Madras High Court
G.C.Suseela Devi vs The Government Of Tamil Nadu on 14 September, 2022
W.P.No.24413 of 2019
IN THE HIGH COURT OF JUDICATURE AT MADRAS
DATED: 14.09.2022
CORAM:
THE HONOURABLE MR.JUSTICE ABDUL QUDDHOSE
W.P.No.24413 of 2019
G.C.Suseela Devi ... Petitioner
vs.
1.The Government of Tamil Nadu,
Rep. by its Secretary to Government (Expenditure),
Finance (Pension) Department,
Fort St. George,
Chennai – 600 009.
2.The District Collector,
Erode District,
Erode.
3.The Director of Medical and Rural Health Services,
Directorate of Medical and Rural Health Services,
Teynampet,
Chennai – 600 006.
4.The Director of Pension,
259, Anna Salai, 3rd Block,
DMS Complex, Teynampet,
Chennai – 600 006.
5.The Treasury Officer,
District Treasury,
Erode,
Erode District.
1/10
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W.P.No.24413 of 2019
6.The Divisional Manager,
United India Insurance Company Limited,
Divisional Office VI, V Floor,
P.L.A.Rathna Towers,
No.212, Anna Salai,
Chennai – 600 006. ... Respondents
Prayer: Writ petition filed under Article 226 of the Constitution of India
for writ of Certiorarified Mandamus calling for the records relating to the
impugned order of the fifth respondent made in proceedings in
Na.Ka.3149/U2/2017 dated 05.10.2017 as confirmed by the third
respondent made in his proceedings in O.Mu.No.16704/Ka.Pi.1/3/2017,
dated 02.04.2018 and quash the same and direct the respondents to
reimburse the medical expenses incurred by the petitioner in taking
treatment for his husband as per her claim made in her application dated
19.06.2017 under the New Health Insurance Scheme 2014.
For Petitioner : Mr.A.S.Kaizer
For Respondents 1 to 5 : Mr.U.M.Ravichandran
Special Government Pleader
For Respondent 6 : Mr.T.Shanmugam
ORDER
This writ petition has been filed challenging the proceedings dated
05.10.2017 issued by the fifth respondent which has been confirmed by the
third respondent by his proceedings dated 02.04.2018 under which the
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W.P.No.24413 of 2019
petitioner's application seeking for reimbursement of medical expenses for
her husband has been rejected on the ground that her husband has taken
treatment in a non-network hospital.
2. The petitioner was working as Tamil Pandit at Government Boys
Higher Secondary School, Kavundapadi, Bhavni, Erode District. She retired
from service on attaining superannuation on 31.12.2007. She is a member of
the New Health Insurance Scheme 2014 for pensioners (including spouse)/
family pensioners. The petitioner claims that she has been paying
subscription charges under the said insurance scheme without committing
any default. The petitioner claims that under the said claim, the pensioners
(including spouse) / family pensioner can avail medical assistance upto a
limit of Rs.2,00,000/- in a block period of four years from 01.07.2014 to
30.06.2018 on cashless basis for the accredited treatments/surgeries.
According to the petitioner, her husband Y.R.S.Mani suddenly fell sick on
07.08.2014 and complained of chest pain. According to the petitioner, he
was immediately rushed to Abi S.K.Hospital, Gobichettipalayam where he
was given first aid and the doctors in the said hospital recommended for the
immediate intensive care treatment in an equipped hospital as his condition
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W.P.No.24413 of 2019
was very serious. According to the petitioner, the Doctors in the said
hospital sent the patient Y.R.S.Mani in an ambulance to Sudha Hospital,
Erode. According to the petitioner, during the said emergency situation, the
petitioner did not have time or occasion to think about the hospitals
approved by the sixth respondent under the New Health Insurance Scheme
2014.
3. According to the petitioner, on admission in Sudha Hospital,
Erode, her husband had immediately undergone, “Angioplasty” surgery in
the said Hospital. According to the petitioner, only thereafter she came to
know that the said Sudha Hospital, Erode is not in the list of Hospitals
approved by the sixth respondent and is a non-network Hospital.
4. The petitioner claims that she had spent a sum of Rs.2,68,133/-
towards medical bills for her husband's treatment in Sudha Hospital, Erode.
