Medical reimbursement claims cannot be denied based on treatment at non-network hospitals, especially in emergencies, as necessity of treatment is paramount.

ORDER :

Battu Devanand, J.

This Writ Petition has been filed to issue a Writ of Certiorarified Mandamus, to call for the records relating to the order passed by the first respondent in Na.Ka.No.703/2018/Ku 3 dated 16.02.2018 and signed on 16.03.2018 and quash the same thereby direct the respondents to pay a sum of Rs.71,683/- spent by the petitioner towards medical expenses with 18% interest from 02.02.2017 until the date of payment.

2. The case of the petitioner is that, he worked in the Government Department as Weaving Inspector and retired from service on 31.10.1988 and drawing pension from the first respondent. The Government of Tamil Nadu has entered into a contract with the United India Insurance Company in the name of Health Insurance Scheme from the year 2014 for the Government employees, pensioners and there family members. The petitioner is contributing his share for payment of premium to the Insurance Scheme. The petitioner is entitled to get general treatment as well as cashless treatment. On 02.02.2017, the petitioner was admitted at Ganga Medical Centre Hospital Pvt., Ltd., Coimbatore in an emergency condition. He underwent a surgery of BPH (Benivn Postrait Hypertrophy). Since he had severe pain in abdomen due to the failure of out put of urine, he was forced to admit in the Hospital on 02.02.2017 and underwent surgery on 03.02.2017 and discharged on 08.02.2017 as per medical advice. For the entire treatment, he has spent a sum of Rs.71,683/-. Thereafter, the petitioner has submitted the claim by enclosing the medical bills along with the discharge summary for reimbursement of medical expenses incurred by him. He submitted claim application for medical reimbursement on 24.02.2017. The said claim was rejected vide proceedings dated 16.02.2018 of the first respondent. The reasons stated for not entertaining the claim of the petitioner is that, he took treatment in the non-network Hospital. Aggrieved by the same, the petitioner filed this writ petition.

3. In the counter affidavit, it is averred that due to the reason that the petitioner took treatment in non-network Hospital, his claim for medical reimbursement is denied.

4. During the course of hearing of this case, the learned Additional Government Pleader appearing for the first respondent has placed a copy of the proceedings dated 26.01.2025 and submits that the District Level Empowered Committee has considered the recommendation of the Treasury Officer, Comibatore with respect to the claim of the petitioner and accordingly, an amount of Rs.28,000/- is sanctioned towards the reimbursement of medical expenses incurred by the petitioner.

5. On perusal of the order dated 26.01.2025, it appears that the package rate for the similar treatment taken in the network hospital has been obtained from the third respondent and determined the said amount.

6. Learned Additional Government Pleader further contends that, as already the eligible amount for disbursement of the petitioner is sanctioned, as per him, nothing survives in this writ petition and sought to dismiss the same.

7. The admitted facts are not in dispute. The petitioner admitted at Ganga Medical Centre Hospital Pvt., Ltd., Coimbatore on 02.02.2017 under emergency condition and he underwent surgery in the said hospital for BPH (Benivn Postrait Hypertrophy) and was discharged on 08.02.2017 and for that treatment, he spent an amount of Rs.71,683/-. He made application for medical reimbursement, but it was rejected by an order dated 16.02.2018 on the ground that the treatment has been taken by the petitioner is in the non-network Hospital.

8. Infact, this Court by its order dated 28.05.2019 in a batch of writ petitions, directed the concerned Committee who is dealing with the medical reimbursement cases shall not reject any claim merely on the reason of taking treatment in non-network Hospital or non listed disease. Admittedly, this order has become final. As such, there is no substance in the contention of the respondents