Point of Law: Medical reimbursement - when the Scheme provides for redressal grievance mechanism through the DLEC, appeal provisions to the SLEC and HLEC and when the Scheme or Government Orders does not empower the Insurance Company to disregard the DLEC's decisions, the present impugned order rejecting the petitioner's claim, which was pursuant to the DLEC's recommendations, cannot be sustained

JUDGMENT :

(Prayer: Petition filed under Article 226 of the Constitution of India to issue a Writ of Certiorarified Mandamus, calling for the records pertaining to the order passed by the fifth respondent dated 18.06.2019 in proceedings O.Mu.No.2368/Ka4/2019 and the order passed by the third respondent vide his proceedings in Na.Ka.Ke. 4/8258/20 dated 09.10.2020, quash the same and consequently, direct the respondents to reimburse the medical expenses incurred by the petitioner within the time frame as fixed by this Court.)

1. The orders passed by the fifth respondent and the third respondent through proceedings dated 18.06.2019 and 09.10.2020 in O.Mu.No.2368/Ka4/2019 and Na.Ka.Ke.4/8258/20 respectively, are put under challenge in the present Writ Petition.

2. The brief facts of the case are as follows:-

The petitioner herein, while working as Head Mistress at Government Higher Secondary School, Ramanujampudur, Thoothukudi District, underwent for C4, C5/C5, C6 HNP with Canal Stenosis and Cord Compression at Mangala Hospital, Tirunelveli from 30.04.2019 to 02.05.2019. The petitioner had incurred medical expenses of Rs.1,27,374/- at Mangala Hospital. The petitioner herein is a member of the New Health Insurance Scheme, 2016. Her application dated 21.05.2019 made to the Joint Director of Health Services, Thoothukudi for medical reimbursement, was forwarded to the District Level Empowered Committee (DLEC) on 21.01.2020 and consequently, the DLEC had recommended reimbursement of the entire amount of Rs.1,27,374/-. Accordingly, the petitioner's application along with the recommendation of DLEC, was forwarded to the fourth respondent/Insurance Company on 08.05.2020. However, by a letter dated 18.09.2020, the Insurance Company had rejected the petitioner's application on the ground that the hospital in which the petitioner had undergone the surgery was a Non Network Hospital and that the medical diagnosis and the consequential treatment was not an emergency, in accordance with G.O.Ms.202, Finance (Salaries) Department, dated 30.06.2016. Thus, the rejection of the petitioner's application came to be communicated to the petitioner through the impugned orders dated 18.06.2019 and 09.10.2020.

3. While the learned counsel for the petitioner contended that the Insurance company has no authority to reject the decision of the DLEC, the learned counsel for the Insurance Company would submit that as per G.O.Ms.202 dated 30.06.2020 and the guidelines for the New Health Insurance Scheme, the decision of the DLEC are not binding on them and further, contended that the scheme itself is in the nature of a contract. It is his further contention that G.O.Ms. 241, Finance (Salaries) Department, dated 24.08.2016 and Finance Department of the Government of Tamil Nadu letter dated 21.08.2020, had clarified that the DLEC's recommendations are not binding on the Insurance Company.

4. The crucial issue involved in the present Writ Petition is as to whether the recommendations of DLEC are binding on the Insurance Company and if not, what would be the option available to the Insurance Company to disregard DLEC's recommendations?

5. It is no doubt true that the scheme of medical reimbursement is in the nature of contract between the insurer and the insured and that, claim for reimbursement requires to be strictly within the terms of the contract. As per the New Health Insurance Scheme, 2016, when a Government employee undergoes any form of medical treatment in a Network Hospital for approved medical treatments/surgeries, they shall be eligible for a cashless assistance, subject to the upper limit of medical assistance under the scheme. The coverage of medical assistance shall also be extended to emergency accident cases, even though the approved treatment/surgery is taken in a Non Network Hospital. Thus, the Scheme redresses the grievance and provides for reimbursement of payment made to a Network Hospital for eligible medical expenses and to Non Network Hospital in c