Madras High Court
R.Jayam vs The Director on 6 October, 2023
W.P.No.10414 of 2020
IN THE HIGH COURT OF JUDICATURE AT MADRAS
DATED: 06.10.2023
CORAM:
THE HONOURABLE MS.JUSTICE R.N.MANJULA
W.P.No.10414 of 2020
R.Jayam ... Petitioner
versus
1.The Director,
Rural Development Department,
Chennai - 600 006.
2.The District Collector,
Namakkal District,
Namakkal.
3.District Treasury Officer,
District Treasury Office,
Namakkal.
4.The United India Insurance Company,
Divisional Office VI,
PLA Rathina Towers,
5th Floor, 212, Anna Salai,
Chennai.
5.SIMS Chellum Hospital,
31/3-C, Vijayaragavachari Road,
Off. Gandhi Road,
Salem - 636 007. ... Respondents
1/8
https://www.mhc.tn.gov.in/judis
W.P.No.10414 of 2020
Prayer: Writ Petition filed under Article 226 of the Constitution of India,
praying to issue a Writ of Certiorarified Mandamus, calling for the records
pertaining to the impugned order passed by the first respondent in
X/K/vz;:6361/fgp1/3/2019 dated 26.08.2019 and quash the same and
consequently direct the first respondent to sanction the medical
reimbursement amount of Rs.3,78,423/- (Rupees Three Lakhs and Seventy
Eight Thousand and Four Hundred and Twenty Three only) to the
petitioner.
For Petitioner : M/s.A.Rajaram
For Respondent Nos.1 to 3 & 5 : M/s.P.Rajarajeswari
Government Advocate
For Respondent No.4 : Mr.P.Sankaranarayanan
ORDER
The petitioner has filed this petition seeking for a writ of
certiorarified mandamus, calling for the records pertaining to the impugned
order dated 26.08.2019 passed by the first respondent and quash the same
and consequently direct the first respondent to sanction the medical
reimbursement amount of Rs.3,78,423/- (Rupees Three Lakhs and Seventy
Eight Thousand and Four Hundred and Twenty Three only) to the
petitioner.
2. The petitioner, who was working as Sub Inspector of Police,
has retired on 31.10.2008. He is also subscribing to the New Health
Insurance Scheme, 2014, for family pensioners from the date of his
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W.P.No.10414 of 2020
retirement. The petitioner suffered with Chronic Bronchia Asthma, Bilateral
Bronchiectasis (Secondary Infection), SVT, Abscess left fore foot / I & D.
So he was admitted in the fifth respondent Hospital on 11.07.2017 and a
surgery was performed on 26.07.2017. He made a representation to the
respondents on 29.04.2019 for claiming the medical expenses of
Rs.3,78,423/- from the fourth respondent Insurance Company. But his claim
was rejected by the first respondent by stating that the Hospital in which the
petitioner had taken treatment does not fall under the list accredited
Hospital. Further the ailment for which the petitioner had undergone surgery
also is not covered under the Scheme.
3. Even though the petitioner might not get the direct benefits of
the Insurance Scheme, in view of the reasons stated by the fourth
respondent, he is always eligible to get the medical benefits under the
Tamil Nadu Medical Attendance Rules. In this regard, it is relevant to refer
the judgment of the Division Bench of this Court held in Star Health and
Allied Insurance Co.Ltd. Vs. A.Chokkar reported in MANU/TN/0618/2010 wherein
it is held as under:-
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W.P.No.10414 of 2020
“24. In the present case, what we have to decide is whether
the State is bound to reimburse the claim, whether the insurance
company is bound to indemnify the beneficiary for the claim made
by him. As held in the decisions referred to above, the insurance
company is strictly bound to strictly by the terms of contract and
cannot be asked to settle a claim which does not fall within the terms
of the contract and therefore the claim made by the beneficiaries in
respect of treatments that were taken in a non-network hospital or
for reimbursement of the claim made the insurance company is not
liable. For this reason, the insurance company had made it clear
that only if the beneficiary took treatment in a network hospital they
would settle the claim and more importantly the facility itself is a
cashless facility. The insurance company cannot pay cash and if we
issue direction to the insurance company to reimburse the claim, we
would be virtually re-writing the contract which we are not entitled
to.
25. The Tamil Nadu Medical Attendance Rules ("the Rules" in
short) clearly lay down the rules regarding dependents and who is
entitled to medical concessions under the Rules. It also defines who
is a well to do person. The Rules lay down the manner in which
claims can be made. According to the learned Advocate General,
these Rules are still in force and therefore when it is a claim not
covered by the present Insurance Scheme, the Government Servants
have the right to make their claims under the Rules. Therefore, as
regards Category-A, where treatment has been taken in a non-
network hospital, the insurance company cannot be asked to cover
the expenses, since the scheme itself makes the network hospitals as
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W.P.No.10414 of 2020
intrinsic. However, the petitioners/claimants were also not no
remediless and that is why we will issue directions to the claimants
to make an application under the Rules or go before the Redressal
Committee.
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.
(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
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W.P.No.10414 of 2020
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.”
4. In view of the above settled legal position, it is up to the
petitioner to avail the medical benefits under the Tamil Nadu Medical
Attendance Rules and which is always available to the persons in
Government service / pensioners. Hence, this Writ Petition is disposed and
the petitioner is at liberty to make medical reimbursement claim under the
New Health Insurance Scheme, within a period of two (2) weeks from the
date of receipt of a copy of this order. In the event of making such claim, the
respondents 1 and 2 shall consider the same and sanction the medical
reimbursement in accordance with the Tamil Nadu Medical Attendance
Rules, within a period of four (4) weeks. No costs.
06.10.2023
Speaking order / Non-speaking order
Index : Yes / No
Neutral Citation : Yes / No
sri
https://www.mhc.tn.gov.in/judis
W.P.No.10414 of 2020
To
1.The Director,
Rural Development Department,
Chennai - 600 006.
2.The District Collector,
Namakkal District,
Namakkal.
3.The District Treasury Officer,
District Treasury Office,
Namakkal.
4.The United India Insurance Company,
Divisional Office VI,
PLA Rathina Towers,
5th Floor, 212, Anna Salai,
Chennai.
5.SIMS Chellum Hospital,
31/3-C, Vijayaragavachari Road,
Off. Gandhi Road,
Salem - 636 007.
https://www.mhc.tn.gov.in/judis
W.P.No.10414 of 2020
R.N.MANJULA, J.
sri
W.P.No.10414 of 2020
06.10.2023
https://www.mhc.tn.gov.in/judis
