High Court · 2025

WP No. 434 of 2024syndrome/Hemorrhagic fever. Whereas the Doctor diagnosed as Severe denque. Hence, the respondent rejected the claim on the ground that the diagnose has not comes under the category as per G.O., which is not sustainable one. It seems that the aim of the scheme and benefits not goes to the employees. 8. Hence, the impugned order is liable to be set aside. Accordingly, the same is set aside and this Court remands the matter back to the third respondent for fresh consideration. This Court directs the petitioner to produce the original medical documents and bills of his wife before the third respondent within a period two weeks from the date of receipt of a copy of this order. Upon receipt of the same, the third respondent shall consider and pass orders within a period of six weeks, thereafter. 9. With the above observation and directions, the writ petition is Allowed. No costs.''4. Except the above modification, remaining portion of the order dated 04.12.2025 shall stand unaltered.04.03.2026rliNote: Registry is directed to issue a fresh order copy after making necessary corrections. M.DHANDAPANI.,J.rli https://www.mhc.tn.gov.in/judis WP No. 434 of 2024 W.P.No.434 of 202404.03.2026 https://www.mhc.tn.gov.in/judis WP No. 434 of 2024IN THE HIGH COURT OF JUDICATURE AT MADRASDATED: 04-12-2025CORAMTHE HONOURABLE MR JUSTICE M.DHANDAPANIWP No. 434 of 2024S.Mohan KumarPetitioner(s)Vs1. The CollectorKancheepuram District, Kancheepuram 631 501.2.The Assistant Commissioner (district)Kancheepuram Rural Taxation Circle, Kancheepuram 631 501.3.United India Insurance Co. Ltd.,By Its Authorised Signatory, Divisional Office Vi, 5th Floor, Pla Rathna Towers, No.212 Anna Salai, Chennai 6.4.The Nodal OfficerUnited India Insurance Company Limited, Kancheepuram 631 501.5.The Joint Director Treasuries AndAccounts Department, District Treasury, Kancheepuram 631 501.6.The Joint DirectorHealth Service, Kancheepuram 631 501.Respondent(s) https://www.mhc.tn.gov.in/judis WP No. 434 of 2024Writ Petition filed under Article 226 of the Constitution of India, praying for issuance of a Writ of Certiorarified Mandamus to call for the records of the third respondent by his proceedings dated 23.08.2023 issued by them to in favour of Mrs.S.Vasanthi, petitioner’s wife and quash the same and to direct the respondents to pay the medical expenses of Rs.2,47,843/- to the petitioner with interest of 6% per annum from the date of claim till the date of payment and within a time stipulated by this Court.For petitioner : Mr.V.ManoharanFor respondents: Mr.S.Balamurugan, Govt. Advocate for RR-1 and 2 Mr.P.Athi Veera Rama Pandiyan for RR-3 and 4ORDER The petitioner has filed the present Writ Petitions praying for issuance of Writ of Certiorarified Mandamus to call for the records of the third respondent by his proceedings dated 23.08.2023 issued by them to in favour of Mrs.S.Vasanthi, petitioner’s wife and quash the same and to direct the respondents to pay the medical expenses of Rs.2,47,843/- to the petitioner with interest of 6% per annum from the date of claim till the date of payment and within a time stipulated by this Court.2. The facts in a nut-shell, are as follows:(a) Originally, the petitioner was appointed as Junior Assistant in the Commercial Tax Department and thereafter, he was promoted up to the grade of https://www.mhc.tn.gov.in/judis WP No. 434 of 2024below Assistant Commissioner, and was holding full in-charge of Assistant Commissioner in the Commercial Department. (b) The Government introduced New Health Medical Insurance Scheme to the Government employees for any medical urgency treatment to them, for which, the Government has issued G.O.No.160 for implementing the New Health Insurance Scheme, 2021 for employees of the State Government Departments, State Public Sector Undertakings, statutory boards, local bodies, State Government Universities, among others and their eligible family members. The United India Insurance Company Limited, Chennai would execute the agreement with the Tamil Nadu Government, following the recommendation of the Tender Scrutinizing Committee, as per G.O.No.160 and it would cover 203 approved treatments and surgeries with 1169 empanelled hospitals, and thereafter, it was extended from time to time.(c) In the said scheme, the members have to pay Rs.495/- as annual premium plus service tax for a period of four years commencing from the date of commencement of the scheme. The payment of premium shall be regulated as per the terms and conditions of the agreement. That amount has to be deducted in the salary. The scheme will commence from the date of agreement up to four years.(d) The petitioner is also an employee of State Government, eligible for the above said scheme. As per the scheme, the petitioner paid Rs.295/- per month as a monthly subscription, for which, necessary monthly deductions are https://www.mhc.tn.gov.in/judis WP No. 434 of 2024made from the petitioner’s salary.