KAMALENDU MALLICK vs POST ODISHA CIRCLE on 6 November 2026

O R D E R

Mr.SudhiRanjan Mishra, Member, J.M.

The applicant challenging the order dated 06.07.2021, 20.07.2020 and 11.06.2020 wherein his medical claim was rejected has filed this OA praying for following reliefs: a) Admit the Original Application. b) After hearing the counsels for the parties be further pleased to quash the orders of rejection vide Memo No. B1/11-R/MB (Kamalendu Mallick) dated 11.06.2020 at Annexure A/7, Memo No. AP/23-331/1998 (Sub) dated 20.07.2020 at Annexure A/9 and order vide No. AP/23- 331/1998 (Sub) dated 06.07.2021 at Annexure A/12. And consequently, orders may kindly be passed directing the respondents to sanction the reimbursement of the medical bills of total amount of Rs. 4,31,721/- submitted by the applicant vide Annexure A/5 & A/6 within a stipulated period. And/or c) Pass any other order(s) as the Hon’ble Tribunal deem just and proper in the interest of justice considering the facts

Kalpeswar Behera and circumstances of the case and allow this OA with costs.

2. The fact of the case as inter alia averred statedby the applicant in the OA is as follows: 2.1 That while the applicant was working as Office Assistant (OA), O/o - SSRM, RMS 'N' Dn, Cuttack, fell seriously ill and he was taken to SCBMCH, Cuttack for immediate treatment by his family members on 18.12.2018. He first attended the neurology department and then referred to the Neurosurgery Department of SCBMCH, Cuttack. The applicant and his family was advised to consult Dr. Niranjan Nanda, Neurosurgeon, SCBMCH, Cuttack. Then he was advised by Dr. Nanda of SCBMCH to do MRland CT Scan of brain. After the required tests, it was identified that the applicant was suffering from brain tumor. The doctors at SCBMCH, Cuttack advised for immediate surgery to avoid any risk of life to the applicant. The family members of the applicant were asked to wait few days for the required surgery at SCBMCH, Cuttack because many patients were already in queue for their surgery at SCBMCH, Cuttack. The applicant was also advised to take some medicines.

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2.2 That the condition of the applicant was suddenly became serious on 04.01.2019 and he was become un-conscious. The family members contacted the treating doctors and it was advised that the applicant was needed an immediate surgery. The family members tried to do immediate surgery at SCBMCH, Cuttack as well as in other Hospitals at Cuttack and Bhubaneswar but they failed. Then they came to know about a specialist doctor of neurosurgery namely Dr. Manas Panigrahi who is serving in KIMS, Secunderabad. The family members contacted the authorities of KIMS Hospital and after confirmation for the surgery they decided to take the applicant to KIMS, Secunderabad immediately. It is worthwhile to state humbly that the KIMS, Secunderabad is coming under the empanelled list of Hospitals under CGHS. 2.3 That the applicant was admitted at KIMS, Secunderabad on 06.01.2019 and underwent surgery on 07.01.2019. After first surgery, the doctors suggested for second surgery after three (3) weeks. The applicant was discharged from KIMS Hospital on

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09.01.2019 and he had paid the bill of Rs 1,74,116/- for his first surgery. 2.4 That, the applicant was again admitted in KIMS Hospital on 29.01.2019 for his second surgery and he was undergone the second surgery on 30.01.2019. The applicant was discharged after the second surgery on 02.02.2019 and he paid the bill of Rs 2,53,717/- for his second surgery. 2.5 That, the applicant submitted his first medical bill of Rs 1,77,254/ on 01.04.2019 to the Respondent No. 3 enclosing all the relevant bill in support of expenditure and submitted his second medical bill on 22.04.2019 with supported bills. It is worthwhile to submit that the family of the applicant spent more than 7 lakh rupees for the surgery and treatment of the applicant by taking private loans. But the total claim of the applicant for reimbursement of medical bill is Rs 4,31,721/-. The applicant being in serious financial crisis repeatedly requested the authorities to sanction his medical bills.

2.6 That, surprisingly the Respondent No. 3 rejected the medical claim of the applicant vide his Memo No. B1/11-R/MB

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(Kamalendu Mallick) dated 11.06.2020 after more than one year on the plea that the applicant was undergone treatment at KIMS, Secundarabad without any referral letter. Further, the Respondent No. 3 did not consider the surgery of brain tumor of the applicant as emergent nature of the treatment which is quite in-human approach. 2.7 That the applicant made appeal to the Respondent No. 2 on 29.06.2020 against the arbitrary and illegal rejection of sanction of his medical bills. The applicant categorically submitted in his appeal that he was un-conscious and his family members decided to take him to KIMS Hospital as urgent surgery was required to save his life. Further, he prayed to sanction his medical bill on humanitarian ground. 2.8 That the Respondent No. 2 rejected the appeal of the applicant vide Memo No. AP/23-331/1998 (Sub) dated 20.07.2020. While rejecting the claim of the applicant the Respondent No. 2 took the plea that the applicant underwent the treatment at a Hospital outside the state without following due paraphernalia. The fact that the applicant was suffering from brain tumor was detected at SCBMCH, Cuttack. Although the

