Balhar Singh v. Union Of India And Others

  
        
  




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Present:

Ms. Aruna Sachdeva, Advocate for the petitioner Mr. Somesh Gupta, Sr. Panel Counsel for respondent/UOI " 

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 1.

The jurisdiction of this Court has been invoked under Article 226/227 of the Constitution of India for issuance of a writ, order or direction especially in the nature of certiorari for quashing of the impugned order (Annexure P.8) and order dated 09.05.2022 (Annexure P.18) vide which the medical claim of the petitioner was rejected.

 

2.

The petitioner, serving with Battalion No. 237, CRPF at Group Centre Pinjore, was residing at Himshikha Colony, Pinjore on outliving permission in 2020. He is a diabetic patient and, during the Covid.19 pandemic, was granted

seven days' leave w.e.f. 25.03.2020. Due to pandemic restrictions and the increased risk of infection, he was not permitted to rejoin duty immediately. On 12.05.2020, he experienced severe chest pain radiating to both shoulders and back and was diagnosed with acute coronary syndrome at Mukat Hospital Heart Institute, Chandigarh, an empanelled CGHS hospital, where he was found to have triple vessel disease and suffered a heart attack. 3.

He was advised further angiographic intervention after six weeks. Owing to the prevailing Covid situation, he shifted to Jalandhar and again suffered severe chest pain on 11.06.2020, for which he was admitted to SAAOL Heart Centre, Jalandhar. He received day.care treatment there from 11.06.2020 to 29.07.2020, including EECP therapy, resulting in improvement of his cardiac function. The total medical expenses incurred were Rs. 1,48,202. Although the petitioner submitted the reimbursement claim through proper channels and the Commandant recommended reimbursement at CGHS rates, the competent authority rejected the claim on the ground that the treatment was not taken as OPD treatment as prescribed under the Medical Attendance Rules, 1944. 4.

During the same period, the petitioner's wife, Mrs. Vipinjeet Kaur, suffered health complications attributed to Covid.related stress. On 09.10.2020, she experienced palpitations and breathlessness and was admitted as a day.care patient to SAAOL Heart Centre, Amritsar, where she remained under treatment until 22.12.2020, incurring expenses of Rs. 1,21,593. Her reimbursement claim was returned because certificates regarding non.availability of treatment at government hospitals were not attached.

5.

Subsequently, on 22.07.2021, she again developed severe chest pair and was first taken to Civil Hospital, Batala, where cardiology services were

unavailable. On medical advice, she was shifted by ambulance to EMC/ESC Super Speciality Hospital, Amritsar, an empanelled CGHS hospital, where she received treatment with expenses amounting to Rs. 13,974 along with ambulance charges. This claim was also returned on technical grounds relating to referral and ambulance certification.

6.

Aggrieved by the repeated rejection of medical reimbursement claims despite emergency circumstances during the Covid.19 pandemic, the petitioner served a legal notice upon the respondents, which remained unanswered. He challenges the rejection of his and his wife's claims as arbitrary, illegal, and violative of Articles 14, 21, and 47 of the Constitution of India, contending that the treatment was undertaken in emergency situations when government and empanelled hospitals were either unavailable or non.functional due to pandemic restrictions.

         7.

Learned counsel for the petitioner contends that the petitioner, while on duty with the CRPF during the Covid.19 pandemic, suffered a heart attack and was taken to Mukat Hospital, Chandigarh, an empanelled CGHS hospital, where emergency treatment was provided. It is submitted that due to Covid restrictions and non.availability of adequate facilities in Government hospitals, the petitioner was compelled to seek further cardiac treatment at SAAOL Heart Centre, Jalandhar, which resulted in substantial improvement in his cardiac condition. The rejection of the reimbursement claim solely on the ground that the hospital was not empanelled or that the treatment was not OPD, is argued to be arbitrary and contrary to settled law.

& 8.

Learned counsel further submits that the petitioner's wife is also a cardiac patient and required emergency medical care during the Covid period when Government and empanelled hospitals were either converted into Covid centres or were not admitting non.Covid patients. It is contended that the treatment taken by her at SAAOL Heart Centre and subsequently at an empanelled hospital in Amritsar was necessitated by medical emergency and unavoidable circumstances, and therefore denial of reimbursement on technical grounds such as absence of referral or ambulance certificate is unjustified. 9.

It is argued that the respondents failed to consider the extraordinary situation prevailing during the pandemic and rejected the claims on hyper. technical grounds, despite the fact that the petitioner submitted all medical documents through proper channel. Learned counsel submits that the action of the respondents violates Articles 14, 21 and 47 of the Constitution of India, as the right to health is an integral part of the right to life. 10.

Reliance is placed on various judgments of the Supreme Court and the High Court, including '         !"#$ % &'', to contend that reimbursement of medical expenses cannot be denied merely because treatment was taken in a non.empanelled hospital or without prior permission, particularly in emergency situations. It is further contended that the respondents were duty.bound to reimburse the admissible amount at CGHS/AIIMS rates within a reasonable time and that prolonged denial has caused undue financial hardship to the petitioner.

