HON’BLE MR. DINESH SINGH, MEMBER

1.    This Appeal has been filed under Section 19 of The Consumer Protection Act, 1986, hereinafter referred to as the ‘Act’, challenging the Order dated 23.03.2016 in C. C. No. 148 of 2009 passed by The State Consumer Disputes Redressal Commission, Delhi, hereinafter referred to as the ‘State Commission’.

The Appellant, All India Institute of Medical Sciences (AIIMS), was the Opposite Party before the State Commission, and is hereinafter being referred to as the ‘AIIMS’.

The Respondent, Dr. Raju Singh, was the Complainant before the State Commission, and is hereinafter being referred to as the ‘Complainant’.

2.    Mr. Bharat Swaroop Sharma, learned Counsel for the Complainant and the Complainant in person were heard. The material on record, including inter alia the impugned Order dated 23.03.2016 of the State Commission and the Memorandum of Appeal, was perused. 

Mr. Sonu Pandey, advocate was present for the AIIMS as proxy Counsel. The learned Counsel for AIIMS was not present. Learned proxy Counsel did not argue.

3.    Brief facts, shorn of unnecessary rhetoric, are that the Complainant is a doctor working as a permanent employee of AIIMS and is a beneficiary of the Central Government Health Scheme (CGHS). He was suffering from urological ailments for the last 10 years. He was investigated and was being treated in the AIIMS. A biopsy was conducted on 26.06.2007. A provisional date was given for an operation in the first week of August 2007 in AIIMS.

The Complainant went on a private visit to U.S.A. on 10.07.2007 with the permission of Director AIIMS. He was to resume his duties on 01.08.2007. He overstayed in the U.S. till 26.08.2007 without intimation to or prior approval of the Director AIIMS.

During the period of overstay, which, as of then, was unauthorized, he undertook investigations and a urological surgery on 07.08.2007.

He resumed his duties in AIIMS on 27.08.2007.

He preferred medical bills amounting to US $ 40,2018.93 relating to the treatment and operation undertaken in the U.S. for reimbursement under the CGHS. The matter was examined by the Standing Committee of AIIMS. It was referred to the Ministry of Health and Family Welfare.

The Ministry, vide its letter of 24.08.20210, cited the rules applicable, and intimated that treatment abroad, though available under the CGHS, did not apply to government servants who were on leave or deputation abroad. The AIIMS accordingly rejected his claim.

Separately, subsequent to his unauthorized overstay abroad, and subsequent to his rejoining duties after his overstay, the period of overstay was regularized.

4.    The State Commission, vide its impugned Order, has accepted the Complaint’s case and inter alia ordered for reimbursement of the medical bills for the treatment and operation in the U.S.

5.    It is but noted that the Complainant was a senior doctor working as C.M.O. Professor Grade in the AIIMS. He was being treated in the AIIMS, which is a premier health facility of this country.

His leave to travel to the U.S. was allowed by the Director AIIMS in the normal wont of administrative decision-making.

He however overstayed in the U.S., and, during the period of overstay, undertook the said treatment and operation.

The CGHS rules, applicable uniformly to all beneficiaries, are clear, that treatment abroad while on leave does not qualify for reimbursement under the CGHS.

In the instant case, the treatment was taken subsequent to the period of leave, during the period of unauthorized overstay.

The rules do not allow CGHS to cover treatment while on leave abroad, by no means can they cover treatment abroad during a period of unauthorized overstay.

The period of unauthorized overstay was subsequently regularized in the normal wont of administrative decision-making. This does not affect the fact that, at the relevant time, when the treatment was taken, the Complainant was in unauthorized overstay. Even if a contention is raised that the unauthorized overstay was subsequently regularized, by way of sanctioning leave, the fact still remains that reimbursement is not permissible under the rules for treatment abroad when on leave abroad.

6.    The State Commission has erred in overlooking the afore salient material facts and aspects while making its appraisal.

7.    The rules cannot be re-written for one particular beneficiary of the CGHS, to anyhow allow him the benefit of reimbursement for treatment and operation abroad while on leave / unauthorized stay abroad, which is specifically proscribed under the rules.

8.    In respect of cases cited in paragraphs 13, 14 and 15 of the State Commission’s Order, in which it has been said that the concerned doctors mentioned therein were given the benefit of treatment abroad under the CGHS, it may be stated that the facts of those cases are not available, the decision-making processes in those cases is not known. Whether or not those cases were correctly examined, whether or not the correct decisions, in conformity with the rules, were taken, whether or not the facts of those cases are distinguishable from the facts of the instant case, cannot be said.

9.    It may also be made explicit that a ‘precedent’ which is bad in rules / law does not help a subsequent case, especially in matters like reimbursement of medical claims under the CGHS, which have inter alia financial and vigilance angles also. The correct course in such cases is to undertake the necessary remedial action re the said ‘precedent’.

10.  It is deemed appropriate and necessary to advise the Director AIIMS to re-examine the cases cited in paras 13, 14 and 15 of the State Commission’s Order of 23.03.2016 and if any case(s) has been wrongly allowed in violation of the rules applicable, to take the necessary remedial action including inter alia fixation of responsibility and recovery, and send its report to the Ministry of Health and Family Welfare within a period of six months of the pronouncement of this Order.

11.  With the examination abridged above, and with the advice as contained in para 10 above, the Appeal is allowed and the Complaint is dismissed.

12.  The Registry is requested to send a copy each of this Order to (i) the Director AIIMS, (ii) the Complainant, (iii) the learned Counsel for the AIIMS and for the Complainant and (iv) the Secretary, Ministry of Health and Family Welfare, Government of India, within three days of the pronouncement of this Order, without fail.

The stenographer is requested to upload this Order on the website of this Commission immediately.