R D GUPTA Vs. D D A

JUDGEMENT

(1.) Manmohan Sarin, J.Petitioner, Mr. R.D. Gupta, employed as Junior Engineer with respondent/DDA, by this writ petition, seeks a direction to the respondent/DDA to reimburse the balance medical claim of Rs. 58,740/- together with interest @ 36% compounded quarterly on account of delay in reimbursing the aforesaid amount. Petitioner, being a Junior Engineer with DDA is covered under the Delhi Development Authorities Medical Scheme, 1988.

(2.) Petitioner was hospitalised on 11.11.2002, for treatment of Umbilical Hernia at Apollo Hospital. Surgery was done at the Apollo Hospital, which is a duly empanelled hospital with DDA. The Hospital raised its bill No. ICS 2002013591 for Rs. 66,625/- for treatment, medicines, consumables and the surgery charges. This is beside the consultancy charges of Rs. 800/- and charges for investigations, amounting to Rs. 2,630/- i.e. in all Rs. 70,055/-. The application for reimbursement was accompanied by Essentiality Certificate, issued by the attending Doctor at the Apollo Hospital, certifying that the treatment and medicines prescribed were essential for the recovery, prevention of serious deterioration in the condition of the patient. Investigations carried were also certified as necessary. Respondent/DDA reimbursed the amount of Rs. 18,260/-, leaving balance amount of Rs. 58,740/- unpaid.

(3.) Learned Counsel for the petitioner submits that the empanelled Doctor of DDA had duly recommended the bill for payment. Petitioner claims that the AO (Medical) of his own, ignoring the recommendation of the attending Doctors at Apollo Hospital and the panel doctor of the respondent restricted the reimbursement to Rs. 18,060/-. He proceeded on the basis that petitioner was eligible for reimbursement only at the rates applicable at St. Stephens Hospital. Besides the petitioner was held not entitled to reimbursement of costly consumables, namely, "staplers" used in the surgery amounting to Rs. 31,444/-.