Ker HC | Whether State empowered to reject medical reimbursement for treatment being from unrecognized department of recognized hospital? HC decides      

Kerala High Court

Kerala High Court: Murali Purushothaman, J., held that there is a Constitutional as well a statutory obligation on the part of the State to bear the expenses for treatment of the government servant and his family.

Background

The petitioner, an Assistant Professor in Catholicate College had took his father, who was totally dependent on him for treatment General Hospital, Pathanamthitta wherein his father was diagnosed with Carcinoma Rectum and was referred to higher center. Accordingly, he was taken to Medical and Surgical Oncology Department of the St. Gregorious Medical Mission Hospital, Pathanamthitta, a private specialty hospital for Cancer treatment. Subsequently, his father had undergone surgery in the Laparoscopic Department of the that Hospital.

Noticeably, the Government had issued a Notification dated 21-01-2016 empanelling certain private hospitals for treatment to facilitate medical reimbursement benefits under the Kerala Government Servants Medical Attendance Rules, 1960. The name of St. Gregorious Medical Mission Hospital, Pathanamthitta was also appeared in the list of private hospitals recognised by the Government for treatment under Rule 8 (3) of the Rules and the Departments recommended included Medical and Surgical Oncology.

The grievance of the petitioner was that his request for reimbursement of Rs. 4,68,038, incurred by him for his father’s treatment had been rejected by the State on the ground that the department of Laparoscopic surgery at St. Gregorious Medical Mission Hospital was not empanelled under the Rules.

Observation and Analysis

Noticeably, for reimbursement request for the treatment undergone between 12-06-2018 and 23-06-2018, for Rs. 65,756 made by the petitioner an amount of Rs. 23,580 was held admissible by the State and accordingly Rs. 18,864 was sanctioned, being 80% of the amount found admissible. The government had that the petitioner’s father was referred to General and Laparoscopic Department by the Medical Oncologist and considering that the treatment was taken on reference from recognized department, sanction was accorded for reimbursement of 80% of the amount found admissible.

Laparoscopy (keyhole surgery) is one of the types of surgical procedure. Under the Rules, ‘medical attendance’ includes surgical treatment. The Laparoscopic surgery for Carcinoma Rectum is part of surgical treatment of the petitioner’s father. Therefore, opining that it is for the Doctor to decide how a patient should be treated and which surgical procedure is safer and suitable to the patient, the Bench held that when Medical and Surgical Oncology department of the Hospital had been recognised by the Government, the State could not reject the claim of the petitioner saying that the General and Laparoscopic surgery department was not recognized by the Government. The Bench opined,

“Undergoing Laparoscopic surgery for Carcinoma Rectum will not make the treatment as one done in a department other than the Medical and Surgical Oncology department in the Hospital. The procedure done and the treatments received at the Hospital is part of the medical and surgical oncology treatments of the petitioner’s father.”

Findings and Conclusion

The Kerala Government Servants Medical Attendance Rules, 1960 had been framed in exercise of the powers under the proviso to Article 309 of the Constitution of India. It provides for reimbursement of the medical expenses incurred by the government servants and their family as defined therein and subject to the conditions provided therein. Further, there is a Constitutional as well a statutory obligation on the part of the State to bear the expenses for treatment of the government servant and his family, therefore, the Bench was of the view that it was impermissible for the respondents to reject the claim of the petitioner for reimbursement of the bills. Accordingly, government order rejecting reimbursement was set aside.

Similarly, for medical reimbursement, what is relevant is whether the claimant had actually taken treatment and the factum of treatment. Since the fact that the petitioner’s father had surgery for Carcinoma Rectum and was treated in the Hospital during different spells was undisputed, the Bench concluded the action of the State was not legally sustainable. Therefore, the State was directed to consider the petitioner’s request afresh and disburse the amounts due to the petitioner pursuant to such within one month therefrom. [George Thomas v. State of Kerala, 2022 SCC OnLine Ker 613, decided on 31-01-2022]


Kamini Sharma, Editorial Assistant has reported this biref.


Appearance by:

For the Petitioners: Jacob P.Alex, Joseph P.Alex and Manu Sankar P., Advocates

For State: Jimmy George, Government Pleader

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