Kalpeswar Behera treating doctors advised for immediate surgery, it could not be done at SCBMCH, Cuttack due to the long queue of patients already waiting for their surgery. Thus the applicant had to undergo brain surgery at KIMS, Secundarabad under emergent situation to save his life. The KIMS, Secundarabad is coming under the empanelled Hospitals under CGHS. Further, as per the rules/provisions no referral is required to get treatment at any empanelled Hospital in emergency situation. 2.9 That finding no alternative and being harassed the applicant approached this Hon'ble Tribunal by filing the O.A No.420/2020. After consideration of the pleadings in the said. OA. No. 420/2020, this Hon'ble Tribunal came to find that the applicant was not in a position to submit all relevant documents and convince the respondent department that the situation compelled him to take medical assistance at Secunderabad. It is further observed by this Hon'ble Tribunal that the fact of treatment and surgery of the applicant has not been disputed and probably the applicant could not convince the department that due to medical emergency he had to approach KIMS, Secunderabad. Thus the Hon'ble Tribunal directed to the applicant to approach the departmental authorities afresh by making one representation

Kalpeswar Behera with all relevant documents and then directed the Respondent No. 2 to consider the same within 4 weeks of time thereafter. This Hon'ble Tribunal categorically directed the respondents that the representation of the applicant should be considered sympathetically in the light of the principle of law and decision taken by Hon'ble Supreme Court in the matter of Shiva KantaJhaVs UOI. This has been directed by this Hon'ble Tribunal in it's order dated 09.04.2021. 2.10 That the applicant made a fresh representation on 24.05.2021 to the Respondent No. 2 enclosing all the relevant documents. The applicant categorically apprised the Respondent No 2 that he was taken to the KIMS, Secunderabad by the family members in an unconscious state under emergent situation. At that time he was in a critical condition and had already lost his vision and hearing ability partially. 2.11 That the Respondent No. 2 without considering the case of the applicant as per the direction of this Hon'ble Tribunal at Annexure - A/10 arbitrarily rejected the representation vide his order No. AP/23-331/1998(Sub) dated 06.07.2021. The Respondent No. 2 repeated his earlier decision without

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considering the decision of the Hon'ble Apex Court in Shiva KantaJhaVs UOI and as well as the Govt. of India's decisions on the subject. Further, he took the false plea that the applicant had not consulted Neuro Surgery department of SCBMCH which is not correct. The applicant consulted Dr. Niranjan Nanda, Neurosurgeon, SCBMCH which can be confirmed from the prescriptions at Annexure - A/1.

2.12 That being denied justice, the humble applicant finds no alternative except to approaching this Hon'ble Tribunal. Hence the applicant files this present OA praying justice and immediate relief.

3. The respondents have filed their counter stating as follows: 3.1 That, the Applicant, Sri Kamalendu Mallick joined the Department as Sorting Assistant (SA) in the O/o the SSRM, RMS 'N' Division, Cuttack on 07.04.2011. The Applicant while working as Sorting Assistant, fell ill and consulted for treatment at Neurology OPD of SCBMCH, Cuttack on18.12.2018. As per the prescription, Sri Mallick had a swelling on the left part of head and was suffering from severe neck pain. The doctor diagnosed

Kalpeswar Behera that, the symptoms might be due to hydrocephalus or Schwannoma in brain or due to other internal problem in head. So, the Applicant was referred to Neurosurgery Department of SCBMCH, Cuttack. Thereafter, Sri Mallick had not consulted Neurosurgery Department of SCBMCH, Cuttack as per record. The Applicant in the instant O.A. submitted that due to emergency condition and to avoid any risk of life to him, his family members have taken him to the Neurology Specialist for treatment at KIMS, Secunderabad. However, the Applicant without consulting the Neurology Department of SCBMCH, Cuttack and without properly establishing the emergency situation of his case, he straight away undergone treatment at KIMS, Secunderabad. 3.1 That, the Applicant was admitted in KIMS, Secunderabad on 06.01.2019 and underwent first surgery on 07.01.2019 and was discharged from the hospital on 09.01.2019. After three weeks, he underwent the second surgery on 30.01.2019 and was discharged on 02.02.2019. The bills amounting to Rs.1,74,116/- and Rs.2,53,717/- for his first and second phase surgery respectively were submitted by the Applicant for reimbursement.

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3.2 On receipt of the medical bills, the Respondent No.3, i.e., the SSRM, RMS, 'N' Division, Cuttack vide Letter No.B1/II-R/MB (Kamalendu Mallick) dated 18.05.2020 forwarded the bills to the Respondent No.2 i.e., the CPMG, Odisha Circle, Bhubaneswar for sanctioning. In response to the above letter, the Respondent No.2, i.e., the CPMG, Odisha Circle, Bhubaneswar considered the case and found that, the Applicant proceeded to KIMS Hospital, Secunderabad without any referral and the emergent nature of treatment was also not established. Hence, concluded the condonation of procedure under emergency by Head of the Circle is not justified and directed that the Head of the Division should take necessary action to dispose of the bills at his end vide letter No. AP/23-331/1998(Sub) dated 02.06.2020. Copy of the Respondent No.2's Letter No. AP/23-331/1998(Sub) dated 02.06.2020 is enclosed herewith as Annexure-R/1. Accordingly, the Respondent No.3, i.e., the SSRM, RMS 'N' Division, Cuttack vide Letter No. B1/II-R/MB (Kamalendu Mallick) dated 11.06.2020 intimated the decision of the Respondent No.2 to the Applicant and rejected citing the grounds taken by the Respondent No.2. Copy of the Respondent No.3's Memo No. B1/11-R/MB(Kamalendu Mallick) dated 11.06.2020 is enclosed

