Madras High Court
Appellant vs M.Karunakaran on 1 August, 2024
Author: V.Bhavani Subbaroyan
Bench: V.Bhavani Subbaroyan
W.A.(MD)No.1111of 2016
BEFORE THE MADURAI BENCH OF MADRAS HIGH COURT
DATED :01.08.2024
CORAM:
THE HONOURABLE MRS.JUSTICE V.BHAVANI SUBBAROYAN
AND
THE HONOURABLE MR.JUSTICE K.K.RAMAKRISHNAN
W.A.(MD)No.1111 of 2016
and
C.M.P(MD)No.6827 of 2016
The General Manager,
The United India Insurance Co.,
No.24, Whites Road,
Chennai – 14.
: Appellant
Vs.
1.M.Karunakaran
2.The Manager,
MD India Health Care Services P Limited,
27, Laxmi Towers, III Floor,
Dr.Radhakrishnan Salai, Mylapore,
Chennai.
3.The Managing Director,
The Tamil Nadu State Transport Corporation,
Thirupathur,
Sivagangai.
4.The State Government of Tamil Nadu,
rep. by its Secretary,
Finance (Salary), Department,
Fort St. George, Chennai – 600 009.
1/17
https://www.mhc.tn.gov.in/judis
W.A.(MD)No.1111of 2016
5.The Commissioner of Treasuries and Accounts,
Panagal Buildings, Saidapet,
Chennai – 600 015.
(R4 & R5 impleaded vide court order dated 07.09.2016
made in CMP(MD)No.7948/2016)
: Respondents
PRAYER: Writ Appeal is filed under Clause 15 of Letters Patent to set aside
the order dated 18.08.2015 passed in W.P.(MD) No.19174 of 2014.
For Appellant : Mr.A.Shajahan
For Respondents : Mr.J.Anandkumar for R1
Mr.D.Sivaraman for R2
Mr.K.Ramaiah for R3
Mr.SRA.Ramachandran
Addl. Govt. Pleader for R4 & R5
***
JUDGMENT
[Judgment of the Court was made by K.K. RAMAKRISHNAN .J.] The writ petitioner, Karunakaran, was working as Senior Technical Assistant in the Tamil Nadu State Transport Corporation, Tirupathur Division, Sivagangai District. He is a member of the Tamil Nadu Health Insurance Scheme. He has also paid subscription of Rs.150/- as premium. His wife namely, Tamaraiselvi suddenly slipped into depression and hence, she was 2/17 https://www.mhc.tn.gov.in/judis W.A.(MD)No.1111of 2016 admitted at Vadamalayan Hospital on 21.10.2012 where, they diagnosed that she was suffering from disease “Brain Anurysm”. Thereafter, she was shifted to Hannah Joseph Hospital, Madurai on 23.10.2012. After the surgery and treatment, she became normal and hence, she was discharged on 05.12.2012. She was treated as inpatient for the above entire period. During the said period, the petitioner incurred total expenditure of Rs.10,50,000/- in Hannah Joseph Hospital. Insofar as Vadamalayan Hospital is concerned, he spent Rs.62,895/-. Hence, total expenditure comes to Rs.11,12,890/-. Thereafter, the petitioner had applied for medical reimbursement under the said scheme through his employer/respondent/transport corporation by submitting a representation dated 15.01.2013. Since the appellant/Insurance Company has not considered his request, he made another representation on 25.05.2013. Since there was no reimbursement, he filed the writ petition seeking for issuance of a Writ of Mandamus to direct the appellant/Insurance Company to grant medical reimbursement to the tune of Rs.11,12,890/- by considering his representation dated 25.05.2013.
2. The appellant/Insurance Company filed their counter stating that initially, the petitioner's wife was admitted at network hospital, namely, Vadamalayan Hospital and she left the hospital and admitted herself at Hannah 3/17 https://www.mhc.tn.gov.in/judis W.A.(MD)No.1111of 2016 Joseph Hospital at Madurai on her own accord. Since the petitioner's wife is said to have taken treatment at the Hannah Joseph Hospital, which was, according to the appellant, “non-network hospital”, he was not entitled for reimbursement. It was further stated that as per the contract entered into between the appellant/Insurance Company and the Government, as per G.O.Ms.No.243, Finance (Salaries) Department, dated 29.06.2012, the petitioner is not entitled to claim of reimbursement on account of taking treatment at the non-network hospital. It was further stated that even as per the scheme, the petitioner is eligible to get Rs.4,00,000/- alone and he is not entitled to get more than the amount.
