Challenging Reimbursement Claim and Case of Medical Expenses incurred Outside State

• Court: High Court of Jammu & Kashmir and Ladakh at Jammu
• Citation: SWP No. 1062/2016
• Case title: Monica Pathania vs. State of J&K and others
• Date of Order: 26.04.2023
• Bench: HON’BLE MR. JUSTICE RAJNESH OSWAL, JUDGE

Parties:

• Appellant: Monica Pathania
• Respondent: State of J&K and others

IMPORTANT PROVISIONS

Rule 6(5) of the J&K Civil Services (Medical Attendance-cum-Allowance) Rules 1990

Treatment outside the State:- Where a beneficiary resides temporarily outside the State and falls ill there suddenly and is advised admission in a hospital, he will, on production of necessary vouchers and certificates, be allowed reimbursement of hospital charges including cost of drugs and charges for investigation, provided it is recommended by the director Health Services of the State after being satisfied that the beneficiary had suddenly fallen ill outside the State where he resides temporarily and was not already suffering from it before his departure from his home town.

The Director Health Services will certify that drugs and services charged for are reasonable and the beneficiary could not wait for treatment in his home town.

OVERVIEW

• The petitioner's claim, requesting reimbursement of medical expenses spent on her husband's treatment, was denied by the respondents in their communication dated 01.06.2015. This rejection has compelled the petitioner to file a writ petition in this Court. The petitioner seeks not only to invalidate the aforementioned communication dated 01.06.2015 but also to compel the respondents to reimburse the medical expenses amounting to Rs. 14,99,511/-, along with 12 percent per annum interest from the date the bills were submitted to the respondents.
• The relevant details for resolving this writ petition are as follows: In 2009, the petitioner, who was a contractual employee of respondent No. 1, went on a personal trip to Nagpur with her husband. Unfortunately, her husband fell seriously ill and was admitted to Kalaptaru Hospital on 15.10.2009.
• After undergoing surgery, he was diagnosed with "Carcinoma Rectum." The petitioner's husband received urgent chemotherapy and radiotherapy at Yashodha Cancer Hospital in Nagpur.
• The petitioner claims to have spent over Rs. 25 lakhs on her husband's treatment, who passed away on 08.09.2011.
• However, she only retained bills totaling Rs. 12,31,711/- for which she sought reimbursement from her employer. In March 2011, she was only paid Rs. 1.5 lakhs. As the treatment continued after 2010, the petitioner submitted additional bills amounting to Rs. 2,67,000/-.
• The respondents requested verification of the treatment from the Director of Health Services on 21.08.2010 (Annexure H to the writ petition), in accordance with Rule 6(5) of J&K Civil Services (Medical Attendance-cum-Allowance) Rules 1990.
• After examining the petitioner's claim, the Directorate of Health Services confirmed the authenticity of the treatment received by the petitioner's husband and informed respondent Nos. 1 and 2 through their communication dated 04.03.2011 (Annexure J to the writ petition). The petitioner approached respondent No. 3 to obtain sanction for her medical reimbursement claim and submitted a representation on 20.03.2014.
• Respondent No. 2 forwarded the petitioner's claim to respondent No. 3 in their communication dated 25.02.2015 (Annexure L to the writ petition). However, respondent No. 3 rejected the petitioner's claim through their communication dated 01.06.2015, which is the subject of the present writ petition.
• The respondents have submitted their response, stating that the petitioner did not obtain permission from her office to travel outside the state and had independently left for Nagpur.
• Post facto permission for four days of leave from 26.09.2009 to 29.09.2009 was granted by the Director of Transport through their communication dated 29.02.2012. Since the petitioner did not have prior permission from her office to travel outside the state and lacked authorization from the administrative department, she is not entitled to any medical reimbursement.
• It is further mentioned that obtaining treatment outside the state requires sanction from the Administrative Department. Therefore, the claim was forwarded to the Principal Secretary of the Planning and Development Department, Civil Secretariat, Jammu.
• However, the administrative department returned the claim through their communication dated 07.06.2011, questioning the submission of the file to the Administrative Department and consequently closing the petitioner's case.
• An amount of Rs. 1.5 lakhs was sanctioned to the petitioner from the Chief Minister's Cancer Relief Fund. Additionally, it is stated that claims for treatments obtained outside the state require a dependence certificate from the beneficiary and an authorization certificate from the Administrative Department, which can be granted upon submission of the certificate in the prescribed format.
• The petitioner did not fulfill these necessary requirements in the present case. Her case was reopened in 2015 upon her request and forwarded to the Administrative Department through their communication dated 25.02.2015.
• However, the Administrative Department returned the original file, stating that the case does not warrant consideration as the treatment outside the state was obtained without any reference.
• The respondents also mention that the petitioner has received her entitled salary for the leave period according to the contractual employees' leave rules of the ERA. The respondents admit that reimbursement of medical claims for contractual/deputation employees of the ERA is only provided after fulfilling the required formalities outlined in the rules.

