Madras High Court
M. Muthulakshmi vs The Principal Secretary To Government on 11 September, 2023
Author: S. Vaidyanathan
Bench: S. Vaidyanathan
W.P. No. 32931 of 2022
IN THE HIGH COURT OF JUDICATURE AT MADRAS
DATED: 11.09.2023
CORAM
THE HON'BLE MR. JUSTICE S. VAIDYANATHAN
AND
THE HON'BLE MR.JUSTICE K. RAJASEKAR
W.P. No. 32931 of 2022
M. Muthulakshmi ..Petitioner
Vs.
1. The Principal Secretary to Government,
Health and Family Welfare Department,
Fort St. George, Chennai.
2. The Registrar General,
High Court of Judicature at Madras,
Chennai.
3. United India Insurance Company Ltd.,
Through its General Manager,
PLA Rathna Towers, 5th Floor,
212 Anna Salai, Chennai.
4. MD India Health Insurance TPA Pvt. Ltd.,
rep. by its Regional Manager,
1\8
https://www.mhc.tn.gov.in/judis
W.P. No. 32931 of 2022
No. 443, 445, Guna Complex,
Anna Salai, Teynampet,
Chennai 600 018. ..Respondents
Prayer: Petition under Article 226 of the Constitution of India praying
for issue of a Writ of Mandamus directing respondents 3 & 4 to
refund/reimburse the petitioner's balance medical expenses bill amount of
Rs.3,84,219/- (Rupees Three Lakhs Eighty Four Thousand Two Hundred
and nineteen) under the cashless medical expenses scheme, along with
applicable rateof interest from 02.09.2022 till the disbursement.
For Petitioner :: Mr.V. Prakash,
Senior Counsel for
Mr.K. Sudalai Kannu
For Respondents :: Mr.P. Ganesan,
Govt. Advocate for R1
Mr.M. Kempraj,
Standing Counsel for R2
Mr.P. Sankaranarayanan for R3
ORDER
(Made by S. Vaidyanathan,J.) The writ petition is filed for issue of a Writ of Mandamus directing respondents 3 & 4 to refund/reimburse the petitioner's balance medical expenses bill amount of Rs.3,84,219/- (Rupees Three Lakhs Eighty Four Thousand Two Hundred and nineteen) under the cashless medical 2\8 https://www.mhc.tn.gov.in/judis W.P. No. 32931 of 2022 expenses scheme, along with applicable rate of interest from 02.09.2022 till the disbursement.
2. The petitioner, who is a residential assistant at the Principal Bench of this Court, was duly covered by the New Health Insurance Scheme, a cashless Insurance cover for the Government employees which is operated by the Government through the 3rd and 4th respondents. The petitioner, at the time of her delivery on 10.08.2022, had to undergo hysterectomy with BSO. As she was entitled for cashless treatment, she had submitted an application to the 2nd and 3rd respondents for availing the same and after due approval from the higher-ups on 12.08.2022, the representatives of the 3rd respondent had informed that the treatment thereafter will be covered by cashless facility and the money spent till then will also be refunded at the time of discharge on production of discharge summary. The petitioner underwent treatment at the hospital from 08.08.2022 to 05.09.2022 and the hospital issued a discharge summary on 02.09.2022 along with the final bill of Rs.4,89,306/-. However, according to the petitioner, approval was given by the 4th respondent only a sum of 3\8 https://www.mhc.tn.gov.in/judis W.P. No. 32931 of 2022 Rs.1,05,807/- and the remaining amount was paid by her by availing loan. The grievance of the petitioner is that the 3rd and 4th respondents, who are bound to pay the entire medical expenses since the petitioner is covered under the cashless scheme, had erroneously rejected the treatment cost without assigning any valid reasons. Hence, the present writ petition.
