Reimbursement of medical expenses incurred on treatment.in pvt hospital by railway employee. Kesava Panicker K.P, S/O ... vs 2 The Chief Medical ... on 14 March, 2013 ERNAKULAM BENCH O.A. NO.585/2012 Dated this the 14th day of March, 2013 C O R A M HONBLE MRS. K. NOORJEHAN, ADMINISTRATIVE MEMBER Kesava Panicker K.P, S/o Purushothama Pillai Station Master, Ollur Railway Station, Southern Railway Trivandrum Division, R/o Thusharam, Kazhchaparambil, Kannadi P.O, Palghat. ...... Applicant (By Advocate Mr. Martin G. Thottan) Vs 1 Union of India Represented by the General Manager Southern Railway Headquarters Office, Chennai-3. 2 The Chief Medical Superintendent Southern Railway, Pettah, Trivandrum ...... Respondents (By Advocate Mr. K. M Anthru) The application having been heard on 7.3.2013 the Tribunal delivered the following: O R D E R HONBLE MRS. K. NOORJEHAN, ADMINISTRTIVE MEMBER The applicant, a Station Master of the Trivandrum Division, Southern Railway, is aggrieved by the rejection of reimbursement of his medical expenses incurred on his treatment. 2 Brief facts of the case as stated by the applicant are that on account of indigestion and stomach pain he was under the treatment of one Dr.Paul Kallukkaran of Polyclinic, Trichur. On experiencing severe stomach ache he was admitted in Karthiyayani Nursing Home, Trichur on 1.3.2012 and he was diagnosed as suffering from piles. On the very next day, during the course of treatment in the Nursing Home, his condition worsened and was referred for specialised treatment. He was admitted in Amrita Institute of Medical Science, Ernakulam as an emergency case on 2.3.12. He was found to be suffering from Polycythemia Vera. He underwent treatment there and was discharged on 10.3.12. It is submitted that since the applicant availed the medical treatment on medical emergency in Amrita Institute of Medical Science, Ernakulam, he preferred a medical bill for reimbursement. However his claim was rejected by the 2nd respondent on the ground that the disease and its treatment was not of an emergent nature. The applicant submitted Annx.A4 certificate issued by the Amrita Institute of Medical Sciences and Research Centre to the effect that the applicant was admitted on an emergency basis and the fact should be considered by the 2nd respondent. Therefore, the rejection of his medical reimbursement claim is unjust and illegal. Hence, he filed this O.A to quash A-3, declare that he is entitled to get reimbursement of the medical expenses and to direct the respondents to reimburse the same forthwith. 3 The respondents in their reply submitted that the applicant initially took treatment privately under Dr.Paul Kalukaran. He was admitted on 1.3.2012 at a Private Nursing Home where it was reported that he was suffering from piles. Such complaints are regularly treated at Railway Hospital, Trivandrum Pettah by qualified Railway Doctors. He did not choose to take treatment from Railway Hospital and preferred to take treatment in private hospital. He had initially taken Ayurvedic treatment for 8 months. He got admitted in Karthiyayani Nursing Home at Trichur on 1.3.2012 and on the next day he was referred for specialised treatment in Amrita Institute of Medical Sciences & Research Centre, Kochi. It is submitted that at no stage of his treatment he gave any intimation to the authorised Medical Officer. They brought to the notice of the Tribunal paras 647 and 648 of Indian Railway Medical Manual which make it mandatory to a Railway employee first to consult their authorised medical officer and proceed in accordance with his advice for obtaining medical treatment outside Railway Hospital. They alleged that the applicant preferred to avail the treatment in a private hospital on his own without the advice of the AMA. They further stated that as per the extant rules Polycythemia is not an emergency case. Therefore, he is not entitled to any reimbursement. 4 The applicant filed rejoinder reiterating the facts as stated in the OA and further submitted that the admission and also shifting of the applicant to Amritha Institute of Medical Sciences was intimated to the Railway doctor vide letter dated 2.3.2012 by the Station Master Ollur Railway Station. He also produced a copy of the order of the Tribunal in OA 71/2010 and claimed that his O.A is covered by the decision of the Tribunal in the OA supra. In that OA the applicants mother, a heart patient who had undergone treatment in private hospital, on emergency was denied reimbursement of expenditure. The respondents were directed to reconsider the case taking the treatment availed as on emergency. 5 Heard learned counsel for the parties and perused the records produced before me. 6 The case of the applicant is that he was admitted in Karthiyayani Nursing Home, Trichur on experiencing stomach pain. On diagnosis he was informed that he was suffering from Piles. During the course of treatment his condition deteriorated and he was immediately referred for specialised treatment in Amrita Institute of Medical Science, Ernakulam. He was admitted there as an emergency case on 2.3.12 where the disease diagnosed as Polycythemia Vera. He underwent the treatment there and was discharged on 10.3.12. In such circumstances, the patient was not in a stable condition to be taken to the Railway hospital at Trivandrum. The contention of the respondents that at any stage of undergoing treatment he did not give any intimation to the authorised Medical Officer was controverted by the applicant by producing Annx.A5 letter written by the Station Master, Ollur, addressed to the Sr.DMO, Trichur. Therefore, it cannot be said that the respondents were not informed about the admission and treatment of the applicant at Amrita Institute of Medical Sciences & Research Centre, Kochi. 7 The emergency clause specified in Para 648 of IRMM 2000 reads as follows:- "Emergency shall mean any condition or symptom resulting from any cause arising suddenly and if not treated at the early convenience be detrimental to the health of the patient or will jeopardize the life of the patient. Some examples are Road accidents, other types of accidents, acute heart attack, etc. under the such conductions when the Railway beneficiary feels that there is no scope of reporting to his/her authorised Railway Medical Officer and avails treatment in the nearest suitable private hospital, the reimbursement claims are to be processed for sanction after the condition of the emergency is confirmed by the authorised railway Medical Officer ex post facto" It is averred that the applicant felt sudden pain in his stomach on 1.3.2012 and he was admitted in Karthiyayani Nursing Home, Trichur where he was diagnosed as suffering from piles. On the very next day i.e 2.3.12 his condition became so bad that he was advised for specialised treatment and he was taken to Amrita Institute of Medical Sciences & Research Centre, Kochi as an emergency case. The Doctor who attended the applicant in Amritha Hospital, issued a certificate that the patient was admitted on emergency basis. Therefore, it cannot be argued by the respondents that his was not an emergency case and does not qualify for reimbursement as per extant rules. 8 In view of the foregoing, I direct the first respondent to consider the claim submitted by the applicant under his discretionary power and reimburse the eligible amount restricted to CGHS (Central Govt.Health Scheme) Rules, treating it as an emergency case. 9 The O.A is disposed of with the above direction. No costs. Dated 14th March, 2013 (K. NOORJEHAN) ADMINISTRATIVE MEMBER
Posted on: Sat, 15 Mar 2014 07:39:02 +0000
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