Madras High Court
Thangavelu vs The Government Of Tamil Nadu on 30 July, 2021
W.P.No.15547 of 2021
IN THE HIGH COURT OF JUDICATURE AT MADRAS
DATED: 30.07.2021
CORAM:
THE HONOURABLE Mr. JUSTICE S.S.SUNDAR
W.P.No.15547 of 2021
and W.M.P.No.16461 of 2021
Thangavelu .. Petitioner
Versus
1.The Government of Tamil Nadu,
Rep. by its Secretary,
Finance (Salaries) Department,
Fort St. George,
Chennai – 600 009.
2.The Government of Tamil Nadu,
Rep. by its Secretary,
Transport Department,
Fort St. George,
Chennai – 600 009.
3.The Director,
Office of the Director of Treasuries and Accounts,
2nd Floor, Panagal Building,
Saidapet, Chennai – 600 015.
4.The Commissioner,
Transport Department,
Chepauk, Chennai.
5.The District Collector,
Tiruppur District.
6.The Joint Director,
Medical and Rural Health Service,
Government Hospital Head Quarters, Tiruppur.
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W.P.No.15547 of 2021
7.The Managing Director,
The United India Insurance Co. Ltd.,
PLA Rathna Towers, 5th Floor,
212 Anna Salai, Chennai – 600 006.
8.The Chairman,
Kovai Medical Centre Hospital (KMCH)
Coimbatore.
9.Endolite India Limited,
9th, 2nd Avenue,
Sivananda Colony, Tatabad,
Coimbatore – 641 012. .. Respondents
PRAYER: Writ Petition filed under Article 226 of the Constitution of India,
praying to issue a Writ of Mandamus directing the respondent 1 to 7 to
reimburse Rs.20,78,979 along with appropriate interest for the medical
expenses incurred by the petitioner under Government of Tamil Nadu,
New Health Insurance Scheme within a time frame as Fixed by this Court
by considering the petitioner's representation dated 30.06.2021.
For Petitioners : Mr.D.R.Arun Kumar
For Respondents : Mr.C.Kathiravan
Government Advocate for R1 to R6
O RD E R
This Writ Petition has been filed for issuance of a Writ of Mandamus
directing the respondents 1 to 7 to reimburse Rs.20,78,979/- along with
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W.P.No.15547 of 2021
appropriate interest for the medical expenses incurred by the petitioner
under Government of Tamil Nadu, New Health Insurance Scheme within a
time frame as may be fixed by this Court by considering the petitioner's
representation dated 30.06.2021.
2.The petitioner joined service as a Motor Vehicle Inspector in the
Transport Department on 10.01.1994 and subsequently, on 20.06.2009,
was promoted to the post of Regional Transport Officer and retired from
service on 31.01.2020 as Regional Transport Officer, Dharapuram. It is
stated by the petitioner that, while he was in service, he went for
inspection of schools as per the direction of this Court, pursuant to the
Kumbakonam School Tragedy. It is also the case of the petitioner that he
accidentally walked on thar road with his bare foot and at the time, the
hot thar on the road damaged his foot, as a result of which, his both legs
below the knees were removed by the 8th respondent hospital after four
surgeries that went unsuccessful. After multiple surgeries, the petitioner
was discharged from the hospital with artificial limbs affixed by the 9 th
respondent under the care and supervision of the 8th respondent hospital
for both the legs, and after four months of treatment, the petitioner had
joined duty on 28.09.2018. It is stated that the petitioner is eligible for
the medical reimbursement as per the Tamil Nadu Medical Health Scheme
formulated by the Government.
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W.P.No.15547 of 2021
3.The petitioner states that a sum of Rs.20,78,979/- was spent for
his treatment and the petitioner submitted an application for
reimbursement of medical expenses, along with medical bills, discharge
summaries and documents to the official respondents for scrutiny and
consideration.
4.The 6th respondent rejected the petitioner's claim by
communication dated 15.11.2019 based on the recommendation of the 5th
respondent dated 29.10.2019. Since the petitioner did not undergo
treatment in the approved hospital as per the Medical Insurance Scheme,
the claim of the petitioner for medical reimbursement was rejected.
Subsequently, it is stated that, as the 5th respondent accepted the
petitioner's representation, the petitioner found himself embarrassed and
ultimately approached this Court for getting a direction to get his medical
reimbursement to the tune of Rs.20,78,979/-
5.Despite several representations having been submitted by the
petitioner for disbursement of medical reimbursement, it is stated that the
respondents have not come forward to settle the amount. Though the
District Collector by his proceedings dated 29.10.2019 accepted the bills,
it is stated that the petitioner's representation for disbursement was not
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W.P.No.15547 of 2021
favourably considered by the respondent. The learned counsel appearing
for the petitioner relied upon several judgments of this Court with regard
to the medical reimbursement. The learned counsel relied upon the
Division Bench judgment in W.P.(MD)No.4404 of 2014 etc., in the
case of Ali Akbar vs. The Principal Secretary to Government,
Department of Finance, Secretariat, St. George Fort, Chennai and
others
“14. ...
