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BEFORE THE MADURAI BENCH OF MADRAS HIGH COURT
L. VICTORIA GOWRI, J.
J. Joel - Appellant
Versus
The State of Tamil Nadu, Rep. by its Secretary, Department of Higher Education, Chennai & Ors. - Respondents
W.P. (MD). No. 9022 of 2023 & W.M.P(MD) No. 8186 of 2023
Decided On : 05-01-2024
Mandamus - Medical Reimbursement - The court directed the petitioner to appeal before the High Level Empowered Committee for a detailed explanation on the quantum of medical reimbursement and ordered the committee to pass appropriate orders within a stipulated time.
Fact of the Case:
The petitioner, a retired Assistant Professor, sought medical reimbursement for a surgery he underwent. The Empowered Committee and State Empowered Committee's orders did not address how the quantum was fixed for the procedure and implant cost, leading to the filing of the writ petition.
Finding of the Court:
The court found that the orders passed by the Empowered Committee and State Empowered Committee were cryptic and did not provide a detailed explanation on the quantum of medical reimbursement. The petitioner was directed to appeal before the High Level Empowered Committee for a detailed explanation, and the committee was ordered to pass appropriate orders within a stipulated time.
Issues: The main issue was the lack of detailed explanation on the quantum of medical reimbursement in the orders passed by the Empowered Committee and State Empowered Committee.
Ratio Decidendi: The court's decision was influenced by the lack of detailed explanation in the previous committee orders and the need for a thorough review of the quantum of medical reimbursement by the High Level Empowered Committee.
Final Decision: The court directed the petitioner to appeal before the High Level Empowered Committee for a detailed explanation on the quantum of medical reimbursement and ordered the committee to pass appropriate orders within a stipulated time.
JUDGMENT
(Prayer: Writ Petition filed under Article 226 of the Constitution of India, praying this Court to issue a Writ of Mandamus, directing the respondents to disburse a sum of Rs. 4,47,200/- (Rupees Four Lakhs Forty Seven Thousand Two Hundred Only), towards the medical reimbursement to the petitioner with interest at the rate of 9 % within the stipulated time fixed by this Court.)
1. The present writ petition has been filed for the issue of a writ of mandamus, directing the respondents to disburse a sum of Rs.4,47,200/- (Rupees Four Lakhs Forty Seven Thousand Two Hundred Only), towards the medical reimbursement to the petitioner with interest at the rate of 9 % within the stipulated time fixed by this Court.
2. Heard, the learned counsel appearing for the petitioner, the learned Government Advocate appearing for the respondents 1 to 3 and 5 and the learned counsel appearing for the fourth respondent. Perused the materials on record.
3. (i)The petitioner joined as the Assistant Professor in English in St.Johns College, Palayamkottai, Tirunelveli District on 11.10.1983 and he retired from service on attaining the age of superannuation on 31.05.2003. He was a regular subscriber to the Tamil Nadu Government Employees Health Fund Scheme since 09.01.1992. On 28.07.2021, due to emergency he was admitted in Christian Medical College, Vellore and had undergone surgery for Bilateral Total Knee Replacement (Genesis II) on 30.07.2021 and was discharged on 12.08.2021. He had incurred a total expenditure of Rs.7,29,000/-, for which, the fourth respondent has paid a sum of Rs.2,82,000/- towards cashless treatment for the period from 28.07.2021 to 04.08.2021 to the hospital directly. At the time of discharge, the petitioner has paid the remaining amount of Rs.4,47,200/- to the hospital.
(ii). On 07.10.2021 the petitioner made a representation requesting the third respondent to disburse Rs.4,47,200/- towards medical reimbursement amount. The third respondent Empowered Committee intimated that already the fourth respondent has approved the maximum amount to the Hospital vide proceedings, dated 12.05.2022.
(iii). In view of the same, the petitioner filed W.P(MD)No.11810 of 2022 before this Court seeking for the disbursal of the remaining amount of Rs.4,47,200/-. This Court, vide order, dated 28.02.2022 directed the petitioner to make an appeal to the second respondent for appropriate remedy.
(iv). On 21.12.2022 the petitioner preferred an appeal before the second respondent/State Empowered Committee requesting reimbursement of Rs.4,47,200/-. However, the second respondent vide order, dated 15.02.2023 confirmed the order passed by the Empowered Committee. Hence, this writ petition came to be filed.
4. The learned counsel for the petitioner vehemently submitted that either the order passed by the Empowered Committee, dated 12.05.2022 or the order passed by the State Empowered Committee, dated 15.02.2023 did not address as to how the quantum has been fixed for the T.K.R. Procedure and implant cost at Rs.2,54,000/-, though the petitioner has separately filed the bill particulars towards the medical expenses incurred by him. Hence, prayed to allow the petition.
5. Per contra, the learned counsel appearing for the fourth respondent vehemently contended that both the District Empowered Committee and State Empowered Committee only after considering the various guidelines has passed the said orders. Hence, there is no infirmity and prayed for dismissal of the petition.
6. A careful perusal of the medical bills produced by the petitioner would reveal that an amount of Rs.1,66,785/- has been charged for Operation Fees and an amount of Rs.1,67,640/- has been charged for Implant-Orth 3 and other expenses incurred towards various other heads such as Anaesthesia, biopsy, Dengue Serology, Diabetes, ECG and Echo. However, without these examinations such kind of major operation could not have been conducted on the petitioner.
7. In view of the discussion made supra, th
The main legal point established in the judgment is the requirement for detailed explanation and review of the quantum of medical reimbursement by the High Level Empowered Committee.
The liability period of the insurance company for medical reimbursement starts from the date of receiving the premium, and the disparity between rates prescribed in private hospitals and Medical Atte....
Medical reimbursement claims cannot be denied based on treatment at non-network hospitals, especially in emergencies, as necessity of treatment is paramount.
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