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In a decision of May 22, 2023, the Delhi High Court ruled in favour of petitioner Group Captain Suresh Khanna who was under treatment at CK Birla Hospital, Gurugram, between April 28 and May 5, 2021, for a period of eight days, for Covid-19 pneumonia. The petitioner had to pay Rs 3,55,286 as treatment costs, but the Ex-Servicemen Contributory Health Scheme (ECHS) only reimbursed him for Rs 1,83,748, on the basis of government-approved rates.
The Union of India, the respondent in this case, made the argument that the hospital had charged beyond the government-approved rates. Justice Pratibha M Singh, in her ruling, noted precedents in law including Dinesh Kumar v Government of the National Territory of Delhi, where it was established that “reimbursement has to be given to the beneficiaries and that it was incumbent upon the concerned government or authority to obtain recovery from the hospital”.
She also cited the instance of the case of Squadron Commander Randeep Kumar Rana where the Division Bench held that the employer was under obligation to pay the government employee, and could make appropriate recoveries in accordance with law from the hospital which had overcharged him. Citing the earlier judgment at length, the ruling of May 22, 2023 noted:
“How a citizen can ensure that a hospital does not charge over and above the package rate? The power to lay down guidelines is with the respondent. A citizen is a mere spectator to what State authority do and decide.
“How a citizen can ensure that a hospital does not charge over and above the package rate? The power to lay down guidelines is with the respondent. A citizen is a mere spectator to what State authority do and decide.
"If the hospital has charged over and above the package rate, the respondent is under an obligation to pay to such charges as the Petitioner has incurred over the package rates at the first instance and if in law state can recover from the hospital concerned, they may do so but they cannot deny their liability to pay to the Government employee who is entitled for medical reimbursement.”
The court ruled that Group Captain Khanna be reimbursed the differential amount of Rs 1,71,528 by July 2023
The ruling cited Shiva Kant Jha v. Union of India, 2018 16 SCC 187, while stating that the Supreme Court “has emphasized that the real test for ascertaining the claim for reimbursement must be the factum of treatment”. The claim, the judgment ruled, cannot be refused on technical grounds. Citing the SC ruling, the judge stated:
“It is a settled legal position that the government employee during his lifetime or after his retirement is entitled to get the benefit of the medical facilities and no fetters can be placed on his rights…The right to medical claim cannot be denied merely because the name of the hospital is 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 is supported by records duly certified by doctors/hospitals concerned. Once it is established, the claim cannot be denied on technical grounds.”
The court ruled that Group Captain Khanna be reimbursed the differential amount of Rs 1,71,528 by July 2023. If payment is delayed, interest at 6% will be liable to be paid from the date when the application of reimbursement was made. If payment is made in the stipulated time, no interest is liable to be paid. The respondent is also free to take action against CK Birla Hospital, in respect of overcharge, if any, including seeking refund of the overcharged amount.
The ruling is significant for all veterans of the defence forces and government employees, and even for citizens in general since the government is pushing for wider insurance coverage – Insurance Regulatory Authority of India is currently planning an all-in-one insurance policy that will cover health, accident, theft, death, and provide households with monetary support in case of illness in the family.
The court ruled that Group Captain Khanna be reimbursed the differential amount of Rs 1,71,528 by July 2023. If payment is delayed, interest at 6% will be liable to be paid from the date when the application of reimbursement was made. If payment is made in the stipulated time, no interest is liable to be paid. The respondent is also free to take action against CK Birla Hospital, in respect of overcharge, if any, including seeking refund of the overcharged amount.
The ruling is significant for all veterans of the defence forces and government employees, and even for citizens in general since the government is pushing for wider insurance coverage – Insurance Regulatory Authority of India is currently planning an all-in-one insurance policy that will cover health, accident, theft, death, and provide households with monetary support in case of illness in the family.
New players will be allowed to enter the insurance market to serve untapped needs of specialized segments of society. The insurance regulator’s history of complaint redressal, however, is far from impressive and massive insurance scams have been reported but poorly investigated.
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*Free lance journalist
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