The judgment emphasizes the need to consider heart ailments as emergent conditions and the coverage of non-network hospitals under the Tamil Nadu New Health Insurance Scheme-2016.

JUDGMENT

(Prayer : Writ Petition filed under Article 226 of the Constitution of India, praying this Court to issue a Writ of Certiorarified Mandamus, to call for the records pertaining to the Impugned Order in 17.03.2022 on the file of the Respondent No.2 and Consequential Impugned Order in 29.03.2022 on the file of the Respondent No.3 and quash the same as illegal and consequently directing the Respondents to grant the Medical Reimbursement Claim of Rs.2,79,800/- (Rupees Two Lakhs Seventy Nine Thousand and Eight Hundred only) incurred for the treatment of open heart surgery (Cardio Vascular and Thoracic Surgery) with accrued interest to the petitioner under the Government of Tamil Nadu New Health Insurance Scheme-2016 within the time stipulated by this Court.)

1.  The present writ petition is filed for a Writ of Certiorarified the same as illegal and consequently directing the Respondents to grant the Medical Reimbursement Claim of Rs.2,79,800/- (Rupees Two Lakhs Seventy Nine Thousand and Eight Hundred only) incurred for the treatment of open heart surgery (Cardio Vascular and Thoracic Surgery) with accrued interest to the petitioner under the Government of Tamil Nadu New Health Insurance Scheme-2016.

2. The brief facts which are necessary for the disposal of this Writ Petition is as follows:-

(i) The petitioner is serving as Assistant Engineer (Distribution), Urban East, TANGEDCO, Thoothukudi District from 01.05.1999. He is also a member of the Tamil Nadu New Health Insurance Scheme, 2016. On 21.05.2020, the petitioner's daughter namely P.Adeline, aged about 5 years old suffered with heart ailment. She was admitted in the nearby hospital for first aid and thereafter, an examination, it was diagnosed that there is a hole in her heart. As a result of which, she was taken to Amrita Institute of Medical Science and Research Centre, Kochi. As per the advice given by the doctor, a Cardio Vascular and Thoracic Surgery was conducted to the petitioner's daughter and she was discharged from the hospital on 10.06.2020. An amount of Rs. 2,79,800/- (Rupees Two Lakhs Seventy Nine Thousand and Eight Hundred only) was spent for medical expenses under emergency situation. Hence, on 24.06.2020, the petitioner made a representation to the 3rd respondent through proper channel and requesting to consider the petitioner's claim for reimbursement of expenses to the tune of Rs.2,79,800/- (Rupees Two Lakhs Seventy Nine Thousand and Eight Hundred only). The said representation was forwarded on 12.10.2020 from the Executive Engineer, Distribution / Urban, TANGEDCO, Thoothukudi to the respondents for further action.

(ii) On 17.03.2022, the 2nd respondent passed the impugned order, rejecting the petitioner's claim and and returned the petitioner's medical reimbursement application on the ground that the treatment has been taken in a Non Network Hospital and the line of treatment with respect to Cardio Vascular and Thoracic Surgery is not emergent. Challenging the order dated 17.03.2022 and the consequential impugned order dated 29.03.2022, this writ petition came to be filed.

3. Mr.I.Pinaygash, the learned Counsel appearing for the petitioner, has submitted that the health condition of the child of the petitioner was certainly emergent and an ailment in the heart cannot be considered by the authorities as a Non-emergent condition. That apart, the fact that the child was treated for heart ailment and an open heart surgery was conducted on her for which a medical expense of Rs.2,79,800/- (Rupees Two Lakhs Seventy Nine Thousand and Eight Hundred only) was incurred under emergency situation is also true and under such situation being a subscriber of Tamil Nadu New Health Insurance Scheme, 2016, the petitioner is entitled to claim for the medical expenses of her daughter. In view of the same, he pressed for allowing this Writ Petition.

4. Per contra, Mr.C.Karthick, the learned Counsel appearing for the 4th respondent, categoric