Madras High Court
Mrs.K.Nithyanandakumari vs The Secretary To Government on 23 April, 2021
W.P(MD)No.8363 of 2021
BEFORE THE MADURAI BENCH OF MADRAS HIGH COURT
DATED: 23.04.2021
CORAM:
THE HONOURABLE MS.JUSTICE V.M.VELUMANI
W.P.(MD)No.8363 of 2021
and
W.M.P(MD)No.6331 of 2021
Mrs.K.Nithyanandakumari ... Petitioner
Vs.
1.The Secretary to Government,
Government of Tamil Nadu,
Finance (Salaries) Department,
Fort St. George, Chennai-9.
2.The Senior Divisional Manager,
United India Insurance Company ltd.,
Divisional office VI,
Rathna Towers, 5th Floor,
No.212, Anna Salai,
Chennai-600 006.
3.The District Collector,
Theni District.
4.The Joint Director,
Health & Family Welfare,
Theni at Periyakulam. ... Respondents
PRAYER: Writ Petition under Article 226 of the Constitution of
India, to issue a Writ of Certiorarified Mandamus, calling for the
records relating to the impugned order of the second respondent,
dated 16.03.2020 and Sl.No.14 of the list annexed therewith
1/9
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W.P(MD)No.8363 of 2021
rejecting petitioner's claim for meidcal claim communicated to the
petitioner by the third respondent on 23.09.2020 and quash the
same and consequently direct the respondents herein to reimburse
the medical claim of Rs.3,50,000/- together with interest at the rate
of 7.5% thereon to the petitioner covered by the medical records
and medical bills within a reasonable time.
For Petitioner : Mr.K.Appadurai
For R1, R3 & R4 : Mr.C.Ramesh,
Special Government Pleader
For R2 : Mr.A.Shajahan
ORDER
This writ petition is filed challenging the orders of the second
respondent, dated 16.03.2020 and consequently direct the
respondents herein to reimburse the medical claim of Rs.3,50,000/-
together with interest at the rate of 7.5% p.a., thereon to the
petitioner covered by the medical records and medical bills ,within
a reasonable time as may be fixed by this Court.
2. Mr.C.Ramar, learned Special Government Pleader takes
notice for the first respondent and Mr.A.Shajahan, learned counsel
takes notice for the second respondent. By consent of both parties,
this Writ Petition is taken up for final disposal at the stage of
admission itself.
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W.P(MD)No.8363 of 2021
3. The petitioner was working as Assistant Professor (Maths)
in C.P.A.College, Bodinayakanur, Theni District. In April 2019, she
suffered acute illness “Rheumatic Heart Disease, S/P CMV, S/P
BMV, Severe Mitral Regurgitation, NYH A II, OLD CVA, Bronchial
Asthma, due to which, she was immediately rushed to
G.Kuppusamy Naidu Memorial Hospital, Coimbatore and admitted
as inpatient for her treatment from 15.04.2019 to 23.04.2019. She
was discharged from the hospital on 23.04.2019, incurring medical
expenses to the tune of Rs.3,50,000/-. She submitted an
application for medical reimbursement on 16.08.2019 to the third
respondent. The third respondent, in-turn forwarded the same to
the fourth respondent by communication, dated 22.08.2019, to
verify the genuineness of the medical records and treatment taken
by her. The fourth respondent by communication, dated
13.09.2019 summoned her with medical records and ID for
verification. After the verification of records, on 30.01.2020 the
fourth respondent recommended to the second respondent for
medical reimbursement and the same was returned by the second
respondent on 16.03.2020 on the ground that the hospital, in which
treatment taken by her was a non-network hospital and the same
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W.P(MD)No.8363 of 2021
was communicated to the petitioner on 23.09.2020.
4. The learned counsel for the petitioner contended that as
per G.O.(Ms)No.391, Finance (Salaries) Department, dated
10.12.2018, the petitioner is entitled for reimbursement of the
amounts spent for the treatment taken by her in a non-network
hospital, as the petitioner had to undergo Mitral Valve Replacement
surgery on emergency basis. He also relied on the order of this
Court in N.Raja v. The Government of Tamil Nadu reported in
2016(3) CTC 394, wherein this Court held that when an employee
underwent treatment in a non-network hospital in emergency, the
employee is entitled for reimbursement of medical expenses and
prayed for allowing the writ petition.