Kalpeswar Behera as Annexure-A/7 to O.A. Thereafter, the Applicant on 29.06.2020 made an appeal to the Respondent No.2 to sanction his medical bills. The Respondent No.2 after considering the appeal of the Applicant rejected his case on the ground that the Applicant has undergone treatment at a Hospital outside the state without following due paraphernalia and communicated the decision to the Applicant vide Memo No. AP/23-331/1998 (Sub) dated 20.07.2020. Copy of Respondent No.2 Memo No. AP/23- 331/1998 (Sub) dated 20.07.2020 is enclosed as Annexure-A/9 to O.A. Aggrieved by the above orders of the Respondent No.2 & 3, the Applicant had approached this Tribunal and filed O.A. No. 420 of 2020. 3.3 The Hon'ble Tribunal in O.A. No. 420 of 2020 vide order dated 09.04.2021 given liberty to the. Applicant to file comprehensive representation before the Respondent No.2, i.e., the Chief Post Master General, Odisha Circle, Bhubaneswar within 3 weeks along with the medical reports and documents about the situation and medical claim, so that the Respondent No.2 shall consider the same by passing a reasoned and speaking order within 4 weeks thereafter.

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3.4 Accordingly, the Applicant on dated 24.05.2021 submitted one comprehensive representation to the Respondent No.2, i.e., the Chief Post Master General, Odisha Circle, Bhubaneswar for reimbursement of his medical bills. 3.5 In obedience to the Order dated 09.04.2021 of the Hon'ble Tribunal, the Respondent No.2 after carefully going through the representation dated 24.05.2021 of the Applicant stated that, "the Applicant failed to sought the prior permission of the Head of the Circle for treatment outside the state. He was also not referred by any Government Hospital or CGHS Wellness Centre for treatment in the Private Empanelled Hospital. Also there are several Government and CGHS Empanelled Hospitals in Odisha which offers such treatment. Thus, the rejection of the claim by the sanctioning authority is justified." 3.6 The above decision was communicated to the Applicant vide Order No. AP/23-331/1998(Sub) dated 06.07.2021. Accordingly, the order dated 09.04.2021 was complied with. 3.7 The Applicant, being unsatisfied by the above order of the Respondent No.2, once again approached the shelter of this Hon'ble Tribunal and filed this O.A.

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3.8 Further, it is pertinent here to mention that, the Applicant had neither produced the prescription of Dr. Niranjan Nanda, Neurosurgeon, SCBMCH, Cuttack during the entire proceedings of the previous O.A. No. 420 of 2020 nor put forth any suggestion issued by him. Now, all of a sudden he produced the prescription of Dr. Nanda, Neurosurgeon, SCBMCH, Cuttack and claiming to have consulted him before proceeding to KIMS Hospital, Secunderabad for treatment. Further, it is humbly submitted that, nowhere in the prescription the urgency of operation/treatment is remarked by the doctor. Moreover, from the prescription it is apparent that, the Applicant has consulted Dr. Niranjan Nanda, Neurosurgeon, not at any Central Government /State Government hospital or CGHS Wellness center.

3.9. That, the doctors at OPD of SCBMCH, Cuttack had referred the case to Neurology Department, SCBMCH, Cuttack. But, the Applicant without any referral advice either by doctor at CGHS dispensary or by doctors of Neurology Department of SCBMCH, Cuttack, proceeded to KIMS, Secunderabad (out of state) to take treatment there on his own decision. The severity of his disease could have been ascertained if the Applicant had gone for the

Kalpeswar Behera medical tests. But, the Applicant had not undertaken any medical tests and had not consulted Neurosurgery Department, SCBMCH, Cuttack. Hence, the urgency of the treatment/surgery could not be established. 3.10 As the Applicant took treatment in KIMS Hospital, Secunderabad, the medical bills of the Applicant were sent to SSPOs, Secunderabad Division for verification. Hence, the delay. Further, vide letter No. B1/II-R/MB (Kamalendu Mallick)dated 18.05.2020, the Respondent No.3 sent the medical bills of the Applicant to the Respondent No.2 for sanction. The Respondent No.2 considered the case of the Applicant and found that, the Applicant proceeded to KIMS, Hospital, Secunderabad without any referral and without any emergency like condition of him. Hence, concluded the condonation of procedure under emergency by Head of the Circle is not justified and directed the Respondent No.3 to take necessary action to dispose of the bills at his end vide letter No. AP/23-331/1998(Sub) dated 02.06.2020. The Respondent No.3 ensuing the directions of the Respondent No.2, rejected the medical bills of the Applicant vide letter No. B1/II- R/MB (Kamalendu Mallick) dated 11.06.2020.

