K. Haripal, Member J
1. The applicant is a former Senior Administrative Officer, retired from the Indian Institute of Rice Research, Hyderabad, under the Indian Council of Agricultural Research (ICAR). He retired from service on 30.11.2015. He is a non-CGHS pensioner of the ICAR. It is an autonomous body under the Ministry of Agriculture and Farmers' Welfare and is governed by the Central Service (Medical Attendance) Rules 1944, herein after referred to as the Rules. He has quoted Rules 3 & 6 of the Rules and says that in terms of the same, a Government servant is entitled for treatment, free of charge from Government hospitals and other recognized hospitals near the place of his residence. For the employees of the ICAR, located at Hyderabad, a dispensary has been opened in the National Academy of Agricultural Research and Management (NAARM), to which pensioners are also entitled to get treatment and reimbursement of bills for both out patient and indoor treatments. But such a dispensary has not been opened in Cochin for the welfare of its employees and pensioners settled in Cochin or nearby cities. The applicant had been undergoing treatment in the Department of Cardiology, Nizam Institute of Medical Science, Hyderabad and on advice on medication as out patient treatment medical bills were reimbursed in Hyderabad. On retirement he is settled down in Kochi and his continuing treatment in Amritha Institute of Medical Science and Research Centre, which is recognized by the ICAR for undertaking medical treatment for serving employees/pensioners. The applicant had made claim for reimbursement of amounts for the treatment from 01.05.2016 to 30.09.2016, 01.10.2016 to 30.06.2017, 05.09.2017 to 05.12.2017 and 01.07.2017 to 30.04.2018, as shown in Annexure A-1 to A-4 for different amounts that comes to Rs.18,649/-, Rs.32,587/-, Rs.3,693/- and Rs.30,170/-respectively. But all those claims have been rejected by the respondents on the ground that 'for pensioners, medicines for out-patient treatment need to be obtained from NAARM Dispensary or with a certificate of non-availability from market. This is as per ICAR Rules for treatment facility available to ICAR pensioners in Hyderabad.' He has produced relevant documents as Annexures A5 and A5A. Thus Annexure A-1 claim was rejected by Annexure A-6. Aggrieved by the same, the OA has been filed. Since the above stated claims were rejected, he did not stake claim for an amount of Rs.21,873/- incurred for the treatment from 01.05.2018 to 30.11.2018.
2. According to the applicant he has not opted for Fixed Medical Allowance and is not receiving any such amount. He was getting medical expenses for out patient treatment after retirement, during the period of his stay in Hyderabad, from December 2015 to April 2016. However on shifting to Cochin on retirement he has been denied the benefit. He has also referred to Annexures A-8 to A-12. According to him he is entitled to get the amounts reimbursed and therefore seeks a declaration that he is entitled to get medical expenses reimbursed in full as claimed through Annexure A-1 to A-4 and medical expenses incurred by Annexure A-7 without any deduction, to direct the respondents to reimburse the medical expenses incurred for out-patient treatment and continue to reimburse the amounts as and when claimed, call for records leading to Annexures A-5, A-5A and A-6 and set aside the same.
3. According to the applicant a Government servant is entitled to get the benefits under Rules 3 & 6 of Central Services (MA) Rules. Such a benefit cannot be denied to the pensioners as well. The High Court of Himachal Pradesh by judgement in CWP No.4621 /2011 has declared the law and said that it is illegal to deny post retirement medical care to retired employees. The High Court also held that it is the prime responsibility of the State to protect the health of its workers; the retired government officials residing in non-CGHS areas are also entitled to the benefits and it is unconstitutional to deny them the benefits.
