High Court · 2025

WP NO. 8426 of 2021 IN THE HIGH COURT OF JUDICATURE AT MADRAS DATED: 27-03-2025CORAMTHE HONOURABLE MRS JUSTICE N. MALAWP No. 8426 of 2021andWMP.No. 8968 of 20211. R.Somasundaram (Deceased)2. PoonguzhaliW/o. Late Somasundaram3.VijayalakshmiD/o.Late Somasundaram4.ChithraD/o.Late Somasundaram5.BharathiW/o. Vaithiyanananand D/o.Late Somasundaram..PetitionersVs1. The Government of Tamil NaduRespondent by its Secretary, Department of Health and Family Welfare, Fort St.George, Chennai2. The Director of Medical and Rural Health ServiceNo.361, DMS Complex, Anna Salai, Chennai3. The District collectorMaster Plan Complex, Nagapattinam Road, Tiruvarur District4. United India Insurance Co.LtdNo.19, Nungambakkam High Road, IV Lane, Chennai- 600 0345. The Treasury officerDistrict Treasury, Tiruvarur District 610002..Respondents1 https://www.mhc.tn.gov.in/judis WP NO. 8426 of 2021 Prayer : Writ Petition is filed under Article 226 of Constitution of India, praying for writ of certiorarified mandamus, Calling for the records of the 5th respondent in his proceedings in Na.Ka.No.2265 / 2019 / E2 dated 19.12.2019 and quash the same as illegal and consequently direct the respondents to reimburse a sum of Rs.1,67,040/- to the petitioner together with the interest under Medical reimbursement schemeFor Petitioners: M/s.D.SaraswathiFor Respondents: Mr.E.Sundaram, GA - R1 & R2 Mr.L.S.M.Hasan Fazil, AGP - R3 & R5 Mr. T. Shanmugam, Standing Counsel - R4ORDERWrit Petition is filed to call for the records of the 5th respondent in his proceedings in Na.Ka.No. 2265/2019/E2 dated 19.12.2019, to quash the same as illegal and consequently direct the respondents to reimburse a sum of Rs.1,67,040 to the petitioner together with interest under Medical reimbursement scheme.2. The 1st petitioner is a retired government employee, receiving pension under old pension scheme. The Government of Tamil Nadu framed a NHIS Scheme for the benefit of government employees and as well as pensioners/family pensioners. As the petitioner was a member of the said scheme, a sum of Rs. 350/- was deducted from his monthly pension towards premium under the above scheme. The NHIS scheme was framed in 2 https://www.mhc.tn.gov.in/judis WP NO. 8426 of 2021 collaboration with the 4th respondent-Insurance company. According to the petitioner, as per the scheme, the petitioner was entitled for medial assistance upto Rs.2,00,000/- on cashless basis for treatment undergone in approved hospitals of 4th respondent-Insurance company and for reimbursement of medical bills for treatment undergone in unapproved hospitals as per eligibility.3. The petitioner states that on 17.03.2019, the petitioner was bitten by poisonous insect while working in his agricultural field. After taking first aid at a primary health centre, Vilakkudy and on advise of the doctors in G.H, Tiuruvaur, the petitioner took treatment in Apollo Hospital,Tondaiyarpet, Chennai, for which he spent a sum of Rs.1,67,040/- from his pension savings. The petitioner submitted a claim to the 3rd respondent, on 14.04.2019. Since no action was taken, the petitioner submitted a representation to the Chief Minister's Cell on 13.06.2019. Thereafter, the 5th respondent sent a rejection letter on 18.12.2019, rejecting the petitioner's claim on the ground that the treatment for snake bite was not covered under the Insurance Scheme. Challenging the rejection order of the 5th respondent, the present writ petition is filed.3 https://www.mhc.tn.gov.in/judis WP NO. 8426 of 2021 4. The 5th respondent filed counter affidavit, stating that the petitioner was not entitled to medical reimbursement under the NHIS 2018 in terms of provisions governing the said scheme. The respondent stated that though the 1st petitioner underwent treatment in network hospital as he underwent unapproved treatment, he was not entitled for reimbursement under the Scheme. According to the respondents the Government had entered into an agreement with the 4th respondent insurance company, for the benefit of the pensioners and identified several diseases, surgeries and also hospitals for awaiting treatment for the