26.Before taking up the individual cases, we must
record that there are certain situations which may arise and in
fact which have arisen, for which the Government must issue
clear guidelines. This the Government has to do, since it has
made the Scheme obligatory for everyone and there is
automatic deduction of premium to an extent of Rs.25/- per
month. The directions are as follows:
(i)The State shall make it clear that if for some reason, which
is satisfactory, the claimant is unable to take treatment in a
network hospital but has been advised or had to go to a non-
network hospital, then his claim would be considered under
the Rules.
(ii)If the claimant has been advised some procedure which is
not covered by the Scheme, there again, it must be made
clear that he can apply under the Rules.
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W.P.No.15547 of 2021
(iii)To safeguard duplication of payments, the Government
can make sure and when they apply under the Rules, that the
claimant himself certifies that he has not made claim under
the Scheme or vice-versa.
(iv)The State shall inform every network hospital that if it
receives complaints from claimants that money was
demanded for admission or for treatment, then that hospital
will be removed from the network. This warning is necessary,
since, at times of crisis, the claimants will not be in a position
to argue with the hospital that this is a "cashless" Scheme.
We are aware that there is an officer of the Star Health
Insurance Company at every network hospital to ensure that
hospitals adhere to the terms of the Scheme but, yet, it is
better to make this position clear to the hospitals, since one
of the questions that has arisen before us is that whether the
claimants will be entitled to reimbursement if, by mistake,
they pay cash.
27.Now coming to the individual cases, in all the case,
whatever may be the category, the petitioners/claimants have
paid the amount. The scheme is a 'cashless' one and,
therefore, it is only the Government which have to make the
payment under the Rules. The Redressal Committee is
empowered to decide the following circumstances, namely,
any difficulty in availing treatment, non-availability of
facilities, bogus availment of treatment for ineligible
individuals, etc. It is really not clear what other complaints
would be covered under the umbrella "etc.". But, however,
since the Paragraph relating to 'Redressal of Grievances'
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W.P.No.15547 of 2021
starts with the sentence "The Hospitals shall extend treatment
to the beneficiaries under the Scheme on a cashless basis", it
is evident that the Committee cannot direct payment of cash.
28.Therefore, if the claimants have made payments
whether for a procedure not covered or whether at a non-
network hospital or they have paid when they have been
treated for a covered procedure in a network hospital, their
only remedy is to approach the Government under the Rules.
If, however, before they take treatment they are informed
that a particular procedure is not covered, then at that stage,
they may approach the Redressal Committee where the
medical expert can decide whether that procedure is covered
or not. The Redressal Committee may also go into the
complaints regarding non-availability of facility at a network
hospital, which may be available in favour of the claimant
when he applies under the Rules. Otherwise, we do not think
that the Redressal Committee can do much in any one of
these cases, since all the petitioners/claimants before us
would have made payments. But, if there is a petitioner who
has not settled the claim and has come before us, then, in the
event, that it is for a procedure that is not covered, he may
approach the Redressal Committee. In view of the fact that
there are the above lacunae in the Scheme, the Government
shall not deny any claim validly made under the Rules only
because the claimant is a member of the Scheme.?
15.In the above case, though it is found that the
insurance company is not liable to reimburse the medical
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W.P.No.15547 of 2021
expenses to the employee, the liability of Government under
the Medical Attendance Rules has been fixed and it is
reiterated that the Government servants are entitled to
medical reimbursement under the Tamil Nadu Medical
Attendance Rules.
16.Another Division Bench of this Court also considered
similar issue in W.A.(MD)No.1579 of 2016 in the case of MD
India Healthcare Services (TPA) Ltd., represented by the
Branch Manager, Chennai v. K.Parameshwari and others,
following the judgment of the Division Bench of this Court,
has confirmed the order of learned Single Judge allowing
similar Writ Petition filed by the Government employee.
17.The learned counsel appearing for the petitioners
also relied upon the judgment of a learned Single Judge of
this Court in the case of N.Raja v. Government of Tamil Nadu
reported in 2016 (3) CTC 394 wherein the writ petition with
similar prayer is allowed with a direction to the State
Government to sanction and reimburse the medical expenses
incurred by the petitioner for his treatment with 9% interest
from the date of remittance of the amount to the hospital by
the petitioner till the date of payment within a period of four
weeks.
18.The learned counsel appearing for the respondents
have no serious objections for allowing the writ petition in
terms of the judgement relied upon by the learned counsels
appearing for the petitioners in the above cases. Hence, the
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W.P.No.15547 of 2021
order impugned in Writ Petition (MD) Nos.4705 of 2015,
3587, 4906 & 14468 of 2016, 1449, 3510, 3513, 4542, 5738,
6352 to 6354, 6623, 6726, 6769, 7943, 7956, 8405, 8611 &
10614 of 2017 are set aside and all the above Writ Petitions
are allowed. No costs. Consequently, connected miscellaneous
petitions are closed.