ISSUES RAISED

The petitioner seeks the court's intervention to quash the rejection of her claim and direct the respondents to reconsider her reimbursement claim in light of the rules and relevant judicial precedents.

ARGUMENTS ADVANCED BY THE APPELLANT

• The petitioner argued that her situation was not one where she intentionally traveled outside the state for planned treatment for her husband. Instead, she and her husband were on a private visit when her husband suddenly became ill, forcing her to incur substantial expenses for his treatment.
• The petitioner further emphasized that the J&K Civil Services (Medical Attendance-cum-Allowance) Rules 1990 are designed for the well-being of employees, and the respondents' decision to reject her claim goes against the principles of these rules.
• Mr. Rahul Pant also cited a judgment from a Division Bench of this Court in the case of State of J&K vs. Dr. Sakhi Willayat, as reported in 2004 (3) JKJ 412 [HC (DB)], to support his arguments.

ARGUMENTS ADVANCED BY THE RESPONDENT

• Mr. Amit Gupta, the respondents' counsel, argued that the petitioner did not seek prior permission to receive treatment outside the state as required by the J&K Civil Services (Medical Attendance-cum-Allowance) Rules 1990.
• Therefore, according to Mr. Gupta, the respondents were justified in rejecting the petitioner's claim.

JUDGEMENT ANALYSIS

• The respondents have rejected the petitioner's claim for medical reimbursement in their communication numbered PD/ERA/31/2014-15 dated 01.06.2015 based on the following two reasons:

1. The treatment obtained outside the state was done without any reference, which is not within the scope of coverage under the J&K Civil Services (Medical Attendance-cum-Allowance) Rules 1990.
2. The hospital where the treatment was received is not included in the list of hospitals covered under the J&K Civil Services (Medical Attendance and Allowance) Rules 1990.

• In the case of Badar Hussain vs. State of J&K, recorded under SWP No. 2097/2013 and decided by a coordinated Bench of this court on 17.05.2017, the government relaxed the rules and permitted the reimbursement of the petitioner's expenses for his son's medical treatment up to the rates applicable in PGI Chandigarh.
• Despite the fact that the hospital where the petitioner's son received treatment was not on the approved list of hospitals, the learned writ court granted the writ and invalidated the order to the extent that it restricted the reimbursement amount.
• This order was appealed in a case titled "Union territory of J&K and others versus Bader Hussain," with the reference number CDLSW No. 8/2018.
• The appeal was dismissed on 24.02.2020 due to a delay in filing, but the Division Bench observed that even if Apollo Hospital Ludhiana was not mentioned in the rules, the claim for reimbursement could not be denied solely based on the hospital not being among the approved hospitals.

CONCLUSION

• Rule 8(2) of the aforementioned Rules grants the government the authority to make exceptions to the rules in cases where strict adherence would result in undue hardship.
• This power to relax the rules is not meant to merely adorn the rule book, but rather to be exercised in genuine cases where following the rules strictly would unfairly impact the beneficiary.
• In the present case, the petitioner, who was a contractual employee at the time, had a dependent husband. Due to an urgent medical situation, while on a private trip with her husband, she incurred significant expenses for his treatment.
• This clearly illustrates the challenging circumstances faced by the petitioner. The respondents had the authority to relax the rules under Rule (Supra) and reimburse the petitioner's medical claim for treatment obtained outside the state from non-approved hospitals. In such situations, a compassionate approach should have been taken when considering the petitioner's claim.
• It appears that the respondents, in rejecting the petitioner's claim for reimbursement of medical expenses incurred on her husband's treatment, overlooked the relevant rules.
• The challenged communication/order numbered PD/ERA/31/2014-15 dated 01.06.2015 is invalidated, and the responsible respondents are instructed to review the petitioner's claim for reimbursement of medical expenses in line with the principles of the rules and make new decisions considering the judicial precedents mentioned earlier.
• They are required to do so within two months from the date they receive a copy of this order. As a result, the appeal is disposed.