Madras High Court
D.Srinivasan vs The Secretary To Government on 2 January, 2024
W.P.(MD).No.25253 of 2023
BEFORE THE MADURAI BENCH OF MADRAS HIGH COURT
DATED : 02.01.2024
CORAM
THE HONOURABLE MRS.JUSTICE L.VICTORIA GOWRI
W.P.(MD).No.25253 of 2023
and W.M.P(MD) No.21442 of 2023
D.Srinivasan
... Petitioner
Vs
1. The Secretary to Government,
Finance (Pension) Department,
Secretariat, Chennai 600 009.
2. The Divisional Manager,
United India Insurance and Co Ltd,
Pla Rathina Towers, 5th Floor,
212, Anna Salai, Chennai-600 006.
3. The District Collector,
Madurai District,
Madurai.
4. The Branch Manager,
Tamil Nadu State Transport Corporation,
Melur Branch,
Madurai District.
... Respondents
Prayer : Writ Petition filed under Article 226 of the Constitution of India,
praying this Court to issue a Writ of Certiorarified Mandamus calling records
of the 2nd respondent i.e the Divisional Manager, United India Insurance
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1/12
W.P.(MD).No.25253 of 2023
Company Limited, Chennai relating to Ref.010600/CRS 32/379/MDI/2023,
dated 23.08.2023 and quash the same and consequently direct the 1st
respondent i.e Secretary to Government, Finance (Pension) Department,
Chennai to make payment of the eligible medical reimbursement amount to the
petitioner, within a specified time frame that may be fixed by this Court.
For Petitioner : Mr.S.Visvalingam
For Respondents : Mr.S.Shaji Bino (R1)
Special Government Pleader
Mr.I.Suthakaran (R2)
Mr.S.C.Herold Singh (R3)
Standing Counsels
ORDER
The present writ petition has been filed challenging the impugned
order of the second respondent in Ref.010600/CRS 32/379/MDI/2023, dated
23.08.2023 and consequently to direct the 1st respondent i.e Secretary to
Government, Finance (Pension) Department, Chennai to make payment of the
eligible medical reimbursement amount to the petitioner, within a specified
time frame fixed by this Court.
2.Heard, the learned counsel appearing for the petitioner, the
learned Special Government Pleader appearing for the first respondent and the
https://www.mhc.tn.gov.in/judis
learned Standing Counsels appearing for the second and third respondents.
Perused the materials on record.
3.The petitioner is presently serving as Driver in Tamil Nadu State
Transport Corporation, Melur branch, Madurai District for the past 23 years.
He is a regular member of new Health Insurance Scheme. He underwent
treatment in Dr. Rao Service Hospital, Melur, Madurai from 01.04.2020 and
discharged on 06.04.2020. The medical diagnosis is bleeding per rectum and
found to have external haemorrhoids and also suffering from giddiness and he
had incurred medical expenditure to the tune of Rs.51,350/-. He applied for
medical reimbursement to the District Committee headed by District Collector,
Madurai. On 06.01.2021 his case was recommended to the United India
Insurance Company. However, vide report, dated 10.06.2021 his case was
rejected by the District Committee on the ground that he underwent treatment
in a non-network Hospital and not a case of emergency. The petitioner
preferred an appeal to the State Level Committee on 25.11.2021. The State-
level Committee recommended the medical claim to the second
respondent/United India Insurance Company and directed the petitioner to
approach the second respondent. However, the second respondent vide
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proceedings, dated 23.08.2023 rejected the petitioner’s claim that he undertook
treatment in a non- network Hospital or non-emergency condition, which is not
payable under the scheme.
5.The Hon’ble Apex Court in the case in 2018(5) MLJ 317 has
dealt with similar case and the relevant portion of the said judgment is extracted
hereunder:
“The right to medical claim cannot be denied merely
because the name of the hospital is not included in the
Government Order. The real test must be the factum of treatment.
Before any medical claim is honoured, the authorities are bound
to ensure as to whether the claimant had actually taken treatment
and the factum of treatment is supported by records duly certified
by Doctors/Hospitals concerned. Once, it is established, the
claim cannot be denied on technical grounds.”
