High Court · 2024

W.P.No.5204 of 2020IN THE HIGH COURT OF JUDICATURE AT MADRASDATED : 24.09.2024CORAM:THE HONOURABLE MR. JUSTICE G.K.ILANTHIRAIYANW.P.No.5204 of 2020P.Sankaran (died)1. Pitchammal2. Jeya3. Mariyappan4. Subbulakshmi5. Manikantan (P1 to P5 substituted as legal heirs of the deceased petitioner P.Sankaran as per order dated 24.09.2024 made in W.M.P.No.28454 of 2024 in W.P.No.5204 of 2020) ... Petitioners-Vs-1. State of Tamil Nadu Rep.by its Secretary to Government, Department of Finance, Secretariat, Fort St. George, Chennai - 600 009.2. The Director of Treasuries and Accounts, Second Floor, Panagal Building, Jeenish Road, Saidapet, Chennai - 600 015.3. The District Collector, Collectorate, Kokirakulam Road, Thirunelveli 627 009.Page 1 of 8 https://www.mhc.tn.gov.in/judis W.P.No.5204 of 20204. The District Treasuries Officer, District Treasuries, Collectorate Campus, Thirunelveli 627 009.5. M/s. United India Insurance Company Ltd., Divisional Office, IV Floor, PLA Ratna Towers, No.212, Anna Salai, Chennai - 600 006.... RespondentsPrayer : Writ Petition filed under Article 226 of Constitution of India praying for the issuance of a Writ of Certiorarified Mandamus, calling for the records pertaining to the impugned order passed by the first Respondent vide G.O.Rt.No.1030 dated 31.10.2019 and quash the same and consequently direct the Respondents to reimburse the medical expenses incurred by the Petitioner in taking treatment which is a sum of Rs.2,11,623/- together with interest at 18 % p.a. from the date of surgery (i.e 20.01.2016) to till the date of disbursement within the time limit to be fixed by this Hon'ble Court.For Petitioners : Mr.M.VijayaragavanFor R1 to R4 : Mr.C.Kathiravan Special Government PleaderFor R5 : Mr.P.Sankaranarayanan ORDERThis writ petition has been filed challenging the order passed by the first respondent dated 31.10.2019, thereby awarded medical reimbursement to the tune of Rs.23,235/-.2. Heard both sides and perused the materials available on record.3. The deceased petitioner (hereinafter called as “ the deceased”) retired Page 2 of 8 https://www.mhc.tn.gov.in/judis W.P.No.5204 of 2020from service on 31.01.2000 from the Tamil Nadu Police Department. After his retirement, the deceased subscribed to the scheme of Tamil Nadu New Health Insurance Scheme, 2014. While being so, the petitioner had knee trouble and as such, he was bedridden. Since his children were in abroad, no one was there to take care of the deceased except his wife. Immediately, his wife admitted him in Rhock Hospital, Pioneer Kumarasamy Nagar, Thirunelveli. The Doctors advised to go for immediate surgery of replacement of knee cap. As suggested by the Doctors, the deceased had undergone knee replacement surgery and he was in the hospital as in-patient for more than ten days. He had incurred medical expenses to the tune of Rs.2,11,623/-. Along with the original bill and medial records, the deceased submitted an application before the fourth respondent for reimbursement of medical expenses under the Tamil Nadu New Health Insurance Scheme, 2014.4. However, it was rejected by an order dated 14.11.2016, on the ground that the petitioner had taken treatment in the non-network hospital. Therefore, the rejection order was under challenge before this Court in W.P.No.13447 of 2018. This Court directed the respondents to consider the medical reimbursement claim and settle the same in accordance with his eligibility, within a period of twelve weeks from the date of receipt of a copy of the order. Page 3 of 8 https://www.mhc.tn.gov.in/judis W.P.No.5204 of 2020However, it was not complied with and as such, the deceased filed a contempt petition before this Court in Cont.P.No.1774 of 2019. Pending contempt petition, the first respondent passed an order dated 31.10.2019, thereby awarded medical reimbursement to the tune of Rs.23,235/- as his medical reimbursement. However, the said amount was refused by the petitioner and once again, the fourth respondent enhanced the medical reimbursement to the tune of Rs.36,670/-. However, it was refused by the petitioner.5. The only ground taken by the first respondent for rejection of the petitioner's claim is that the petitioner did not take