Madras High Court
S.Dhanalakshmi vs The Government Of Tamil Nadu on 12 October, 2015
Author: R.Subbiah
Bench: R.Subbiah
BEFORE THE MADURAI BENCH OF MADRAS HIGH COURT DATED : 12.10.2015 CORAM THE HONOURABLE Mr.JUSTICE R.SUBBIAH W.P.(MD).No.13159 of 2015 and M.P.No.1 of 2015 S.Dhanalakshmi ....Petitioner Vs. 1.The Government of Tamil Nadu, rep. by its Secretary, Fort St. George, Chennai-600 009. 2.The United India Insurance Co. Ltd., Divisional Office VI, 5th Floor, P.L.A.Rathna Towers, No.212, Annasalai, Chennai-600 006. 3.The Commissioner of Treasuries and Accounts, 2nd Floor, Panagal Building, Jeenish Road, Saidapet, Chennai-15. 4.The Joint Director, Rural Health Services, Usilampatti, Madurai District. .... Respondents Prayer:- Writ Petition has been filed under Article 226 of the Constitution of India praying for issuance of a writ of Certiorarified Mandamus calling for the records relating to the impugned order made by the 2nd respondent dated 08.01.2015 and to quash the same as illegal and consequentially to direct the respondents 1 and 2 to pay and make good to the petitioner a sum of Rs.44,581/- towards the medical expenses incurred by the petitioner for her son within a time stipulated by this Court. Appearance for the parties !M/s.Mr.E.Marees Kumar for Ajmal Associates - for the petitioner ^Mr.M.Murugan, GA - For respondents 1, 3 & 4 Mr.A.Shajakan ? for 2nd respondent :ORDER
This writ petition has been filed praying for issuance of a writ of Certiorarified Mandamus calling for the records relating to the impugned order passed by the 2nd respondent dated 08.01.2015 and to quash the same as illegal and consequentially to direct the respondents 1 and 2 to pay and make good to the petitioner a sum of Rs.44,581/- towards the medical expenses incurred by the petitioner for her son within a time stipulated by this Court.
2. The case of the petitioner, in brief, is as follows:-
The petitioner herein is working as B.T. Assistant in the Corporation Middle School, Madurai. She is covered by the Government of Tamil Nadu, New Health Insurance Scheme-2012 being in the service of the Government of Tamil Nadu. She has been regularly subscribing insurance, for which necessary monthly deductions are made from her salary. On 22.04.2014, the petitioner's minor son Amitesha, aged 10 months, started vomiting continuously without any reason. After administering medicine from the nearby Doctor, the petitioner was under the impression that it was due to food poisoning and the child would get back to stable health. But, on the next day ie., on 23.04.2014 the health condition of the petitioner's son had gone from bad to worse; therefore, she rushed to nearby Child Specialist in Karthik Hospital at Madurai. On diagnosis, it came to light that it was due to obstructed hernia. The petitioner's son could not take food in the normal course. After through medical check up, the Doctor advised the petitioner that unless her son undertakes surgery immediately for obstructed hernia, it would lead to lot of complications. Therefore, on the advice of the Doctor, the petitioner's son had undergone surgery on the very same day at 04.00 p.m. Since the petitioner was deputed for election duty, due to urgency of the petitioner's son's health condition, the petitioner submitted a representation for cancelling the election duty to the District Collector, Madurai District, on 23.04.2014 explaining the urgency involved. Accordingly, it was accepted by them and she was permitted to be with her son during the course of operation. An operation was also conducted to the petitioner's son at Karthik Hospital at Madurai. In view of the urgency involved, the petitioner could not take prior permission for conducting operation from the Insurance Company. For undergoing an operation, she had incurred an amount of Rs.44,581/- for which she has necessary medical bills and the same were submitted for claim to the 2nd respondent. In this connection, the petitioner has made a detailed representation to all the respondents herein, pursuant to which, the petitioner was called upon by the third respondent to know the genuineness of her claim through his letter dated 02.07.2014. The Joint Director along with the other Doctors examined the medical records at his office and accordingly, issued a genuineness certificate to the petitioner vide letter dated 11.07.2014. Thereafter, the matter was referred to the District Collector for further action. The District Collector, Madurai District has asked the petitioner to appear before him on 12.11.2014. On the said date, in the presence of the officials namely the District Collector, the Insurance Officials and the third respondent herein and Treasury Officials, the petitioner's documents were once again perused by the officials. After satisfying all the relevant records, the District Collector, Madurai District, being the Project Director, has recommended her case to the first respondent herein through his letter dated 25.11.2014 for getting the medical expenses reimbursed. When she was under a bona fide impression that the amount incurred towards her son's medical expenditure will be reimbursed to her, to her shock and surprise, inspite of the fact the insurance officials had accepted her claim before the District Collector, during the meeting held on 12.11.2014, they had rejected her claim vide their letter dated 08.01.2015, on the ground that her son has taken treatment in a non-network hospital. Challenging the same, the present writ petition has been filed by the petitioner.
