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2019 Supreme(Mad) 2523
IN THE HIGH COURT OF JUDICATURE AT MADRAS
M. DHANDAPANI, J.
A.P. Subramaniam - Petitioner
Versus
The Joint Director of Health Services, Salem & Others - Respondents
W.P. No. 22071 of 2018
Decided On : 24-09-2019
For the Petitioner:V. Elangovan, Advocate
For the Respondents: Jayanthy, Additional Government Pleader
The real test for medical claim reimbursement should be the factum of treatment, and it cannot be denied on technical grounds.
Headnote:
Medical Reimbursement - Government Health Insurance Scheme - (2012) 16 SCC 187, Order of the Division Bench of this Court dated 04.02.2019 - [G.O Ms. No.242, Tamil Nadu Medical Attendance Rules] - The court discussed the entitlement of government employees to medical facilities, the role of network hospitals, and the right to claim reimbursement for treatment in non-network hospitals. The judgment emphasized that the real test for medical claim reimbursement should be the factum of treatment, and it cannot be denied on technical grounds. The court directed the competent authority to examine the claim for medical reimbursement under the Tamil Nadu Medical Attendance Rules and disburse the eligible amount.
Fact of the Case:
The petitioner, a retired Higher Grade Teacher, sought reimbursement of medical expenses for heart surgery at a non-network hospital under the Government Health Insurance Scheme.
Finding of the Court:
The court allowed the writ petition, directing the competent authority to examine the claim for medical reimbursement under the Tamil Nadu Medical Attendance Rules and disburse the eligible amount.
Issues: Entitlement to medical reimbursement for treatment in a non-network hospital under the Government Health Insurance Scheme.
Ratio Decidendi: The real test for medical claim reimbursement should be the factum of treatment, and it cannot be denied on technical grounds.
Final Decision: The writ petition is allowed, and the competent authority is directed to examine the claim for medical reimbursement under the Tamil Nadu Medical Attendance Rules and disburse the eligible amount.
JUDGMENT :
(Prayer: Writ petition filed under Article 226 of the Constitution of India praying to issue a Writ of Certiorarified Mandamus, to call for the records relating to the order of rejection passed in proceedings in Na.Ka.No.8191/K4/2017 dated 03.05.2018 on the file of the 1st respondent and quash the same and direct the respondents to reimburse the medical expenses of Rs.2,16,000/- incurred by the petitioner for his heart surgery at G.Kuppusamy Naidu Memorial Hospital at Coimbatore.)
1. Writ Petition is filed for issuance of a Writ of Certiorarified Mandamus calling for the records relating to the order of rejection passed in proceedings in Na.Ka.No.8191/K4/2017 dated 03.05.2018 on the file of the 1st respondent and quash the same and direct the respondents to reimburse the medical expenses of Rs.2,16,000/- incurred by the petitioner for his heart surgery at G.Kuppusamy Naidu Memorial Hospital at Coimbatore.
2. Heard the learned counsel appearing for the petitioner and the learned Additional Government Pleader appearing for the respondents. By consent of both sides, the writ petition is taken up for final disposal.
3. The case of the petitioner is that the petitioner was appointed as as Higher Grade Teacher and retired from service on superannuation on 30.06.2007. After retirement, he is receiving pension from the District Treasury Office, Salem. He joined in the Government National Health Insurance Scheme and he is paying Rs.180/- as a monthly premium every month without fail. The petitioner’s Insurance ID Card No.SLM/T/NHISP 14/021824. While so, the petitioner was suffering from heart disease and due to sudden chest pain, he was admitted in G.Guppusamy Naidu Memorial Hospital at Coimbatore and underwent heart surgery on 18.05.2016. He spent Rs.2,16,000/- for the heart surgery and treatments. The Finance (Salaries) Department issued a G.O Ms. No.242 dated 29.06.2012 introducing a New Health Insurance Scheme, 2012 for providing health care assistance to the employees of Government Departments, Public Sector Undertakings, Statutory Board, Local Bodies, State Government Universities, Willing State Government with provision to avail assistant upto Rupees Four Lakhs and consequently appointed the United India Insurance Company Limited, Chennai, which in turn formed the 3rd respondent. The petitioner is eligible to get medical assistance under the above scheme. Hence, the petitioner made a representation to the respondent on 29.06.2016 for the reimbursement of the medical expenses and the same was rejected by the 1st respondent vide impugned order dated 03.05.2018 on the ground that the treatment was taken in a non-network hospital. Hence, this writ petition has been filed.
4. The learned counsel for the petitioner would submit that in the very same issue, the Division Bench of this Court by an order in W.A.No.2749 dated 04.02.2019, rejected the reasons stated in the impugned order and issued a direction to the respondent to pay the medical reimbursement amount. He further submitted that the amount has been deducted towards medical insurance from the monthly income of the petitioner and therefore, the petitioner is entitled to claim medical reimbursement. However, the same issue was considered in the following judgments, wherein it is held that the pensioner, who underwent treatment in a non network hospital, is also entitled for medical reimbursement.
(i) (2018) 16 SCC 187 (Shiva Kant Jha vs. Union of India);
“17. It is a settled legal position that the Government employee during his lifetime 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 b
