Medical Reimbursement Claims Cannot Be Rejected Merely Because Prior Referral Order Was Not Obtained Before Taking Treatment Outside State: Tripura HC [Read Judgment]

The Tripura High Court has observed that medical reimbursement cannot be denied only on the ground that the employee did not obtain prior referral order from the Medical Board before taking treatment from outside the State.

Kali Sankar Baidya, a Head Clerk engaged in District judiciary, under took the full treatment for his nasal cancer, at Vellore Hospital. His application seeking medical reimbursement for total expenditure of   Rs.3,72,031 was rejected on the ground that he did not obtain prior referral order from the Medical Board. 

He approached the High Court challenging the rejection order and contended that he had applied for a referral order before taking treatment outside the State. As his medical condition was fast deteriorating, he did not wait for it and instead approached the Vellore Hospital. The Government opposed his plea raising two objections 1) that there was no referral order allowing him to take the treatment from outside the State and 2) that there were no extra ordinary urgent grounds for him to have travelled outside the State for his treatment without presenting himself before the Medical Board.

The Chief Justice Akil Kureshi overruled the objections raised by the Government and observed thus: 

"Firstly, as noted the petitioner was struggling with aggressive infection on his nose which did not get cured despite his treatment at the hands of ENT specialist and skin specialist. The petitioner therefore desired to have further investigations and opinion from the experts. He, therefore, approached the authorities for permission to travel outside State. His request dated 29th November, 2019 met with no immediate response. He could not wait any longer. He started his travel on 5th December, 2019. It was only thereafter that the Medical Board conveyed to him that unless and until he is present a referral order cannot be issued in his favour. On 7th December, 2019 the hospital at Vellore detected that the petitioner was suffering from cancer. Under such circumstances it was not expected for the petitioner to have waited for the Medical Board to call him for personal appearance for grant of referral order which would delay his treatment. As things turned out, having gone to Vellore for investigations, the petitioner ended up the undergoing entire treatment even without returning home for which purpose his leave was sanctioned by the employer... 

Under such circumstances to expect the petitioner to wait for the referral order is unreasonable. It is not even the case of the respondents that the specialized treatment needed for such cancer is readily available within the State. In other words going by the stand of the respondents if the petitioner had presented himself before the Medical Board and waited for long enough for the Medical Board to respond to his request for grant of referral order, the same would have been granted.Only on that ground to deny the benefit of reimbursement of medical expenditure would be interpreting the policy of the Government too rigidly. Further, the ground that there was no urgency in the petitioner departing for treatment, also must be rejected. After having waited for long enough for the treatment prescribed by the local doctors to have effect and the treatment having failed to have desired effect, the petitioner had to have a proper diagnosis and line of treatment. It is not as if the petitioner departed immediately without informing the employer or even the Medical Board. The petitioner did approach the Medical Board but could not give too long a time for Medical Board to respond. The petitioner had to take a calculated risk of departing without prior referral order."

The court noted that, in a judgment in Samar Bhusan Chakraborty Vrs. The State of Tripura delivered last year, the court had observed that merely because prior referral order from the Medical Board was not obtained, such bills cannot be rejected. Thus, the court directed the Government to process the medical reimbursement bills and release the same to the extent as per the Government policy the same are payable, within eight weeks.

Case: Kali Sankar Baidya vs The State Of Tripura [W.P(C) No. 289/2020]
Coram: Chief Justice Akil Kureshi
Counsel: Adv Arijit Bhowmik, Addl. Govt. Advocate A D. Sharma

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