Madras High Court
V.Daisy Mary vs The District Collector on 17 April, 2013
Author: D.Hariparanthaman
Bench: D.Hariparanthaman
BEFORE THE MADURAI BENCH OF MADRAS HIGH COURT DATED: 17/04/2013 CORAM THE HONOURABLE MR.JUSTICE D.HARIPARANTHAMAN W.P.(MD).No.6299 of 2013 V.Daisy Mary .. Petitioner Vs. 1.The District Collector Madurai District, Madurai. 2.The Joint Director, Medical and Rural Health Services Department, Madurai District Headquarters, Usilampatti, Madurai District. .. Respondents Prayer Writ Petition is filed under Article 226 of the Constitution of India to issue a Writ of Mandamus directing the first respondent to pass orders on the petitioner's representation dated 15.10.2012 which was forwarded by the second respondent in reference No.1012/MD/2012 dated 03.01.2013 and to reimburse the amount of Rs.2,12,368.00 (Rupees Two Lakh Twelve thousand Three hundred sixty eight only) to the petitioner's which was paid by her to the approved Hospital under the Health Insurance Scheme, 2012 for the petitioner's husband K.Ayyapparaja's surgery of 'PTCA with stenting to LAD' within a period of stipulated by this Court. !For Petitioner ... Mr.A.Haja Mohideen ^For Respondents... Mr.R.Karthikeyan :ORDER
The petitioner is a Teacher in the Government Higher Secondary School at Achampatti, Madurai District. The petitioner's husband suddenly fell ill on 10.08.2012 and in order to save his life, he was rushed to Vadamalayan Hospital immediately and he was admitted as inpatient. The petitioner's husband was treated for Coronory Artery Disease (Single Vessel Disease) and he underwent "PTCA with Stenting to LAD". The said surgery was covered by G.O.Ms.No.243, Finance (Salaries) Department, dated 29.06.2012. The said Government Order is relating to New Health Insurance Scheme, 2012 (In short NHIS). The petitioner is a contributor to the said scheme. Hence, her family is entitled to the benefits under the scheme. Vadamalayan Hospital is one of the approved hospital under G.O.Ms.No.243, Finance (Salaries) Department, dated 29.06.2012. However, Vadamalayan Hospital, insisted that the petitioner shall pay the amount for treatment.
2. In these circumstances, the petitioner paid Rs.2,12,368/- towards medical expenses. Ultimately her husband was discharged on 13.08.2012. The petitioner requested the respondents to reimburse the medical expenses that was incurred in the Vadamalayan Hospital as stated above. But, the second respondent sent a letter dated 03.01.2013 stating that the understanding between the Vadamalayan Hospital and the Insurance Company has been signed only on 30.08.2012, while the husband of the petitioner was admitted on 10.08.2012. Hence, the petitioner has filed this writ petition seeking for a direction to the respondents to pay Rs.2,12,368/- that was spent in Vadamalayan Hospital under the NHIS-2012.
3. By consent of both parties, the writ petition itself is taken up for final hearing.
4. The learned counsel for the petitioner has brought to my notice that Vadamalayan Hospital is one of the approved hospitals as per G.O.Ms.No.243, Finance (Salaries) Department, dated 29.06.2012. Vadamalayan Hospital is shown at serial no 101 in the list of approved hospitals. According to her, since Vadamalayan Hospital is shown as approved hospital, she is entitled to the benefit under the NHIS-2012. If there was any delay in signing the memorandum of understanding between the Vadamalayan Hospital and the Insurance Company, the petitioner cannot be blamed for the same.
5. Furthermore, the learned counsel has submitted that when the petitioner's husband was struggling for life due to heart problem, the family cannot search for an approved hospital and the person has to be admitted immediately in the nearby hospital. Therefore, the respondents cannot deny the benefit of NHIS-2012. Even if the hospital is not approved under the scheme, according to the petitioner, the respondents are bound to reimburse the actual medical expenses. The real test is as to whether there was actual treatment given by the hospital. The respondent cannot take a technical view in this matter.
6. The learned counsel for the petitioner has further submitted that before the NHIS-2012, the medical expenses were directly paid by the Government itself. Similar pleas were taken by the Government to deny the medical reimbursement. According to him, various orders were passed by this Court directing the Government to reimburse the medical expenses even if such a bypass surgery was made in a unapproved hospital.