3. The Writ Court, after considering the submission of both sides, allowed the writ petition by directing the appellant/Insurance Company to disburse the amount claimed by the petitioner within a period of four weeks from the date of proposal of the respondent/employer. The learned Single Judge did not accept the contention of the appellant that the hospital, in which, the petitioner's wife has taken treatment, was non-network hospital and also the ceiling limit of the contractor. Challenging the order of the learned Single Judge, the appellant/Insurance Company has filed the present writ appeal. 4/17 https://www.mhc.tn.gov.in/judis W.A.(MD)No.1111of 2016
4. The learned Standing Counsel for the appellant/Insurance Company submitted that even though the learned Single Judge has passed the order granting medical reimbursement, subsequently, the same learned Single Judge declined to grant relief by accepting the ground of “non-network hospital” in the guidelines issued in G.O.Ms.No.243, Finance (Salaries) Department, dated 29.06.2012 in some other similar case and the same learned Single Judge has held that the person like the petitioner, is not entitled to claim medical reimbursement from the Insurance Company and they are entitled to claim the same “from the Government” and not from the Insurance Company since there was no clause in the Contract to grant the medical reimbursement for taking treatment apart form the non-network network hospitals. In support of his contention, he has produced the following reported and unreported Judgments:
“1. 2010-2-L.W.90 (Star Health and Allied Insurance Co. Ltd., vs. A.Chokkar and another.
2. W.A(MD)No.1382 of 2017 dated 09.11.2017
3. W.A(MD)No.843 of 2017 dated 28.11.2017
4. W.A(MD)No.1057 of 2019 dated 22.10.2019
5.W.A.No.1902 of 2018 dated 14.03.2019
6. (2019) 2 MLJ 1 [State Level Empowered Committee vs. Paramasivam]” 5/17 https://www.mhc.tn.gov.in/judis W.A.(MD)No.1111of 2016
5. After filing the appeals, the Secretary, Finance (Salary), Department and the Commissioner of Treasuries and Accounts were impleaded as party respondents.
6. The learned counsel for the first respondent/writ petitioner submitted that as per the scheme produced by the petitioner in G.O.Ms.No.243, Finance (Salaries) Department, dated 29.06.2012, there is a specific clause in para 8. As per the said clause, in addition to these hospitals, the employees' families will be also “eligible for treatment in other institutions” to be approved by the Insurance Company and third party administrator. In this clause, “it is only stated for treatment”. In this case, the treatment is not disputed. The interpretation in the clause 8 has to be adopted in favour of the writ petitioner also. Hence, the learned Single Judge was correct in directing the issuance of the compensation from the appellant/Insurance Company.
7. The learned counsel further submitted that the hospital was also included in the network hospital subsequently and the treatment given by the non-networking hospital is surgery for repair of “Aneurysm, which was the one of the treatments given in Annexture II of the scheme”. When there was no 6/17 https://www.mhc.tn.gov.in/judis W.A.(MD)No.1111of 2016 dispute relating to the treatment, it is always open to the appellant/Insurance Company to disburse the amount.
8. The learned counsel further submitted that the similar issue was raised before the Hon'ble Supreme Court. In paragraph 13 of the Judgment reported in (2018)5 MLJ 317 (SC) [Shiva Kant Jha vs. Union of India], the Honourable Supreme Court has declined to accept the argument of the Insurance Company that treatment was taken before the non-network hospital is not a ground to decline the relief when treatment is covered under the scheme and also the same was not disputed. He also stated that when there was an ambiguity in the provisions of the health insurance scheme, the benefit always goes in favour of the claimants. He further submitted that Judgments of the Division Bench furnished by the appellant/Insurance Company are not applicable to the present case. In the said cases, no interpretation was given to the clause 8 of the scheme. Hence, this Court has to re-look into the clause 8 of the G.O.Ms.No.243 dated 29.06.2012. Hence, he seeks for the dismissal of this appeal.
9. The learned Additional Government Pleader appearing for the respondents 4 and 5/Government submitted that a scheme was framed and the 7/17 https://www.mhc.tn.gov.in/judis W.A.(MD)No.1111of 2016 clause stated that there was no bar for the employees' family members to take treatment in other institutions, but the only condition is that it should be approved by the Insurance Company after taking treatment. In the said circumstances, the Insurance Company is liable to pay compensation as they are receiving the premium from the each employees. Hence, he seeks for dismissal of this writ appeal.
