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BEFORE THE MADURAI BENCH OF MADRAS HIGH COURT
HONOURABLE MR. JUSTICE G.R.SWAMINATHAN, S.SRIMATHY
Secretary to Government, Finance (Salaries) Department – Appellant
Versus
S.Dhanalakshmi – Respondent
ORDER
G.R.SWAMINATHAN, J.
Heard both sides.
2. The first respondent herein is working as B.T.Assistant in a school run by the Madurai Corporation. She suffered from infection of gum in upper and lower jaw. She happened to be in Nagercoil during the relevant time. She consulted a doctor in Edens Dental & Maxillo Facial Hospital (Pvt) Ltd., Nagercoil. She was advised to undergo surgery immediately. Even though it was a non-network hospital, considering the emergency, she underwent surgery by incurring a sum of Rs.1,22,254/-. She lodged a claim for reimbursement. The matter was taken up by the District Level Empowered Committee on 11.12.2018. However, the said recommendation was not implemented on the ground that the petitioner had taken treatment in a non-network hospital. Hence, the petitioner filed W.P.(MD)No.6981 of 2019. The writ petition was disposed of vide order dated 25.03.2019 in the following terms:-
“5. The learned counsel appearing for the petitioner submitted that in similar circumstances, this Court, passed orders in W.P(MD)No.9761 of 2013 (S.Vijaya Vs. The Additional Director, Tamil Nadu Health Scheme, Directorate of Medical and Rural Health Service Campus, New Building 2n
Recommendations by District Level Empowered Committee regarding medical reimbursements are binding, and claims cannot be denied based on non-network treatment when such claims are legitimate.
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 on technical grounds, and the factum of treatment should be the real test for honoring medical claims.
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.
In emergencies, patients cannot be expected to verify if a hospital is part of a network for insurance coverage, and claims must be assessed based on existing medical conditions.
The obligation of the department to reimburse medical treatment in a private or unrecognized hospital as per the applicable Rules, despite technicalities of the Medi-claim policy.
Claimants are required to establish emergency treatment necessity to qualify for full medical reimbursement beyond prescribed rates as per established policies.
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