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3.11 It is imperative to mention here that, as per the GOI, Ministry of Health & Family Welfare, Dept. of Health & Family Welfare OM No.S.11011/29/2019-EHS dated 13.09.2019, no CGHS beneficiary can be refused admission to any of the CGHS empanelled hospital in emergency case. But, the emergency condition in the present case could not be established after duly verified by the Inspector of Posts, RMS N-1st Sub Division Cuttack-753003. Copy of IP N-1st Sub Division, Cuttack letter no. IP N-1st/Corr./2017-18 dated 16.03.2020 is enclosed herewith as Annexure-R/2. 3.12 That, the rejection of the medical bill claim by the Respondents is not illegal and arbitrary. The Respondents after carefully going through the case of the Applicant found that, the Applicant proceeded to KIMS, Hospital, Secunderabad without any referral and without any emergency like condition of him. Hence, concluded the condonation of procedure under emergency by Head of the Circle is not justified. Thereafter, the Respondent No.3 ensuing the findings of Respondent No.2, rejected the medical bills of the Applicant vide letter No. B1/II-R/MB (Kamalendu Mallick) dated 11.06.2020.

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3.13 That, the Respondent No.2 with due application of mind carefully gone through the case appeal dated 29.06.2020 of the Applicant and found that, the treatment was done at a hospital outside the state without following due procedure. Accordingly, he rejected the appeal vide letter No. AP/23-331/19987(Sub) dated 20.07.2020. The Applicant was suffering from swelling on the left part of head which was detected at Neurology OPD of SCBMCH, Cuttack. Further, the doctor diagnosed that, these symptoms might be due to hydrocephalus or Schwannoma in brain or due to other internal problem in head. So, the patient was referred to Neurosurgery Department of SCBMCH, Cuttack. During Inquiry by the Inspector of Posts N 1 Sub Division, Cuttack, it is revealed that, the severity of the disease could be advised by the Neurology Department of SCBMCH, Cuttack after verifying the prescribed medical tests. As, no medical tests have been done by the Applicant, the severity of the disease could not be established. Hence, the statement that, there was a long queue of patients waiting for surgery and hence he proceeded to KIMS, Secunderabad owing to emergency situation is not appropriate.

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3.14 That, in obedience to the order dated 09.04.2021 of the Hon'ble Tribunal passed in O.A. No. 420 of 2020 filed by the Applicant, the Respondent No.2, i.e., the Chief Post Master General, Odisha Circle, Bhubaneswar, on receipt of representation dated 24.05.2021 of the Applicant, considered his case and rejected on the ground that, the Applicant failed to sought prior permission of Head of the Circle for treatment outside the state. He was also not referred by any Government Hospital or CGHS Wellness Centre for treatment in the Private Empanelled Hospital. Also, there are several Government and CGHS Empanelled Hospitals in Odisha which offers such treatment. Thus, the rejection of the claim by the sanctioning authority is justified. Copy of the Respondent No.2 Order No. AP/23-331/1998(Sub) dated 06.07.2021 is annexed as Annexure-A/12 to O.A. 3.15 Further, it is humbly submitted that, the prescription of Dr. Niranjan Nanda, Neurosurgeon, SCBMCH, Cuttack enclosed by the Applicant as Annexure-A/1 was not there in the previous O.A. No. 420 of 2020 filed by the Applicant on the same subject. The Applicant had not at all produced the said prescription during the entire proceedings of the previous O.A. No. 420 of

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2020. Now, all of a sudden the Applicant produced the prescription of Dr. Niranjan Nanda, Neurosurgeon, SCBMCH, Cuttack and claiming to have consulted him before proceeding to KIMS Hospital, Secunderabad for treatment. And, it is pertinent here to mention that, nowhere in the prescription the urgency of operation/treatment is remarked. Further, the Applicant seems to have consulted Dr. Niranjan Nanda, Neurosurgeon, not in any Central Government/ State Government or CGHS Wellness center. Thus, the Applicant by ignoring all these official procedures has violated the Departmental guidelines. Hence, the rejection of medical bills of the Applicant is justified and proper. 3.16 That, it is humbly submitted that, there is no such provision for reimbursement of medical bills merely when the treatment is carried out in the empanelled hospital unless the case is identified as emergency. In the present case, although the Applicant is labeling his case as emergency one but the same is not remarked and confirmed in documentary form by the treating doctors. 3.17 That, it is humbly submitted that, in the letter dated 09.11.2017 enclosed as Annexure-A/14, "CGHS beneficiaries can

Kalpeswar Behera undergo treatment at private hospitals empanelled under CGHS of specific treatment procedures listed under CGHS rate list are advised by a Specialist in a Central Government / State Government specialist hospital or a CGHS Medical Officer without any requirement of any other referral (permission) letter." 3.18 Though, the Applicant in the instant case claiming to have consulted a specialist, i.e., Dr. Niranjan Nanda, Neurosurgeon, but not in any Central Government / State Government hospital or CGHS Wellness center. By doing so, the Applicant failed to follow the due procedure of the above said letter. 3.19 That, as submitted by the Applicant that, brain tumor was detected at SCBMCH, Cuttack is totally wrong. Nowhere, the doctor remarked "brain tumor" in the prescription. The Applicant, in fact, had a swelling on left part of head which was detected at Neurology OPD of SCBMCH, Cuttack. Further, the doctor diagnosed that; these symptoms might be due to hydrocephalus or Schwannoma in brain or due to other internal problem in head. So, the patient was referred to Neurosurgery Department of SCBMCH, Cuttack. During inquiry by the Inspector Posts N 1st Sub Division, Cuttack, it is revealed that, the severity of the

Kalpeswar Behera disease could be advised by the Neurology Department of SCBMCH, Cuttack after verifying the prescribed medical tests. As, no medical tests have been done by the Applicant, the severity of the disease could not be established. Hence, the statement that, there is a long queue of patients waiting for surgery and thus, without finding any opportunity he proceeded to KIMS, Secunderabad owing to emergency condition is not at all correct. The Applicant himself tagged his ease as urgent and suo- moto taken decision to move to KIMS, Secunderabad. Further, the 2nd para of 5.4 of the O.A. speaks "no refusal of admission of a CGHS beneficiary in any CGHS empanelled hospital under emergency condition." But, the emergency condition of the Applicant is yet to be established. 3.20 Further, it is humbly submitted that, the 3rd para of 5.4 of the O.A. speaks about reimbursement of medical bills of a CGHS beneficiary even in cases of treatment at non-empanelled private hospital under emergency condition. However, the emergency condition of the Applicant is not established in this case. Therefore, his claim for reimbursement of his medical bills has been rejected.