3. Heard both parties.
4. Pursuant to the order dated 07.08.2023, the Joint Director of Medical and Rural Health Services (Medical) has submitted a report, which is extracted below:
“Based on the direction from the Court to submit a detailed report regarding the case, a letter vide ref. No. 46497/A1/1/2023 dated 23.08.2023, sent to UIIC to give clarifications/break up details regarding approval of an amount of Rs.1,05,087/- to the petitioner.
As per the reply from the UIIC vide the letter dated 30.08.2023, it was observed that UIIC didn’t pay any amount for the Re-laparatomy procedure done twice to the patient Mrs.Muthulakshmi.
1. As per G.O.Ms. No. 160 Finance (Salaries) 4\8 https://www.mhc.tn.gov.in/judis W.P. No. 32931 of 2022 Department dated 29.06.2021, Order No. 6-point 4(b) Hysterectomy (uterus removal surgery) the upper limit of medical assistance shall be Rs.50,000/-. In this instant case the patient underwent emergency laparotomy followed by Hysterectomy due to PPH.
2. As the patient developed Hemo peritoneum, the patient underwent Re-laparatomy twice on 10.08.2022 and 12.08.2022.
3. As per G.O.Ms. No. 160 Finance (Salaries) Department dated 29.06.2021,procedure No.103(i) Under General Other Surgeries, surgical management of complications/follow up of covered procedures is also covered under NHIS.
4. The patient has undergone the surgical procedure of hysterectomy and also surgical management of complications twice (laparotomy) which are covered under NHIS.
Hence, it is humbly submitted to the Hon’ble Court, that based on the break up details for Rs.1,05,087/- and after scrutinizing the relevant documents, it is ascertained that this scheme is a cashless scheme and UIIC has failed to ensure cashless treatment to their beneficiary for the following:
1.Amount to be sanctioned for Re-laparotomy done twice on 5\8 https://www.mhc.tn.gov.in/judis W.P. No. 32931 of 2022 10.8.2022 and 12.8.2022
2.Apart from this UIIC has also reduced major amount for Pharmacy charges as detailed below:
Actual Pharmacy amount Rs.2,43,751/-
Reimbursed by UIIC Rs.32,537/-
NOT SANCTIONED Rs. 2,11,214/-
5. The above report of the Joint Director of Medical and Rural Health Services, based on the break-up details and after scrutinising the relevant documents, reveals that the scheme itself is a cashless scheme and UIIC has failed to ensure cashless treatment to the petitioner. Since the entire medical expenses need to be met by the Insurance Company, adjusting the amount already paid, rest of the amount will have to be reimbursed. The petitioner is expected to submit the bills again as it is stated by the learned counsel for the Insurance Company that once the amount had not been sanctioned pertaining to a particular bill, the same would have been returned to the party. Hence, the petitioner is expected to re-submit the bills to the respondent concerned within a period of 30 days from the date of receipt of a copy of this order and within 30 days thereafter, the eligible amount shall be sanctioned to the petitioner after adjusting the 6\8 https://www.mhc.tn.gov.in/judis W.P. No. 32931 of 2022 amount already paid. We also expect that the Insurance Company complies with cashless scheme so that the persons, who may be affected by any ailment covered under the scheme need not knock at the doors of this Court as the purpose of the scheme will have to reach the beneficiaries.
6. The writ petition is disposed of accordingly. No costs.
(S.V.N.J.) (K.R.S.J.)\ nv 11.09.2023 To
1. The Principal Secretary to Government, Health and Family Welfare Department, Fort St. George, Chennai.
2. The Registrar General, High Court of Judicature at Madras, Chennai.
3. The General Manager, United India Insurance Company Ltd. PLA Rathna Towers, 5th Floor, 212 Anna Salai, Chennai.
S. VAIDYANATHAN,J AND K. RAJASEKAR,J.
7\8 https://www.mhc.tn.gov.in/judis W.P. No. 32931 of 2022 nv
4. MD India Health Insurance TPA Pvt. Ltd., rep. by its Regional Manager, No. 443, 445, Guna Complex, Anna Salai, Teynampet, Chennai 600 018.
W.P. No. 32931 of 2022
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