10. This Court has considered the rival submissions of all the learned counsel and perused the materials available on record. To appreciate the contention of the parties, it is relevant to extract hereunder clause 8 of the scheme and also treatments list annexed in the Annexure II:
“8.The diseases, treatments and surgeries under the broad based specialities approved under the New Health Insurance Scheme, 2012 are listed in the Annexure -II to this order. The hospitals already in Tamil Nadu Government Employees Health Fund Scheme and approved by the United India Insurance Company Limited / Third Party Administrator under the New Health Insurance Scheme, 2012 are listed in the Annexure-III. In addition to these hospitals, the employee families will be also eligible for treatment in other institutions to be approved by the Insurance Company and Third Party Administrator. The Nodal Officers of the United India Insurance Company Limited situated in the District Headquarters and Toll Free Helpline Number are listed in the Annexure-IV. The lists of approved treatments and surgeries approved hospitals and the addresses of the Offices situated in the District Headquarters are also hosted on the websites of Government of Tamil Nadu in Finance Department (www.tn.gov.in/departments/finance.html), 8/17 https://www.mhc.tn.gov.in/judis W.A.(MD)No.1111of 2016 Treasuries and Accounts Department (www.tn.gov.in/karuvoolam) and the United India Insurance Company Limited, Chennai/Third Party Administrator (www.mdindiaonline.com). The additional list of hospitals included and list of deleted hospitals, if any covered in this Scheme will also be hosted in the above websites for ready reference from time to time on receipt of the same from the United India Insurance Company Limited / Third Party Administrator.” Annexure-II LIST OF DISEASES, TREATMENTS AND SURGERIES CLASSIFIED UNDER THE BROAD BASED SPECIALITIES Sl.No. Name of Diseases, Treatments and Surgeries CARDIOLOGY AND CARDIO THORACIC SURGERY Heart Surgery including
1. (a) Coronary By-Pass Surgery (CABG)
2.(b) Valve Replacement and Other Valvulo Plastics
3.(c) Correction of all Congenital Heart Diseases
4.(d) Angioplasty and PTCA Stent
5.(e) Baloon Valvuloplasty
6.(1) Permanent and Temporary Pacemaker Implantation
7.(g) Embolectomies for Peripheral Artery Embolism
8. (h) Surgeries for Repair of Aneurysm
9.(i) Enhanced External Counter Pulsation Therapy (EECP).............9/17
https://www.mhc.tn.gov.in/judis W.A.(MD)No.1111of 2016
11. On perusal of the above said clause, it is clear that there was no bar to take treatment in hospital other than the listed network hospital. They are permitted to take the eligible treatments in the other institutions but it should be approved by the Insurance Company and third party administrator. In this case, as per the averments made in the writ petition, the petitioner sent a representation to the Department as well as the Insurance Company. There was no dispute over the submission of the representation to disburse the medical reimbursement. It is not the case of the insurance company that they have considered the representation and sent a communication to the family members informing them that the treatment taken by the petitioner is not eligible for the claim as treatment has been taken in non-approved hospital.
12.In the precedents relied by the learned counsel for the appellant, there was no discussion and interpretation to the above Clause 8 of the scheme. Therefore, this Court independently perused Clause 8 and applied the purposive interpretation to clause 8 by taking holistic view of entire scheme of the Act.
13.Medical emergency requires immediate treatment without any delay. In the case of emergency, the patient may not be in a position to search the network hospital listed out in the Government Order. Further, family 10/17 https://www.mhc.tn.gov.in/judis W.A.(MD)No.1111of 2016 members of the Government Servant are not expected to know the scheme of the Government and also scheme of the hospital. Looking into the other aspects, namely, if there was no network hospital, in the vicinity of occurrence place, it is impossible for the patient to search for such hospital and admit the patient risking the life. In the said circumstances, practical difficulties have also to be looked into for interpreting the above clause 8.
14. This Court perused all the Judgments relied on by the learned counsel for the appellant/Insurance Company. There was no discussion about clause 8. In the said circumstances, this Court is duty bound to rely on the Judgment of the Hon'ble Supreme Court reported in (2018)5 MLJ 317 (SC) (cited supra). In the said Judgment, in paragraph 13, the Honourable Supreme Court has held as follows:
“13. It is a settled legal position that the Government employee during his life time or after his retirement is entitled to get the benefit of the medical facilities and no fetters can be placed on his rights. It is acceptable to common sense, that ultimate decision as to how a patient should be treated vests only with the Doctor, who is well versed and expert both on academic qualification and experience gained. Very little scope is left to the patient or his relative to decide as to the manner in which the ailment 11/17 https://www.mhc.tn.gov.in/judis W.A.(MD)No.1111of 2016 should be treated. Speciality Hospitals are established for treatment of specified ailments and services of Doctors specialized in a discipline are availed by patients only to ensure proper, required and safe treatment. Can it be said that taking treatment in Speciality Hospital by itself would deprive a person to claim reimbursement solely on the ground that the said Hospital is not included in the Government Order. The right to medical claim cannot be denied merely because the name of the hospital is not included in the Government Order. The real test must be the factum of treatment. Before any medical claim is honoured, the authorities are bound to ensure as to whether the claimant had actually taken treatment and the factum of treatment is supported by records duly certified by Doctors/Hospitals concerned. Once, it is established, the claim cannot be denied on technical grounds. Clearly, in the present case, by taking a very inhuman approach, the officials of the CGHS have denied the grant of medical reimbursement in full to the petitioner forcing him to approach this Court.”