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3.21 That, the averments made in para 5.5 of the O.A. are not admitted. The Applicant in this avers that, the rejections of claim of his medical bills were not supported by any rule/provision. That, it is humbly submitted that, the Respondent No.2, i.e., the Chief Postmaster General, Odisha Circle, Bhubaneswar vide order enclosed at Annexure-A/12, submitted that, "As per Government of India Ministry of Health and Family Welfare OM No.33.4/59-H I dated 18.07.1960 noted in Rule 6(4) of CS (MA) rules, treatment outside district/State is admissible provided necessary and suitable facilities for treatment are not available in a Government or recognized Hospital at the District or State Headquarter orwithin the District or State where the patient falls

ill. In the instant case, the Applicant was residing/working at Cuttack and at SCB Medical College and Hospital; Cuttack is having all such facilities of treatment. While he was under treatment at SCB Medical College and Hospital, Cuttack, he was referred to the Neurosurgery Department of the same college and Hospital on 18.12.2018 for proper diagnosis of the disease. But instead of taking further treatment at SCB Medical College and Hospital, Cuttack, Sri Mallick, the Applicant without any referral and urgency proceeded to out of the state and undergone

Kalpeswar Behera treatment in a Hospital at Secunderabad."The reason for rejecting the Applicant's bill is clearly mentioned in the order issued by the Respondent No.2, still then the Applicant is claiming to have not cited the reason for rejection of his medical bills. Hence, the averment made in the para should be rejected. 3.22 That, it is humbly submitted that, it is up to the discretion of the Applicant to claim part or full reimbursement of his medical bills. That, if the applicant had followed due rules of procedure then there would have been no disputes in reimbursement of his medical bills as per prevalent rules on the subject. 3.23 That, it is humbly submitted that, had the Applicant followed the rules/provisions of the Department, the medical bills submitted by him would have been sanctioned. But, he failed to follow due procedure for his treatment that finally driven to rejection of his medical bills. The Applicant here stressed on emergency situation of his case due to which he had to receive treatment at KIMS, Secunderabad. But, the emergency condition is yet to be established. Further, the instant case is different from the case mentioned by the Applicant and the case of the

Kalpeswar Behera precedent given in Annexure-A/18 is confined to that particular case only. It is humbly submitted that, the steps taken on the medical bills of the Applicant were appropriate and as per rules of the Department. Hence they prayed for dismissal of the OA.

4. The applicant has filed rejoinder reiterating the stand taken by him in the OA.

5. Heard both sides and perused the records.

6. Ld. Counsel for the respondents filed written notes of arguments stating therein:

6.1. Scope of the case: The Applicant seeks reimbursement of Rs. 4,31,721/- for treatment at KIMS, Secunderabad, an out-of- State, non-consulted, non-referred hospital, without prior permission of the Head of Circle and without established medical urgency in writing from the treating specialists at SCBMCH, Cuttack.

6.2. No referral / no permission obtained (Rule 6(4), CS(MA) Rules, 1944; OM dated 18.07.1960)Treatment outside the district/State is admissible only where necessary and suitable facilities are not available within the State. SCBMCH, Cuttack, a

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Government hospital with a functioning Neurosurgery Department, is precisely such a facility. The Applicant's own pleadings (Para 4.3 of OA) admit that he was referred to the Neurosurgery Department, SCBMCH, but proceeded to KIMS without completing consultation there or obtaining any referral/permission. Annexure R/2 (Inspector of Posts' verification report dated 16.03.2020) records that no medical tests were undergone and the Neurosurgery Department was never actually consulted, this fact goes to root of the "necessity" test under Rule 6(4).

6.3. Emergency not established by competent medical authority. Reimbursement for treatment obtained without permission is permissible only where genuine emergency is certified by treating doctors this is the ratio even within Shiva Kant Jha (Para 13-14), which speaks of "records duly certified by Doctors/Hospitals." Here: The prescription of Dr. Niranjan Nanda nowhere records "urgency" or "emergency."No discharge summary/emergency certificate from SCBMCH or KIMS at time of admission certifying life-threatening urgency was produced with the original claim.

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This is unlike Shiva Kant Jha, where the CRT-D implant and its emergent necessity were not disputed on facts; the dispute there was only about rates and prior sanction.

6.4. Shiva Kant Jha is confined to its own facts. The Supreme Court itself, at Para 15, held: "We also make it clear that the said decision is confined to this case only." This self-limiting clause was inserted precisely to prevent the judgment being used as a general rule bypassing the referral/permission framework. Reliance on it to claim an automatic, unconditional entitlement, regardless of whether emergency is documented, misreads the judgment.

