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Central Administrative Tribunal - Allahabad
Kanhaiya Lal, Aged About 55 Years ... vs Union Of India, Through The ... on 9 January, 2013

CENTRAL ADMINISTRATIVE TRIBUNAL

ALLAHABAD BENCH

ALLAHABAD

*********

Original Application No. 1089 of 2009

Allahabad this the __09th day of January, 2013

Honble Mr. Shashi Prakash, Member-A

Kanhaiya Lal, aged about 55 years S/o Shri Nand Lal Agarwal, R/o House No. 82/72, Mahabiran Lane, Mutthiganj, District - Allahabad.

Applicant

By Advocate: Shri Rakesh Verma

Vs.

1. Union of India, through the Secretary, Ministry of Labour, Shram Shakti Bhawan, Rafi Marg, New Delhi.

2. The Director, Directorate General of Health Services (CGHS Desk-I) Nirman Bhawan, New Delhi.

3. The Additional Director, C.G.H.S., Sangam Place, Civil Lines, Allahabad.

4. The Deputy Welfare Commissioner, Office of the Welfare & Cess Commissioner, Labour Welfare Organisation, 555-A/2, New Mumfordganj, District  Allahabad.

5. The Administrative-cum-Accounts Officer, Labour Welfare Organisation, Office of the Welfare & Cess Commissioner, 555-A/2, New Mumfordganj, District  Allahabad

Respondents

By Advocate: Shri S.M. Mishra

O R D E R

Instant O.A. has been instituted to seek the relief in terms of directing the respondents to reimburse the applicant the cost of heart valve amounting to ` 30,940/- which the applicant has incurred from personal account.

2. As per the O.A., the facts of case are that the wife of applicant was referred by the competent authority to Escorts Heart Institute and Research Centre Limited, New Delhi under Rules 3, 5 and 6 of the Central Services (Medical Attendance) Rules, 1944. A referred person by the department is authorized for medical attendant, consultation with the Medical Specialist and medical treatment. It is averred that the Rules also provide that the amount paid by the Government servant on account of such consultation/ treatment shall be reimbursed to him by the department. The wife of applicant was admitted in Escorts Heart Institute and Research Centre Limited, New Delhi (for short Escorts Hospital) on 11.10.2004 and underwent a surgery of the heart wherein one heart valve was replaced by a new one. She was released on 03.11.2004. The total expenses incurred on account of the aforesaid treatment was ` 2,17,280/-. The entire amount, which was paid by the applicant, was reimbursed except the amount relating to the cost of heart valve worth `30,940/- on the ground that cost of mitral valve is a part of the package of Mitral Valve Replacement as approved by the C.G.H.S., therefore, not separately reimbursed. The applicant made several representations to the respondents for reimbursement of the cost of heart valve. While the applicant did not receive any response in this regard, the respondent No. 5 by a letter dated 15.05.2006 made a reference to respondent No. 2 along with the representation of the applicant. The respondent No. 2 by letter dated 15.05.2006 clarified that the cost of mitral heart valve is not included in the package charges and the cost of heart valve is to be reimbursed to the beneficiaries on actual cost basis (annexure A-5). It is alleged by the applicant that despite receiving the clarification, the respondent No. 5 did not release the reimbursement. Instead the respondent No. 5 again referred the matter back without any reference to the clarification which had been sent to him from respondent No. 2 vide letter dated 15.05.2006 in response to clarification sought by him (annexure A-4). Till date, the applicant has still not been reimbursed the cost of heart valve. Aggrieved by the action of respondent No. 5, the applicant has filed the present O.A.

3. Shri Rakesh Verma, learned counsel for the applicant argued that despite the specific and unambiguous clarification provided by the respondent No. 2, who is the competent authority in the matter, that the cost of heart valve is not included in the package charge and that it is separately reimbursable, the respondent No. 5 is unnecessarily dragging the matter in colourable exercise of power. Hence, his action is illegal and cannot be sustained. He stated that in terms of the clarification, the applicant is entitled to the reimbursement of the cost of heart valve which should be released to the applicant forthwith.