6.In view of the same, the petitioner has filed this writ petition
challenging the order passed by the second respondent, dated 23.08.2023.
7.The second respondent had filed a counter and submitted that in
view of the fact that the petitioner’s case does not involve any emergency
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condition and he took treatment in a non-network Hospital prayed for dismissal
of the writ petition.
8.However, in 2018(5)MLJ 317, this Court in the case of United
India insurance Co Vs A.N.Natharsha reported in Manu/TN/1247/2019, with
a similar case and has passed favourable orders to the petitioner therein and the
relevant portion is extracted as follows:
“7. The Hon'ble Supreme Court of India in Shiva Kant Jha
-vs- Union of India [2018 (5) MLJ 317], dealing with unfair
treatment meted out to several retired Government servants in their
old age for medical reimbursement under similar provisions of the
Central Government Health Scheme, held in para nos. 13, 14 and 15
as follows:-
“13. With a view to provide the medical facility to the
retired/serving CGHS beneficiaries, the Government has
empanelled a large number of hospitals on CGHS panel,
however, the rates charged for such facility shall be only at
the CGHS rates and, hence, the same are paid as per the
procedure. Though the Respondent-State has pleaded that
the CGHS has to deal with large number of such retired
beneficiaries and if the Petitioner is compensated beyond the
policy, it would have large ramification as none would
follow the procedure to approach the empanelled hospitals
and would rather choose private hospital as per their own
free will. It cannot be ignored that such private hospitals
raise exorbitant bills subjecting the patient to various tests,
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procedures and treatment which may not be necessary at all
times.
14. It is a settled legal position that the Government
employee during his life time or after his retirement is
entitled to get the benefit of the medical facilities and no
fetters can be placed on his rights. It is acceptable to
common sense, that ultimate decision as to how a patient
should be treated vests only with the Doctor, who is well
versed and expert both on academic qualification and
experience gained. Very little scope is left to the patient or
his relative to decide as to the manner in which the ailment
should be treated. Speciality Hospitals are established for
treatment of specified ailments and services of Doctors
specialized in a discipline are availed by patients only to
ensure proper, required and safe treatment. Can it be said
that taking treatment in Speciality Hospital by itself would
deprive a person to claim reimbursement solely on the
ground that the said Hospital is not included in the
Government Order. The right to medical claim cannot be
denied merely because the name of the hospital is not
included in the Government Order. The real test must be the
factum of treatment. Before any medical claim is honoured,
the authorities are bound to ensure as to whether the
Claimant had actually taken treatment and the factum of
treatment is supported by records duly certified by
Doctors/Hospitals concerned. Once, it is established, the
claim cannot be denied on technical grounds. Clearly, in the
present case, by taking a very inhuman approach, the
officials of the CGHS have denied the grant of medical
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reimbursement in full to the Petitioner forcing him to
approach this Court.
15. This is hardly a satisfactory state of affairs. The
relevant authorities are required to be more responsive and
cannot in a mechanical manner deprive an employee of his
legitimate reimbursement. The Central Government Health
Scheme (CGHS) was propounded with a purpose of
providing health facility scheme to the Central Government
employees so that they are not left without medical care after
retirement. It was in furtherance of the object of a welfare
State, which must provide for such medical care that the
scheme was brought in force. In the facts of the present case,
it cannot be denied that the Writ Petitioner was admitted in
the above said hospitals in emergency conditions. Moreover,
the law does not require that prior permission has to be
taken in such situation where the survival of the person is the
prime consideration. The doctors did his operation and had
implemented CRT-D device and have done so as one
essential and timely. Though it is the claim of the
Respondent-State that the rates were exorbitant whereas the
rates charged for such facility shall be only at the CGHS
rates and that too after following a proper procedure given
in the Circulars issued on time to time by the concerned
Ministry, it also cannot be denied that the Petitioner was
taken to hospital under emergency conditions for survival of
his life which requirement was above the sanctions and
treatment in empanelled hospitals.”
