Writ petition not maintainable without exhausting internal grievance redressal mechanism under health insurance scheme.

7.District Treasury Officer Madurai District, Madurai District. ... Respondents PRAYER: Writ Petition filed under Article 226 of the Constitution of India, praying this Court to issue a Writ of Mandamus directing the respondents to forthwith reimburse a sum of Rs.53,770/- being the actual medical expenditure already incurred by the petitioner towards intravitreal injection of Aflibercept for eye treatment at Nethra Eye and Retina Speciality Hospital, Madurai, and further direct the respondents to reimburse the future medical expenses required for the said treatment, based on G.O.No.204, Finance (Health Insurance) Department, dated

30.06.2022.

For Petitioner : M/s.W.Pamelin For Respondents : Mr.S.Shaji Bino-for R1 to R3, R6 & R7 Special Government Pleader Mr.I.Robert Chandrakumar – for R4

ORDER

This writ petition has been filed seeking a Writ of Mandamus directing the respondents to forthwith reimburse a sum of Rs.53,770/- being the actual medical expenditure already incurred by the petitioner towards intravitreal injection of Aflibercept for eye treatment at Nethra Eye and Retina Speciality Hospital, Madurai, and further direct the respondents to reimburse the future medical expenses required for the said treatment, based on G.O.(Ms)No.204, Finance (Health Insurance)

Department, dated 30.06.2022.

2. Heard M/s.W.Pamelin, learned counsel for the petitioner, Mr.S.Shaji Bino, learned Special Government Pleader appearing for the respondents 1 to 3, 6 and 7 and Mr.I.Robert Chandrakumar, learned counsel appearing for 4^th respondent 4.

3. With the consent of both the parties, the writ petition is disposed of at the admission stage itself.

4. The petitioner herein, while working as a Tahsildar became a member of Tamil Nadu Pensioners Health Insurance Scheme 2022, has been regularly contributing the premium to the said scheme. While being so, in the month of July 2025, the petitioner has availed a medical facility in connection with eye problem and incurred a total expenditure of about Rs.64,000/- and accordingly submitted necessary application for reimbursement under the said scheme to the 4^th respondent. However, the 4^th respondent reimbursed only an amount of Rs.10,230/- as against the total expenditure incurred by the petitioner Rs. 64,000/-, thereby not allowing the expenditure for the balance amount of Rs.53,770/-. Hence, the petitioner approached this Court by filling the present writ petition.

5. The Tamil Nadu Pensioners Health Insurance Scheme, 2022 has been introduced pursuant to the orders issued by the Government in G.O.(Ms)No.204 Finance (Health Insurance Department) dated 30^th June 2022. In terms of the said scheme, in case of any grievance, there was a grievance redressal mechanism that was provided under paragraph No.15 of the annexure to the said Government Order. In terms of Clause 7 of paragraph No.15 of the annexure. The Grievance Redressal Officer has been appointed to look after the grievances of any of the Members of the scheme. The relevant clauses 7 and 8 read as under :

“(7) The Grievance Redressal Officer shall examine the claims to verify if the claims relate only to Eligible Medical Expenses and recommend to the District Level Empowered Committee for reimbursement of such sums of money that relate to Eligible Medical Expenses. In case of claims relating to Non-Network Hospital, he shall examine and submit to the District Level Empowered Committee with his opinion as to whether the claim relates to Emergency Care or treatment/surgery undergone following an Accident or non-emergency care. The Grievance Redressal Officer shall submit his report with his opinion to District Level Empowered Committee within a period of one month from the date of receipt of claim