3. The 2nd respondent has filed a counter, inter alia, contending that the Government of Tamil Nadu has introduced the New Health Insurance Scheme- 2012 on 01.07.2012 for employees of the Government of Tamil Nadu. The Government has issued G.O.No.243 (Finance) dated 29.06.2012 and NHIS-2012 providing the necessary guidelines and procedure for taking treatment more fully:
(a)the scheme is on cashless basis and no payment is to be paid by the employee to the approved hospitals (net work hospitals)
(b)Payment will be made to the Hospital only for approved treatment procedures mentioned in the G.O.
(c)Payment will be made only after the pre-authorization approval is obtained
(d)Any claim in deviation of the above procedure for re-imbursement is liable to be rejected.
Normally, the Managing Director of India Health Care Services (TPA) Private Limited would give pre-authorization approval only based on the request received from network Hospital based on NHIS ID cards or annexure VII form available in G.O.243. In the instant case, the petitioner's son namely Master Amitesha has taken treatment in Karthik Hospital, Madurai on 23.04.2014 which is not a net-work hospital and the said Hospital is not covered under the above said scheme. There are 113 listed procedures in G.O.No.243 dated 29.06.2012 which are approved procedures under the NHIS-2012 scheme and the 2nd respondent has empanelled the Net Work Hospitals which are listed in the G.O.No.680 which is issued by Finance (Salaries) Department under 29.07.2013. Since the petitioner has not followed the procedures prescribed under the above said scheme, more fully as per the said G.O., before taking the treatment and she got the treatment for her son on her own, the 2nd respondent- insurance company has no liability whatsoever to reimburse the amount of expenditure incurred for the treatment for her son. Thus, the 2nd respondent sought for dismissal of the writ petition.
4. Heard the learned counsel appearing for the respective parties and perused the materials available on record.
5. A perusal of the documents would reveal the fact that the petitioner had incurred medical expenditure to the tune of Rs.44,581/- for her son. It is the case of the petitioner that she is working as B.T. Assistant in the Corporation Middle School, Madurai and she is covered by the Government of Tamil Nadu, New Health Insurance Scheme-2012 being in the service of the Government of Tamil Nadu. On 22.04.2014, the petitioner's minor son Amitesha, aged 10 months, started vomiting continuously without any reason. After administering medicine from the nearby Doctor, the petitioner was under the impression that it was due to food poisoning and the child would get back to stable health. But, on the next day ie., on 23.04.2014 the health condition of the petitioner's son had gone worse; therefore, she rushed to nearby a Child Specialist in Karthik Hospital at Madurai. After through medical check up, the Doctor advised the petitioner that unless her son undertakes surgery immediately for obstructed hernia, it would lead to lot of complications. Therefore, on the advice of the Doctor, the petitioner's son had undergone surgery on the very same day at 04.00 p.m.
6. The treatment taken by the petitioner's son is not under dispute. In an emergency, the petitioner cannot be asked to search for a network hospital listed out by the insurance company. The petitioner's claim for medical reimbursement was negatived by the Insurance company only on the ground that the petitioner's son has taken treatment in a non-network hospital. It is apt to mention that in various decisions of this Court, it has been held that the trauma undergone by an applicant for performing surgery either for himself or for his family members cannot be described at all. Further, I find that the relationship between the petitioner and the Insurance Company is purely contractual. In a similar case, in W.P.No.13594 & 29192 of 2013 (K.Srinivasan Vs State Government of Tamil Nadu and another), this Court by order dated 04.09.2014 has given direction to the Government to reimburse the claimed amount. The relevant portion in the said order reads as follows:-
?14.The Tamil Nadu Medical Attendance Rules clearly lay down the rules regarding dependents and who is entitled to medical concessions under the Rules. As per the said rules, the petitioners are entitled to claim medical reimbursement against the Government. Similar issue was considered by the Divisional Bench of this Court in the case reported in 2010(2) LW 90 (Star Health and Allied Insurance Co. Ltd., Vs. A.Chokkar & Another), wherein in paragraphs 25 and 26 the Division Bench held thus, ?25.The Tamil Nadu Medical Attendance Rules ('the Rules' in short) clearly lay down the rules regarding dependents and who is entitled to medical concessions under the Rules. It also defines who is a well to do person. The Rules lay down the manner in which claims can be made. According to the learned Advocate General, these Rules are still in force and therefore when it is a claim not covered by the present Insurance Scheme, the Government Servants have the right to make their claims under the Rules. Therefore, as regards Category-A, where treatment has been taken in a non- network hospital, the insurance company cannot be asked to cover the expenses, since the scheme itself makes the network hospitals as intrinsic. However, the petitioners/claimants were also not no remediless and that is why we will issue directions to the claimants to make an application under the Rules or go before the Redressal Committee.