7. On the other hand, the learned counsel for the respondents has submitted that the second respondent has written a letter dated 03.01.2013 to the petitioner that since the understanding between the Vadamalayan hospital and the insurance company was signed only on 30.08.2012, while the husband of the petitioner was admitted in the hospital on 10.08.2012. Therefore, the petitioner is not entitled to medical reimbursement.
8. I have considered the submissions made on either side. The petitioner's husband suffered heart problem on 10.08.2012. The petitioner is residing at Thirupparankundram, Madurai. Immediately, the husband of the petitioner was taken to Vadamalayan Hospital and he was admitted as inpatient and surgery was performed. He was discharged on 13.08.2012 after the surgery was over. The petitioner incurred Rs.2,12,368/-. Under the NHIS the petitioner is entitled to reimburse up to Rs.4,00,000/-.
9. Vadamalayan Hospital, Madurai insisted for payment of medical expenses, though the Vadamalayan Hospital is a approved hospital under G.O.Ms.No.243, Finance (Salaries) Department, dated 29.06.2012. As rightly contended by the learned counsel for the petitioner, Vadamalayan Hospital, Madurai is shown as serial No.101 in the approved list of hospitals. Since Vadamalayan Hospital has insisted to make the payment, the petitioner had no other option except to make the payment. The husband of the petitioner was discharged from the hospital on 13.08.2012. When the petitioner made a claim to the respondents to reimburse the amount, the second respondent sent a letter dated 03.01.2013 refusing to reimburse the amount. The relevant passage that is relied on by the Government Advocate is extracted hereunder:-
"Thiru.K.Ayyapparaja Husband of the petitioner was admitted in Vadamalayan Hospital, Madurai on 10.08.2012 at 19.38 hours and was discharged 13.08.2012 at 20.32 hours, and where as the memorandum of understanding between Vadamalayan Hospital, Madurai and the Insurance Company has been signed only on 30.08.2012. As such during the time of treatment of the Husband of the petitioner, Vadamalayan Hospital was not the approved list of the hospital."
10. According to the second respondent, the petitioner is not entitled to the medical claim under the NHIS-2012, since the memorandum of understanding between the Vadamalayan Hospital, Madurai and the Insurance Company was signed subsequently i.e. after the admission of the husband of the petitioner. While the memorandum of understanding signed on 30.08.2012, the husband was treated between 10.08.2012 and 13.08.2012. Hence, according to the second respondent, the petitioner is not entitled to the medical benefits under NHIS-2012.
11. I am not in agreement with the view taken by the second respondent in the letter dated 03.01.2013. The purpose of the scheme NHIS is to give medical coverage to the employees and their families. It is stated in paragraph 5 of the Government Order in G.O.Ms.No.243, Finance (Salaries) Department, dated 29.06.2012 as follows:-
"The Employees and their eligible Family Members covered under this scheme shall avail assistance upto the limit of Rupees Four Lakh in a block of four years commencing from 10.07.2012 to 30.06.2016 on a CASHLESS model for the approved treatments and surgeries in the hospitals approved by the Insurance Company/Third Party Administrator under this Scheme."
When the scheme states that it is a cashless model, the poor Government employee was made to pay a huge amount due to heart surgery performed on her husband. The respondents were heartless and took a technical view in this mater.
12. In fact, the Vadamalayan Hospital, Madurai is an approved hospital under G.O.Ms.No.243, Finance (Salaries) Department, dated 29.06.2012. Even assuming that Vadamalayan Hospital, Madurai is not an approved hospital, I am in full agreement with the submissions made by the learned counsel for the petitioner that the family members of the Government employees cannot search for a approved hospital, when the person was struggling for his life. This Court has issued various orders before the NHIS came into existence and reimbursement was made directly by the Government and the Government shall not take such a technical view.
13. In view of the afore-said reasons, the respondents are directed to pay the medical expenses incurred by the petitioner in the Vadamalayan Hospital, Madurai along with 9% interest till the payment is made. The writ petition is ordered in the above terms. No costs.
jikr To
1.The District Collector Madurai District, Madurai.
2.The Joint Director, Medical and Rural Health Services Department, Madurai District Headquarters, Usilampatti, Madurai District.