treatment from the network hospital. As per G.O.Ms.No.171, Finance (Pension) Department, dated 26.06.2014, does not have any stipulation as to how much money to be disbursed for surgeries.6. A perusal of records revealed that the deceased had underwent surgery of his replacement of knee cap and spent a sum of Rs.2,11,623/- in the private hospital. The State Government had introduced Tamil Nadu Government Employees Health Fund Scheme, 1991 vide G.O.Ms.No.18 Finance (Allowance) Department, dated 09.01.1992 and Tamil Nadu Government Pensioner's Health Fund Scheme, 1995 vide G.O.Ms.No.562, Finance (Pension) Page 4 of 8 https://www.mhc.tn.gov.in/judis W.P.No.5204 of 2020Department, dated 11.07.1995. Accordingly, the pensioners can undergo certain specialized surgeries/treatments in the Government approved private hospitals and can avail medical assistance upto the limit specified in the said schemes. The said 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.7. Insofar as the surgery conducted by the Non-Network hospital is concerned, the Government passed order in G.O.Ms.No.222 Finance (Pension) Department dated 30.06.2018, for medical reimbursement and the relevant portion of the said Government Order as follows:-“ 4. ..... (2) Non-Network Hospital Claims: Eligible Medical Expenses incurred in Non-Network Hospital during Hospitalisation for Emergency care or following an Accident by the Beneficiary shall be reimbursed by the Insurance Company subject to the Ceiling Criteria upon submission of claim by the Beneficiary or his/her legalheirs to the Grievance Redressal Officer as listed in the Annexure-V to these Guidelines and the approval of the District Level Empowered Committee or State Level Empowered committee or High Level Empowered Committee. The amounts that can be claimed for reimbursement will be limited to package rates as notified by Government on the recommendations of the Page 5 of 8 https://www.mhc.tn.gov.in/judis W.P.No.5204 of 2020Accredition Committee as per the process stated in clause 15 of these Guidelines.5. Thus, it is clear that medical expenses incurred in non network hospital during hospitalisation for emergency care or following an accident by the beneficiary shall be reimbursed by the Insurance Company subject to the ceiling criteria upon submission of claim made by the beneficiary. ....” 8. As stated supra, the deceased was bedridden and he could not able to move anywhere and as such, it was advised to go for knee surgery. Therefore, the petitioner was immediately admitted into the private hospital, which is a non-network hospital and undergone surgery. Due to which, he had occurred expenditure to the tune of Rs.2,11,623/-. Therefore, the deceased had undergone surgery under emergency situation as per the medical advise. As per the above Government Order, the medical expenses incurred for emergency care in the non-network hospital can be reimbursed.9. In view of the above, the impugned order cannot be sustained and is liable to be quashed. Accordingly, the impugned order passed by the first Respondent vide G.O.Rt.No.1030 dated 31.10.2019, is hereby quashed. The first respondent is directed to reimburse the entire medical expense incurred by the deceased to the petitioners herein with interest at the rate of 6% p.a, within a period of four weeks from the date of receipt of a copy of this order.Page 6 of 8 https://www.mhc.tn.gov.in/judis W.P.No.5204 of 202010. Accordingly, this writ petition stands allowed. No costs.24.09.2024(2/2)Internet: YesIndex : Yes/NoSpeaking/Non Speaking ordermnPage 7 of 8 https://www.mhc.tn.gov.in/judis W.P.No.5204 of 2020G.K.ILANTHIRAIYAN. J,mnTo1. The Secretary to Government, State of Tamil Nadu Department of Finance, Secretariat, Fort St. George, Chennai - 600 009.2. The Director of Treasuries and Accounts, Second Floor, Panagal Building, Jeenish Road, Saidapet, Chennai - 600 015.3. The District Collector, Collectorate, Kokirakulam Road, Thirunelveli 627 009.4. The District Treasuries Officer, District Treasuries, Collectorate Campus, Thirunelveli 627 009.5. M/s. United India Insurance Company Ltd., Divisional Office, IV Floor, PLA Ratna Towers, No.212, Anna Salai, Chennai - 600 006.W.P.No.5204 of 202024.09.2024Page 8 of 8

