Supreme Court - Daily Orders
The Chairman Cum Managing Director ... vs G. Latha on 23 September, 2021
Bench: D.Y. Chandrachud, M.R. Shah
SLP(C) 374-379/2019
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ITEM NO.301 Court 4 (Video Conferencing) SECTION XII
S U P R E M E C O U R T O F I N D I A
RECORD OF PROCEEDINGS
Petition(s) for Special Leave to Appeal (C) Nos.374-379/2019
(Arising out of impugned final judgment and order dated 01-03-2018
in WASR No.7594/2018 01-03-2018 in WASR No.7598/2018 01-03-2018 in
WASR No.7606/2018 01-03-2018 in WASR No.7617/2018 01-03-2018 in
WASR No.7624/2018 01-03-2018 in WASR No.7631/2018 passed by the
High Court of Judicature at Madras)
THE CHAIRMAN CUM MANAGING DIRECTOR UNITED Petitioner(s)
INDIA INSURANCE CO. LTD.
VERSUS
G. LATHA & ORS. Respondent(s)
Date : 23-09-2021 These petitions were called on for hearing today.
CORAM :
HON'BLE DR. JUSTICE D.Y. CHANDRACHUD
HON'BLE MR. JUSTICE M.R. SHAH
For Petitioner(s) Mr. P.P. Malhotra, Sr. Adv.
Mr. Vineet Malhotra, Adv.
Mr. Mohit Paul, AOR
Mr. Vishal Gohri, Adv.
Ms. Sunaina Phul, Adv.
Mr. Shubhendu Kaushik, Adv.
For Respondent(s) Mr. S.D. Dwarakanath, Adv.
Ms. Manju Jetley, AOR
Mr. K. V. Vijayakumar, AOR
Mr. D. Kumanan, AOR
Signature Not Verified
Mr. Sheikh Fakhruddin Kalia, Adv.
Digitally signed by
Chetan Kumar
Date: 2021.09.28
18:03:57 IST
Reason:
SLP(C) 374-379/2019
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Mr. R. Anand Padmanabhan, Adv.
Mrs. Debarati Sadhu, Adv.
Mr. Shashi Bhushan Kumar, AOR
Dr. Joseph Aristotle S., AOR
Ms. Preeti Singh, Adv.
Ms. Ripul Swati Kumari, Adv.
Mr. G. Sivabalamurugan, AOR
UPON hearing the counsel the Court made the following
O R D E R
1 On 22 July 2021, DO Letter No 37012/Fin.(Salaries)/2019-1 dated 1 November 2019 of the Principal Secretary to the Government of Tamil Nadu in the Finance Department was placed on the record. Responding to a decision of the Madurai Bench of the High Court of Judicature at Madras, the State Government issued liberalized guidelines to govern claims for reimbursement of medical expenses incurred by employees, pensioners and family pensioners of the State of Tamil Nadu. Clause 6 of the Guidelines covers four distinct situations as extracted below:
“I For an approved treatment/surgery undertaken in a Network hospital, either a part of the claim or no claim has been settled by the Insurance Company.
II For an approved treatment/surgery undertaken in a Non-
Network hospital for Emergency Care or following an accident.
III For an unapproved treatment/surgery undertaken either in Network Hospital or Non-Network Hospital for Emergency Care or following an accident.
SLP(C) 374-379/2019 3 IV For any treatment/surgery undertaken in a Non-Network hospital for Non-emergency care (or) for an unapproved treatment/surgery undertaken in a network hospital for Non- emergency care.”
2 Clause II above covers an approved treatment/surgery undertaken in a non-
network hospital for emergency care or because of an accident. 3 In view of the above Guidelines, a submission was made on behalf of the State of Tamil Nadu that if the respondent – pensioners move the District Level Empowered Committee in terms of the Guidelines, their case for reimbursement will be duly determined, expeditiously. Accordingly, the following directions were issued on the previous date of hearing:
“…the respondents who are the claimants, shall, within a period of three weeks, submit their claims in terms of the revised guidelines of 2019 with necessary documentation to the District Level Empowered Committee constituted under the Guidelines. The Committee shall take its decision on the claims which have been submitted for reimbursement in terms of the Guidelines of 2019 as well as the further Guidelines dated 29 April 2021 issued under letter No 19022/Pension/2021-1 of the Additional Chief Secretary in the Finance (Pension) Department within a period of four weeks of the submission of claims. The State of Tamil Nadu shall, thereupon, reimburse the claims and file an affidavit indicating the decision which has been taken and the extent of reimbursement, if any, provided under the Guidelines of 2019 as well as the further Guidelines dated 29 April 2021 to each of the respondent – pensioners on account of medical reimbursement. The amount which is paid and accepted will be subject to the present proceedings and SLP(C) 374-379/2019 4 without prejudice to the rights and contentions of parties.”
4 In pursuance of the above directions, an affidavit has been filed on behalf of the State of Tamil Nadu. According to the affidavit, the State requested the Commissioner of Treasuries and Accounts on 29 July 2021 as the administrator of the New Health Insurance Scheme to arrange to obtain the recommendations of the District Level Empowered Committee on the claims of the respondent–pensioners. By a letter dated 17 August 2021, the Commissioner of Treasuries and Accounts stated that United India Insurance Company, Chennai has already settled the reimbursement claims due to the pensioners in accordance with the judgment of the Madras High Court subject to the outcome of the present Special Leave Petitions. Hence, since the insurance claims have been reimbursed in accordance with the provisions of the NHIS, the matter has been left to this Court to pass an appropriate order in the interests of justice.
5 Mr P P Malhotra, learned senior counsel appearing on behalf of the petitioner – insurer has relied upon the provisions of clause II (f) and (g) of the Guidelines which reads as follows:
“(f) If the patient has undertaken an approved treatment/surgery under Emergency in a non-network hospital, then the Insurance company is not liable to reimburse the medical claim.
(g) If the Committee is satisfied that the patient has undertaken an approved treatment/surgery in a Non- Network Hospital under Emergency, then the Committee SLP(C) 374-379/2019 5 shall pass order to direct the PAO/PPO/District Treasury Officer, within a period of 30 days from the date of receipt of application, to reimburse medical claim as per the package rate for that approved treatment/surgery undertaken in a similarly placed network hospital in and around the locality. If there is no such similarly placed network hospital in the locality, then the Committee shall identify any other similarly placed network hospital under the scheme in Tamil Nadu for reference.” 6 Clause (f) noted above provides that if a patient has received approved treatment or surgery in an emergency in a non-network hospital, the insurer is not liable to reimburse the medical claim. In the present case, based on the judgment of the High Court, the insurer has paid the claim. Its submission is that the claim was not liable to be reimbursed by it in view of the above guideline and the State must reimburse the insurer. 7 In this backdrop, having due regard to the Guidelines which have been formulated by the State government, we direct that the State Government shall reimburse to the United India Insurance Company the amount which has been paid over to the respondent-pensioners. This shall be without prejudice to the rights and remedies which are available to the State government in accordance with law. We clarify that since the matter has been resolved before this Court, it is not necessary for this Court to express any opinion on the issues of law which were raised by the rival parties. They are left open, particularly since the Court has been apprised of the fact that proceedings are pending before the High Court of Judicature at Madras in SLP(C) 374-379/2019 6 other cases, including Writ Appeals.
8 The Special Leave Petitions are accordingly disposed of. 9 Pending applications, if any, stand disposed of.
(CHETAN KUMAR) (SAROJ KUMARI GAUR)
A.R.-cum-P.S. Court Master