(e) On 10.09.2022, the petitioner’s wife Mrs.Vasanthi had severe fever and heavy pain and also vomiting. On 12.09.2022, her health condition went bad to worst and hence, with the assistance of the petitioner’s relation, she was admitted at Sree Ramachandra Medical College and Hospital, Porur, Chennai. On diagnosis, it came to light that she was due to severe Dengue fever. After thorough medical check-up, the Doctor advised that she has to be admitted there, otherwise it would lead to a lot of complications. Therefore, on the advise of the Doctor, she was admitted on the very same day and in view of the urgency involved, the petitioner could not get prior permission for that from the Insurance Company. For undergoing treatments, the amounts were also paid initially by the petitioner. Totally, the petitioner incurred Rs.2,47,843/- and she was discharged from the hospital on 20.09.2022. Then, she was bedridden for about 10 days in his house as rest. (f) Thereafter, the petitioner made his claim on 12.10.2022 to the third respondent’s coordinator, i.e. the fourth respondent through proper channel by second respondent. Along with the petitioner’s claim, he enclosed Discharge Summary and medical bills, which supports the claim of the petitioner to Rs.2,47,843/-. They forwarded the District Empowered Committee and requested them to meet early redressal on the issue. It has been forwarded for reimbursement of the petitioner’s claim before the third respondent after getting approval from the District Empowered Committee. https://www.mhc.tn.gov.in/judis WP No. 434 of 2024(g) Under the impression that they sent the said amount to the petitioner’s Bank Accounts, but instead of sending the petitioner’s claim, the third respondent returned the petitioner’s claim to the patient name, who is the petitioner’s wife, on the sole ground that the said diagnosis and line of management is not covered and hence, the claim cannot be considered as per G.O.No.160, dated 29.06.2021 issued by the Fiance (Salaries) Department of the Government of Tamil Nadu. The above said reason for returning of the petitioner’s claim is against the guidelines issued by this Court. Already, the Government also issued G.O.Ms.No.241, dated 24.08.2016 informing the medical authorities to avoid unnecessary litigation and again they issued G.O. in G.O.Ms.No.171 and the third respondent returned the claim of the petitioner into the petitioner’s wife’s name Mrs.S.Vasanthi on 23.08.2023, which is against law and the same is liable to be quashed.3. The fifth respondent has filed counter affidavit stating as follows:(a) The petitioner’s wife is dependent on the petitioner. The petitioner was praying for medical assistance under the Tamil Nadu New Health Insurance Scheme, 2021 for treatment given to his wife. As per the provisions laid down in G.O.Ms.No.160, Finance (Salaries) Department, dated 29.06.2021, there is no scope to give medical assistance under the Tamil Nadu New Health Insurance Scheme in the category of severe Dengue. Hence, the claim of the petitioner was denied by the third respondent. https://www.mhc.tn.gov.in/judis WP No. 434 of 2024(b) The petitioner has stated about his salary deduction regarding the monthly subscription towards NHIS and the same has already been accepted by the second respondent.(c) The petitioner has stated that his wife suffered severe fever, heavy abdominal pain and vomiting and her health condition became worse and hence, she was admitted in Sree Ramachandra Medical College and Hospital, Porur, Chennai and on diagnosis, it was found that she was suffering from severe Dengue fever. After thorough medical investigation, the Doctor has advised to admit her on 12.09.2022. The petitioner did not obtain prior permission for that from the Insurance Company for his wife’s treatment and the amount was paid initially by him in total. The petitioner incurred a total sum of Rs.2,47,843/- towards expenses and his wife was discharged from the hospital on 20.09.2022. The petitioner has stated that his claim was forwarded on 12.10.2022 to the third respondent/Insurance Company by the fourth respondent, which was submitted through proper channel by the second respondent. Along with his claim, he had enclosed the discharge summary and medical bills, which supported his claim of Rs.2,47,843/-. The same were forwarded to the District Level Empowered Committee and a request was made to make necessary recommendations in the case and it was forwarded to the third respondent for reimbursement of his claim after getting approval from the District Level Empowered Committee.(d) The petitioner has stated that Sree Ramachandra Hospital has been https://www.mhc.tn.gov.in/judis WP No. 434 of 2024included in the list of approved hospital and the medical reimbursement can be claimed even if the treatment was taken in an emergency condition for non-listed treatment. Hence, by enclosing the relevant documents, he has submitted the reimbursement claim to the second respondent, but the third respondent has rejected the claim of the petitioner on the ground that the said diagnosis and line of management is not covered and hence, the claim cannot be considered as per G.O.Ms.No.160, Finance (Salaries) Department, dated 29.06.2021.