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.

ORDER :

1. The petitioner is the wife of one Mariya Pakthan, who is a retired Craft Instructor from Subbiah Vidyalayam Middle School, Devarpuram Road, Tuticorin. He has retired from service on 01.07.2020. He was a member of the New Health Insurance Scheme 2018, for pensioners. On 08.01.2018 at 12.20 a.m, the petitioner's husband was suffering with severe abdominal pain. Therefore, the petitioner has taken him to the nearest hospital, namely, Sacred Heart Hospital, Tuticorin, wherein, he was diagnosed with ''Appendicular perforation with terminal ileal''. In order to avoid further complications, he underwent appendicectomy surgery through Laparoscopy. While he was in IMCU, he died due to cardiac arrest on 25.01.2018. A sum of Rs.2,42,385/- has been incurred by the petitioner towards her husband's medical treatment. Therefore, the petitioner has submitted an application on 28.02.2018 to the third respondent along with the medical records, for reimbursement of the amount spent by her for her husband's medical treatment. The third respondent has rejected the claim of the petitioner that the treatment has been taken in a non-network hospital and therefore, she is not entitled for medical reimbursement under the New Health Insurance Scheme 2018, by his proceedings in Na.Ka.No.525/2017/Ra3, dated 23.08.2018.

2. The learned counsel appearing for the petitioner submits that due to medical emergency, this petitioner has taken her husband to the nearby hospital and at that relevant point of time, she could not verify the list of hospitals, in which, treatment has to be taken for claiming medical expenses. Despite giving best treatment, her husband died on 25.01.2018. In order to safeguard her husband and to avoid further complications, she has admitted her husband in a nearby hospital. On the stand of the respondents that the petitioner’s husband has been treated in a non network hospital, the learned counsel has relied on the order the learned counsel has relied on the order of this Court in N. Raja Vs. The Government of Tamil Nadu, Rep. by its Secretary, Adi Dravidar Welfare Department and others , 2016 (3) CTC 394 and the order passed by the Honourable Supreme Court in Shiva Kant Jha Vs. Union of India , (2018) 16 SCC 187 and submits that the Honourrable Supreme Court has held that 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.

3. The learned Additional Government Pleader appearing for the respondents 1 to 3 submits that as per the terms and conditions of the contract alone, the medical expenses can be reimbursed. In this case, the petitioner has taken treatment for her husband in a non-network hospital and therefore, she is not eligible to maintain this writ petition.

4. The learned counsel appearing for the fourth respondent Insurance Company submits that they are bound by the contract. The Government has entered into a contract with United India Insurance Company and they can disburse the amount of medical claim only as per the terms of the contract. He further submits that this petitioner has taken treatment for her husband in a non-network hospital and that too for non-emergency case, when there is a specific condition that the medical expenses can be reimbursed only when treatment is taken in a network hospital. According to the learned counsel, there are more number of speciality hospitals, however, the petitioner has opted for Sacred Heart Hospital, Tuticorin. Therefore, according to the learned counsel, the p