BEFORE THE MADURAI BENCH OF MADRAS HIGH COURT
R.N. MANJULA, J.
P. George - Petitioner
Versus
The District Collector, Nagercoil, Kanyakumari District – Respondent
W.P.(MD).No.9577 of 2024
Decided on : 18-04-2024
ORDER :
R.N. MANJULA, J.
1. By consent of both the parties, the Writ Petition is taken up for final disposal at the admission stage itself.
2. This Writ Petition has been filed to quash the order dated 17.02.2023 passed by the second respondent, and consequently direct the respondents herein to reimburse the amount of Rs.4,53,745/- (Rupees Four Lakhs Fifty Three Thousand Seven Hundred and Forty Five only), to the petitioner, being the medical expenditure incurred by him for the treatment undergone at G.G.Hospital, Thiruvananthapuram along with interest at the rate of 9% per annum from 05.08.2022, the date of recommendation made by the District Level Empowered Committee (DLEC) as against Rs.1,81,640/- (Rupees One Lakh Eighty One Thousand Six Hundred and Forty only) is concerned, and the interest at the rate of 9% per annum from the date of filing of this Writ Petition, as against Rs.2,72,105/- (Rupees Two Lakhs Seventy Two Thousand One Hundred and Five only) is concerned.
3. Heard Mr.C.Kishore, learned counsel, appearing for the petitioner, Mr.M.Rameshkumar, learned Government Advocate for the respondents 1 to 3 and and Mr.C.Karthik, learned counsel for the respondents 4 and 5.
4. Mr.C.Kishore, learned counsel for the petitioner submitted that the petitioner who is a Government servant covered under the Tamil Nadu Government Employees Health Fund Scheme had taken treatment for his illness by getting admitted at G.G.Hospital, Thiruvananthapuram from 21.03.2021 to 30.03.2021 and thereafter on 31.03.2021 and on 07.04.2021. The petitioner claims reimbursement for both the spell and the same was recommended by the District Level Empowered Committee. However, the second respondent has sent the impugned communication dated 17.02.2023 to the petitioner stating that the petitioner has not submitted the original medical records in support of his claim.
5. Now, Mr.C.Kishore, learned counsel for the petitioner submitted that the recommendation has been given for two spells of the treatment given in the hospital and the impugned proceedings have been issued without describing the relevancy of the spell of treatment for which the medical documents are required.
6. In fact, the petitioner has submitted the original documents on 22.04.2021 with regard to the first spell of treatment. In respect of second spell of treatment, the petitioner is in possession of all those medical bills and he is ready to produce before the second respondent whenever it is needed. Since the impugned proceedings dated 17.02.2023 has been issued without acknowledging the original medical bills submitted by him for the first spell of treatment and without adding any explanation as to whether the demand was only in respect of second spell of treatment, the petitioner is confused. In fact, Mr.C.Kishore, learned counsel for the petitioner submitted that the original copies of the medical bills are submitted to the District Level Empowered Committee and in pursuance thereof, the the District Level Empowered Committee had made a recommendation for medical reimbursement to the petitioner. Even though the recommendation has been made, the second respondent has passed the impugned proceedings dated 17.02.2023 without any basis. Aggrieved over the same, the petitioner has come before this Court by way of filing this Writ Petition.
7. It is learnt that the petitioner has submitted the original documents before the District Level Empowered Committee in respect of the first spell due to his ignorance. In such case, the second respondent can address the first respondent to send the original medical bills in respect of the petitioner's claim regarding the first spell and take it up for consideration. So far as the medical bills in respect of the second spell, the petitioner himself can send the bills directly to the second respondent with a clear cover letter and on receipt of the same, the second respondent shall consider and make recommendation and consequently the fourth respondent shal
The main legal point established in the judgment is the requirement for detailed explanation and review of the quantum of medical reimbursement by the High Level Empowered Committee.
Medical reimbursement claims cannot be denied based on treatment at non-network hospitals, especially in emergencies, as necessity of treatment is paramount.
Medical reimbursement claims must follow procedure via district health authorities and empowering committee.
The right to medical claim cannot be denied solely because the hospital is not included in the government order. The factum of treatment and supporting records certified by doctors/hospitals are cruc....
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.
Writ petition not maintainable without exhausting internal grievance redressal mechanism under health insurance scheme.
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