Allowed

K.Balasubramaniam, v. The Principal Secretary to

Madras HC15 Dec 2022WP/8322/2018

Case brief

AI extract

What is this about?

The High Court allowed a writ petition seeking quashing of an insurance company's order rejecting medical reimbursement due to the hospital being non-network. Relying on settled law, the court held that the Government is liable to reimburse such expenses under Tamil Nadu Medical Attendance Rules and directed immediate payment of the medical charges with interest.

What did the court decide?

Quashment of order dated 16.03.2018 and direction to respondents 1 and 3 to reimburse medical expenses of Rs. 1,70,891/- with 6% p.a. interest within six weeks.

K.Balasubramaniam, Vs The Principal Secretary… — Pension and Retirement Benefits | Madras HC (2022)

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W.P.No.8322 of 2018

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IN THE HIGH COURT OF JUDICATURE AT MADRAS

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DATED : 15.12.2022

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CORAM

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THE HONOURABLE MR.JUSTICE M.S.RAMESH

W.P.No.8322 of 2018

K.Balasubramaniam

... Petitioner

The Principal Secretary to Government, Finance (Pension) Department, Government of Tamil Nadu, Fort St.George, Chennai-600 009.

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The District Collector, Coimbatore and Ex-Officio Chairman, Grievance Redressal Mechanism, District Level Empowered Committee for New Health Insurance Scheme 2014 for Pensioners/Family Pensioners, Collectortae, Coimbatore.

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The Treasury Officer, District Treasury, Coimbatore- 641 018.

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The Divisional Manager, United India Insurance Company Ltd., Divisional Office-VI, PLA Ratna Towers, 5^th Floor, No.212, Anna Salai, Chennai-600 006

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... Respondents

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https://www.mhc.tn.gov.in/judis

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W.P.No.8322 of 2018

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Petition filed under Article 226 of the Constitution of India praying for the issuance of a Writ of Certiorarified Mandamus to call for the records of the third respondent pertaining to proceeding bearing e.f.703/2018/f;ê3, dated 16.03.2018 herein and quash the same and further direct the respondents to reimburse the medical expenses of Rs.1,70,891/- incurred by the petitioner for taking medical treatment at Kovai Medical Center and Hospital Ltd., Coimbatore together with interest at the rate of 9% per annum.

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For petitioner ... Mr.K.S.Viswanathan For Respondents ... Mr.T.Chezhiyan AGP For R.1 to R.3 Mr.P.Sankaranarayanan For R.4

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O R D E R

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The petitioner and his wife are the members of New Health Insurance Scheme 2014, for pensioners/Family Pensioners of Government of Tamil Nadu. When he was admitted for some medical ailment in Kovai Medical Centre and Hospital Limited, Coimbatore on 17.02.2017, he had incurred medical charges to the tune of Rs.1,70,891/-. His claim for reimbursement of the medical expenses came to be rejected on the ground that the medical treatment undertaken by the petitioner was through a Non-Network Hospital, through impugned order dated

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https://www.mhc.tn.gov.in/judis

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W.P.No.8322 of 2018

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16.03.2018. Challenging the same, the present writ petition has been filed.

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Learned counsel for the petitioner submits that the claim with regard to medical insurance has already been settled in a batch of writ petitions.

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Learned Additional Government Pleader submits that as against the recommendation of the District Level Empowered Committee, an appeal lies to the State Level Empowered Committee and therefore, the petitioner may approach the State Level Empowered Committee for redressing his grievance.

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The issue as to whether the claim for medical reimbursement can be rejected on the ground that the hospital, in which, the claimant had undertaken the treatment is not covered under the Scheme or that the treatment/procedure is not included in the list or Schedule for which the Insurance Scheme covers, has already been dealt in various writ petitions and it was held that in such cases, the Insurance Company is not liable to reimburse the medical expenses of the employee and the liability for such reimbursement would be on the Government under the Tamil Nadu Medical Attendance Rules.

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https://www.mhc.tn.gov.in/judis

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W.P.No.8322 of 2018

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In one set of case in Ali Akbar vs The Principal Secretary to Government and another in WP (MD)Nos.4404 of 2014 etc., batch, this proposition was upheld in the following manner:-

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“ 15 . In the above case, though it is found that the insurance company is not liable to reimburse the medical expenses to the employee, the liability of Government under the Medical Attendance Rules has been fixed and it is reiterated that the Government servants are entitled to medical reimbursement under the Tamil Nadu Medical Attendance Rules.

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21. It is made clear that the State Government shall not reject the claim of the petitioner for medical reimbursement either on the ground that the hospital in which the claimant had undertaken treatment is not covered under the scheme or on the ground that the treatment/procedure is not included in the list/schedule for which the insurance scheme covers. The application for medical reimbursement also cannot be rejected on the ground that the claimant had taken treatment by paying cash.

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22. It is further made clear that the Government or the Authorised Officer who has to decide the applications

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https://www.mhc.tn.gov.in/judis

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W.P.No.8322 of 2018

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under the Tamil Nadu Medical Attendance Rules is directed to dispose of the applications within a period of three months from the date on which the applications are forwarded to the Government or the Officer concerned.”

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6. The aforesaid extract is self explanatory. As such, the rejection of the petitioner's claim for medical reimbursement on the ground that the medical treatment undertaken by him in a Non-Network Hospital cannot be sustained and it is for the Government to reimburse the same under the provisions of the Tamil Nadu Medical Attendance Rules.

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When the issue has already been settled by this Court in a catena of decisions with regard to the entitlement of the Government employees/Pensioners for medical reimbursement, directing the petitioner to avail the appeal remedy before the State Level Empowered Committee may not be appropriate and hence the submission of the learned Additional Government Pleader in this regard stands rejected.

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https://www.mhc.tn.gov.in/judis

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W.P.No.8322 of 2018

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Accordingly, the impugned order dated 16.03.2018 on the file of third

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respondent stands quashed and consequently, there shall be a direction to the respondents 1 and 3 to forthwith disburse the medical claim made by the petitioner herein under the Tamil Nadu Medical Attendance Rules and reimburse the amount together with interest at the rate of 6% p.a within in period of six weeks from the date of receipt of a copy of this order.

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In the result, the writ petition is allowed. No costs.

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15.12.2022

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Index: Yes/ No

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Speaking Order/Non-speaking Order sr

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The Principal Secretary to Government, Finance (Pension) Department, Government of Tamil Nadu, Fort St.George, Chennai-600 009.

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The District Collector, Coimbatore and Ex-Officio Chairman, Grievance Redressal Mechanism, District Level Empowered Committee for New Health Insurance Scheme 2014 for Pensioners/Family Pensioners, Collectortae, Coimbatore.

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