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BEFORE THE MADURAI BENCH OF MADRAS HIGH COURT
BATTU DEVANAND, J.
S. Porkamalam – Appellant
Versus
The State of Tamil Nadu, Rep., by its Additional Chief Secretary, Finance Department,Chennai & Others – Respondents
W.P. No. 14959 of 2021
Decided On : 18-07-2023
Writ Petition - Medical Reimbursement Claim - New Health Insurance Scheme - G.O.Ms.No.280, Finance (Salaries) Department, dated 24.06.2020 - G.O.Ms.No.281, Finance (Pension) Department, dated 24.06.2020 - G.O.Ms.No.165, Finance (Health Insurance) Department, dated 1st June, 2022 - 4(iv) Government Employees/Pensioners who have already taken treatment for Non-critical COVID-19 care in empanelled Hospitals from 01.03.2020 to till date are directed to submit their claims for reimbursements by appealing to the Commissioner of Treasuries and Accounts, Chennai. The Commissioner of Treasuries and Accounts shall recommend to the United India Insurance Company Limited to reimburse the payment from the Corpus fund provided by the Government. Non critical Covid-19 claims as per G.O.(Ms).No.280, Finance (Salaries) Department, dated: 24.06.2020 can only be in empaneled and COVID authorized hospital, Critical care which is covered in New Health Insurance Scheme, shall be covered as per existing contract. - Sanction is accorded for an adhoc amount of Rs.10.00 crore (Rupees ten crore only) to clear the claims of the eligible expenses incurred by the Government Employees and their eligible family members and Pensioners (including spouse) / Family Pensioners under Non-Critical COVID care treatment undertaken in Non-Network hospitals by creating two Corpus Funds one for Rs.6.00 crore [Rupees six crore only] for Pensioners (including spouse) / Family Pensioners and Rs.4.00 crore [Rupees four crore only] for Government Employees and their eligible family members considering the welfare of the Employees / Pensioners. There shall be no change in the existing modalities followed in respect of reimbursement claims settled by United India Insurance Company Limited from the funds released by Government under these Corpus Fund. - Government Employees/Pensioners who have already taken treatment for Non-Critical COVID care in Non-empanelled Hospitals from 01.03.2020 to till date are directed to submit their claims for reimbursement by applying to the Commissioner of Treasuries and Accounts, Chennai. The Commissioner of Treasuries and Accounts shall forward the applications along with documents to the United India Insurance Company Limited to reimburse the eligible amount from the Corpus Fund provided by the Government as is followed as per the G.Os first and second read above without reference to the District Level Empowered Committee.
Fact of the Case:
The petitioner, a retired Secondary Grade Teacher, was diagnosed with Covid-19 and incurred medical expenses of Rs.2,62,596. The claim for medical reimbursement under the New Health Insurance Scheme was rejected on the grounds of non-critical Covid-19 claim in a non-network hospital.
Finding of the Court:
The court found the rejection of the petitioner's claim to be in violation of the Right to Life guaranteed under Article 21 of the Constitution of India, considering the unprecedented and unforeseen nature of the Covid-19 pandemic and the petitioner's age and health conditions.
Issues: The main issue was the rejection of the petitioner's 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.
Ratio Decidendi: The court held that the rejection of the claim was inhuman, irrational, unreasonable, unjust, against public interest, and violative of the Right to Life guaranteed under Article 21 of the Constitution of India, considering the circumstances of the Covid-19 pandemic and the petitioner's age and health conditions.
Final Decision: The court set aside the proceedings of the Respondent No.3, directed the petitioner to re-submit her claim, and ordered the Respondent No.4 to settle the claim without delay. The respondents were also directed to pay exemplary cost of Rs.25,000 to the petitioner.