4. Shri S.M. Mishra, learned counsel for the respondents drew attention of this Court to annexure CA-1, which is a copy of the extract of package rate fixed by the Central Government Health Scheme for Mitral Valve Replacement (for short MVR). He submitted that according to C.G.H.S., the cost of MVR has been fixed at `1,20,000/-. He contended that the entire amount except the cost of MV was reimbursed to the applicant because the package charge as decided by the C.G.H.S. is inclusive of the cost of MV, which was confirmed by the Additional Director, C.G.H.S., Allahabad. Subsequently, after receiving the representation of applicant, the case was referred to the Directorate General Health Services, New Delhi. Subsequent reminders were also sent in this regard for providing a clarification on the matter but no official reply was received instead the applicant produced a copy of the letter of respondent No. 2 i.e. Directorate General Health Services, New Delhi by hand to respondent No. 5 which was not taken cognizance. He argued that till such time, official clarification is not received from the respondent No. 2, it is not possible on the part of respondents to release the reimbursement of the cost of Heart Valve to applicant.

5. Heard the submissions made by learned counsel for the parties and perused the pleadings.

6. The issue to be decided in the present O.A. is whether the cost of Mitral Valve (for short MV) consists an integral part of the package or not? The respondents have relied upon the charges approved by the C.G.H.S. for various packages (annexure CA-1). According to this list, the MV package cost approved by the C.G.H.S. is ` 1,20,000/-. It may be relevant to note that under column No. 3 of the list, the term used is treatment procedure which indicates that the approved cost mentioned therein against different investigation pertains to procedures and does not appear to include the cost of any part which is required to be replaced/changed. Hence, it may not be unreasonable to infer that if any of the procedure mentioned therein involved replacement of a part in the body, the cost of that part is required to be reimbursed. In the procedures involving heart surgery (excepting by pass procedure) there is a requirement of either placement of stent in the artery or change of valve in the case of valve replacement. The C.G.H.S. rate approved as per the list is apparently for the procedure of surgery. As the heading of the column 2 of the list indicates Treatment Procedure and the additional cost incurred due to injection/placement has to be separately considered for reimbursement. Therefore, in the instant case even taking into account the list as annexed at annexure CA-1 is considered, the cost of the part implanted/replaced has to be separately reimbursed.

7. Further, it is observed that an amount of `1,86,340/- has been reimbursed to the applicant on account of MVR of his wife. It escapes comprehension as to how if the package charges is only to the extent of `1,20,000/- an amount over and above that was reimbursed to the applicant. This very fact negates the entire stand of the respondents. In addition, it is also not understood what are the reasons on the basis of which the respondent No. 5 has not taken cognizance of the letter dated 15.05.2006 issued by respondent No. 2, in reply to the reference made by him regarding whether the cost of MV is included or not in the package charges. The fact that the letter was not received in his office and that it was handed over to him by the applicant cannot be a ground for not recognizing the letter. If they had any doubt with regard to veracity of the letter, they should have referred it back to the Office of respondent No. 2 seeking a clarification whether the letter was issued by that office or not. Subsequent independent reference appears to be only a technique for procrastinating and delaying the entire process and seems to be motivated with intention to deny the applicant of his entitlement for reimbursement of cost of MV.

8. Having regard to the above, it is felt that in view of the clarification provided by the Directorate General Health Services (CGHS Desk  I), New Delhi that the package does not include the cost of MV and that the reimbursement of this part may be made to the applicant, as per actuals, makes it plain that the applicant is entitled for reimbursement of the cost of MVR. Accordingly, the respondent No. 5 is directed to release the imbursement of `30,940/- incurred by the applicant in connection with the MVR of his wife. The amount due to the applicant will be released to the applicant within a period of one month from the date of receipt of a certified copy of this Order.

9. With the above directions, the O.A. is allowed. No order as to costs.

{Shashi Prakash}

Member-A

/M.M/

6