19.The petitioners in Writ Petition (MD).Nos.4705 of
2015, 3587, 4906 & 14468 of 2016, 1449, 3510, 3513, 4542,
5738, 6352 to 6354, 6623, 6726, 6769, 7943, 7956, 8405,
8611 & 10614 of 2017 whose application for medical
reimbursement have been rejected either by the Treasury
Officer of the District Treasury or by the Joint Director of
Medical and Rural Health Services or by the Insurance
Company are directed to submit the proposal to the
respondent concerned who has communicated the rejection of
claim for medical reimbursement of the petitioners concerned
and on receipt of claim application by the petitioners, the
respondent concerned in the respective Writ Petition is
directed to forward the application for medical reimbursement
to the Government or the authorised officer of the
Government who has been authorised to consider and dispose
of the medical reimbursement claim under the Tamil Nadu
Medical Attendance Rules. The State Government or the
authorised officer of the Government to whom the application
is forwarded by the respondent concerned shall disburse the
eligible amount to the respective petitioner with interest at
the rate of 9% p.a. from the date of settlement of the medical
bills by the petitioner till the amount is disbursed to the
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W.P.No.15547 of 2021
petitioner by the Government or by the department or by the
officer concerned within a period six weeks from the date on
which the petitioners' application is forwarded. The medical
reimbursement claim cannot be rejected on the ground that
treatment was taken in non-network hospitals or that the
decease or procedure is not covered by the scheme or that
petitioner has paid cash. In none of the case the fact that the
petitioner had taken treatment / undergone treatment and
spent the amount is not seriously disputed. Hence, there is no
justification for keeping the application for medical
reimbursement unnecessarily and further delay or rejection of
claim by arbitrary orders will attract interest at the rate of
12% p.a. from this date.
.
.
.
21.It is made clear that the State Government shall not
reject the claim of the petitioner for medical reimbursement
either on the ground that the hospital in which the claimant
had undertaken treatment is not covered under the scheme or
on the ground that the treatment / procedure is not included
in the list / schedule for which the insurance scheme covers.
The application for medical reimbursement also cannot be
rejected on the ground that the claimant had taken treatment
by paying cash.
22.It is further made clear that the Government or the
Authorised Officer who has to decide the applications under
the Tamil Nadu Medical Attendance Rules is directed to
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W.P.No.15547 of 2021
dispose of the applications within a period of three months
from the date on which the applications are forwarded to the
Government or the Officer concerned.
23.Assuming that the scheme is announced as a
cashless scheme, it is reported that many hospitals which are
included in the schedule of hospitals and bound to treat the
Government servant free of cost, admit the employee as in-
patient only after the Government servant pays for treatment.
Hence, the Government shall examine the unreasonable
rejection of claims by the insurance company on the ground
that the treatment is taken by the Government servant after
paying cash. Since the insurance companies have tie-up with
hospitals which are included in the schedule, receipt of money
by the hospitals for taking treatment cannot be a reason for
rejecting such application. Hence, the Government shall insist
the Insurance companies to honour the medical claims even if
the treatment is taken after paying cash.
6.This Court in several judgements has repeatedly held that the
claim made by the Government servants for medical reimbursement
should be considered under the Medical Attendance Rules and that the
respondents are liable to pay interest at 9% p.a. if there is any delay in
disbursement of eligible amount.
7.The learned counsel further stated that the medical
reimbursement cannot be kept on hold without considering the
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W.P.No.15547 of 2021
representations of the petitioner as he has been highly exhausted already
by taking treatment.
8.Under such circumstances, this Court is inclined to allow this writ
petition and this Court had an occasion to hold that, irrespective of the
fact whether the procedure is included or the hospitals are included for
the purpose of medical reimbursement, the application for medical
reimbursement cannot be rejected. The respondents are directed to
consider the petitioner's application for medical reimbursement in the light
of the directions of this Court in several precedents which are referred
into in this order, within a period of twelve weeks from the date of receipt
of a copy of this order. No costs. Consequently, connected miscellaneous
petition is closed.
9.The learned counsel appearing for the petitioner also relied upon
two judgements holding that the Government servants are also entitled to
interest at 6% p.a. The respondents are directed to pay interest at 6%
p.a. from the date of application for the amount the petitioner is entitled.
30.07.2021
Index:Yes
Speaking order
ssr
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W.P.No.15547 of 2021
To
1.The Secretary to Government,
Finance (Salaries) Department,
Fort St. George,
Chennai – 600 009.
2.The Secretary to Government,
Transport Department,
Fort St. George,
Chennai – 600 009.
3.The Director,
Office of the Director of Treasuries and Accounts,
2nd Floor, Panagal Building,
Saidapet, Chennai – 600 015.
4.The Commissioner,
Transport Department,
Chepauk, Chennai.
5.The District Collector,
Tiruppur District.
6.The Joint Director,
Medical and Rural Health Service,
Government Hospital Head Quarters, Tiruppur.
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W.P.No.15547 of 2021
S.S.SUNDAR. J.,
ssr
W.P.No.15547 of 2021
and W.M.P.No.16461 of 2021
30.07.2021
https://www.mhc.tn.gov.in/judis/
