Madras High Court
P.K.Palaniswamy vs The District Collector on 26 June, 2023
W.P.No.36823 of 2016
IN THE HIGH COURT OF JUDICATURE AT MADRAS
DATED : 26.06.2023
CORAM :
THE HONOURABLE MR.JUSTICE P.B.BALAJI
W.P.No.36823 of 2016
P.K.Palaniswamy ... Petitioner
Vs.
1.The District Collector,
Thirupur District, Thirupur.
2.The Treasury Officer,
Treasury Office,
Thirupur.
3.The Deputy Treasury Officer,
Sub Treasury Office,
Kangaiyam.
4.The Managing Director,
United India Insurance Company Limited,
Divisional Office VI,
PLA Rathana Towers,
5th Floor, 212, Anna Salai,
Chennai – 600 006. ... Respondents
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W.P.No.36823 of 2016
Prayer: Petition filed under Article 226 of the Constitution of India, to issue a
Writ of Mandamus, directing the respondents more particularly the fourth
respondent to pay and make good to the petitioner the sum of Rs.1,23,158/-
(Rupees One Lakh Twenty Three Thousand One Hundred and Fifty Eight only)
towards the medical expenses incurred by the petitioner for the treatment
undergone “for the left Knee arthrotomy and subtotal syrovectomy medical
treatment” at “PSG hospitals”, Avinashi Road, Peelamedu, Coimbatore as per
his representation made to the second respondent on 18.02.2015.
For Petitioner : Mr.S.Vijayanand
For Respondents :
For R1 to R3 : Mr.M.S.Premkumar
Government Advocate
For R4 : Mr.P.Sankaranarayanan
ORDER
The petitioner has filed the present writ petition seeking issuance of a
Writ of Mandamus, to direct the fourth respondent Insurance Company to pay
by way of indemnification a sum of Rs.1,23,158/- being medical expenses
incurred by the petitioner for the treatment undergone by him in line with his
representation to the second respondent on 18.02.2015.
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W.P.No.36823 of 2016
2. The case of the petitioner is that he was employed as Physical
Education Teacher in Government Higher Secondary School at Kangayam. He
retired from service in the year 1995. He is covered under the New Health
Insurance Scheme (NHIS) for the pensioners (including spouse)/family
pensioners, 2014.
3. In December 2014, the petitioner fell ill and he was admitted to PSG
Hospitals, Coimbatore on 12.12.2014 and he was advised emergency procedure
by way of a surgery on his left knee and on the very same date, he underwent
surgery and a further surgery on 22.12.2014. Later, he was discharged from
the hospital on 31.12.2014. Subsequently, he made a representation dated
18.02.2015, to the second respondent by enclosing all the bills and records of
the hospital and requested for reimbursement of the surgery expenses etc. The
first respondent wrote to the third respondent vide communication dated
29.06.2015, informing the fourth respondent about the claim for
reimbursement. However, the fourth respondent rejected the claim of the
petitioner.
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W.P.No.36823 of 2016
4. The grievance of the petitioner is that, by way of subscription, a sum of
Rs.150/- per month, is deducted from the pensionary amount payable to him
and his claim has to be processed favourably.
5. Despite a procedure prescribed under G.O.Ms.No.171, Finance
(Pension) Department dated 26.06.2014, the fourth respondent has unilaterally
rejected the petitioner's claim even though the District Empowered Committee
recommended the petitioner's case for reimbursement.
6. Though the petitioner has sought for a direction to be issued to the
fourth respondent/Insurance Company to reimburse the expenses incurred by
the petitioner by way of medical expenses, the issue in this regard is no longer
res integra and squarely covered by the Judgment of the Division Bench of this
Court in W.A.(MD)No.480 of 2009 and a batch of writ petitions in
W.P.(MD)Nos.1699 of 2009 dated 26.02.2010 in the case of Star Health and
Allied Insurance Company Limited, represented by its Project Officer Vs
A.Chokkar and another.
7. The Hon'ble Division Bench of this Court after considering the case of
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W.P.No.36823 of 2016
various petitioners with regard to their entitlement for reimbursement towards
medical expenses incurred and also taking into account the New Health
Insurance Scheme (NHIS) Rules, 2007 and also the Tamil Nadu Medical
Attendance (TNMA) Rules, held that the Insurance Company is not bound to
indemnify the claim of the beneficiaries as the Insurance Company is strictly
bound by the terms of contract.
8. The Hon'ble Division Bench of this Court also directed that the
Government having made the New Health Insurance Scheme (NHIS) obligatory
for other employees as there is an automatic deduction of premium, the State
should step in and meet the expenses of the employees concerned.
9. The Hon'ble Division Bench of this Court has also issued directions to
the State Government in this regard and ultimately held that the Government
will have to make the payment under the Rules namely TNMA Rules.
