Medical claims for treatment in non-network hospitals cannot be denied solely based on network status, ensuring the actual treatment received is prioritized.

ORDER :

1. This Writ Petition has been filed challenging the orders dated 09.02.2022, 20.05.2022 & 15.06.2023 passed by the respective respondents whereby, the claim of the petitioner seeking reimbursement of medical expenses was rejected on the ground that treatment was taken in a non-network hospital.

2. The petitioner is working as PG assistant in Economics in the 7^th respondent school. She had joined in the New Health Insurance Scheme under which her husband is also entitled to medical reimbursement for expenses incurred towards treatment. Due to heart ailments, the petitioner’s husband was admitted on 31.03.2021 at G.Kuppuswamy Naidu Memorial Hospital at Coimbatore for taking treatment. After his discharge, the petitioner submitted various representations to the respondents seeking reimbursement of the medical expenses incurred. However, her claim was rejected by impugned orders on the ground that the said Hospital is a non-network Hospital citing various Government Orders. Aggrieved by such rejection, the petitioner has come up with the present Writ Petition.

3. When the matter is taken up, learned counsel appearing for the petitioner submitted that the issue involved in the instant Writ Petition is no longer res integra squarely covered by the order passed by this Court in W.P.No.31948 of 2023 dated 05.04.2024 and therefore, this Writ Petition may be allowed in the light of the order passed in W.P.No.31948 of 2023.

4. Heard the learned counsel for the respondents on the aforesaid contention.

5. A similar issue came up for consideration before this Court in W.P.No.31948 of 2023 dated 05.04.2024 wherein, it was held that rejection of claim for reimbursement on the ground that the treatment was taken in a non- network hospital cannot be sustained. The relevant portion of the said order is extracted hereunder:-

“3. The issue as to whether a medical claim can be rejected on the ground that the employee/pensioner had taken treatment in a non-network hospital is no more res integra. In several decisions of this Court, this aspect has been considered and the rejection by the Insurance Company on the ground that the treatment was taken in a non-network hospital, was held as impermissible.

4. This Court, in the case of M. Kavitha Vs. The State of Tamil Nadu, Finance (Salaries) Department and others passed in W.P. (MD) No. 2540 of 2020 dated 28.02.2020 had held that rejection of a claim for reimbursement, on the ground that the treatment was taken in a non-network hospital, cannot be sustained. The relevant portion of the order reads as follows:-

"3. The proposition as to whether the authorities can reject the request of their employees for medical reimbursement of their treatment undertaken, on the ground that the hospital is a non-network / non- scheduled hospital under the Scheme, is no more res integra, in view of the various judicial pronouncements made. One such order passed in W.P.No.34466 of 2019 dated 11.12.2019 has dealt with this aspect, in the following manner:

This writ petition has been filed challenging the impugned order passed by the 4th respondent rejecting the claim of medical reimbursement made by the petitioner and for a consequential direction to direct the respondents to pay the petitioner the medical reimbursement with interest.

2. It is seen from the records that the petitioner is a retired Head Master of the Panchayat Union School. The petitioner is a subscriber to the New Health Insurance scheme, which was introduced by the government in the year 2014. The subscription towards the insurance is being deducted regularly from the monthly pension. During May 2019, the wife of the petitioner underwent an operation and an emergency surgery was done on 17.05.2019. The petitioner was under the bo