Madras High Court
P.Arumugam vs The Inspector General Of ... on 13 September, 2022
W.P.No.1974 of 2018
IN THE HIGH COURT OF JUDICATURE AT MADRAS
DATED : 13.09.2022
CORAM
THE HONOURABLE Mr.JUSTICE R.SUBRAMANIAN
W.P.No.1974 of 2018
P.Arumugam ... Petitioner
Vs
1.The Inspector General of Registration
Tamil Nadu, 120, Santhome High Road
Chennai - 600 028.
2.MD Indian Health Care Services (TPA) Private Ltd.,
(A Unit of United India Insurance Company Ltd.,)
No.27, Lakshmi Towers, 3rd Floor
Dr.Radhakrishnan Salai
Mylapore, Chennai - 600 004.
3.The Joint Director
Health Care Service Centre
Government of Tamil Nadu
Salem District.
4.The Assistant Treasury Officer
Sankari
Salem District. ... Respondents
Prayer : Writ Petition filed under Article 226 of Constitution of India praying
1/7
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W.P.No.1974 of 2018
to issue a Writ of Certiorarified Mandamus calling for the records of the
impugned proceeding issued by the third respondent herein vide
No.Oo.Mu.No.3108/Ka4/2017, dated 01.11.2017 and quash the same and
consequently direct the respondents 2 to 4 to take necessary steps to make
necessary payment of reimbursement of the sum of Rs.1,91,245/- (Rupees one
lakh ninety one thousand two hundred and forty five only) with 9% interest till
the date of realization towards the medical bills and voucher received from the
hospital, by strictly complying with the provisions of G.O.Ms.No.171, dated
26.06.2014 and also along with reference to the covered judgment in
W.P.No.1408 of 2016 dated 05.04.2016 and pass such further or other orders
as it may deem fit and proper in the circumstances of the case.
For Petitioner : Mr.G.Thangavel
For Respondents : Mr.U.Baranidharan
Additional Government Pleader [RR1, 3 & 4]
R2 - Served [No appearance]
ORDER
The petitioner, aggrieved by rejection of his claim for medical
reimbursement vide impugned order, has filed the present writ petition.
2. The petitioner is a pensioner and he is enrolled under the Health Care
Service scheme launched by the Government of Tamil Nadu vide
G.O.Ms.No.171 dated 26.06.2014, in order to provide health care assistance to
pensioners and their family members on a cashless basis. Under the said
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W.P.No.1974 of 2018
scheme, the pensioners who are enrolled therein are entitled for protection or
reimbursement for a block period of four years from 01.07.2014 to
30.06.2018.
3. It is claimed by the petitioner that on 21.03.2017, he suffered acute
cerebral interhemispheric subdural hematoma (SDH) which is a condition
associated with the nervous system of the brain, leading to leakage of blood
from the blood vessels. Therefore, the petitioner had to undergo craniotomy
and SDH evacuation. The surgery was an emergency surgery and it was
performed on the petitioner on 21.03.2017. The petitioner had expended a
sum of Rs.1,76,043/- for the surgery. When the petitioner made a claim for
reimbursement, the same was rejected by the third respondent on the ground
that the surgery had been performed in a Non-network hospital and it is
performed after the expiary period of insurance cover.
4. The second respondent / Insurance Company though served has not
appeared through counsel.
5. The learned Government Pleader appearing for the State would
contend that the two grounds on which the petitioner's claim was rejected are
valid and therefore, the petitioner cannot be favoured with reimbursement.
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W.P.No.1974 of 2018
6. It is not in dispute that the petitioner is a beneficiary under the
scheme. The question of having treatment done in a Non-network hospital is
no longer a res integra. This Court in several decisions held that
reimbursement should not be confined to treatment done in network hospitals
and it would also include treatment done in non-network hospitals. One such
judgement of this Court is in W.P.No.1408 of 2016 dated 05.04.2016 [N.Raja
Vs. The Government of Tamil Nadu, Rep by its Secretary, Adi Dravidar
Welfare Department, Fort St.George, Chennai - 600 009 and 2 others],
wherein this Court had held that the claim for reimbursement cannot be
rejected on the ground that the treatment is done in a Non-network hospital.
So long as the fact that the treatment was taken or treatment was done is not in
dispute, then the petitioner will be entitled to reimbursement. As far as the
period is concerned, G.O.Ms.No.171 would itself state that it covers a block
period of four years within 01.07.2014 to 30.06.2018. The fact that the
petitioner has been paying his subscription is not in dispute and that the
petitioner had underwent surgery on 21.03.2017, which is within the block
period of four years. Therefore, the rejection of the petitioner's claim on the
ground that the surgery was not done on the date during which period the
policy cover was in force, cannot also be accepted.
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W.P.No.1974 of 2018
7. In view of the fact that both the grounds that were raised by the third
respondent to reject the claim of the petitioner do not stand the test of judicial
scrutiny, the impugned order of the third respondent dated 01.11.2017
rejecting the claim of the petitioner is set aside and the respondents concerned
are directed to reimburse the cost of the treatment, in accordance with law to
the petitioner. The needful be done within a period of eight weeks from the
date of receipt of a copy of this order.
8. The writ petition stands allowed with the above directions. No costs .
13.09.2022
Index : Yes / No
Internet : Yes / No
Speaking order / Non-speaking order
To:
1.The Inspector General of Registration
Tamil Nadu, 120, Santhome High Road
Chennai - 600 028.
2.The Joint Director
Health Care Service Centre
Government of Tamil Nadu
Salem District.
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W.P.No.1974 of 2018
3.The Assistant Treasury Officer
Sankari
Salem District.
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W.P.No.1974 of 2018
R.SUBRAMANIAN. J.,
ds
W.P.No.1974 of 2018
13.09.2022
https://www.mhc.tn.gov.in/judis
