Madras High Court
J.R.Subramanian vs The District Collector on 16 June, 2021
W.P.(MD)No.8346 of 2021
BEFORE THE MADURAI BENCH OF MADRAS HIGH COURT
DATED: 16.06.2021
CORAM:
THE HONOURABLE MS.JUSTICE V.M.VELUMANI
W.P.(MD)No.8346 of 2021
J.R.Subramanian ... Petitioner
Vs.
1.The District Collector,
Collectorate, Madurai,
Madurai District.
2.The District Treasury Officer,
District Tresury,
Collectorate Complex,
Madurai-625 020.
3.The United India Insurance Co., Ltd.,
Represented by the Divisional Manager,
Divisional Office VI,
PLA Rathna Towers, 5th Floor,
No.212, Anna Salai,
Chennai-600 006. ... Respondents
PRAYER: Writ Petition is filed 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 O.Mu.No.
6291/2020/M1, dated 02.2021 signed on 26.02.2021 on the file
of the second respondent and quash the same as illegal and
consequently to direct the respondents to provide the medical
reimbursement to the petitioner within the time stipulated by this
Court.
1/10
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W.P.(MD)No.8346 of 2021
For Petitioner : Mr.S.Louis
For R1 & R2 : Mr.P.Subbaraj
Government Advocate
For R3 : Mr.A.Shajahan
ORDER
The petitioner has filed this writ petition to quash the
Impugned Order in O.Mu.No.6291/2020/M1, dated 02.2021,
signed on 26.02.2021, passed by the second respondent as illegal
and for a direction to the respondents to provide the medical
reimbursement to the petitioner, within the time stipulated by this
Court.
2.The petitioner was working as Textile Control Officer in
Karur and retired from service on 31.08.2014. He is a member of
New Health Insurance Scheme and premium amount is deducted
regularly from his monthly pension. The petitioner suffered serious
Urinary problem and due to emergency, he was admitted at Balaji
Hospital, Anna Nagar, Madurai on 10.02.2020 and underwent
surgery on 11.02.2020. He was discharged on 14.02.2020. The
petitioner spent Rs.45,000/- for medical treatment and submitted
his application on 27.02.2020 for reimbursement to the second
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W.P.(MD)No.8346 of 2021
respondent enclosing all the documents. The second respondent
referred the claim of the petitioner to the District Level Empowered
Committee headed by the first respondent. The first respondent
recommended the case of the petitioner by his proceedings, dated
05.10.2020 to the third respondent. But the third respondent
returned the proposal on the ground that the petitioner has taken
treatment in a non-network hospital. The second respondent inturn
returned the papers to the petitioner by the impugned
communication dated 26.02.2021. The petitioner has come out
with the present writ petition challenging the said order of return
by the second respondent.
3. The learned counsel appearing for the petitioner submitted
that the petitioner suffered severe stomach pain and due to
emergency, he was admitted in Balaji Hospital, Anna Nagar,
Madurai and underwent surgery on 11.02.2020. This Court in a
number of judgments held that claim of medical reimbursement
cannot be rejected on technicality when the employee is a member
of New Health Insurance Scheme, managed by the third
respondent Insurance Company. Once the District Level
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W.P.(MD)No.8346 of 2021
Empowered Committee recommended the case of the petitioner,
the third respondent cannot reject the same. Even if the third
respondent fails to provide the medical reimbursement the State
Government has to provide the medical reimbursement and prayed
for setting aside the order of the second respondent.
4. Mr.P.Subbaraj, learned Government Advocate appearing
for the respondents 1 & 2 and Mr.A.Shajakhan, learned counsel
appearing for the third respondent submitted that a member of
New Health Insurance Scheme entitled to medical reimbursement
only when he takes treatment in a network hospital. As per the
terms and conditions, if the member takes treatment in a non-
network hospital, the third respondent Insurance Company is not
liable to reimburse the medical expenses. The application of the
petitioner was returned, as he has taken treatment in a non-
network hospital and in such circumstances, the petitioner is not
entitled to get medical reimbursement incurred by him and prayed
for dismissal of the writ petition.
5.Heard the learned counsel appearing for the petitioner, the
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W.P.(MD)No.8346 of 2021
learned Government Advocate appearing for the respondents 1 & 2
and the learned counsel appearing for the third respondent and
perused the materials available on record.
6. From the materials on record, it is seen that the petitioner
is a member of New Health Insurance Scheme. The premium of
said scheme for the petitioner is deducted every month from his
pension. New Health Insurance is a contract between the
Insurance Company, Government and employer and they are bound
by terms and conditions of scheme. In turn a member of scheme
also bound by the scheme. As per the scheme, the Insurance
Company is liable to reimburse the medical expenses incurred only
when he takes treatment in a network hospital. When a member of
the scheme takes treatment in a non net work hospital due to
emergency, the employee is not left with any remedy. I had an
occasion to consider the issue in the writ petition in W.P(MD)No.
8363 of 2021, dated 23.04.2021 and held as follows:-
“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-
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W.P.(MD)No.8346 of 2021
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
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
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W.P.(MD)No.8346 of 2021
permissible under the Tamil Nadu Medical
Attendance Rules and G.O.Ms.No.1023, Health 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.”
7. The ratio in the said order is applicable to the facts of the
present case. 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. As per the said Rules, the petitioner is entitled upto
Rs.2,00,000/-. In the present case, the claim of the petitioner is
only Rs.45,000/-.
8. Accordingly, the impugned order of the second respondent
in O.Mu.No.6291/2020/M1, dated 02.2021 is set aside. The
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W.P.(MD)No.8346 of 2021
petitioner is directed to resubmit the application along with
relevant documents to the respondents 1 & 2 within a period of two
weeks from the date of receipt of a copy of this order. On receipt of
the said representation, the respondents 1 & 2 are directed to pay
a sum of Rs.45,000/- as per the Tamil Nadu Medical Attendance
Rules to the petitioner, within a period of four weeks thereafter.
9. With the above directions, the writ petition is allowed. No
costs.
16.06.2021
Index:Yes/No
Internet:Yes/No
am
Note :
In view of the present lock down
owing to COVID-19 pandemic, a
web copy of the order may be
utilized for official purposes, but,
ensuring that the copy of the order
that is presented is the correct copy,
shall be the responsibility of the
advocate / litigant concerned.
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W.P.(MD)No.8346 of 2021
To
1.The District Collector,
Collectorate, Madurai,
Madurai District.
2.The District Treasury Officer,
District Tresury,
Collectorate Complex,
Madurai-625 020.
https://www.mhc.tn.gov.in/judis/
W.P.(MD)No.8346 of 2021
V.M.VELUMANI,J.,
am
W.P.(MD)No.8346 of 2021
16.06.2021
https://www.mhc.tn.gov.in/judis/
