BEFORE STATE CONSUMER DISPUTES REDRESSAL COMMISSION, CIRCUIT BENCH, RAJASTHAN, JAIPUR


APPEAL No. 507/2006


1.

Central Health Scheme, through Addl. Director, Radhakrishan Hotel Building, Near Railway Station, Jaipur.

2.

Medical & Health Services, through Director General, CGHS, Nirman Bhawan, New Delhi.

..Appellants-OPs


VS


Shri Sudhindra Gemawat S/o Shri Phutar Mal, R/o 3-Na-3, Jawahar Nagar, Jaipur.

..Respondent-Complainant


Before:

Mr. G.S. Hora, Presiding Member

Mr. Sikandar Punjabi, Member


Present:

Mr. Kunal Rawat, counsel for the Appellants

Mr. Ashok Mehta, counsel for the Respondent


ORDER Dated:24.03.2009


PER Mr. G.S. HORA, PRESIDING MEMBER


This appeal arises out of the order dated 16.2.2006 passed by the learned District Forum, Jaipur-II, Jaipur whereby allowing the complaint partly directed the Appellants to pay to the Complainant a sum of Rs. 2,81,792/- within a period of two months failing which the Complainant will also get interest @ 9% per annum on the above amount from the date of order besides Rs. 10,000/- as compensation towards mental agony and Rs. 2,000/- as cost of litigation.


The Complainant who is a retired IAS Officer is covered under Central Government Health Scheme (CGHS). He met with an accident on 5.5.2001 due to which he sustained grevious injuries including fracture of hip joint. His hip replacement was not possible in Jaipur, therefore he was recommended to go to All-India Institute of Medical Sciences (AIIMS), New Delhi.


On his request, the Complainant was allowed to get treatment at Bombay Hospital, Bombay but it was made clear in the order dated 11.5.2001 that the financial entitlement will be that of AIIMS, New Delhi. In Bombay Hospital, the Complainant was operated by Dr.

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Nilan Shah for right femur, right tibiafibula, left hip replacement and left humerus. Two bills one of SMS Hospital for Rs. 2,610/- and the other of Bombay Hospital for Rs. 4,05,145/- were submitted to the competent authority for reimbursement but the amount as claimed was not paid to the Complainant. The Complainant was paid only a sum of Rs. 1,31,925/-. The Complainant's contention is that he was entitled to get reimbursement of the amount spent by him on treatment in Bombay, therefore, he claimed Rs. 2,81,792.45 besides Rs. 41,862/- spent on air travel.


The reply was filed by the Appellants wherein reliance was placed on Memorandum dated 11.3.1993 issued by the Ministry of Health & Family Welfare, GOI and on the basis of this Memorandum, it was made clear to the Complainant that no reimbursement under CGHS in excess of the ceiling prescribed for test/treatment is permissible. It was also stated that where the expenditure on treatment exceed the limit fixed by the Ministry, the contributions may be made by the beneficiary from his own resources. It was also stated in the reply that at the time of recommending the case of the Complainant to Bombay Hospital, it was made clear in the order that the financial entitlement will be that of AIIMS, New Delhi. The learned District Forum after hearing both the parties, allowed the claim as indicated above. Feeling aggrieved, this appeal has been filed.


The learned counsel for the Appellant has placed on record the Office Memorandum dated 11.7.1997 issued by the Ministry of Health & Family Welfare, GOI whereby some of the private hospitals were recognised for treatment of CGHS beneficiaries and Bombay Hospital was one of them. In para 2, it was made clear that CGHS beneficiaries taking treatment in the recognised hospitals will be entitled for reimbursement as per the package rates given in the Annexure 1 & 2. It was also made clear in para 16 that the expenditure to be reimbursed by the parent department/office CGHS Directorate as the case may be would be restricted to the package deal rates/rates approved by the Government from time to time. The expenditure in excess of the approved rates/package deal would have to be borned by the beneficiary himself. The learned counsel for the Appellant also relied upon the judgement of the Supreme Court passed in the case of State of Punjab vs Ram Lubhaya Bagga 1998 (4) SCC 117. In para 29, it was observed as under:


“No State of any country can have unlimited resources to spend on any of its projects. That is why it only approves its projects to the extent it is feasible. The same holds good for providing medical facilities to its citizens including its employees.

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Provision of facilities cannot be unlimited. It has to be to the extent finances permit. If no scale or rate is fixed then in case private clinics or hospitals increase their rate to exorbitant scales, the State would be bound to reimburse the same. Hence we come to the conclusion that principle of fixation of rate and scale under this new policy is justified and cannot be held to be violative of Article 21 or Article 47 of the Constitution of India.”


The learned counsel for the Respondent relied upon 2007 (IV) CPJ 122 Rajasthan State Pension & Pensioners Welfare Department & Anr vs Sachinand Pandey, Himmat Singh vs State of Rajasthan & Ors, Western Law Cases 2005 (2) 268, State of Punjab & Ors vs Mohinder Singh Chawla etc JT 1997 (1) SC 416 and submitted that the Government is bound to provide medical facilities to all its employees and therefore the Complainant was also entitled to get full reimbursement of the amount spent by him on his treatment. The learned counsel also objected to the production of Memorandum dated 11.7.1997 contending that such a Memorandum was never filed before the learned District Forum. It was further submitted that the ceiling was for a period of two years and therefore after July, 1999 as there was no ceiling fixed by the Government, the full reimbursement should have been allowed. It was also pointed out that even as per Annexture 1 & 2, the payment has not been made to the Complainant.


We have considered the arguments advanced by both the sides.


We are of the view that if the Government as per their resources fixed ceiling for the treatment in non-goverment hospitals recognised by the Government then the entitlement shall be to that extent only. It has been made clear by the Supreme Court that provision of medical facilities cannot be unlimited. It has to be to the extent finances permit. We feel that in view of the Memorandum dated 11.7.1997, the matter should be re-examined by the learned District Forum so that justice is done to both the parties. It is also possible that the rates must have been revised keeping in view the escalation in prices. The present matter pertains to the year 2001 and between 11.7.1997 and 2001, all the rates must have been revised by the Ministry of Health of which the learned counsel for the Appellant may not be aware.


Consequently, while setting aside the impugned order of the learned District Forum, we remand the case back to the learned District Forum to decide afresh the complaint keeping in view the Memorandum dated 11.7.1997 and any other Memorandum or orders

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issued subsequently. The case has become very old, therefore, the learned District Forum is directed to dispose of the matter within a period of two months of the receipt of this order.


Both the parties are directed to appear before the learned District Forum, Jaipur-II, Jaipur on 30.04.2009.



Member Presiding Member