5. The learned Special Government Pleader appearing for the
respondents 1,3 & 4 and the learned counsel appearing for the
second respondent separately contended that the petitioner is
residing at Theni and knowing fully well that G.Kuppusamy Naidu
Memorial Hospital, Coimbatore, is a non-network hospital and took
treatment therein. Therefore, the petitioner is not entitled for
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W.P(MD)No.8363 of 2021
reimbursement of medical expenses from the respondents as per
the medical scheme. As per the medical scheme, the first
respondent is liable to pay the medical expenses, if only, the
treatment taken in a network hospital approved by the first
respndent. If treatment is taken in a non-network hospital, the
first respondent is not liable to reimburse the medical expenses
spent by the petitioner and petitioner is not entitled to the relief
sought for in the present writ petition.
6. Heard the learned counsel appearing for the petitioner and
the learned Special Government Pleader appearing for the first
respondent and the learned counsel appearing for the second
respondent.
7. From the materials on record, it is seen that in an
emergency, the petitioner had underwent Mitral Valve Replacement
Surgery in G.Kuppusamy Naidu Memorial Hospital, Coimbatore,
which is a non-network hospital. The Insurance Policy is in between
the insurance company, Government and its employer and the same
is contractual in nature. The insurance company will be liable to
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W.P(MD)No.8363 of 2021
meet the medical expenses only as per the terms of the insurance
policy. The learned counsel for the petitioner and the learned
Special Government Pleader contended that in the policy, it has
been held that the fourth respondent is liable to pay the medical
expenses, only if the treatment is taken in a network hospital
approved by them. The petitioner had taken a treatment in a non-
network hospital and therefore, the fourth respondent is not liable
to pay the medical expenses incurred by the petitioner. In the
order relied on by the learned counsel for the petitioner in the case
of N.Raja v. The Government of Tamil Nadu reported in
2016(3) CTC 394, it has been held that when an employee
undergoes treatment in an emergency in a non-network hospital,
the employee is eligible for reimbursement from the Government.
Further, in Clause 5(4) of G.O.Ms.No.391, dated 10.12.2018, it is
stated that an employee/eligible family members undergoes
emergency treatments/surgeries, not covered under this Scheme
either in a network Hospital or a non-network Hospital, no claim
can be filed under the New Health Insurance Scheme. However,
they shall be eligible for claim to the extent permissible under the
Tamil Nadu Medical Attendance Rules and G.O.Ms.No.1023, Health
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W.P(MD)No.8363 of 2021
and Family Welfare Department, dated 17.06.1980. As per the
said Rules, the petitioner is entitled upto Rs.2,00,000/-. In view of
the Judgment of the Division Bench relied on by the Single Judge in
the order in N.Raja v. The Government of Tamil Nadu reported
in 2016(3) CTC 394 and G.O.(Ms)No.391, dated 10.12.2018, the
petitioner is entitled to the benefit of medical reimbursement as
per the Tamil Nadu Medical Attendance Rules. In view of the same,
the respondents are directed to pay the eligible amount as per the
Tamil Nadu Medical Attendance Rules to the petitioner, within a
period of twelve weeks from the date of receipt of a copy of this
order.
8. With the above observations and direction, the writ petition
is allowed. No costs. Consequently, connected miscellaneous
petition is closed.
23.04.2021
Index:Yes/No
Internet:Yes/No
am
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W.P(MD)No.8363 of 2021
To
1.The Government of Tamil Nadu,
Finance (Salaries) Department,
Fort St. George, Chennai-9.
2.The Senior Divisional Manager,
United India Insurance Company ltd.,
Divisional office VI,
Rathna Towers, 5th Floor,
No.212, Anna Salai,
Chennai-600 006.
3.The District Collector,
Theni District.
4.The Joint Director,
Health & Family Welfare,
Theni at Periyakulam.
https://www.mhc.tn.gov.in/judis/
W.P(MD)No.8363 of 2021
V.M.VELUMANI,J.,
am
W.P.(MD)No.8363 of 2021
23.04.2021
https://www.mhc.tn.gov.in/judis/