6.5. Jha's relief flowed from Article 142 jurisdiction, not from an interpretation of CS(MA) Rules binding Tribunals. As held by the Division Bench of the Bombay High Court in Bina Saxena v. Union of India, 2023 SCC OnLine Bom 1265, the equitable relief in Shiva Kant Jha was granted by the Supreme Court in exercise of its extraordinary power under Article 142 to do complete justice a power neither this Hon'ble Tribunal nor a High Court possesses. Consequently, Shiva Kant Jha cannot be treated as laying down an inflexible rule of law overriding Rule 6(4) CS(MA)

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Rules in every case; it is persuasive on the principle (factum of treatment matters, technicalities shouldn't defeat genuine claims) but does not dispense with the requirement of establishing genuine emergency through contemporaneous medical certification.

6.6. Reimbursement is capped by prescribed rates, not actual expenditure State of Punjab v. Ram Lubhaya Bagga, (1998) 4 SCC 117. Even assuming, without admitting, that the treatment is held reimbursable, the Government's obligation under Rule 12 CS(MA) Rules is to reimburse at prescribed/CGHS rates, not the actual amount billed by the private hospital, which the Applicant himself concedes was billed at KIMS's own rates. The Hon'ble Supreme Court in Ram Lubhaya Bagga categorically held the State is entitled to cap reimbursement at approved rates.

6.7. Applicant's own limitation-appeal correspondence discloses inconsistency. The claim was rejected twice (11.06.2020 and 20.07.2020) and reconsidered afresh pursuant to this Tribunal's order dated 09.04.2021 in O.A. 420/2020 and rejected a third time (06.07.2021) on the same, unremedied deficiency: absence of documented referral/emergency. The Respondent-authorities

Kalpeswar Behera have not acted mechanically; each rejection order records independent reasons tied to the specific rules (Annexures A/7, A/9, A/12, R/1).

6.8. No violation of Articles 14 & 16. Since similarly situated CGHS beneficiaries who fail to referral/permission or fail to establish documented emergency are treated identically, there is no discrimination. Treating this Applicant differently (i.e., waiving the requirement for him alone) would itself invite an Article 14 challenge from other beneficiaries denied on the same ground.

6.9. That in the above mentioned position, the O.A. as devoid of merit, needs dismissal and uphold the impugned orders dated 11.06.2020, 20.07.2020 and 06.07.2021, with costs.

7. In the context of reimbursement of medical bills, the Hon’ble Supreme Court in Shiva Kant JhaVs Union of India (2018) 16 SCC 187 cited by the applicant, observed and directed as under: “16) With a view to provide the medical facility to the retired/serving CGHS beneficiaries, the government has empanelled a large number of hospitals on CGHS panel, however, the rates charged for such facility shall be only at the CGHS rates and, hence, the same are paid as per the procedure. Though the respondent-State has pleaded that the CGHS has to deal with large number of such retired beneficiaries and if the petitioner is compensated beyond the

Kalpeswar Behera policy, it would have large scale ramification as none would follow the procedure to approach the empanelled hospitals and would rather choose private hospital as per their own free will. It cannot be ignored that such private hospitals raise exorbitant bills subjecting the patient to various tests, procedures and treatment which may not be necessary at all times.

17. It 1s a settled legal position that the Government employee during his life time or after his retirement is entitled to get the benefit of the medical facilities and no fetters can be placed on his rights. It is acceptable to common sense, that ultimate decision as to how a patient should be treated vests only with the Doctor, who 1s well versed and expert both on academic qualification and experience gained. Very little scope is left to the patient or his relative to decide as to the manner in which the ailment should be treated. Specialty Hospitals are established for treatment of specified ailments and services of Doctors specialized in a discipline are availed by patients only to ensure proper, required and safe treatment. Can it be said that taking treatment in Speciality Hospital by itself would deprive a person to claim reimbursement solely on the ground that the said Hospital is not included in the Government Order. The right to medical claim cannot be denied merely because the name of the hospital 1s not included in the Government Order. The real test must be the factum of treatment. Before any medical claim is honoured. the authorities are bound to ensure as to whether the claimant had actually taken treatment and the factum of treatment 1s supported by records duly certified by Doctors/Hospitals concerned. Once, it is established. the claim cannot be denied on technical grounds. Clearly. in the present case, by taking a very inhuman approach, the officials of the CGHS have denied the grant of medical reimbursement in full to the petitioner forcing him to approach this Court.

18) This is hardly a satisfactory state of affairs. The relevant authorities are required to be more responsive and cannot in a mechanical manner deprive an employee of his legitimate reimbursement. The Central Government Health Scheme (CGHS) was propounded with a purpose of providing health facility scheme to the central government employees so that they are not left without medical care after retirement. It was in furtherance of the object of a welfare State. which must provide for such medical care that the scheme was brought in force. In the facts of the present case, it cannot be denied that the writ petitioner was admitted in the above said hospitals in emergency conditions. Moreover, the law does not require that prior permission has to be taken in such situation where the survival of the person is the prime consideration. The doctors did his operation and had implanted CRT-D device and have done so as one essential and timely. Though it is the claim of the respondent-State that the rates were exorbitant whereas the rates charged for such facility shall be only at the CGHS rates and that too after following a proper procedure given in the Circulars i1ssued on time to time by the concerned

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Ministry, it also cannot be denied that the petitioner was taken to hospital under emergency conditions for survival of his life which requirement was above the sanctions and treatment In empanelled hospitals.

