The right to medical claim cannot be denied solely because the hospital is not included in the government order, especially in emergency situations. The authorities are obligated to ensure treatment and reimbursement in such circumstances.

JUDGMENT :

(Prayer: Writ petition filed under Article 226 of the Constitution of India praying to issue a Certiorarified Mandamus to call for the records pertaining to the order passed by the 3rd respondent herein in his proceedings in O.Mu.No.7545/Ka.Pi/1/3/2018 dated 03.01.2019 and quash the same and consequentially direct the respondents to grant medical reimbursement of Rs.2,03,841/- towards my medical claim dated 19.12.2017 for the medical treatment taken to the petitioner’s wife Mrs.A.M.V.Viola, together with interest at the rate of 12% per annum for the delayed payment and disburse the same.)

1. This writ petition has been filed challenging the order passed by the 3rd respondent dated 03.01.2019, rejecting the claim made by the petitioner for medical reimbursement and for a consequential direction to direct the respondents to grant medical reimbursement towards the claim made by the petitioner for the medical treatment given to his wife.

2. The case of the petitioner is that he is a retired Government servant, who is a Member of the Tamil Nadu Government New Health Insurance Scheme for pensioners. The petitioner is contributing towards the said claim. The petitioner’s wife suffered a serious problem and she has admitted in a hospital for an emergency operation. This operation was conducted in the year 2016 and the petitioner incurred a sum of Rs.2,03,841/- towards medical expenses.

3. The petitioner made a claim for Medical reimbursement and the same was rejected on the ground that the hospital where the operation was undertaken does not fall within the Network hospitals stipulated in the scheme.

4. The learned counsel for the petitioner submitted that as against the rejection of the claim, the petitioner made an Appeal before the 4th respondent and the 4th respondent has also rejected the Appeal by an order dated 03.01.2019 on the very same ground. The learned counsel submitted that even though a second appeal has been filed before the 3rd respondent, the petitioner has directly approached this Court since the issue is covered by the earlier order passed by this Court.

5. Per contra, Mr.P.S.Sivashanmuga Sundaram, learned counsel appearing for the respondents submitted that the petitioner has already preferred an Appeal before the 3rd respondent and therefore, necessary direction can be issued to the 3rd respondent to pass orders in the Appeal, in line with the earlier orders that have been passed by this Court.

6. This Court has carefully considered the submissions made on either side and also perused the entire materials available on record.

7. The issue with regard to the rejection of the medical reimbursement on the ground of treatment undertaken in a non-network hospital has already been dealt with by this Court on a number of occasions. It will be relevant to extract the latest order that was passed by this Court in WP No.34456 of 2019 dated 11.12.2019:-

“This writ petition has been filed challenging the impugned order passed by the 4th respondent rejecting the claim of medical reimbursement made by the petitioner and for a consequential direction to direct the respondents to pay the petitioner the medical reimbursement with interest.

2. It is seen from the records that the petitioner is a retired Head Master of the Panchayat Union School. The petitioner is a subscriber to the New Health Insurance scheme, which was introduced by the government in the year 2014. The subscription towards the insurance is being deducted regularly from the monthly pension. During May 2019, the wife of the petitioner underwent an operation and an emergency surgery was done on 17.05.2019. The petitioner was under the bonafide impression that he is covered by the scheme and he will be getting the medical reimbursement. The Hospital in which the operation was done, gave a final bill for a sum of Rs.95,925/-. The hospital authorities refused to take the medical insurance and left with no other option, the petitioner had to pay the entire bill amount