15. On reading the above Judgment, it is clear that when there was no dispute relating to the treatment taken by the employee's family members and there was no dispute relating to the disease of the employee, the claim cannot be denied on technical grounds. In this case, there was no dispute that the writ petitioner/first respondent's wife suffered from the disease “Brain Anurysm” 12/17 https://www.mhc.tn.gov.in/judis W.A.(MD)No.1111of 2016 and treatment was taken. In the above said circumstances, the learned Single Judge had correctly appreciated the facts and law and fixed the liability upon the Insurance Company to pay the amount of medical reimbursement. This Court finds no reason to interfere with the decision rendered by the Writ Court.
16. It is well settled law that when there was a dispute in interpretation of the provision of the scheme meant for the welfare of the employee, ambiguity should be discarded and the interpretation to achieve the object of the scheme has to be adopted. The insurance polices, being uberrimae fiedi the contracting parties are to keep utmost faith.
17. The employee's medical scheme is social welfare legislature and is to achieve the social justice. The Government has introduced this programme and entrusted the disbursement of the medical reimbursement upon collecting the payment from each of the employees and submitted to the Insurance Company as a premium. Once they received the premium, unless there is a material violation of the scheme, namely, the Contract, the Insurance Company can seek exemption to pay the medical reimbursement. 13/17 https://www.mhc.tn.gov.in/judis W.A.(MD)No.1111of 2016
18. In this case, the Insurance Company has not produced the Contract entered between the Government and the Insurance Company, however, they stated that the contract and the implementation of the programme is only in the form of the G.O.Ms.No.243, Finance [Salaries] Department, dated 29.06.2012, which is not accepted by this Court. Without any contract, the Government Order cannot be issued. The Government Order is issued by the Government relating to the terms of the scheme and it is not treated as a contract between the company and the Government. Subsequent inclusion of the hospital, namely, Hannah Joseph Hospital, is in favour of the respondent/writ petitioner and the same has to be taken into consideration by the Insurance Company.
19. In the said circumstances, this Court does not find any merit in the contention of the appellant/Insurance Company and they cannot escape from payment of the medical reimbursement only on technical grounds that the treatment was not taken in the listed network hospital.
20. It is the specific case of the first respondent/writ petitioner that he initially admitted his wife in the listed hospital and for giving better treatments, 14/17 https://www.mhc.tn.gov.in/judis W.A.(MD)No.1111of 2016 his wife was shifted to Hannah Joseph Hospital, which is a specialised hospital for treatment for Brain. In the said circumstances, it is not the case of the appellant/Insurance Company that the first respondent/writ petitioner has sought fake claim without taking treatment. The appellant/Insurance Company has admitted the treatment and disease. Therefore, this Court finds no merit in the contention of the appellant/Insurance Company.
21. As per the scheme, maximum limit is Rs.4,00,000/-. Hence, the Insurance Company is liable to pay the amount of Rs.4,00,000/-. Therefore, this Court has no other option except to accept the contention of the appellant / Insurance Company since the scheme is only limited to Rs.4,00,000/-.
22. In view of the above discussion, this Writ Appeal is partly allowed with the following directions:
(i)the award amount passed by the writ Court is reduced to Rs.4,00,000/- from Rs.11,12,890/-.15/17
https://www.mhc.tn.gov.in/judis W.A.(MD)No.1111of 2016
(ii) the appellant Insurance Company is directed to pay the amount of Rs.4,00,000/- with 6% at the rate of interest per annum, from 15.01.2013 to till the date of payment.
There shall be no order as to costs. Consequently, connected miscellaneous petition is closed.
[V.B.S.,J.] [K.K.R.K.,J.]
01.08.2024
NCC : Yes/No
Index : Yes / No
Internet : Yes
skn/sbn
To
1.The Commissioner of Treasuries and Accounts, Chennai – 15.
2.The Joint Director, Rural Health Services, Usilampatti, Madurai District.
3.The Secretary, Government of Tamil Nadu, Finance (Salary), Department, Fort St. George, Chennai – 600 009.
16/17 https://www.mhc.tn.gov.in/judis W.A.(MD)No.1111of 2016 V.BHAVANI SUBBAROYAN, J.
and K.K.RAMAKRISHNAN, J.
skn/sbn W.A.(MD)No.1111 of 2016 and C.M.P(MD)No.6827 of 2016 01.08.2024 17/17 https://www.mhc.tn.gov.in/judis