19) In the present view of the matter, we are of the considered opinion that the CGHS is responsible for taking care of healthcare needs and well being of the central government employees and pensioners. In the facts and circumstances of the case, we are of opinion that the treatment of the petitioner in non-empanelled hospital was genuine because there was no option left with him at the relevant time. We, therefore, direct the respondent-Stat to pay the balance amount of Rs.4,99,555/- to the writ petitioner. We also make it clear that the said decision is confined to this case only.

20) Further, with regard to the slow and tardy pace of disposal of MRC by the CGHS in case of pensioner beneficiaries and the unnecessary harassment meted out to pensioners who are senior citizens, affecting them mentally, physically and financially, we are of the opinion that all such claims shall be attended by a Secretary level High Powered Committee in the concerned Ministry which shall meet every month for quick disposal of such cases. We, hereby, direct the concerned Ministry to device a Committee for grievance redressal of the retired pensioners consisting of Special Directorate General, Directorate General, 2 (two) Additional Directors and 1 (one) Specialist in the field which shall ensure timely and hassle free disposal of the claims within a period of 7 (seven) days. We further direct the concerned Ministry to take steps to form the Committee as expeditiously as possible. Further, the above exercise would be futile if the delay occasioned at the very initial stage, ie, after submitting the relevant claim papers to the CMO-I/C. therefore, we are of the opinion that there shall be a timeframe for finalization and disbursement of the claim amounts of pensioners. In this view, we are of the opinion that after submitting the relevant papers for claim by a pensioner, the same shall be reimbursed within a period of 1 (one) month.”

8. Recently, placing reliance on the Shiv Kant Jha (Supra), Hon'ble Delhi High Court vide its judgment dt. 10.05.2023 in WP (C) No. 10684/2022 & CM APPL. 31035/2022 (2023:DHC:3138- DB), observed as under: “12 The medical claim for treatment undertaken in emergency should not be denied for reimbursement merely because the hospital is not empanelled. The test remains whether the claimant had actually undertaken the treatment in

Kalpeswar Behera emergent condition as advised and if the same is supported by record. Preservation of human Iife is of paramount importance. The State is under an obligation to ensure timely medical treatment to a person in need of such treatment and a negation of the same would be a violation of Article 21 of the Constitution of India. Administrative action should be just on test of fair play and reasonableness. Accordingly. keeping into consideration the constitutional values. the executive instructions need to be applied than rejecting the claim on technical ground of undertaking treatment in a non- empanelled hospital. since the GHS/State is responsible to ensure proper medical treatment in an emergent condition and further cannot escape the liability, if the treatment undertaken is genuine. Any denial of claim by the authorities in such cases only adds to the misery of the Government servant in further forcing him to resort to Court of law. Xxx 13 It needs to be kept in perspective that patient has a little scope to decide the nature of treatment and merely looks forward to an expert guidance/treatment for relieving him from immense pain and suffering The patient in distress is not in a position to go against the specialist medical advice for surgery in emergency.”

9. In the case of Anirudh Prataprai Nansi v. State of Maharashtra, 2025 SCC OnLine Bom 2391, decided on 6-6-2025, Hon’ble High Court of Bombay observed as under:- “37. From the plain reading of the aforesaid Office Memorandum, it is clear that a provision is made for relaxation in reimbursement of the medical expenses incurred in special cases, in peculiar circumstances, as also in cases of emergency and other special circumstances. From the contents of the aforesaid Office Memorandum and even otherwise, we fail to understand as to how a requirement of heart transplant cannot be considered to be an extraordinary and not an emergent and inevitable surgery, as a heart transplant is required only when the heart is failing, the consequences of which are just to be imagined. As to what is the plight of the patient in such situation, would not require any elaboration. It is in these circumstances, the case of the petitioner ought to have been considered by the High Power Committee.

38. From the impugned decision, it appears to us that a narrow, pedantic and/or a too technical view has been taken by the HPC in rejecting the full medical reimbursement to the petitioner. We would not find that the

Kalpeswar Behera petitioner's application for full medical reimbursement could not have been rejected on the ground that it was a planned surgery and/or merely because the rates being notified, the petitioner ought not to be granted any reimbursement.

39. Even assuming that the aforesaid Office Memorandum providing for relaxation of the conditions was not to be issued, it cannot be said that the respondents were powerless or would lack authority to consider special cases of reimbursements of medical expenses when the treatment received is of such serious nature, in considering applications of reimbursement in such category. These are all executive powers as conferred on the Central Government under the provisions of Article 73 of the Constitution, which are coterminous with the power to legislate. In the absence of any specific legislation, exercise of such power and more particularly for preservation of fundamental rights necessarily has a legitimate constitutional recognition.

40. It also cannot be that the rules governing reimbursement are sacrosanct and nothing outside the rules in exceptional/special cases and especially deserving cases, can be considered for reimbursement by the Central Government. It would not require elaboration that in such matters it is an accepted position that there is a free play in the joints and such category of cases are required to be considered on their merits. A case to case legitimate decision protecting the fundamental rights is expected to be taken by the concerned officers. Such powers are conferred only to be utilized and more particularly when there is a need to exercise such powers not only to protect the fundamental rights but right to life and right to livelihood. Thus, apart from the Office Memorandum dated 15 July 2014 providing for relaxation, the High Power Committee even otherwise could exercise such powers of relaxation and in such deserving case, exercise its discretion to award full medical reimbursement.