(e) The present Writ Petition relates to the prayer of the petitioner for reimbursement of medical expenses under the NHIS for Government employee incurred by him towards the unapproved treatment given to his wife. The details relating to the advent of New Health Insurance Scheme (NHIS) which provides for reimbursement of medical expenses incurred by a Government servant, as below.(f) Prior to the launch of NHIS for Government servants, 2008 and its predecessors, namely the Tamil Nadu Government Employees Health Fund Scheme, 1991 and the Tamil Nadu Government Pensioner’s Health Fund Scheme, 1995, the Statement Government had provided free medical treatment in Government Medical Institutions to Government servants and pensioners under the Tamil Nadu Medical Attendance Rules. The said Rules also envisage reimbursement of medical expenses incurred towards treatments taken in private medical institutions to the extent prescribed in the said Rules. The said reimbursements are allowed only where such treatments are certified to be https://www.mhc.tn.gov.in/judis WP No. 434 of 2024emergent in nature by the competent authority and they had to be undergone during emergencies beyond the conscious control of the Government servant or pensioner. Subsequently, as a welfare measure for Government servants and pensioners, so as to give them access for better medical facilities available in private sector, the State Government introduced the Tamil Nadu Government Employees Health Fund Scheme, 1991, vide G.O.(Ms).No.18, Finance (Allowance) Department, dated 09.01.1992 and the Tamil Nadu Government Pensioner’s Health Fund Scheme, 1995, vide G.O.(Ms).No.562, Finance (Pension) Department, dated 11.07.1995. Under the said Health Fund Schemes, the Government servants/pensioners can undergo certain specialized advanced surgeries/treatments in the Government approved private hospitals and can avail medical assistance up to the limit specified in the said schemes. Thereafter, the aforesaid schemes were replaced by New Health Insurance Scheme for Government servants, vide G.O.(Ms).No.430, Finance (Salaries) Department, dated 10.09.2007 and New Health Insurance Scheme for pensioners and family pensioners, vide G.O.(Ms).No.462, Finance (Pension) Department, dated 27.12.2013 by entering into agreements with Insurance Companies. (g) The said Insurance Schemes are for block period of four years and the maximum quantum of cashless assistance for the block period was initially fixed as Rs.2 lakhs in respect of serving Government employees and Rs.1 lakh in respect of pensioners and family pensioners. The said Insurance Schemes are being continued till date with enhanced limits of cashless medical assistance. https://www.mhc.tn.gov.in/judis WP No. 434 of 2024These Insurance Schemes were designed as Cashless Schemes, under which a Government servant or pensioner/family pensioner and his/her spouse can undergo specified list of medical procedures and surgeries in empanelled hospitals (referred to as network hospitals to signify hospitals included in the Insurance coverage network) after obtaining pre-authorisation of Insurance Company, without having to make any payment to the hospital in cash. However, in the said Insurance Schemes, it is explicitly stated that the benefits of cashless treatment would not cover unlisted medical procedures, surgeries and treatments undergone in network or non-network hospitals or listed treatments and surgeries undergone in non-network hospitals. In the said Insurance Scheme, there is no provision for reimbursement of any medical expenses and cashless treatment alone is permitted. However, in case the network hospitals charged the subscriber for undergoing any of the approved treatment or surgeries, a mechanism for making complaints to District and State Redressal Committee was made in the said Insurance Scheme itself so that if such instances were proved, the Insurance Company will reimburse such payments to the subscribers and in turn, the Insurance Company could recover the same from the network hospitals under their bilateral agreements with the network hospitals.