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2017 Supreme(Mad) 1709
IN THE HIGH COURT OF JUDICATURE AT MADRAS
S.M. SUBRAMANIAM, J.
G.Latha – Petitioner
Vs.
M.D. India Health Care Services (TPA) Pvt. Ltd. and Others – Respondents
W.P.Nos.839, 27679, 27926, 29495, 40705 and 40706 of 2016 And WMP Nos.21084, 21085, 34702 and 34703 of 2016 and 14034 of 2017
Decided On : 04-09-2017
For the Petitioner: Mr. J. Muthukumaran
For the Respondent: Mr. P. Sankaranarayanan, Mr. S. Gunasekaran, Additional Government Pleader, Mr. P. Paramasivadoss, Mr. C. Munusamy
The denial of medical reimbursement would be a violation of fundamental rights under Article 21 of the Constitution of India, and the State has an obligation to provide medical facilities to its citizens.
Headnote:
Medical Reimbursement - Health Scheme - Article 21 of the Constitution of India - [Health Scheme, Article 21] - The court discussed the procedural aspects of medical claims under the Health Scheme and emphasized that the genuinity of the treatment should be verified by the Competent Authorities. It highlighted the right to life under Article 21 and the obligation of the State to provide medical facilities to its citizens. The court held that denial of medical reimbursement would be a violation of fundamental rights and directed the Insurance Company to settle the claims within a specified period.
Fact of the Case:
The writ petitions challenged the rejection of medical reimbursement claims submitted by the petitioners for treatment taken in unapproved hospitals under the Health Scheme. The court emphasized the procedural aspects and the genuinity of the treatment, and highlighted the right to life under Article 21 of the Constitution of India.
Finding of the Court:
The court found that the denial of medical reimbursement would be a violation of fundamental rights and directed the Insurance Company to settle the claims within a specified period. It criticized the postponement and routine adjournments sought by the respondents, and emphasized the obligation of the State to provide medical facilities to its citizens.
Issues: The issues revolved around the rejection of medical reimbursement claims based on treatment in unapproved hospitals, the procedural aspects of the Health Scheme, and the obligation of the State and Insurance Company to settle the claims in a timely manner.
Ratio Decidendi: The court emphasized the verification of the genuinity of the treatment by the Competent Authorities, highlighted the right to life under Article 21, and held that denial of medical reimbursement would be a violation of fundamental rights. It also criticized the postponement and routine adjournments sought by the respondents.
Final Decision: The court quashed the orders rejecting the medical reimbursement claims and directed the Insurance Company to settle the claims within a period of six weeks from the date of receipt of the order. It emphasized the joint liability of the Government and the Insurance Company and the obligation to provide immediate assistance to medical victims.
All these writ petitions were filed challenging the orders of rejection of the claim of medical reimbursement submitted by the respective writ petitioners on the ground that the treatment was taken in an unapproved hospitals as per the Health Scheme.
2. The learned counsel appearing on behalf of the writ petitioners made a submission that all the writ petitioners are members of the Health Scheme introduced by the State for the employees, both retired as well as in-service.
3. As per the Health Scheme, the monthly subscriptions are being recovered from the salary/pension. Accordingly, the writ petitioners are eligible for claiming medical reimbursement under the Health Scheme.
4. In all these writ petitions, the writ petitioners/spouses had taken treatment in the hospitals by undergoing surgery and other treatments. After discharge, the writ petitioners have submitted their respective applications, seeking medical reimbursement. However, the claims are rejected on the ground that the hospital in which the treatment was taken are not listed in the Scheme and therefore, they are not entitled to avail the benefit of medical reimbursement.
5. The learned Additional Government Pleader appearing on behalf of the respondents, states that the hospitals which are not listed are not approved under the Health Scheme and if the treatment is taken in a hospital which is not listed, the respondents will not be in a position to honour the claim of the writ petitioners.
6. This apart, there was no pre-authorisation approval before making final settlement by the respective writ petitioners. The writ petitioners have filed these writ petitions before approaching the Higher Authorities by way of an appeal.
7. This Court is of the view that all these procedural aspects in respect of medical claim are available in the Scheme. However, the genuinity of the treatment alone to be verified by the Competent Authorities. The claim of medical reimbursement cannot be denied on account of certain technical or procedural violations. Once the treatment/surgery undergone by a member of the Health Scheme is ascertained and found genuine, then it is for the Competent Authorities to process the same. Contrarily, in all these cases, the order of rejection was passed on the ground that the hospital is not listed.
8. Persons may be admitted in hospitals on account of certain emergent circumstances or otherwise. In all such cases, it may not be possible for the patients to get admitted after finding the list of hospitals under the Health Scheme. Normally patients will be admitted in the nearby hospital or in a Speciality Hospital as per their convenience and choice. Under these circumstances, the genuinity of the treatment alone is to be verified by the Competent Authorities and not the hospital in which the treatment is taken. The principle regarding these aspects were time and again followed by the Apex Court and various other High Courts and directions were issued to disburse the medical reimbursement claim.
9. The learned counsel appearing for the United India Insurance Company submitted that the Insurance Company will settle the medical reimbursement claims only based on the terms and conditions of the contract and not otherwise. Further, it was urged that in such circumstances, the Government has to settle the medical reimbursement claims, because the writ petitioners are State Government pensioners/in-service employees and the liability of the Insurance Company is limited to the extent of honouring the terms and conditions of the contract.
10. The nature of the Medical Scheme is bipartite, in view of the fact that the writ petitioners had served several years as Government employees with the State Government and the State Government issued policies in order to provide certain medical facilities to the employees/retired employees. In turn, the task of settling the medical claims is entrusted to the Insurance Companies in recent times. Thus, the nature of transact
