The right to medical claim cannot be denied on technical grounds, and the factum of treatment should be the real test for honoring medical claims.

JUDGMENT

(Prayer: Writ Petition filed under Article 226 of the Constitution of India, praying this Court to issue a Writ of Certiorarified Mandamus calling records of the 2nd respondent i.e the Divisional Manager, United India Insurance  Company Limited, Chennai relating to Ref.010600/CRS 32/379/MDI/2023, dated 23.08.2023 and quash the same and consequently direct the 1st respondent i.e Secretary to Government, Finance (Pension) Department, Chennai to make payment of the eligible medical reimbursement amount to the petitioner, within a specified time frame that may be fixed by this Court.)

1. The present writ petition has been filed challenging the impugned order of the second respondent in Ref.010600/CRS 32/379/MDI/2023, dated 23.08.2023 and consequently to direct the 1st respondent i.e Secretary to Government, Finance (Pension) Department, Chennai to make payment of the eligible medical reimbursement amount to the petitioner, within a specified time frame fixed by this Court.

2. Heard, the learned counsel appearing for the petitioner, the learned Special Government Pleader appearing for the first respondent and the learned Standing Counsels appearing for the second and third respondents. Perused the materials on record.

3. The petitioner is presently serving as Driver in Tamil Nadu State Transport Corporation, Melur branch, Madurai District for the past 23 years. He is a regular member of new Health Insurance Scheme. He underwent treatment in Dr. Rao Service Hospital, Melur, Madurai from 01.04.2020 and discharged on 06.04.2020. The medical diagnosis is bleeding per rectum and found to have external haemorrhoids and also suffering from giddiness and he had incurred medical expenditure to the tune of Rs.51,350/-. He applied for medical reimbursement to the District Committee headed by District Collector, Madurai. On 06.01.2021 his case was recommended to the United India Insurance Company. However, vide report, dated 10.06.2021 his case was rejected by the District Committee on the ground that he underwent treatment in a non-network Hospital and not a case of emergency. The petitioner preferred an appeal to the State Level Committee on 25.11.2021. The Statelevel Committee recommended the medical claim to the second respondent/United India Insurance Company and directed the petitioner to approach the second respondent. However, the second respondent vide proceedings, dated 23.08.2023 rejected the petitioner’s claim that he undertook treatment in a non- network Hospital or non-emergency condition, which is not payable under the scheme.

4. The Hon’ble Apex Court in the case in 2018(5) MLJ 317 has dealt with similar case and the relevant portion of the said judgment is extracted hereunder:

“The right to medical claim cannot be denied merely because the name of the hospital is not included in the Government Order. The real test must be the factum of treatment. Before any medical claim is honoured, the authorities are bound to ensure as to whether the claimant had actually taken treatment and the factum of treatment is supported by records duly certified by Doctors/Hospitals concerned. Once, it is established, the claim cannot be denied on technical grounds.”

5. In view of the same, the petitioner has filed this writ petition challenging the order passed by the second respondent, dated 23.08.2023.

6. The second respondent had filed a counter and submitted that in view of the fact that the petitioner’s case does not involve any emergency condition and he took treatment in a non-network Hospital prayed for dismissal of the writ petition.

7. However, in 2018(5)MLJ 317, this Court in the case of United India insurance Co Vs A.N.Natharsha reported in Manu/TN/1247/2019, with a similar case and has passed favourable orders to the petitioner therein and the relevant portion is extracted as follows:

“7. The Hon'ble Supreme Court of India in Shiva Kant Jha -vs- Union of India [2018 (5) MLJ 317], dealing with unfair treatment