Madras High Court
M.A.Jawaharudeen vs State Of Tamil Nadu on 19 April, 2021
W.P(MD)No.8040 of 2021
BEFORE THE MADURAI BENCH OF MADRAS HIGH COURT
DATED: 19.04.2021
CORAM:
THE HONOURABLE MS.JUSTICE V.M.VELUMANI
W.P.(MD)No.8040 of 2021
and
W.M.P(MD)No.6138 of 2021
M.A.Jawaharudeen ... Petitioner
Vs.
1.State of Tamil Nadu,
Represented by the Secretary to Government,
Department of Health and Family Welfare,
Secretariat, Fort St. George,
Chennai-9.
2.The State of Tamil Nadu,
Rep. by the Secretary to Government,
Finance (Pension Department),
Secretariat, Chennai-9.
3.The District Collector,
Collectorate,
Tirunelveli District.
4.The Joint Director of Medical and Rural Health Services,
O/o.Joint Director of Medical and Rural Health Services,
Tenkasi, Tirunelveli District.
5.The United India Insurance Company ltd.,
Rep. by the Divisional Manager,
Divisional office,
5th Floor PLA Rathna Tower,
212, Anna Salai,
Chennai-600 006. ... Respondents
1/9
https://www.mhc.tn.gov.in/judis/
W.P(MD)No.8040 of 2021
PRAYER: Writ Petition under Article 226 of the Constitution of
India, to issue a Writ of Certiorarified Mandamus, to call for the
records pertaining to the impugned order in Na.Ka.No.
5917/Ka5/2018, dated 16.09.2019 on the file of the respondent No.
4 and consequential impugned order in Na.Ka.No.5917/Ka5/2018
dated 11.01.2021 on the file of the Respondent No.4 and quash the
same as illegal and consequential direction to the respondents to
grant the Medical Reimbursement claim of Rs.1,93,952/- (Rupees
one Lakh Ninety Three Thousand Nine Hundred and Fifty Two only)
with accrued interest to the petitioner under the Government of
Tamil Nadu New Health Insurance Scheme-2016 within the time
stipulated by this Court.
For Petitioner : Mr.I.Pinaygash
For R1 to R4 : Mr.C.M.Mari Chellaiah Prabhu
Additional Government Pleader
ORDER
This writ petition is filed challenging the orders of the fourth
respondent in Na.Ka.No.5917/Ka5/2018, dated 16.09.2019 and
consequential impugned order in Na.Ka.NO.5917/Ka5/2018 dated
11.01.2021 and quash the same and for a direction to the
respondents to reimburse the Medical Expenses of Rs.1,93,952/-
incurred by the petitioner, for taking Medical treatment with
accrued interest.
https://www.mhc.tn.gov.in/judis/
W.P(MD)No.8040 of 2021
2. The petitioner has taken a Medical Insurance, bearing
Number PWD/01/PM340/NHIS16/2000043. On 05.10.2018, he felt
heavy pain in his right shoulder during his sleep and his family
doctor advised him to take MRI scan and after seeing the MRI scan
report, which was received on 06.10.2018, the doctor advised him
to consult an Ortho doctor. At his advise, on 06.10.2018 he
contacted one Dr.Ajith Inigo MS, Ortho, who conducts Arthroscopic
Repair of Ligaments Surgery (which is covered under the NHIS
Scheme 2016 as serial No.13(d)) in the list of diseases in Annexure
II. After examining the petitioner and verifying the reports, the
Doctor advised him to undergo an Arthroscopic surgery at the
earliest, since the condition of the shoulder is in such a stage.
Therefore, he was admitted in the Rhock Hospital on 07.10.2018
and the surgery about the Arthroscopic Repair of Ligaments for his
right shoulder has been done on 08.10.2018 and he was discharged
from the hospital on 12.10.2018. The total expenses incurred by
the petitioner for the said surgery is Rs.1,93,952/- and he paid the
same to the hospital, as the hospital is a non-Network hospital. The
petitioner made a representation to the fourth respondent on
27.10.2018 and requested reimbursement of Rs.1,93,952/-. The
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W.P(MD)No.8040 of 2021
fourth respondent rejected his request and refused to provide
medical reimbursement on the ground that Rhock Hospital,
Tirunelveli is a Non Network Hospital and hence, not
recommended for medical reimbursement.
3.Again, on 09.12.2019 the petitioner sent a representation to
the fourth respondent to consider his claim for reimbursement in
the light of the similar orders passed by this Court in W.P(MD)No.
13429 of 2013, dated 28.05.2019. However, that was also rejected
by the fourth respondent on 11.01.2021 mentioning the very same
reason. In the circumstances, the petitioner has come out with the
present writ petition and prayed for setting aside the orders of the
fourth respondent and for a direction to the respondents for
reimbursement of medical expenses of Rs.1,93,952/- incurred by
the petitioner, for treatment together with accured interest.
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 in the non-network hospital,
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W.P(MD)No.8040 of 2021
as the petitioner had to undergo Arthroscopic Repair of Ligaments
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 counsel appearing for the respondents
contended that the petitioner is residing at Tirunelveli and knowing
fully well that Rhock Hospital, Tirunelveli, is a non-network hospital
and took treatment therein. Therefore, the petitioner is not
entitled for 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 by 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.
https://www.mhc.tn.gov.in/judis/
W.P(MD)No.8040 of 2021
6. Heard the learned counsel appearing for the petitioner and
Mr.C.M.Mari Chellaiah Prabhu, learned Additional Government
Pleader appearing for the respondents.
7. From the materials on record, it is seen that in an
emergency, the petitioner had underwent Arthroscopic Repair of
Ligaments Surgery in Rhock Hospital, Tirunelveli, 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 meet the medical
expenses only as per the terms of the insurance policy. The learned
counsel for the petitioner and the learned Additional 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 in the case of N.Raja v. The
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W.P(MD)No.8040 of 2021
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 and Family
Welfare Department, dated 17.06.1980. 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 for the medical
expenses incurred by him from the respondents. In view of the
same, the respondents are directed to pay the amount of medical
reimbursement to the petitioner, within a period of twelve weeks
from the date of receipt of a copy of this order.
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W.P(MD)No.8040 of 2021
8. With the above observations and direction, the writ petition
is allowed. No costs. Consequently, connected miscellaneous
petition is closed.
19.04.2021
Index:Yes/No
Internet:Yes/No
am
To
1.The Secretary to Government,
Department of Health and Family Welfare,
Secretariat, Fort St. George,
Chennai-9.
2.The Secretary to Government,
Finance (Pension Department),
Secretariat, Chennai-9.
3.The District Collector,
Collectorate,
Tirunelveli District.
4.The Joint Director of Medical and Rural Health Services,
O/o.Joint Director of Medical and Rural Health Services,
Tenkasi, Tirunelveli District.
https://www.mhc.tn.gov.in/judis/
W.P(MD)No.8040 of 2021
V.M.VELUMANI,J.,
am
W.P.(MD)No.8040 of 2021
19.04.2021
https://www.mhc.tn.gov.in/judis/