4. On behalf of the respondents, the 2nd respondent filed reply challenging the very maintainability of the Original Application. According to him none of the reliefs can be granted. He admits that the applicant had retired as Senior Administrative Officer from the Indian Institute of Rice Research, Hyderabad. The ICAR pensioners are not entitled for reimbursement of expenses for out-patient treatment. They are only entitled to get fixed medical allowance in lieu of OP treatment. Exception is to register with the dispensaries attached to the institutes within their place of residence and avail medical facilities as per ICAR Rules. The applicant had submitted his option only on 21.01.2019 and on the same, action is being taken. At the same time, he has stated that the applicant has not exhausted all his remedies and could have given representation against the decision of the DDO before the Director of ICAR and again before the DG, that has not been done. According to them applicant is entitled to get reimbursement of medical claims only in respect of inpatient treatment and reimbursement of expenses of out-patient treatment is beyond the purview of the Rules. Therefore, the OA is sought to be dismissed.
5. I heard the learned counsel for the applicant Shri P.V. Mohanan as well as Shri P. Santhosh Kumar, Standing Counsel for the respondents. Referring to note-(i) below Rule 2(e) of the CS(MA) Rules, 1944 the learned counsel for the applicant submitted that 'Medical Attendance' 'includes attendance at the hospital/dispensary (i.e. at the out-patient department) or at the residence of the Government servant or at the consulting room of the authorised medical attendant, whether maintained at the hospital, or its own residence, by arrangement with him.' So the learned counsel wanted to say that pensioner is entitled to get reimbursement of expenses incurred for out-patient treatment as well. According to the learned counsel Rule 3(1)(2) and Rule 6(1) (2) of the Rules are applicable. The applicant has not opted for FMA or CGHS, so that he has to get medicines from NAARM or reimbursement from NAARM. He is now 67 years old and a cardiac patient. He cannot be asked to go to Hyderabad for getting the reimbursement. Therefore the respondents have a duty to reimburse the huge medical expenses incurred by him for his treatment. He has also invited my attention to Annexures A-8, A-9, A-12 etc. According to the learned counsel, the delay in filing the application for reimbursement is not a reason for rejecting the same. His pension was settled only on 14.12.2018 and that he can make an application for condonation of delay. Referring to Annexure A-14 he states that Amrita Institute of Medical Sciences and Research Centre, Cochin, is a recognized medical centre, so long as he is settled down in Cochin he is entitled to get treatment from that centre.
6. On the other hand, according to Shri P. Santhosh Kumar, option was given only on 21.01.2019. Learned counsel also reiterated that statutory remedies available to the applicant have not been availed. But he could not state definitely what are such statutory remedies before exhausting which the applicant had approached this Tribunal.
7. Applicant is aggrieved by non-granting of reimbursement of various medical expenses incurred by him for out-patient treatment which he had claimed before the respondents. Annexure A-5 indicates that the applicant is not entitled to get reimbursement of expenses incurred for out-patient treatment, that if medicines are prescribed in out-patient treatment, it should be obtained from NAARM dispensary or with a certificate of non-availability from market and that this is done as per ICAR rules for treatment facility available to pensioners in Hyderabad. Annexure A-6 claim was rejected since it was made after a period of 6 months. The applicant submits that he will move for condonation of delay for such claims. However, the crux of rejection of the claim is that the respondents have no liability to reimburse out-patient expenses.
8. The correctness of this contention can be examined. In this connection the applicant has relied on Annexures A-8, A-9 and A-12 communications issued by the respondents.
9. Annexure A-8 seems to be the mother circular regarding the extensin of medical facilities for retired employees of the ICAR including its institutes. It is appropriate to extract paragraphs 1 to 4 and 6 of the said OM for our convenience:-
“1. ICAR pensioners shall avail medical facilities to the extent available at the dispensaries at the ICAR Instts. located in and around the place of their settlement. This dispensary facility shall be admissible to ICAR pensioners and their other dependent family members. The scheme will also cover the family pensioners and the employees retiring with CPF benefits. The facility will be at par with the pensioners availing CGHS facility.
2. The pensioners shall get themselves registered with the respective dispensaries of the Instts.
3. In case medical officer/in-charge of the dispensaries refers ICAR pensioner or his/her dependent family members to Govt./Recognized Hospitals by the Instts. concerned for consultation/specialist treatment from OPD, the medicines so prescribed shall be supplied by the ICAR dispensaries. In case of non availability of the medicine in the dispensary, that should be procured by the dispensary on urgent basis and supplied to the patient. However, no reimbursement shall be admissible to the pensioners for OPD treatment at the Govt/ recognized hospitals.