JUDGMENT
(Prayer:Petition filed under Article 226 of the Constitution of India, praying for issuance of Writ of Certiorarified Mandamus, to call for the records of the third respondent in Na.Ka.No.5790/2021/No.1 signed on dated 09.06.2021 and quash the same and consequently to direct respondents 1 to 4 to settle the medical reimbursement claim under New Health Insurance Scheme for pensioners dated 16.09.2020 to the Petitioner)
1. This writ petition has been filed seeking to issue a Writ of Certiorarified Mandamus to call for the records of the proceedings issued by the Respondent No.3 in Na.Ka.No.5097/2021/1, dated 09.06.2021 and quash the same and for the consequential direction to the respondents to settle the medical reimbursement claim dated 16.09.2020 under New Health Insurance Scheme for pensioners to the petitioner in the interest of justice.
2. The facts of the case are that the petitioner is a retired Secondary Grade Teacher, AGP School, Shencottah. The petitioner is a beneficiary and insured under New Health Insurance Scheme (NHIS) for employees and pensioners (including spouse) formulated by the Respondent No.1 during 2014 and continued vide G.O.Ms.No.222, Finance (Pension) Department, dated 30th June, 2018. The annual premium of Rs.3,800/- plus GST per pensioner/family pensioner payable by the State Government to the United Insurance Company, Chennai, shall be recovered from the pensioners/family pensioners at the rate of Rs.350/- per month by deduction in monthly pension. The petitioner is paying Rs.350/- per month as premium by deduction in monthly pension and as such, the petitioner is insured under NHIS.
3. Due to the pandemic caused by Covid-19, the Health and Family Welfare Department, Government of Tamil Nadu has issued G.O.Ms.No.240, dated 05.06.2020 to cover the treatment of Covid-19 under Chief Minister''s Comprehensive Health Insurance Scheme (CMCHIS). Consequently, through G.O.Ms.No.280, Finance (Salaries) Department, dated 24.06.2020, the State Government has issued directions for the treatment of critical and non-critical Covid-19 positive cases for employees and pensioners covered under NHIS and ceiling rates were fixed. A sum of Rs.5 Crores was sanctioned towards contribution to the corpus fund for Covid-19 treatment in NHIS. Through G.O.Ms.No.281, Finance (Pension) Department, dated 24.06.2020, a sum of Rs.2.5 Crores towards contribution to the corpus fund for Covid-19 treatment in NHIS for pensioners/family pensioners has been sanctioned.
4. The petitioner was diagnosed with Covid-19 positive and admitted in Meeran Hospital, Tenkasi on 24.08.2020, which is an approved hospital by the Government for Covid-19 treatment and discharged on 02.09.2020 after 10 days. She incurred medical expenses of Rs.2,62,596/-. As the petitioner is the pensioner under NHIS, she is entitled for medical reimbursement of medical expenses incurred by her towards Covid-19 treatment. The petitioner made a claim on 16.09.2020 to the Respondent No.2 herein. The Respondent No.2 has forwarded the same to the Respondent No.3 for taking necessary action. In turn, the Respondent No.3 has forwarded the same to the Respondent No.4 to provide reimbursement. However, the Respondent No.4 has rejected the petitioner''s claim on the ground that the claim is non-critical Covid-19 claim in the non-network hospital and as such, the claim cannot be considered under both NHIS and corpus fund mode and the same was intimated to the petitioner vide impugned proceedings by the Respondent No.3. Aggrieved by the rejection of the claim of the petitioner, the petitioner is constrained to file this writ petition.
5. The respondents filed their counter affidavits.
6. In the counter affidavit filed by Respondents No.1 to 3, it is averred at paragraph No.8 as extracted hereinunder:
“8. In this connection it is further submitted that in G.O.(Ms).No.280, Finance (Salaries) Department, dated 24.06.2020 issued in connection with treatment for Covid
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....
Medical reimbursement claims cannot be denied based on treatment at non-network hospitals, especially in emergencies, as necessity of treatment is paramount.
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 claims for treatment in non-network hospitals cannot be denied solely based on network status, ensuring the actual treatment received is prioritized.
A Writ of Mandamus is maintainable to compel an administrative or insurance authority to process and settle medical reimbursement claims under a government-sponsored health scheme, particularly when ....
In emergency medical situations, full reimbursement of medical expenses is mandated regardless of any imposed ceiling limits, emphasizing the right to timely medical treatment.
In emergency situations, patients are not required to seek treatment only in a network hospital for medical reimbursement, as established by settled law.
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