UNION OF INDIA Vs. AVULA SOMAIAH

JUDGEMENT

(1.) The present writ petition is filed challenging the order passed by the Central Administrative Tribunal, Hyderabad Bench, Hyderabad (hereinafter referred to as 'Tribunal') in O.A.No.021/ 00226/2023, dtd. 11/6/2025, wherein the learned Tribunal was pleased to allow the said O.P., directing the respondents to reimburse the entire expenditure incurred by the respondent/claimant towards the medical treatment of the applicant and his wife, within a period of three months from the date of receipt of a copy of the order.

(2.) The applicant joined in the petitioners-organization as Postal Assistant on 15/7/1981 and got superannuated on 30/9/2022, after serving the Department for more than 40 years. As he was covered under the Central Government Health Scheme (CGHS) and was availing the CGHS facility as and when required. Further, on 3/4/2022 due to acute chest pain, applicant was admitted in the Star Hospital, Banjara Hills, Hyderabad in emergency and had undergone Heart Bypass Surgery i.e., "Coronary Artery Bypass Graft Surgery" on 4/4/2022. After recovery from the said ailment, he was discharged from the said hospital on 8/4/2022 on payment of medical expenditure for Rs.4,36,700.00. Likewise the wife of the applicant was admitted in Yeshoda Hospital, Secunderabad on 27/4/2022 due to acute headache in emergency condition, she had undergone 'Endo Vascular Coiling of Right ICA (Ophthalmic Segment) Aneurysm' on 28/4/2022. She was discharged from the said hospital on 30/4/2022 on payment of Rs.5,04,400.00. As the applicant was entitled for reimbursement of the expenditure, he has filed application for reimbursement of the said amounts incurred by him towards the said operations conducted in emergency situation. That on 25/10/2022, the 3rd respondent informed the applicant that outpatient medical claims were sent to Khairatabad Head Office, for settlement at their end but, however, However, the said amounts were restricted from Rs.5,04,400.00 to Rs.3,68,215.35 and Rs.4,36,700.00 to Rs.2,75,127.68, and sent to the Regional Office for post facto approval. Further, when the applicant has approached the writ petitioners-organization for releasing the total amount expenditure incurred by him, the petitioners have informed him that his claim was settled in terms of 2014 rates. It is contended that as the applicant and his wife had taken treatment in the year 2022 in a emergency condition, applying the rates of 2014 under CGHS Scheme is unjustified. Further, it is contended by the applicant that he and his wife had to undergo operations only in a emergency condition, which was life-threatening and at that point of time that there was no other go, except to reach the appropriate nearest hospitals for medical attention. Further it is contended that though the applicant was entitled for the total reimbursement, petitioners have restricted the claim to lesser amounts by applying the 2014 rates and have not paid the total reimbursement despite the applicant meeting the eligibility criteria.

(3.) Per contra, learned counsel for petitioners have filed reply statement before the learned Tribunal, though the authorities have not denied the fact applicant took treatment from 3/4/2022 to 8/4/2022 and underwent 'Coronary Artery Bypass Grafting Surgery of X3 grafts' as per the operation notes and the amount of Rs.4,36,700.00 charged by the respective hospitals, however only contended that though the patient got admitted under the emergency condition he has not obtained prior permission and further contended that the hospitals are non-CGHS empanelled hospitals and the total bill amount submitted by the applicant was sent to the Regional Office for approval, who in turn sent the bill to the Additional Director, CGHS for clarification. Upon which, the Additional Director, CGHS vide letter No.CGHS/HYD/SS/2022- 23/9893, dtd. 29/11/2022, instructed to process the bill as per the CGHS Code-529 for the applicant and as per the said Code, the amount was restricted to Rs.1,46,136.00 and the same amount was sanctioned to the applicant and insofar as the wife of the applicant it is contended that she was admitted in Yesodha Hospital, Secunderabad, which is also non-CGHS empanelled hospital and it was admitted that she took treatment from 27/4/2022 to 30/4/2022 and undergone 'Endovascular coiling of right ICA (Ophthalmic Segment) Aneurysm' procedure as per the discharge summary and the hospital authorities have charged an amount of Rs.5,04,400.00 and further contended that though the patient got admitted under the emergency condition there was no prior permission obtained from the authorities and as the hospital is a non-CGHS empanelled hospital, the bill was sent to the Regional Office for approval and further clarification to the Additional Director, CGHS. Upon the clarification, Additional Director vide his letter No.CGHS/HYD/ SS/2022-23/9893, dtd. 29/11/2022 directed the Department to process the bill as per CGHS Code-986, hence the amount was restricted as per the said code to Rs.39,560.00 and the same amount was sanctioned by the officials. Further, it is stated that vide Department of Health and Family Welfare Memo No.F.No.2-1/2012/ CGHS/VC/CGHS(P), dtd. 1/8/2013, the 'CGHS package rate' shall mean and include lump sum cost of inpatient treatment and such other procedures and medicine are not included in the said health procedures and contended that the amounts were sanctioned and paid as per the CGHS rates and as per the codes. The writ petitioner/respondent authorities contended that there are no merits in the O.A. Further, writ petitioners are contended that the Tribunal has not appreciated the facts in proper perspective and allowed the O.A. directing the writ petitioners authorities to pay total amount incurred by the respondent/applicant without any justification and prayed to set aside the orders of the learned Tribunal by allowing the instant writ petition.