4. Medical reimbursement in respect of the indoor treatment in a Govt. Hospital/recognised hospitals by the Instts. concerned shall be admissible provided the patient is referred for specialist treatment by the Medical Officer-in-Charge of the ICAR dispensary. Reimbursement of such claims shall be regulated under CS(Medical Attendance) Rules as applicable for Govt/recognised Hospitals and to the extent admissible to the ICAR pensioners availing CGHS facilities in Delhi.
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6. ICAR pensioners/family pensioners residing in areas not covered under CGHS administered by the Ministry of Health and Family Welfare or the dispensaries established at some of the Institutes of ICAR would be entitled for a fixed medical allowance of Rs.100/- per month for hospitalisation. The existing pensioners as well as future retirees shall have to exercise one time option to avail of medical facilities under ICAR dispensaries for day to day medical treatment or to claim fixed medical allowance at the rate of Rs.100/- per month. Those pensioners who will opt for medical allowance will however be eligible for reimbursement of hospitalisation expenses as per rules. “
10. That means Annexure A-8 communication dated 22.01.1999 indicates that medical facilities are available to pensioners also through ICAR dispensaries of the institutes for which pensioners shall get themselves registered with the respective dispensaries of the Institute. It is further stated that even if a person gets treatment from outside the dispensary, from recognized hospitals, the medicines so prescribed will be supplied by the ICAR dispensaries. If such medicines are not available it should be procured and supplied to the patient by the dispensary on urgent basis. It is made very clear that no reimbursement shall be admissible for OPD treatment at the Government/recognised hospitals.
11. Similarly paragraph 6 says that pensioners/family pensioners residing in areas not covered under CGHS or the dispensary established at some of the institutes of ICAR would be entitled for FMA of Rs.100/- p.m. for meeting expenditure on day to day medical treatment, out-patient treatment, that do not require hospitalisation. It is further stated that for the same, the pensioners as well as future retirees shall exercise one time option. It is the admitted case that the applicant has not given any option nor he is claiming FMA. It is also admitted that applicant is residing in Cochin, which is a CGHS area so that he has not made any option and he is not entitled to get FMA.
12. It is seen that for treatment of pensioners there is centralized control by the ICAR institutes. Even in out-patient treatment, if they have been prescribed some medicines from a recognized hospital that can be procured only from the dispensary. May be because of wide spread protests from the employees, some relaxation has been made through Annexure A-9 regarding the same. Relevant portion of the Annexure A-9 is extracted here:
“......It has now been decided with the approval of Governing Body that the pensioners may be allowed to purchase the medicines which are not available in the Institute/dispensary and obtain reimbursement of the cost of medicines prescribed by Specialist Consultant in OPD.”
It is an admitted position that there is no dispensary attached to ICAR institute in Cochin. A clarification was sought regarding such case. But satisfactory explanation has not been given through Annexure A-11.
13. Annexure A-12 is the last communication dated 13.08.2010 on the subject, the relevant portion reads thus:-
“.....As per the existing practice, the pensioners are required to prefer the claims for reimbursement of medical expenses to the institutes from where they retired. The representations have been received from the pensioners that they are facing a lot of hardships due to this arrangement. The pensioners' plea is that this arrangement is inconvenient as they have to move around in their old age to fulfill the procedural requirements and have to wait unduly long for settlement of their claims thus causing financial hardships to them. The matter has been considered and it has been decided that the pensioners may opt for claiming reimbursement from any of the ICAR institutes located in and around the place of their settlement to ensure speedy disposal of their claims. This option may be exercised only once and no change in the option may be allowed ordinarily barring the exceptional cases on merits of each case. The pensioners will be required to submit a formal request in this regard to the ICAR Institutes from where they retired which in turn shall forward such requests to the ICAR Institutes from where the pensioners intend to claim reimbursement. For this purpose, the Institutes shall be given extra budget, if necessary for catering to additional expenditure on account of reimbursement of medical claims of pensioners.”
