for reimbursement on November 14, 2017 along with the emergency certificate at CGHS Dispensary, Rajouri Garden. However, respondent was reimbursed only an amount of Rs.31,556/- against the claim for Rs.2,60,000/-. Aggrieved by the rejection of his claim, vide letter dated October 16, 2018, respondent preferred O.A. No.4664/2018 before the Tribunal.
The claim of the respondent was opposed by the petitioners. It was submitted before the Tribunal that an emergency certificate was not submitted by the respondent from Mata Chanan Devi Hospital, wherein he took the treatment on November 03, 2017. The case of the respondent was also examined by the Standing Technical Committee on October 10, 2018, which did not find justification in the treatment availed by the respondent, as it was not a case of medical emergency and the treatment is stated to be available in several Government hospitals at a lower price.
Considering the records of treatment at VIMHANS, the Tribunal had earlier observed that there is no reason to refute the emergency as indicated in the certificate issued by VIMHANS and the fact that the respondent was operated on November 04, 2017, makes it clear that there was a medical emergency.
Siding with the order of the Tribunal, the Delhi High Court said that it needs to be kept in perspective that the patient has little scope to decide the nature of treatment and merely looks forward to expert guidance/treatment for relieving him from immense pain and suffering.
"The patient in distress was not in a position to go against the specialist's medical advice for surgery in an emergency. Even assuming that in an emergency, gamma knife surgery may not render an immediate relief as contended by learned counsel for the petitioners, but it is an established alternative medical treatment for trigeminal neuralgia as per literature, the High Court said."
"There may be a difference of opinion on the line of treatment to be adopted by the experts but only the treating physician/surgeon appears to be the best placed to adopt the right course of treatment in an emergent situation," it added.