     

11.

Learned counsel for the respondents submits that the petitioner joined the CRPF in the year 1989 and was posted with 237 Battalion, CRPF, Pinjore from 31.05.2018 to 26.08.2022. During his posting, the petitioner submitted medical

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reimbursement claims relating to his own treatment amounting to Rs. 1,48,292 and for the treatment of his wife amounting to Rs.1,21,593, Upon receipt of the claims, due verification was undertaken by the department in accordance with the Medical Attendance Rules, 1944.

12.

It is contended that the petitioner's treatment at SAAOL Heart Centre, Jalandhar was examined by seeking clarification from the hospital, which revealed that while the initial admission on 11.06.2020 was under emergency, the subsequent treatment from 11.06.2020 to 29.07.2020 was provided as day.care treatment. The matter was referred to higher authorities and medical establishments of CRPF for technical and administrative opinion. Composite Hospital, CRPF, Ranchi opined that the petitioner was not under continuous emergency treatment during the said period and that the case was not recommended for medical reimbursement under the applicable rules. 13.

Learned counsel submits that although the petitioner's claim was provisionally calculated at CGHS rates amounting to Rs.1,34,292 and forwarded for administrative approval, the competent authority rejected the claim on the ground that the petitioner had not undergone treatment as per the prescribed OPD process under Rule 6 of the Medical Attendance Rules, 1944. Accordingly, the claim was returned to the petitioner with due intimation. 14.

With regard to the medical claim pertaining to the petitioner's wife, it is submitted that the treatment was undertaken in a private hospital without submission of an emergency certificate, referral slip, or certification regarding non.availability of treatment in a Government hospital. Despite being afforded opportunity, the petitioner failed to produce the requisite documents as mandated under the rules. The case was also referred to the Director of Health and Family

 Welfare for assessment of applicable Government rates; however, no response was received.

15.

Accordingly, learned counsel for the respondents prays for dismissal of the writ petition as being devoid of merit. ( 16.

The primary issue before this Court is whether the rejection of the petitioner's and his wife's medical reimbursement claims by the respondents, on technical grounds under the Medical Attendance Rules, 1944, is justifiable, given that the treatment was necessitated by emergency cardiac conditions during the Covid.19 pandemic, when government and empanelled hospitals were either unavailable or non.functional. The petitioner suffered a heart attack on 12.05.2020 and required immediate intervention at an empanelled CGHS hospital in Chandigarh. Subsequently, due to Covid.related restrictions, he underwent further medically necessary treatment at SAAOL Heart Centre, Jalandhar. Similarly, the petitioner's wife required urgent cardiac care during the same period at private hospitals, and later at an empanelled hospital in Amritsar, due to non.availability of cardiology services in government hospitals. 17.

The contention of the respondents that the claims were inadmissible arises from non.compliance with procedural formalities treatment not classified as OPD, absence of referral or emergency certificates, and lack of non.availability certification from government hospitals. However, it is settled law, as laid down by the Supreme Court in   )   # *$ that medical reimbursement cannot be denied merely because treatment was taken in a non.empanelled hospital or without prior permission, particularly in cases of emergency or life. threatening situations. Relevant paragraph of the same is reproduced as under:

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 18.

In the present case, the medical records establish that both the petitioner and his wife faced urgent cardiac emergencies, making the treatment unavoidable. The repeated rejection of the petitioner's and his wife's medical reimbursement claims during the Covid.19 pandemic amounts to a clear violation of constitutional rights. Under Article 21 of the constitution, access to medical treatment is an integral part of the right to life, and denying reimbursement for emergency treatment obstructs their ability to obtain necessary healthcare during a life.threatening situation. Similarly, Article 14 is violated as the rigid application of procedural technicalities in emergency circumstances, while ignoring the practical difficulties posed by the pandemic, constitutes arbitrary and unequal

) treatment. Further, under Article 47, the State has a duty to ensure access to healthcare, and enforcing strict rules during a public health crisis runs contrary to this obligation. Taken together, the respondents' actions reflect administrative arbitrariness and cause undue hardship to the petitioner and his family. 19.

Moreover, the emergency nature of the treatment, the extraordinary Covid.19 circumstances, and the settled principles in Shiv Kant Jha's case (supra) justify overriding procedural technicalities. Accordingly, the claims are admissible, and the respondents are obliged to reimburse the admissible amount without delay.

 *  20.

In view of the above, the petition is allowed, and the respondents are directed to reimburse the petitioner's and his wife's medical expenses, within four weeks, failing which interest will be deemed to accrue from completion of four weeks waiving any procedural deficiencies caused by the pandemic emergency. The respondents are further directed to adopt a pragmatic approach in processing reimbursement claims arising from emergency medical situations to avoid undue hardship in the future.

21.

Pending application(s), if any, also stands disposed of. " 

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