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IN THE HIGH COURT OF JUDICATURE AT MADRAS
ABDUL QUDDHOSE, J.
G.C. Suseela Devi - Appellant
Versus
The Government of Tamil Nadu, Rep. by its Secretary to Government (Expenditure), Finance (Pension) Department, Chennai & Others - Respondent
W.P. No. 24413 of 2019
Decided On : 14-09-2022
Emergency Treatment - New Health Insurance Scheme 2014 - 2016 (3) CTC 394, 2010 (2) LW 90
Fact of the Case:
The petitioner, a retired government employee, sought reimbursement for medical expenses incurred for her husband's emergency treatment at a non-network hospital under the New Health Insurance Scheme 2014. Her application was rejected by the respondents, citing treatment at a non-network hospital as the reason.
Finding of the Court:
The court found that in emergency situations, patients are not required to seek treatment only in a network hospital for medical reimbursement. The rejection of the petitioner's application was deemed to be in contravention of settled law, and the matter was remanded back to the first respondent for fresh consideration.
Issues: The main issue was whether the petitioner was eligible for medical reimbursement under the New Health Insurance Scheme 2014 for her husband's emergency treatment at a non-network hospital.
Ratio Decidendi: The court held that in emergency situations, patients are not bound to seek treatment only in a network hospital for medical reimbursement, as established by previous court decisions.
Final Decision: The court quashed the rejection of the petitioner's application and remanded the matter back to the first respondent for fresh consideration within a specified time frame.
JUDGMENT
(Prayer: Writ petition filed under Article 226 of the Constitution of India for writ of Certiorarified Mandamus calling for the records relating to the impugned order of the fifth respondent made in proceedings in Na.Ka.3149/U2/2017 dated 05.10.2017 as confirmed by the third respondent made in his proceedings in O.Mu.No.16704/Ka.Pi.1/3/2017, dated 02.04.2018 and quash the same and direct the respondents to reimburse the medical expenses incurred by the petitioner in taking treatment for his husband as per her claim made in her application dated 19.06.2017 under the New Health Insurance Scheme 2014.)
1. This writ petition has been filed challenging the proceedings dated 05.10.2017 issued by the fifth respondent which has been confirmed by the third respondent by his proceedings dated 02.04.2018 under which the petitioner's application seeking for reimbursement of medical expenses for her husband has been rejected on the ground that her husband has taken treatment in a non-network hospital.
2. The petitioner was working as Tamil Pandit at Government Boys Higher Secondary School, Kavundapadi, Bhavni, Erode District. She retired from service on attaining superannuation on 31.12.2007. She is a member of the New Health Insurance Scheme 2014 for pensioners (including spouse)/ family pensioners. The petitioner claims that she has been paying subscription charges under the said insurance scheme without committing any default. The petitioner claims that under the said claim, the pensioners (including spouse) / family pensioner can avail medical assistance upto a limit of Rs.2,00,000/- in a block period of four years from 01.07.2014 to 30.06.2018 on cashless basis for the accredited treatments/surgeries. According to the petitioner, her husband Y.R.S.Mani suddenly fell sick on 07.08.2014 and complained of chest pain. According to the petitioner, he was immediately rushed to Abi S.K.Hospital, Gobichettipalayam where he was given first aid and the doctors in the said hospital recommended for the immediate intensive care treatment in an equipped hospital as his condition was very serious. According to the petitioner, the Doctors in the said hospital sent the patient Y.R.S.Mani in an ambulance to Sudha Hospital, Erode. According to the petitioner, during the said emergency situation, the petitioner did not have time or occasion to think about the hospitals approved by the sixth respondent under the New Health Insurance Scheme 2014.
3. According to the petitioner, on admission in Sudha Hospital, Erode, her husband had immediately undergone, “Angioplasty” surgery in the said Hospital. According to the petitioner, only thereafter she came to know that the said Sudha Hospital, Erode is not in the list of Hospitals approved by the sixth respondent and is a non-network Hospital.
4. The petitioner claims that she had spent a sum of Rs.2,68,133/- towards medical bills for her husband's treatment in Sudha Hospital, Erode. The petitioner submitted an application dated 13.04.2015 before the second respondent seeking for reimbursement of the said sum under the National Health Insurance Scheme 2014. The second respondent has also forwarded the application to the fifth respondent for appropriate action. The fifth respondent under the impugned proceedings dated 05.10.2017 has rejected the petitioner's application seeking for medical reimbursement of a sum of Rs.2,68,133/- which the petitioner claims that she has incurred towards medical bills for the treatment given to her husband at Sudha Hospital, Erode. However, the fifth respondent has rejected the petitioner's application only on the ground that the petitioner's husband has taken treatment in a non network hospital and therefore, not eligible to get medical reimbursement. The third respondent has also confirmed the proceedings of the fifth respondent dated 05.10.2017 by his proceedings dated 02.04.2018.
5. Both the proceedings have been challenged by the petitioner in this writ petition on the grou
In emergency situations, patients are not required to seek treatment only in a network hospital for medical reimbursement, as established by settled law.
Legitimate medical claims cannot be denied on technical grounds when emergency circumstances necessitate treatment; the focus must be on the fact of treatment supported by valid records.
Medical claims for treatment in non-network hospitals cannot be denied solely based on network status, ensuring the actual treatment received is prioritized.
The right to medical claim cannot be denied solely because the hospital is not included in the government order. The factum of treatment and supporting records certified by doctors/hospitals are cruc....
Medical reimbursement claims cannot be denied based on treatment at non-network hospitals, especially in emergencies, as necessity of treatment is paramount.
The rejection of a medical reimbursement claim under the New Health Insurance Scheme for pensioners, based on the classification of the claim as non-critical Covid-19 in a non-network hospital, was h....
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