Retired Employee Medical Reimbursement: Claim conditional on timely submission of original documents.

The applicant, Shri Gautam Chanda, a retired BSNL employee, sought reimbursement for medical bills totaling Rs. 1,14,870/- and Rs. 1,10,453/- for the emergency treatment of his unmarried dependent sister, Miss Jasasmita Chanda, at Bethany Hospital, Shillong.

Miss Chanda was admitted on August 1, 2022, for severe abdominal pain and nausea, and an emergency certificate was issued by the doctor.

The applicant submitted the medical bills for reimbursement on February 24, 2023.

Verbally informed that Bethany Hospital was no longer empanelled, the applicant submitted a copy of his medical card and the doctor's advice certifying the emergency.

Despite several applications and a reminder on July 22, 2024, the bills remained unreimbursed.

The respondents stated that the reimbursement application was pending due to non-submission of mandatory supporting documents, as per their RTI reply on February 7, 2024.

They claimed that the indoor medical bills were returned on April 15, 2024, via registered post for non-submission of documents, but the applicant refused to accept the mail.

The applicant, in his rejoinder, argued that due to the emergency, he could not provide all documents initially but later submitted his medical card and doctor's advice.

He also cited BSNL instructions allowing indoor treatment in non-empanelled hospitals in emergencies, with reimbursement restricted to CGHS rates after verification.

The respondents' counsel acknowledged that emergency admission to non-empanelled hospitals is permissible with an emergency certificate.

However, there were discrepancies in the dates on the emergency certificates submitted by the applicant, requiring original documents for verification, which he had not provided.

The respondents' counsel confirmed that the claim would be considered upon submission of original documents, and the applicant's counsel agreed.

1. Whether the applicant is entitled to the reimbursement of medical bills for emergency treatment of his dependent sister in a non-empanelled hospital?

2. Whether the non-submission of original mandatory supporting documents by the applicant prevents the processing of the medical reimbursement claim?

The court primarily referenced the BSNL Employees Medical reimbursement policy and specific instructions published vide office order No. BSNL/ADMN/1 dated April 22, 2003, which outline the procedure for applying for medical reimbursement for indoor treatment and the mandatory supporting documents.

It also considered instructions regarding "Reimbursement of medical claim for retired employees of BSNL," specifically para 3.0(vi), which states that retired employees or their dependents may receive indoor treatment from non-empanelled hospitals only in emergency cases, provided the designated officer in BSNL is informed and reimbursement is restricted to prevailing CGHS rates after due verification.

The court's analysis focused on the applicant's entitlement to medical reimbursement for emergency treatment in a non-empanelled hospital versus the respondents' requirement for mandatory documentation.

While the BSNL policy permits emergency treatment in non-empanelled hospitals, subject to specific conditions like informing the designated officer and subsequent verification, the respondents highlighted the applicant's failure to submit critical supporting documents and discrepancies in the emergency certificates.

The court acknowledged the verbal agreement between the counsels for both parties during the hearing, where the respondents agreed to process the claim if the original documents were submitted.

This effectively resolved the immediate impasse by upholding the procedural requirement for documentation while recognizing the underlying entitlement for emergency treatment.

The respondents were then directed to process the claim within a further period of 30 days.

The court made no order as to costs.