(h) By design, not all medical procedures/surgeries are covered in the said Insurance Schemes. This was done to maintain the premium of the Insurance Schemes at affordable levels. With the advent of respective New Health https://www.mhc.tn.gov.in/judis WP No. 434 of 2024Insurance Schemes, the Tamil Nadu Government Employees Health Fund Scheme and the Tamil Nadu Government Pensioner’s Health Fund Scheme ceased to operate. But the Tamil Nadu Medical Attendance Rules are still in vogue. As far as the medical procedures and surgeries not covered under NHIS are concerned, the Government servants as well as pensioners can utilise the medical facilities available in Government medical institutions under the Tamil Nadu Medical Attendance Rules at free of cost. Under the said Rules, the Government Servants and pensioners are also entitled for reimbursement of medical expenses incurred by them for undergoing any emergency treatment or surgery in private hospitals, subject to ceiling prescribed under the Tamil Nadu Medical Attendance Rules. However, such reimbursement is available subject to condition that the competent authority shall certify that such treatment or surgery is emergent in nature or it has been undertaken during contingencies specified in the said Rules.(i) Under NHIS, medical assistance for approved surgery/treatments undergone in network private hospitals, are available in cashless manner only and there is no provision for reimbursement of medical expenses under the said Insurance Schemes. For the first time, only in NHIS for pensioners, 2018, the State Government permits reimbursement of medical expenses for approved treatments undergone by pensioners in non-network private hospitals in case of emergency case or following an accident. In such cases, where the beneficiary had approached a non-network hospital, then he has to pay the medical https://www.mhc.tn.gov.in/judis WP No. 434 of 2024expenses to the hospital and then seek cash reimbursement for such approved treatment or surgeries undertaken and such reimbursement is subject to eligible medical expenses and ceiling criteria under the said scheme. For treatment undergone in non-network hospitals, under non-emergency circumstances at the willful option of the Government servant or pensioner, the expenditure is required to be met by individual himself/herself and Government is not obliged to compensate it to any extent, either under NHIS or under Tamil Nadu Medical Attendance Rules. (j) In G.O.Ms.No.202, Finance (Salaries) Department, dated 30.06.2016, orders have been issued to implement NHIS, 2016 to provide health care assistance to employees and their family members with a provision to avail assistance up to Rs.4 lakhs for a block period of four years from 01.07.2016 to 30.06.2020 on cash-less basis and further, the Government extended this Scheme for a further period of one year, i.e. from 01.07.2020 to 30.06.2021 to avail medical assistance upto Rs.4 lakhs as per G.O.Ms.No.279, Finance (Salaries) Department, dated 24.06.2020. The Scheme has been extended for another four year period from 01.07.2021 to 30.06.2025 to avail medical assistance upto Rs.5 lakhs as per G.O.Ms.No.160, Finance (Salaries) Department, dated 29.06.2021.(k) NHIS, 2016 for Government employee is being implemented as per G.O.Ms.No.202, Finance (Salaries) Department, dated 30.06.2016 on cash-less basis. The said Scheme is compulsory for all Government employees. It is for a https://www.mhc.tn.gov.in/judis WP No. 434 of 2024block period of four years from 01.07.2021 to 30.06.2025. The subscribers can undergo any approved treatment/surgeries in the hospitals approved by the Insurance Company/third party Administrator on a cash-less basis. The procedure to be followed at the time of admitting the subscribers (including spouse) for accredited treatments/surgeries are given in the above-said Government Orders. The Government employees are now subscribing a sum of Rs.300/- per month, towards the said NHIS, 2021.(l) The petitioner being a Government employee, is supposed to know all the procedures and conditions prescribed in the NHIS, 2016, but he has committed breach of terms and conditions of the said Scheme and has prayed for reimbursement of medical expenses, which is not allowable under the said Scheme. If such ineligible cases are allowed by this Court to be reimbursed separately outside the purview of the said Scheme, that too from out of the hard-earned tax payer’s money, then similar persons will begin to violate the terms and conditions of the said Scheme and start claiming reimbursement of medical expenses in contravention of the provisions of the said Scheme, which will naturally lead to restriction of spending of Government exchequer’s money for other developmental activities in this State.(m) In Star Health and Allied Insurance Company Limited Vs. A.Chokkar, the Division Bench of the Madurai Bench of Madras High Court, held as follows:“24. In the present case, what we have to https://www.mhc.tn.gov.in/judis WP No. 434 of 2024decide is whether the State is bound to reimburse the claim, whether the insurance company is bound to indemnity the beneficiary for the claim made by him. As held in the decisions referred to above, the insurance company is strictly bound to strictly by the terms of contract and cannot be asked to settle claim which does not fall within the terms of the contract and therefore the claim made by the beneficiaries in respect of unapproved treatments that were taken in a network hospital or for reimbursement of the claim made the insurance company is not liable. For this reason, the insurance company had made it clear that only if the beneficiary took treatment in a network hospital they would settle the claim and more importantly the facility itself is a cashless facility. The insurance company cannot pay cash and if we issue direction to the insurance company to reimburse the claim, we would be virtually rewriting the contract which we are not entitled to.