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BEFORE THE MADURAI BENCH OF MADRAS HIGH COURT
R. SURESH KUMAR, J.
S. Marimuthu - Appellant
Versus
The Government of Tamil Nadu, Represented by its Secretary, Department of Health and Family Welfare, Chennai & Others - Respondents
W.P.(MD).Nos.13429, 16503 of 2013, 14165 of 2015, 420, 839, 4640, 14983, 21297, 21803, 24455 of 2016, 2610 of 2017, 4062 of 2017, 4148 of 2017, 4623 of 2017, 4783 of 2017, 7942 of 2017, 10747 of 2017, 10773 of 2017, 10868 of 2017, 10904 of 2017, 11051 of 2017, 11210 of 2017, 11733 of 2017, 11982 of 2017, 12075 of 2017, 12369 of 2017, 12855 of 2017, 13742 of 2017, 14467 of 2017, 15443 of 2017, 15468 of 2017, 18660 of 2017, 19316 of 2017, 19732 of 2017, 19814 of 2017, 19816 of 2017, 20054 of 2017, 20390 of 2017, 20391 of 2017, 21128 of 2017, 21183 of 2017, 21184 of 2017, 21190 of 2017, 21333 of 2017, 21644 of 2017, 21748 of 2017, 21822 of 2017, 21937 of 2017, 22093 of 2017, 22455 of 2017, 22879 of 2017, 23173 of 2017, 23422 of 2017, 23982 of 2017, 343 of 2018, 1811 of 2018, 6357 of 2018, 7038 of 2018, 7064 of 2018, 7065 of 2018, 7270 of 2018, 7931 of 2018, 8814 of 2018, 9087 of 2018, 9148 of 2018, 9535 of 2018, 9819 of 2018, 10098 of 2018, 11912 of 2018, 11927 of 2018, 12336 of 2018, 12389 of 2018, 12820 of 2018, 12858 of 2018, 13179 of 2018, 13180 of 2018, 13379 of 2018, 13380 of 2018, 13484 of 2018, 13512 of 2018, 13514 of 2018, 13918 of 2018, 14050 of 2018, 14723 of 2018, 15365 of 2018, 15521 of 2018, 16591 of 2018, 16795 of 2018, 16923 of 2018, 17404 of 2018 and 17332 of 2018 and connected miscellaneous petitions
Decided on : 28-05-2019
The Court held that the State Government cannot abdicate its duty and responsibility by merely rejecting the case of the medical reimbursement claim on technical grounds. The Court directed the District Level Empowered Committee to reconsider every individual case and not reject any claim merely on the reason of non-network hospital or non-listed disease. The Court also directed the Insurance Company to immediately reimburse the medical claim with 6% interest from the date of due till date of payment, within a period of thirty days from the date of receipt of such order to be passed by the Empowered Committee of the District concerned.
Fact of the Case:
The writ petitions were filed by Government employees and pensioners challenging the rejection of their medical reimbursement claims under the New Health Insurance Scheme (2012, 2014, 2016 and 2018) on the grounds of treatment taken in a non-network hospital or for a disease not listed in the scheme.
Finding of the Court:
The Court held that the State Government cannot abdicate its duty and responsibility by merely rejecting the case of the medical reimbursement claim on technical grounds. The Court directed the District Level Empowered Committee to reconsider every individual case and not reject any claim merely on the reason of non-network hospital or non-listed disease. The Court also directed the Insurance Company to immediately reimburse the medical claim with 6% interest from the date of due till date of payment, within a period of thirty days from the date of receipt of such order to be passed by the Empowered Committee of the District concerned.
Issues: Whether the State Government can reject medical reimbursement claims on the grounds of treatment taken in a non-network hospital or for a disease not listed in the scheme.
Ratio Decidendi: The Court held that the State Government cannot abdicate its duty and responsibility by merely rejecting the case of the medical reimbursement claim on technical grounds. The Court directed the District Level Empowered Committee to reconsider every individual case and not reject any claim merely on the reason of non-network hospital or non-listed disease. The Court also directed the Insurance Company to immediately reimburse the medical claim with 6% interest from the date of due till date of payment, within a period of thirty days from the date of receipt of such order to be passed by the Empowered Committee of the District concerned.