8. In this context, it would also be useful to refer to clause
14(4) of the Guidelines for Implementation of New Health Insurance
Scheme, 2018, for Pensioners (including Spouse)/Family Pensioners
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in the Appendix to G.O. Ms. No. 222, Finance (Pension) Department,
dated 30.06.2018 issued by the Government of Tamil Nadu, which is
extracted below:-
“14.(4) In case, a Pensioner/Family Pensioner
undergoes emergency treatments/surgeries not covered
under this Scheme in either Network Hospital or Non-
Network Hospital, no claim can be filed under the
Health Insurance Scheme. However, they shall be
eligible for claim to the extent permissible under the
Tamil Nadu Medical Attendance Rules and the G.O.
Ms. No. 1023, Health and Family Welfare Department,
dated 17.06.1980. It may be noted that the Tamil Nadu
Medical Attendance Rules requires that treatment in
private hospitals should not be resorted to except in
case of emergencies. Clause 2(3) of the aforesaid
Government Order states that in genuine cases of
emergency, the claims will be restricted to the
expenditure that would have been incurred had the
patient taken treatment in a Government hospital
excepting diet charges. For claims under Tamil Nadu
Medical Attendance Rules, the Beneficiaries may apply
to the authority in the department in which the
Government employee last served who is competent to
process and forward pension proposal to the
Accountant General, Tamil Nadu. The Head of Office
shall process the claims and pay the eligible claims
under the Tamil Nadu Medical Attendance Rules.”
Though that Governmental Order has been issued after the claim
has been made in this case, the aforesaid guidelines, which are
based upon the instructions provided in the earlier Government
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orders and the Tamil Nadu Medical Attendance Rules, are
obviously clarificatory in nature and would apply to past cases
as well.
9. In the light of this incontrovertible legal position coupled
with the facts of this case, since the Petitioner had taken treatment at
a Non-Listed Hospital, the Fourth Respondent cannot be held liable
for medical reimbursement under the New Health Insurance Scheme
and the conclusion of the Writ Court to that extent cannot be
sustained. However, the First to Third Respondents as the employer
of the Petitioner are liable to settle the claim of the Petitioner under
the Tamil Nadu Medical Attendance Rules, with interest at the rate
prescribed under those Rules, and if no such rate of interest has been
prescribed, at the rate of 7.5% per annum till payment. Accordingly,
it is directed that the competent authority of the Government of
Tamil Nadu shall examine the claim made by the Petitioner for
medical reimbursement as one made under the Tamil Nadu Medical
Attendance Rules, and sanction and disburse eligible amount
towards the same along with interest in the manner indicated supra,
and file a report of compliance in that regard before the Registrar
(Judicial) of this Court by 30.06.2019.”
9.In the case in hand, the State Level Committee had already
recommended the case of the petitioner on 25.11.2021 to the second
respondent. The second respondent ought to have complied with the
recommendation of the State Level Committee or should have go for an appeal
before the High-level Empowered Committee in this regard. Having not done
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both the exercise, the second respondent/Insurance Company passed the
impugned order by rejecting the claim of the petitioner. The said exercise is an
non-est in law. Hence, this Court is inclined to quash the impugned order and
consequently direct the second respondent to make payment of medical
reimbursement to the petitioner within a period of eight weeks from the date of
receipt of copy of this order.
10.With the above directions, the writ petition stands allowed. No
costs. Consequently connected miscellaneous petition is closed.
02.01.2024
NCC : Yes / No
Index : Yes / No
Internet : Yes
PNM
To
https://www.mhc.tn.gov.in/judis
1. The Secretary to Government,
Finance (Pension) Department,
Secretariat, Chennai 600 009.
2. The Divisional Manager,
United India Insurance and Co Ltd,
Pla Rathina Towers, 5th Floor,
212, Anna Salai, Chennai-600 006.
3. The District Collector,
Madurai District,
Madurai.
4. The Branch Manager,
Tamil Nadu State Transport Corporation,
Melur Branch,
Madurai District.
L.VICTORIA GOWRI, J.
https://www.mhc.tn.gov.in/judis
PNM
ORDER IN
and W.M.P(MD) No.21442 of 2023
02.01.2024
https://www.mhc.tn.gov.in/judis