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, where unapproved treatment has been taken in a network hospital, the insurance company cannot be asked to cover the expenses, since the scheme itself makes the network hospitals as intrinsic.However, the petitioner/claimants were also not to remediless and that is why we will issue directions to the claimants to make an application https://www.mhc.tn.gov.in/judis WP No. 434 of 2024under the Rules or go before the Redressal Committee.”(n) The Division Bench of Madurai Bench of Madras High Court in Star Health and Allied Insurance Company Limited Vs. A.Chokkar has laid down the ratio that while individuals who have undergone approved/unapproved treatment in non-network hospitals or unapproved medical procedures and surgeries in network hospitals or non-network hospitals though not entitled for reimbursement under the New Health Insurance Scheme, they would be entitled for reimbursement of medical expenses under Tamil Nadu Medical Attendance Rules to the extent permissible thereunder and subject to the fulfilment of the conditions prescribed therein.(o) In the present case, the petitioner had given treatment to his wife, he is not entitled to total reimbursement of medical expenses under NHIS 2016/2021/2025.(p) As held by the Division Bench of this Court in A.Chokkar’s case, the petitioner would be eligible for medical reimbursement under Tamil Nadu Medical Attendance Rules to the extent permissible under the said Rules, subject to conditions prescribed therein. Therefore, the petitioner should have made an application under the Tamil Nadu Medical Attendance Rules to the competent authority for reimbursement of eligible expenses with the above stated justification.(q) The claim of the petitioner is related to reimbursement of amount https://www.mhc.tn.gov.in/judis WP No. 434 of 2024incurred by him for giving treatment to his wife and for reasons stated above in the counter affidavit, it is stated by the respondents that the petitioner is not entitled to get reimbursement. Hence, for the above reasons, the fifth respondent prayed to dismiss the present Writ Petition.4. The learned counsel for the respondent further submitted that the parties are governed by terms of contract and since the contract covers only emergency treatment or surgeries in private hospitals, the present case of the petitioner would not fall within the domain of such ''emergency treatment or surgery'' and the petitioner are not no remediless and he has to make an application before the Redressal Committee and not before this Court by filing a writ petitions. Therefore, the petitioner is not entitled for reimbursement. 5. Heard the learned counsel for the petitioner and the learned counsel for the respondents and perused the materials available on record.6. This Court is in complete agreement with the contentions raised by the 5th respondent. The 5th respondent, in its detailed counter, has narrated entire background history of the evolution of medical care for government employees. The government employees were predominantly required only to take treatment from Government hospitals. The scope was enlarged to accommodate taking treatments in private hospitals during emergency situations. But that would not https://www.mhc.tn.gov.in/judis WP No. 434 of 2024mean that a Government employee or dependent can rush to take treatment from government hospital at if drop of a hat and claim reimbursement. The insurance company are not bound to honour every claim thrown at them. The parties are governed by terms of contract unless the claim would fall within the agreed terms and conditions. The insurance company is not bound to reimburse. 7. There is no merits in the contentions raised by the petitioner. The writ petition therefore is dismissed. No costs.04-12-2025rliIndex:Yes/NoSpeaking/Non-speaking orderInternet:YesNeutral Citation:Yes/NoTo1.The CollectorKancheepuram District, Kancheepuram 631 501.2.The Assistant Commissioner (district)Kancheepuram Rural Taxation Circle, Kancheepuram 631 501.3.United India Insurance Co. Ltd.,By Its Authorised Signatory, Divisional Office Vi, 5th Floor, Pla Rathna Towers, No.212 Anna Salai, Chennai 6. https://www.mhc.tn.gov.in/judis WP No. 434 of 20244.The Nodal OfficerUnited India Insurance Company Limited, Kancheepuram 631 501.5.The Joint Director Treasuries AndAccounts Department, District Treasury, Kancheepuram 631 501.6.The Joint DirectorHealth Service, Kancheepuram 631 501. https://www.mhc.tn.gov.in/judis WP No. 434 of 2024M.DHANDAPANI J.rliWP No. 434 of 202404-12-2025