Final Decision: The Court quashed the impugned orders and remanded the writ petitions to the District Level Empowered Committee for reconsideration. The Court directed the Committee to not reject any claim merely on the reason of non-network hospital or non-listed disease and to pass suitable orders directing the Insurance Company to reimburse the claim or recommending the State authorities to reimburse the claim under Medical Attendance Rules. The Court also directed the Insurance Company and the State authorities to reimburse the medical claims with 6% interest within a period of thirty days from the receipt of the order or recommendation from the District Empowered Committee.
(Prayer: Writ Petition is filed under Article 226 of the Constitution of India praying for the issuance of a Writ of Certiorarified Mandamus, to call for the records pertaining to the Impugned Order Mu.Mu.No.15553/KaPi2/3/2/2011 dated 16.04.2012 on the file of the Respondent No.2 and quash the same as illegal and consequently for a direction, directing the respondents to disburse the sum of Rs.46,120.20/- together with further interest under Medical Reimbursement Scheme.)
In all these writ petitions in this batch of cases, the issue raised is the entitlement of the writ petitioners, who are either Government employee or pensioner of the State Government and its undertakings or their family members/legal heirs/next kith and kin, to get medical reimbursement under the New Health Insurance scheme implemented by the State Government from time to time.
2. In all these cases, since the issue raised is one and the same and the relief sought for in each of the writ petitions in this batch are also same or similar, all these writ petitions were heard together and are being disposed of by this common order.
3. Factual background :
(i) The State Government originally was having a scheme called “Tamil Nadu Government Employees Health Fund Scheme (herein after referred to as Health Fund Scheme), which was implemented by issuance of G.O.Ms.No.18, Finance Department, dated 09.01.1992.
(ii) When the said Health Fund Scheme was in vogue, as it was felt that, the said Health Fund Scheme did not provide necessary or adequate assistance by way of reimbursement of the medical needs of the state employees, on getting various representations at various point of time from the employees and the pensioners, the State Government thought it fit to introduce a new health insurance scheme to Government employees and employees of local bodies, public sector undertakings, statutory bodies and State Government Universities. Accordingly, G.O.Ms.No.430, Finance (Salaries) Department, dated 10.09.2007 was issued, under which, the Health Insurance scheme for the Government and Public sector undertaking employees have been introduced by the State Government, which was continued for block year of four years from 11.06.2008 up to 10.06.2012.
(iii) Since the Health Insurance scheme expired with the block year by 10.06.2012, the Government issued G.O.Ms.No.139, dated 27.04.2012 of Finance (Salaries) Department, for extension of the Health Insurance scheme beyond 10.06.2012. Accordingly the New Health Insurance scheme 2012 was introduced by the issuance of G.O.Ms.No.243, Finance (Salaries) Department, dated 29.06.2012 (herein after referred to as 2012 scheme). According to the 2012 scheme, the scheme will be in operation for four years commencing from 01.07.2012 to 30.06.2016 and the scheme would be administered through the third party administrator under the control of United India Insurance Company, Chennai. Every employees of the State Government and Public sector undertakings shall pay premium of Rs.150/- per month to the State Government and the said amount would be deducted from their salary. The 2012 scheme shall be compulsory for all Government employees. In turn, the State Government entered into an agreement with United India Insurance Company Ltd., Chennai (herein after referred to as Insurance Company) and accordingly, the annual premium of Rs.1,860/- would be paid by the State Government to the Insurance company as an yearly premium for the employee, under which the employee as well as his family would be covered under the Insurance scheme 2012.
(iv) The scheme is on cashless basis and no payment for treatment of approved disease need to be made by the employee to the approved hospital. The maximum reimbursement by way of direct payment payable by the Insurance company to the hospital, where treatment was taken in the whole block year by the employee/family member, shall be Rs.4,00,000/-. Accordingly the insurance scheme 2012 was implemented for a block
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