Case Title: NORTH DELHI MUNICIPAL CORPORATION versus SUDHA SHARMA
Case No: W.P.(C) 10565/2017
Decided on: 20th May , 2024
Quorum: HON’BLE MS. JUSTICE REKHA PALLI and HON’BLE MR. JUSTICE SAURABH BANERJEE
Facts of the case
Sh. Krishan Kant Bhardwaj, the husband of Sudha Sharma, a staff nurse with the North Delhi Municipal Corporation, had bariatric surgery at the Shri Balaji Action Medical Institute. On January 14, 2016, Sudha Sharma went to the North Delhi Municipal Corporation’s Outpatient Department (OPD) clinic to get her husband treated. He was sent to HRH Hospital/MCD Panel Hospital for additional care following exams. He was then recommended to have bariatric surgery at Balaji Hospital, which is a hospital with an MCD panel, and on January 18, 2016, he had the procedure. It was decided that the surgery was required, and he had to pay Rs. 2,55,521 for both the procedure and the necessary medications. The company denied the reimbursement claim as the surgery had not been previously approved. After then, Sudha Sharma submitted an original application to be reimbursed, which was allowed by the Central Administrative Tribunal.
Issues
1. Was Prior Permission Necessary for the Bariatric Surgery Reimbursement Claim?
2. Did the Tribunal Justify Allowing the Claim Despite Lack of Prior Approval?
3. Was the Petitioner Justified in Rejecting the Claim Based on Procedural Grounds?
Legal Provisions
Ministry of Health and Family Welfare Office Memorandum dated 06.11.2013, which describes the requirements and maximum amounts that must be met in order to receive authorization or reimbursement for bariatric surgery treatments under the CGHS/CS (MA) Rules, 1944 [T4]. Guidelines mandating prior authorization for bariatric surgery since it is regarded as an elective or planned procedure, as well as the process for securing authorization from the appropriate body on the basis of a government specialist’s advice prior to the surgery’s execution [T5].
Appellant Contentions
The appellant in this case, the North Delhi Municipal Corporation, argued that the reimbursement claim was properly denied in accordance with the Ministry of Health and Family Welfare’s OM dated April 6, 2013. They contended that previous consent ought to have been sought before the surgery was performed since bariatric surgery is a voluntary, scheduled procedure rather than an emergency. The appellant contended that the claim was properly denied since no prior authorization was obtained for the surgery. They attempted to overturn the Tribunal’s contested ruling, which instructed processing the reimbursement claim.
Respondent Contentions
Respondent Sudha Sharma contended that her husband’s medical condition, as determined by the Government Medical Officer, required bariatric surgery. They emphasized that the procedure was carried out at the MCD panel hospital, to which he had been directed, and that the Experts Committee had not discovered any instances of non-compliance with protocols or needless medical care. The claim was legitimate, according to Sudha Sharma, and the policy’s intention to repay employees for medical expenses was violated by the refusal of payment. Consequently, they asked the court to handle their claim for payment of the costs associated with the bariatric procedure.
Court Analysis and Judgement
In the case of North Delhi Municipal Corporation v. Sudha Sharma, the court considered the arguments made by each party with reference to the bariatric surgery reimbursement claim. The respondent’s husband had bariatric surgery at the MCD panel hospital to which he was directed, the court observed, despite the fact that norms demand prior clearance for such procedures. The court noted that the doctors at the panel hospital had determined that the surgery was essential and that there had been no denial of the claim’s veracity. The respondent’s claim for reimbursement was granted by the court, taking into account the hospital’s recommendation to perform surgery in order to treat the medical condition as soon as possible. In spite of the absence of prior authorization, the court recognized the urgency of the circumstances and the fact that the surgery was carried out for less money than was authorized. As a result, the court maintained the tribunal’s ruling approving the respondent’s request for payment of the costs associated with the bariatric procedure. The North Delhi Municipal Corporation filed a writ case, but the court dismissed it, finding no flaw in the contested ruling. In addition, the court allowed the petitioner time to pay the remaining claim amount after verification and ordered the release of the deposited funds in the respondent’s favor. Finally, the court decided in Sudha Sharma’s favor, ordering the North Delhi Municipal Corporation to handle her husband’s reimbursement claim for the costs of bariatric surgery.
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Judgement Analysis Written by – K.Immey Grace
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