W.P.No.5204 of 2020IN THE HIGH COURT OF JUDICATURE AT MADRASDATED : 24.09.2024CORAM:THE HONOURABLE MR. JUSTICE G.K.ILANTHIRAIYANW.P.No.5204 of 2020P.Sankaran (died)1. Pitchammal2. Jeya3. Mariyappan4. Subbulakshmi5. Manikantan (P1 to P5 substituted as legal heirs of the deceased petitioner P.Sankaran as per order dated 24.09.2024 made in W.M.P.No.28454 of 2024 in W.P.No.5204 of 2020) ... Petitioners-Vs-1. State of Tamil Nadu Rep.by its Secretary to Government, Department of Finance, Secretariat, Fort St. George, Chennai - 600 009.2. The Director of Treasuries and Accounts, Second Floor, Panagal Building, Jeenish Road, Saidapet, Chennai - 600 015.3. The District Collector, Collectorate, Kokirakulam Road, Thirunelveli 627 009.Page 1 of 8 https://www.mhc.tn.gov.in/judis W.P.No.5204 of 20204. The District Treasuries Officer, District Treasuries, Collectorate Campus, Thirunelveli 627 009.5. M/s. United India Insurance Company Ltd., Divisional Office, IV Floor, PLA Ratna Towers, No.212, Anna Salai, Chennai - 600 006.... RespondentsPrayer : Writ Petition filed under Article 226 of Constitution of India praying for the issuance of a Writ of Certiorarified Mandamus, calling for the records pertaining to the impugned order passed by the first Respondent vide G.O.Rt.No.1030 dated 31.10.2019 and quash the same and consequently direct the Respondents to reimburse the medical expenses incurred by the Petitioner in taking treatment which is a sum of Rs.2,11,623/- together with interest at 18 % p.a. from the date of surgery (i.e 20.01.2016) to till the date of disbursement within the time limit to be fixed by this Hon'ble Court.For Petitioners : Mr.M.VijayaragavanFor R1 to R4 : Mr.C.Kathiravan Special Government PleaderFor R5 : Mr.P.Sankaranarayanan ORDERThis writ petition has been filed challenging the order passed by the first respondent dated 31.10.2019, thereby awarded medical reimbursement to the tune of Rs.23,235/-.2. Heard both sides and perused the materials available on record.3. The deceased petitioner (hereinafter called as “ the deceased”) retired Page 2 of 8 https://www.mhc.tn.gov.in/judis W.P.No.5204 of 2020from service on 31.01.2000 from the Tamil Nadu Police Department. After his retirement, the deceased subscribed to the scheme of Tamil Nadu New Health Insurance Scheme, 2014. While being so, the petitioner had knee trouble and as such, he was bedridden. Since his children were in abroad, no one was there to take care of the deceased except his wife. Immediately, his wife admitted him in Rhock Hospital, Pioneer Kumarasamy Nagar, Thirunelveli. The Doctors advised to go for immediate surgery of replacement of knee cap. As suggested by the Doctors, the deceased had undergone knee replacement surgery and he was in the hospital as in-patient for more than ten days. He had incurred medical expenses to the tune of Rs.2,11,623/-. Along with the original bill and medial records, the deceased submitted an application before the fourth respondent for reimbursement of medical expenses under the Tamil Nadu New Health Insurance Scheme, 2014.4. However, it was rejected by an order dated 14.11.2016, on the ground that the petitioner had taken treatment in the non-network hospital. Therefore, the rejection order was under challenge before this Court in W.P.No.13447 of 2018. This Court directed the respondents to consider the medical reimbursement claim and settle the same in accordance with his eligibility, within a period of twelve weeks from the date of receipt of a copy of the order. Page 3 of 8 https://www.mhc.tn.gov.in/judis W.P.No.5204 of 2020However, it was not complied with and as such, the deceased filed a contempt petition before this Court in Cont.P.No.1774 of 2019. Pending contempt petition, the first respondent passed an order dated 31.10.2019, thereby awarded medical reimbursement to the tune of Rs.23,235/- as his medical reimbursement. However, the said amount was refused by the petitioner and once again, the fourth respondent enhanced the medical reimbursement to the tune of Rs.36,670/-. However, it was refused by the petitioner.5. The only ground taken by the first respondent for rejection of the petitioner's claim is that the petitioner did not take treatment