Judicial Analysis Court Copy Headnote Facts Arguments Court observation

2025 Supreme(Online)(Mad) 10477

IN THE HIGH COURT OF JUDICATURE AT MADRAS
Honourable Mr Justice M.DHANDAPANI
S.MOHAN KUMAR – Appellant
Versus
THE COLLECTOR – Respondent
Writ Petition

Advocates:
For the Appellants/Petitioners: V. Manoharan
For the Respondents: S. Balamurugan, P. Athi Veera Rama Pandiyan

Under the New Health Insurance Scheme, only approved treatments in network hospitals are covered; unapproved treatments cannot be reimbursed, but government employees may seek relief under the Tamil Nadu Medical Attendance Rules.

Headnote:(A) Constitution of India - Article 226 - New Health Insurance Scheme (NHIS), 2021 - Government Orders G.O.Ms.No.160 dated 29.06.2021 and G.O.Ms.No.202 dated 30.06.2016 - Tamil Nadu Medical Attendance Rules - Insurance contract - Terms and conditions - Reimbursement of medical expenses - Unapproved treatment - Emergency treatment - Alternative remedy. (Paras 2, 3, 6)

(B) Insurance schemes for government employees are contractual in nature - The insurance company is bound only by the terms of the contract - The NHIS provides cashless treatment for approved medical procedures in network hospitals - There is no provision for reimbursement of unapproved treatments - However, government employees are not remediless and can seek reimbursement under the Tamil Nadu Medical Attendance Rules for emergency treatments subject to conditions prescribed therein. (Paras 3, 5, 6)

Facts of the case:
The petitioner, a government employee, sought reimbursement of Rs.2,47,843/- incurred for his wife’s treatment for severe dengue fever at a private hospital. The treatment was not among the approved list under the NHIS, and prior permission was not obtained. The insurance company rejected the claim. The petitioner filed a writ petition under Article 226.

Findings of Court:
The court agreed with the respondents that the claim is not covered under the NHIS as per the contractual terms. The insurance company is not liable to reimburse expenses for unapproved treatments. The court held that the petitioner has a remedy under the Tamil Nadu Medical Attendance Rules by approaching the competent authority for reimbursement of eligible expenses, subject to fulfilment of conditions such as certification of emergency. The writ petition was dismissed. (Paras 6, 7)

Issues: Whether the petitioner is entitled to reimbursement of medical expenses under the NHIS for an unapproved treatment? Whether the insurance company can be directed to reimburse outside the terms of the contract? What is the alternative remedy available to the petitioner?

Ratio Decidendi: The parties are governed by the terms of the insurance contract. The NHIS does not provide for reimbursement of unapproved treatments, but the petitioner can seek relief under the Tamil Nadu Medical Attendance Rules. The court cannot rewrite the contract or compel the insurance company to pay for non-covered treatments. (Paras 3, 5, 6, 7) Result : Writ petition dismissed. No costs. (Para 7)

ORDER

The petitioner has filed the present Writ Petitions praying for issuance of Writ of Certiorarified Mandamus to call for the records of the third respondent by his proceedings dated 23.08.2023 issued by them to in favour of Mrs.S.Vasanthi, petitioner’s wife and quash the same and to direct the respondents to pay the medical expenses of Rs.2,47,843/- to the petitioner with interest of 6% per annum from the date of claim till the date of payment and within a time stipulated by this Court.

2. The facts in a nut-shell, are as follows:

(a) Originally, the petitioner was appointed as Junior Assistant in the Commercial Tax Department and thereafter, he was promoted up to the grade of below Assistant Commissioner, and was holding full in-charge of Assistant Commissioner in the Commercial Department.

(b) The Government introduced New Health Medical Insurance Scheme to the Government employees for any medical urgency treatment to them, for which, the Government has issued G.O.No.160 for implementing the New Health Insurance Scheme, 2021 for employees of the State Government Departments, State Public Sector Undertakings, statutory boards, local bodies, State Government Universities, among others and their eligible family members. The United India Insurance Company Limited, Chennai would execute the agreement with the Tamil Nadu Government, following the recommendation of the Tender Scrutinizing Committee, as per G.O.No.160 and it would cover 203 approved treatments and surgeries with 1169 empanelled hospitals, and thereafter, it was extended from time to time.

(c) In the said scheme, the members have to pay Rs.495/- as annual premium plus service tax for a period of four years commencing from the date of commencement of the scheme. The payment of premium shall be regulated as per the terms and conditions of the agreement. That amount has to be deducted in the salary. The scheme will commence from the date of agreement up to four years.

(d) The petitioner is also an employee of State Government, eligible for the above said scheme. As per the scheme, the petitioner paid Rs.295/- per month as a monthly subscription, for which, necessary monthly deductions are made from the petitioner’s salary.

(e) On 10.09.2022, the petitioner’s wife Mrs.Vasanthi had severe fever and heavy pain and also vomiting. On 12.09.2022, her health condition went bad to worst and hence, with the assistance of the petitioner’s relation, she was admitted at Sree Ramachandra Medical College and Hospital, Porur, Chennai. On diagnosis, it came to light that she was due to severe Dengue fever. After thorough medical check-up, the Doctor advised that she has to be admitted there, otherwise it would lead to a lot of complications. Therefore, on the advise of the Doctor, she was admitted on the very same day and in view of the urgency involved, the petitioner could not get prior permission for that from the Insurance Company. For undergoing treatments, the amounts were also paid initially by the petitioner. Totally, the petitioner incurred Rs.2,47,843/- and she was discharged from the hospital on 20.09.2022. Then, she was bedridden for about 10 days in his house as rest.

(f) Thereafter, the petitioner made his claim on 12.10.2022 to the third respondent’s coordinator, i.e. the fourth respondent through proper channel by second respondent. Along with the petitioner’s claim, he enclosed Discharge Summary and medical bills, which supports the claim of the petitioner to Rs.2,47,843/-. They forwarded the District Empowered Committee and requested them to meet early redressal on the issue. It has been forwarded for reimbursement of the petitioner’s claim before the third respondent after getting approval from the District Empowered Committee.

(g) Under the impression that they sent the said amount to the petitioner’s Bank Accounts, but instead of sending the petitioner’s claim, the third respondent returned the petitioner’s claim to the patient name, who is the petitioner’s wife, on th

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2025 Supreme(Online)(Mad) 10477

IN THE HIGH COURT OF JUDICATURE AT MADRASHonourable Mr Justice M.DHANDAPANIS.MOHAN KUMAR – AppellantVersusTHE COLLECTOR – RespondentWrit Petition

Under the New Health Insurance Scheme, only approved treatments in network hospitals are covered; unapproved treatments cannot be reimbursed, but government employees may seek relief under the Tamil Nadu Medical Attendance Rules.

IN THE HIGH COURT OF JUDICATURE AT MADRAS
Honourable Mr Justice M.DHANDAPANI
S.MOHAN KUMAR – Appellant
Versus
THE COLLECTOR – Respondent
Writ Petition