10. Though the Hon'ble Division Bench of this Court had directed certain
individual cases in the said batch of writ petitions and writ appeal to approach
the Redressal Committee to decide whether the procedure is covered or not and
also to go into other issues that may arise in the facts of those cases, it is seen
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W.P.No.36823 of 2016
that in the present case, the petitioner's claim has been recommended by the
District Empowered Committee and came to be rejected by the State Level
Committee only.
11. The exercise of now directing the petitioner to go before the Redressal
Committee would be a futile exercise. The relevant Government Order namely
G.O.Ms.No.171, Finance (Pension) Department dated 26.06.2014, relates
Redressal of Grievances. Clause 12 (a) and 12(b) of the aforesaid Government
Order are extracted hereunder:-
"12. Redressal of Grievances:
(a) Any complaints about difficulty in availing
accredited treatments/surgeries, non-availability of facilities, bogus
availment of treatment for ineligible individuals etc., shall be
submitted to the Pension Pay Officer, Chennai and other districts to
the District Treasury Officers at the District Headquarters. The
complaints received shall be placed for decision of an Empowered
Committee at District Level headed by the District Collector, having
the Joint Director of Medical and Rural Health Services Department
and the Pension Pay Officer, Chennai/District Treasury Officer
concerned as the case may be and a official representative of the
United India Insurance Company as member. In respect of
Pensioners/Family Pensioners drawing pension/family pension
directly from Banks under Public Sector Bank Schemes, the
complaints if any shall be sent to the Director of Treasurers and
Accounts, Chennai.
(b) An appeal against the decision of the District Level
Empowered Committee may be preferred by the Pensioners/Family
Pensioners to the State Level Empowered Committee headed by the
Director of Treasuries and Accounts and having the Director of
Medical and Rural Health Services as Member Secretary and an
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W.P.No.36823 of 2016
official representative nominated by the United India Insurance
Company as members."
12. Here in the instant case, the District Level Empowered Committee has
already recommended the claim for reimbursement. There is no procedure
contemplated in G.O.Ms.No.171, Finance (Pension) Department dated
26.06.2014, where, the State Level Empowered Committee can reject or over
turn such recommendation of the District Level Empowered Committee. In fact
clause 12(b) only provides for an appeal against the decision of the District
Level Empowered Committee by the pensioners/family pensioners to the State
Level Empowered Committee.
13. However, it is seen that the State Level Empowered Committee in the
instant case, which is also referred to in the Counter Affidavit filed by the third
respondent has rejected the claim of the petitioner though reliance is placed
under G.O.Ms.No.171, Finance (Pension) Department dated 26.06.2014.
14. The counter affidavit does not substantiate the reasons for such
rejection, especially when the District Level Empowered Committee had
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W.P.No.36823 of 2016
recommended the petitioner's claim for reimbursement. The Government Order
also does not contemplate a scenario where, once the District Level Empowered
Committee recommends a claim, the State Level Empowered Committee can
overrule the decision or recommendation.
15. As already discussed above, even an appeal is provided only for the
pensioners/family pensioners and not to the State, the petitioner also has not
been put a notice about any such rejection and in the entire counter affidavit, it
is stated that the fourth respondent Insurance Company has to reimburse the
medical expenses. For the first time, it is brought to the notice of the Court,
even the State Level Empowered Committee has rejected the petitioner's claim in
terms of G.O.Ms.No.171, Finance (Pension) Department dated 26.06.2014.
16. In any event, the petitioner ought to have been put on notice before
the District Level Empowered Committee, passed any order of rejection as
claimed in their counter affidavit.
17. For the foregoing reasons, this Writ Petition is disposed of with the
following directions:-
(1) The fourth respondent/Insurance Company cannot be saddled with
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W.P.No.36823 of 2016
the liability and consequently, the fourth respondent/Insurance Company is not
bound to indemnify or make good the medical expenses incurred by the
petitioner.
(2) The second and third respondents are bound to reimburse the medical
expenses incurred by the petitioner and they are directed to reconsider the claim
of the petitioner in the light of the recommendation of the District Level
Committee dated 29.06.2015 and pass orders on the petitioner's claim, within a
period of four (4) weeks from the date of receipt of a copy of this order. No
costs.
26.06.2023
Index : Yes / No
Internet : Yes / No
Speaking Order/Non-Speaking Order
Neutral Citation : Yes / No
arb
P.B.BALAJI, J.
arb
To
1.The District Collector,
Thirupur District, Thirupur.
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W.P.No.36823 of 2016
2.The Treasury Officer,
Treasury Office,
Thirupur.
3.The Deputy Treasury Officer,
Sub Treasury Office,
Kangaiyam.
W.P.No.36823 of 2016
26.06.2023
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