The petitioner submitted an application dated 13.04.2015 before the second
respondent seeking for reimbursement of the said sum under the National
Health Insurance Scheme 2014. The second respondent has also forwarded
the application to the fifth respondent for appropriate action. The fifth
respondent under the impugned proceedings dated 05.10.2017 has rejected
the petitioner's application seeking for medical reimbursement of a sum of
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W.P.No.24413 of 2019
Rs.2,68,133/- which the petitioner claims that she has incurred towards
medical bills for the treatment given to her husband at Sudha Hospital,
Erode. However, the fifth respondent has rejected the petitioner's
application only on the ground that the petitioner's husband has taken
treatment in a non network hospital and therefore, not eligible to get medical
reimbursement. The third respondent has also confirmed the proceedings of
the fifth respondent dated 05.10.2017 by his proceedings dated 02.04.2018.
5. Both the proceedings have been challenged by the petitioner in this
writ petition on the ground that eventhough the petitioner's husband had
taken treatment in a non network hospital, the petitioner is eligible for
medical reimbursement as the said treatment was taken only in an
emergency situation.
6. Learned counsel for the petitioner also drew the attention of this
Court to the decision of a learned Single Judge of this Court in the case of
N.Raja vs. The Government of Tamil Nadu rep. by its Secretary and
others reported in 2016 (3) CTC 394 involving an identical matter. He also
submits that the learned Single Judge has followed the Division Bench
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W.P.No.24413 of 2019
judgment of this Court in the case of Star Health and Allied Insurance Co.
Ltd vs. A.Chokkar & Another reported in 2010 (2) LW 90 .
7. Learned counsel for the sixth respondent would reiterate the
contents of the insurance policy and would submit that only in terms
thereof, the petitioner's application has been rejected and therefore, there is
no illegality in the same.
8. As rightly pointed out by the learned counsel for the petitioner, it is
now settled law as laid down by the various decisions of this Court
including the decision relied upon by the learned counsel for the petitioner
in the case of N.Raja vs. The Government of Tamil Nadu rep. by its
Secretary and others reported in 2016 (3) CTC 394 referred to supra that in
emergency situations, for seeking medical reimbursement, there is no
necessity for the patient to take treatment only in a network hospital.
9. In the instant case, the petitioner has pleaded that only due to the
grave emergency, her husband was treated in a non network hospital namely
Sudha Hospital, Erode. There is no contra evidence produced by the
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W.P.No.24413 of 2019
respondent to disprove the said contention of the petitioner. Therefore,
necessarily the contention of the petitioner that only due to the grave
emergency, the petitioner's husband was treated in a non network hospital
has to be accepted by this Court.
10. However, with regard to the quantum of the money that has to be
paid to the petitioner towards medical reimbursement is concerned, it is for
the respondents to consider the same on merits and in accordance with law.
Since the impugned proceedings rejecting the petitioner's application
seeking for medical reimbursement has been passed in contravention of the
settled law which enables the patient to take treatment in a non network
hospital in case of grave emergency, the said proceedings will have to be
necessarily quashed and the matter will have to be remanded back to the
first respondent on merits and in accordance with law within a time frame to
be fixed by this Court.
11. For the foregoing reasons, the impugned proceedings dated
05.10.2017 passed by the fifth respondent and dated 02.04.2018 passed by
the third respondent are hereby quashed and the matter is remanded back to
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W.P.No.24413 of 2019
the first respondent for fresh consideration on merits and in accordance with
law and the first respondent is directed to pass final orders on merits and in
accordance with law in the light of the decision rendered by this Court in the
case of N.Raja vs. The Government of Tamil Nadu rep. by its Secretary
and others reported in 2016 (3) CTC 394 referred to supra within a period
of twelve weeks from the date of receipt of a copy of this Order.
12. With the aforesaid directions, this writ petition is disposed of. No
costs.
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Index:Yes/No
Internet:Yes/No
To
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W.P.No.24413 of 2019
1.The Secretary to Government (Expenditure),
Finance (Pension) Department,
Fort St. George,
Chennai – 600 009.
2.The District Collector,
Erode District, Erode.
3.The Director of Medical and Rural Health Services,
Directorate of Medical and Rural Health Services,
Teynampet,
Chennai – 600 006.
4.The Director of Pension,
259, Anna Salai, 3rd Block,
DMS Complex, Teynampet,
Chennai – 600 006.
5.The Treasury Officer,
District Treasury,
Erode,
Erode District.
6.The Divisional Manager,
United India Insurance Company Limited,
Divisional Office VI, V Floor,
P.L.A.Rathna Towers,
No.212, Anna Salai,
Chennai – 600 006.
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W.P.No.24413 of 2019
ABDUL QUDDHOSE, J.
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W.P.No.24413 of 2019
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