Applicant submits that pursuant to the same Annexure A13 option has been given by which he has opted to claim medical reimbursement through CMFRI, Kochi as an institute of the ICAR.
14. Now the question is how far Annexure A-13 would salvage the situation and would help the applicant in getting the reliefs granted.
15. I have no doubt that the respondents do not have a definite case. They have stated that the ICAR pensioners like the applicant is not entitled to get out-patient treatment expenses reimbursed, for which Annexure A-8 document has been relied on. At the same time they have stated that the applicant has not exhausted remedies, he had given his option only in 2019, which is under process etc. These two arguments cannot go together. It is not known whether if the expenses of out-patient treatment are not reimbursable, would the position change if he gives a representation and gives an option as claimed by them.
16. In my opinion the answer is in the negative. The question that emerges is as to whether applicant is entitled to get expenses of out-patient treatment reimbursed. Annexure A-8 suggests an emphatic negative answer. It is stated in paragraph 3 that no reimbursement shall be admissible to pensioners for OPD treatment at the Government/ recognized hospitals. In my view that position remains the same even though relaxation was granted through Annexures A-9 and A-12. The applicant could not bring in any document permitting him to claim reimbursement of out-patient treatment.
17. Even though the provisions of CS(MA) Rules were quoted by the applicant it is not known as to how that would advance his case. CS(MA) Rules is applicable only to serving Government servants. The case of retired employee has been clearly excluded from the purview of the Rules. Therefore such provisions are not applicable. Even in the case of CGHS, it is not applicable to the applicant since he has not given any option nor necessary amounts have been paid by him. It is only stated that employees can be treated at par with CGHS. In other words it being an autonomous body, CGHS is not applicable to the retired employees like the applicant. Even otherwise, without making the one time payment, a pensioner cannot claim the benefits of the CGH Scheme.
18. Moreover, as stated earlier, the standing instructins do not permit reimbursement of all expenses incurred in out-patient treatment. I have no doubt that such a position is against the instructions and observations made by the High Courts and the Apex Court. I have occasion to notice the observations made by the Apex Court that no fetters can be put with regard to the claims made by the retired employees. Even though positive directions were issued by the Apex Court for looking into the matter, Government have not taken the matter seriously. ICAR pensioners are governed by Annexures A-8, A-9 and A-12 etc. These communications do not permit reimbursement of out-patient treatment. Exercising option and getting amounts collected etc. in my judgement is applicable only in case of in-patient treatment of ICAR pensioners. In the absence of clear provision enabling retirees to reimburse expenses incurred in out-patient treatments, the claim of the applicant is not sustainable. At the most, once given the option, pensioners shall be allowed to purchase the medicines which are not available in the Institute/dispensary and obtain reimbursement of cost of medicines prescribed by Specialist Consultant in OPD.
19. As indicated, the mother circular in this regard is Annexure A-8 dated 22.01.1999. Annexures A-9 and A-12 etc have been issued pursuant to the communication in Annexure A-8. In Annexure A-8 it is explicitly made clear that reimbursement claim shall not be admissible to the pensioners for out-patient treatment. That has been reiterated in Annexure A-9 also. That proposition holds the field. The applicant has not challenged the correctness of this instruction in Annexures A-8 and A-9. So long as Annexures A-8 and A-9 hold the field, in my view. the applicant cannot claim reimbursement of the amount incurred for his out-patient treatment even if he makes a claim through the NAARM dispensary in Hyderabad.
20. The learned counsel for the applicant is quite right when he stated that it is immoral and illegal to deny out-patient treatment expenses of a retired pensioner. They cannot be discriminated against. When age advances such expenses also will swell. Moreover, driving the aged retirees to the ICAR dispensaries for procuring the medicines etc. creates an anomalous situation which needs to be addressed at the earliest. Therefore, there must be a scheme for meeting such expenses of pensioners like the applicant. I hope and direct the respondents to address the issue and take positive decisions at the earliest within a period of 90 days from today.
21. With this direction the OA is dismissed. No costs.
(Dated this the 12th day of May, 2023)