pensioners. The respondents stated that despite the facilities under the NHIS 2018, several Government pensioners continued to seek reimbursement for medical expenses for treatment undergone either in unapproved hospitals or for unapproved treatments. The respondents relied on the judgment of this Court in the case of Star Health & Allied Insurance Company Limited Vs. A. Chokkar wherein the Hon'ble Division Bench, held that while individuals undergoing 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, were nevertheless entitled for 4 https://www.mhc.tn.gov.in/judis WP NO. 8426 of 2021 reimbursement of medial expenses under Tamil Nadu Medical Attendance Rules to the extent permissible, subject to the fulfilment of the conditions prescribed therein. 5. Heard both sides and perused the materials available on record.6. The learned counsel for the petitioners relying on para 18 of the respondent's counter submitted that it would suffice if directions are issued to the respondents to consider the claim for medical reimbursement of the 1st petitioner under the Tamil Nadu Medical Attendance Rules, and to pass orders within a time frame as fixed by this Court.7. The learned Additional Government Pleader in reply submitted that, if the petitioner submits application claiming reimbursement under Tamil Nadu Medical Attendance Rules to the competent authority, the same will considered and the eligible amount will be sanctioned under provisions of the said rules.8. Admittedly, the claim of the deceased 1st petitioner for medical reimbursement under NHIS 2018, cannot be considered, as the treatment undergone by the deceased 1st petitioner for snake bite was not covered by the scheme. The respondents, in paragraph 18 of the counter affidavit, relying on 5 https://www.mhc.tn.gov.in/judis WP NO. 8426 of 2021 the Hon'ble Division Bench judgment of this Court in Star Health & Allied Insurance Company Limited vs. A. Chokkar (W.P(MD).No. 480 of 2009 & etc., batch , dated 26.02.2010), submited that the petitioner may submit his claim under the Tamil Nadu Medical Attendance Rules to the competent authority, and the same would be considered in accordance with the provisions of the said rules. 9. Considering the facts and circumstances of the case, and in light of the categorical submissions of the 5th respondent in paragraph 18, of the counter affidavit, I am of the view that it would be appropriate to direct the respondents to consider the claim for medical reimbursement for the deceased 1st petitioner under the Tamil Nadu Medical Attendance Rules. Accordingly, the following directions are issued:i. Since the deceased 1st petitioner died, the legal heirs/petitioners 2 to 5 shall submit a fresh representation, along with the necessary documents, to the 5th respondent for medical reimbursement for the deceased 1st petitioner/Government Pensioner under the Tamil Nadu Medical Attendance Rules, within a period of two weeks from the date of receipt of a copy of this order.6 https://www.mhc.tn.gov.in/judis WP NO. 8426 of 2021 ii. On receipt of such representation, the 5th respondent shall within two weeks forward the application to the 2nd respondent.iii. The 2nd respondent, in light of the decision of the Hon'ble Division Bench of this Court in Star Health & Allied Insurance Company Limited vs. A. Chokkar cited supra, shall pass orders in accordance with the law, within a period of four (4) weeks thereafter.10. With the above directions, the writ petition is disposed of. No costs. Consequently, connected miscellaneous petition is also closed.27-03-2025Index : Yes/NoInternet : Yes/NoakTo1. The Secretary,Department of Health and Family Welfare, Fort St.George, Chennai.2. The Director of Medical and Rural Health ServiceNo.361, DMS Complex, Anna Salai, Chennai3. The District CollectorMaster Plan Complex, Nagapattinam Road, Tiruvarur District7 https://www.mhc.tn.gov.in/judis WP NO. 8426 of 2021 N.MALA, J.ak4. United India Insurance Co.LtdNo.19, Nungambakkam High Road,IV Lane, Chennai- 600 0345. The Treasury officerDistrict Treasury, Tiruvarur District 610002WP N0. 8426 of 2021andWMP.No. 8968 of 202127.03.20258