41. The present case indisputedly is a case of heart transplant which by all standards is a serious ailment. Certainly, the surgery is one of urgency and critical importance, and could not have been postponed. It is a special circumstance. It is imperative that such surgeries are expedited in the interest of human life without an embargo of an expenditure which is secondary to human life.

42. The respondents have not come with a case that immediate transplant facility was available or the organ was available for transplant, in any of its empanelled or CGS hospitals. If that be the case, certainly it cannot be said that the petitioner undergoing a heart transplant at a private hospital, where the organ was available and which could be immediately transplanted without any waste of time, was not an emergent and / or wrong decision on the part of the petitioner, and/or nonetheless despite such availability, he

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ought to have awaited for the heart transplant in the hospital which the CGHS authorities would intend. This would have brought about a situation of the petitioner requiring to unwarrantedly suffer an ordeal of a fruitless wait. The petitioner rightly preferred not to wait in such uncertainty and availed of the heart transplant at the private hospital.

43. In these circumstances, we are of the clear opinion that in a situation to save his life, the petitioner was certainly entitled to take a decision to have a heart transplant at a private hospital, in the absence of such facilities being readily / timely made available, in all the empanelled hospitals. Hence, the petitioner was required to be granted full reimbursement of all the expenditure, when such expenditure was not in dispute. Not granting full reimbursement, in these circumstances in our opinion, is not only violative of the fundamental rights but strikes at the very root, purpose and essence of these basic human rights as guaranteed by the Constitution, i.e., Right to Life under Article 21. It was this fundamental right which is being asserted by the petitioner when in such circumstances he demanded reimbursement of medical expenses, and for violation of these rights seeking a remedy to approach the writ Court, cannot be said to be any misconceived approach on the part of the petitioner, more particularly the respondent's accepting an earlier order passed by this Court on the writ petition filed by the petitioner.

44. It is in such circumstances, it was necessary for the High Power Committee to weigh the case of the petitioner with human sensitivity. However, the High Power Committee in its usual, routine and mundane method appears to have taken the impugned decision without hearing the petitioner, despite the clear orders of this Court in the prior proceedings filed by the petitioner.

45. We may also observe that although some medical facilities are available in CGHS hospitals, it is not possible that such specialized medical facilities are available. It is for such reason, necessarily treatment is required to be availed by such patients from private hospitals, for which reimbursement is sought from the Central Government. In such situation, the Central Government is under an obligatory position to grant reimbursement on case to case basis. It may be true that for certain ailments, rates are fixed, however, the health issues are such that there cannot be a straight jacket formula in arriving at the rates for reimbursement and in a given situation, the Competent officer or the HPC would be required to grant reimbursement considering the treatment as received by the patient/employee. In many of such reimbursements, there may not be any issue or dispute on the amount of reimbursement, however, this would not mean that in very peculiar, serious, specialized cases of medical treatment, the reimbursement needs to be only as per the rates which are pre- determined. This would be most unrealistic, unfair and discriminatory as in the present situation. Any employee, merely because he has retired, ought not to be differently treated when it comes to genuine and realistic health

Kalpeswar Behera expenditure. There is another aspect that the reimbursement rates are not revised from time to time in the absence of which, they are rendered unrealistic.

46. Thus, patients like the petitioner, who is a pensioner, cannot be deprived of benefits of medical reimbursement when he received treatment at private hospital, more particularly, when the petitioner's case is accepted as a genuine case, which in our opinion, was certainly of an urgent nature. In the present case, the respondents in no manner whatsoever dispute the treatment of the petitioner and the expenditure incurred. The respondents have all powers to examine the credentials of the applications and enquire about the genuineness of the claim. Thus, once the facts of the petitioner's case remained indisputed, i.e., when the medical treatment was not in dispute in the petitioner receiving specialized or urgent treatment and when the amount claimed by the petitioner is the actual expenditure incurred by him is also not in dispute, in these circumstances, to make the petitioner suffer for reimbursement, in our opinion, amounts to travesty of justice and a glaring violation of the fundamental rights guaranteed to a citizen who is the former employee of the Central Government. In such circumstances, in our opinion, the High Power Committee ought to have been humanely sensitive in dealing with the petitioner's case and ought not to have adopted a mechanical and a narrow-minded approach.

47. Thus, we have no manner of doubt that looked from any angle, the petition needs to eminently succeed. It is, accordingly, allowed in terms of prayer clauses (A) and (B). Needful reimbursement be done to the petitioner within a period of four weeks from today.”

10. In view of the above settled position of law, the action of the respondents in rejecting the claim of the applicant is found to be illegal. Accordingly, the impugned order dated 11.06.2020, 20.07.2020 and 06.07.2021 are quashed. Resultantly the respondents are directed to sanction the reimbursement of the medical bills amount of Rs. 4,31,721/- submitted by the applicant vide Annexure A/5 and A/6 within a period of 90 days from date of receipt of copy of this order.

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11. The OA is allowed. Pending MA’s stands disposed of. No costs.

(PRAMOD KUMAR DAS) (SUDHI RANJAN MISHRA) MEMBER (A) MEMBER (J)

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