'Employee Is Entitled To Medical Reimbursement In Case Of Emergency Even If Hospital Isn't Empanelled Under Any Scheme', Delhi High Court

A Single Judge Bench of the Delhi High Court comprising Justice Jyoti Singh held that the Petitioner was entitled to claim medical reimbursement even if the hospital was not the one empanelled under CGHS in case the admission to such hospital was done during an emergency. The Bench held that the Petitioner could not be denied reimbursement as she was severely injured and could not approach the hospitals empanelled under the scheme. Background The Petitioner was an employee in the school since 08.08.2000 and on 18.09.2013, she faced an accident that left her in an extremely critical condition with her head severely injured. Initially she was admitted in Guru Tegh Bahadur Hospital, Shahdara but due to the severe head injury, she was referred to Sir Ganga Ram Hospital on 19.09.2013. The Petitioner had to undergo a major brain surgery and after prolonged treatment, she was discharged. Later due to not having recovered, she was admitted two more times and was finally discharged on 11.01.2014. A medical certificate of fitness was issued to her by the treating doctor on 01.03.2014. Further, an Emergency Certificate was issued to the Petitioner on 11.10.2017. The Petitioner claimed that she had spent approximately Rs.5,85,523/- on the medical treatment and sought reimbursement for the said amount from the school authorities. She made the claim before the Directorate of Education as well, however she was not reimbursed. Aggrieved from the same, she approached the High Court. Contentions of Petitioner: The Counsel for the Petitioner submitted that the DoE and the School were jointly responsible for reimbursing the medical claims of the Petitioner since the institute was an aided school and received grant from the Government of NCT of Delhi. Relying on several judgments including Milap Singh v. Union of India and Anr., 2004 SCC OnLine Del 493 and Ram Kumar Kaushik v. Govt. of NCT of Delhi and Ors., 2016 SCC OnLine Del 1467, the Counsel argued that the Petitioner had to be admitted in the hospital in emergency and therefore the rejection of her claim owing to not falling under the CGHS Scheme was not justified. It was submitted that in case of emergencies, even if an employee was admitted in the hospital not empanelled under any medical scheme, he/she would still be entitled to claim reimbursement. Contentions of Respondents: The Counsel for the DoE submitted that there were several hospitals empanelled under CGHS but the Petitioner did not approach those during the medical emergency and therefore she could not claim reimbursement. It was further contended that the accident took place four years prior to the issuance of the medical certificate and that the Petitioner was terminated after major penalty proceedings were initiated against her. The Counsel submitted that the Petitioner could not claim reimbursement as the termination was under challenge before the Delhi School Tribunal. The contentions of the school majorly were that it was an aided school and acted on the directions of DoE. Findings of the Court: The Court held that the issue that needed to be decided was as to whether the Petitioner could be denied reimbursement on the ground that she had not approached the hospitals empanelled under the CGHS Scheme. It held that SGRH issued an Emergency Certificate which was placed on record. It was stated that since the certificate was issued by Vice Chairman and Senior Consultant, Department of Neurosurgery of SGRH, the authenticity of the certificate was not disputed. The Court considered the circumstances of the Petitioner and held that since the Petitioner had to be admitted in a hospital in emergency, the Respondents could therefore not deny the medical reimbursement on the ground that Petitioner did not take treatment from a hospital empanelled under the CGHS Scheme. The Bench cited the decision of the Supreme Court in Shiva Kant Jha v. Union of India, (2018) 16 SCC 187, wherein it was held, 'When an employee is admitted to a hospital in emergency condition, law does not require prior permission where survival of the person is the prime consideration. It is also observed that though it is the claim of the State that the rates in the hospital in question were exorbitant and that the rates charged for such facility and reimbursement can only be at CGHS rates and that too after following the laid down procedure, it also cannot be denied that the Petitioner was taken to hospital under emergency condition for survival of his life, which requirement was above the sanctions and treatment in empanelled hospitals.' Another decision of the Delhi High Court in Union of India and Another v. Joginder Singh, 2023 SCC OnLine Del 2707 was cited, wherein the Court had held, 'The medical claim for treatment undertaken in emergency should not be denied for reimbursement merely because the hospital is not empanelled. ...

'Employee Is Entitled To Medical Reimbursement In Case Of Emergency Even If Hospital Isn't Empanelled Under Any Scheme', Delhi High Court

Syed Nazarat Fatima

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