from the network hospital. As per G.O.Ms.No.171, Finance (Pension) Department, dated 26.06.2014, does not have any stipulation as to how much money to be disbursed for surgeries.6. A perusal of records revealed that the deceased had underwent surgery of his replacement of knee cap and spent a sum of Rs.2,11,623/- in the private hospital. The State Government had introduced Tamil Nadu Government Employees Health Fund Scheme, 1991 vide G.O.Ms.No.18 Finance (Allowance) Department, dated 09.01.1992 and Tamil Nadu Government Pensioner's Health Fund Scheme, 1995 vide G.O.Ms.No.562, Finance (Pension) Page 4 of 8 https://www.mhc.tn.gov.in/judis W.P.No.5204 of 2020Department, dated 11.07.1995. Accordingly, the pensioners can undergo certain specialized surgeries/treatments in the Government approved private hospitals and can avail medical assistance upto the limit specified in the said schemes. The said 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.7. Insofar as the surgery conducted by the Non-Network hospital is concerned, the Government passed order in G.O.Ms.No.222 Finance (Pension) Department dated 30.06.2018, for medical reimbursement and the relevant portion of the said Government Order as follows:-“ 4. ..... (2) Non-Network Hospital Claims: Eligible Medical Expenses incurred in Non-Network Hospital during Hospitalisation for Emergency care or following an Accident by the Beneficiary shall be reimbursed by the Insurance Company subject to the Ceiling Criteria upon submission of claim by the Beneficiary or his/her legalheirs to the Grievance Redressal Officer as listed in the Annexure-V to these Guidelines and the approval of the District Level Empowered Committee or State Level Empowered committee or High Level Empowered Committee. The amounts that can be claimed for reimbursement will be limited to package rates as notified by Government on the recommendations of the Page 5 of 8 https://www.mhc.tn.gov.in/judis W.P.No.5204 of 2020Accredition Committee as per the process stated in clause 15 of these Guidelines.5. Thus, it is clear that medical expenses incurred in non network hospital during hospitalisation for emergency care or following an accident by the beneficiary shall be reimbursed by the Insurance Company subject to the ceiling criteria upon submission of claim made by the beneficiary. ....” 8. As stated supra, the deceased was bedridden and he could not able to move anywhere and as such, it was advised to go for knee surgery. Therefore, the petitioner was immediately admitted into the private hospital, which is a non-network hospital and undergone surgery. Due to which, he had occurred expenditure to the tune of Rs.2,11,623/-. Therefore, the deceased had undergone surgery under emergency situation as per the medical advise. As per the above Government Order, the medical expenses incurred for emergency care in the non-network hospital can be reimbursed.9. In view of the above, the impugned order cannot be sustained and is liable to be quashed. Accordingly, the impugned order passed by the first Respondent vide G.O.Rt.No.1030 dated 31.10.2019, is hereby quashed. The first respondent is directed to reimburse the entire medical expense incurred by the deceased to the petitioners herein with interest at the rate of 6% p.a, within a period of four weeks from the date of receipt of a copy of this order.Page 6 of 8 https://www.mhc.tn.gov.in/judis W.P.No.5204 of 202010. Accordingly, this writ petition stands allowed. No costs.24.09.2024(2/2)Internet: YesIndex : Yes/NoSpeaking/Non Speaking ordermnPage 7 of 8 https://www.mhc.tn.gov.in/judis W.P.No.5204 of 2020G.K.ILANTHIRAIYAN. J,mnTo1. The Secretary to Government, State of Tamil Nadu Department of Finance, Secretariat, Fort St. George, Chennai - 600 009.2. The Director of Treasuries and Accounts, Second Floor, Panagal Building, Jeenish Road, Saidapet, Chennai - 600 015.3. The District Collector, Collectorate, Kokirakulam Road, Thirunelveli 627 009.4. The District Treasuries Officer, District Treasuries, Collectorate Campus, Thirunelveli 627 009.5. M/s. United India Insurance Company Ltd., Divisional Office, IV Floor, PLA Ratna Towers, No.212, Anna Salai, Chennai - 600 006.W.P.No.5204 of 202024.09.2024Page 8 of 8