26.Before taking up the individual cases, we must record that there are certain situations which may arise and in fact which have arisen, for which the Government must issue clear guidelines. This the Government has to do, since it has made the Scheme obligatory for everyone and there is automatic deduction of premium to an extent of Rs.25/- per month.
The directions are as follows:-
(i)The State shall make it clear that if for some reason, which is satisfactory, the claimant is unable to take treatment in a network hospital but has been advised or had to go to a non-network hospital, then his claim would be considered under the Rules.
(ii)If the claimant has been advised some procedure which is not covered by the Scheme, there again, it must be made clear that he can apply under the Rules.
(iii)To safeguard duplication of payment, the Government can make sure and when they apply under the Rules, that the claimant himself certifies that he has not made claim under the Scheme or vice-versa.
(iv)The State shall inform every network hospital that if it receives complaints from claimants that money was demanded for admission or for treatment, then that hospital will be removed from the network. This warning is necessary, since, at times of crisis, the claimants will not be in a position to argue with the hospital that this is a 'cashless' Scheme. We are aware that there is an officer of the Star Health Insurance Company at every network hospital to ensure that hospitals adhere to the terms of the Scheme but, yet, it is better to make this position clear to the hospitals, since one of the questions that has arisen before us is that whether the claimants will be entitled to reimbursement if, by mistake, they pay cash.' In the said judgment the Division Bench directed the State Government to inform every network hospital that if there is any complaint from claimants regarding demand of money for admission or for treatment is received, the concerned hospital will be removed from the network. In spite of such direction given by the Division Bench of this Court as early as in the year 2010, the hospitals in which petitioner's son (in W.P.No.13594/2013) took treatment and petitioner's husband (in W.P.No.29192/2013) was hospitalised, insisted for payment of amount for extending treatment, for which petitioners cannot be blamed. It is not disputed that the Government have not removed the hospitals from the approved list, which insisted to pay the amounts, as on date. Thus, the fault is entirely with the Government.
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17.In the light of the judgments cited supra, which covers the matter in issue, petitioners are entitled to succeed in their claim against the first respondent/Government. Consequently both the writ petitions are disposed of as against the first respondent/Government with direction to the first respondent/Government to sanction and reimburse the eligible medical expenses, by receiving claim from the petitioners and after ascertaining the genuineness of the claim with reference to the bills/vouchers submitted, pay the same with 9% interest from the date of remittance of amount to the listed hospitals by the respective petitioner till date of payment, within a period of four weeks from the date of receipt of copy of this order. No costs.?
In the above said decision, the learned Single Judge of this Court, by following the decision of the Division Bench, has given direction to the State Government to reimburse the amount. Keeping the said decision in mind, I have carefully gone through the factual aspects of this case. In the instant case also, in the emergent situation, it is not possible for the petitioner to search for the list of network hospital. Under such circumstances, the above said decision is squarely applicable to the present facts of the case also.
7. Hence, applying the above said decision, this Court directs the first respondent to sanction and reimburse the medical expenses of Rs.44,581/- (Forty Four Thousand and Five Hundred Eighty one only) incurred by the petitioner for the treatment of her son, with 9% interest from the date of remittance of amount to the hospital by the petitioner, i.e. from 30.04.2014, till the date of payment to her, within a period of four weeks from the date of receipt of a copy of this order. No costs. Consequently, connected Miscellaneous Petition is closed.
To
1.The Secretary, Government of Tamil Nadu, Fort St. George, Chennai-600 009.
2.The United India Insurance Co. Ltd., Divisional Office VI, 5th Floor, P.L.A.Rathna Towers, No.212, Annasalai, Chennai-600 006.
3.The Commissioner of Treasuries and Accounts, 2nd Floor, Panagal Building, Jeenish Road, Saidapet, Chennai-15.
4.The Joint Director,
Rural Health Services,
Usilampatti,
Madurai District. .