High Court · 2025

W.P.No.34565 of 2019IN THE HIGH COURT OF JUDICATURE AT MADRASDATED : 06.03.2025CORAMTHE HONOURABLE MS.JUSTICE R.N.MANJULAW.P.No.34565 of 2019D.Rajakumar ... PetitionerVs. 1.The Secretary to Government, Finance (Pension) Department, Government of Tamil Nadu, Fort St.George, Chennai 600 009. 2.The United India Insurance Co.Ltd., No.24, Whites Road, Chennai 600 014. 3.M.D.India Health Care Services (TPA) Pvt. Ltd., No.27, Lakshmi Towers, 3rd Floor, Dr.Radhakrishnan Salai, Mylapore, Chennai 600 004. 4.Madras Medical Mission, 4-A, Dr.JJ Nagar, Mogappair, Chennai - 600 037. 5.The District Collector, District Level Empowered Committee, Collectorate, Singaravelar Maaligai, 62, Rajaji Salai, Chennai 600 001. Page No.1 of 9 https://www.mhc.tn.gov.in/judis W.P.No.34565 of 2019(R4 & R5 impleaded as per order dated 29.01.2025 in W.M.P.No.3126 of 2025)... Respondents Prayer : Writ Petition filed under Article 226 of the Constitution of India, to issue a Writ of Mandamus, to direct the respondents to reimburse the balance sum of Rs.1,80,952/- with interest at the rate of 12% per annum from 13.03.2019 till date of reimbursement. For Petitioner : Mr.T.Sai Krishna For Respondents : Mr.A.M.Ayyadurai, GA for R1 & R5 Mr.P.Sankaranarayanan for R2 Ms.T.Jayalakshmi for M/s.Paul & Paul for R3 No appearance for R4 ORDERThis Writ Petition has been filed to direct the respondents to reimburse the balance sum of Rs.1,80,952/- with interest at the rate of 12% per annum from 13.03.2019 till date of reimbursement. 2. Heard Mr.T.Sai Krishna, learned counsel for the petitioner, Mr.A.M.Ayyadurai, learned Government Advocate for R1 & R5, Mr.P.Sankaranarayanan, learned counsel for R2, Ms.T.Jayalakshmi, learned counsel for R3 and perused the materials available on record. 3. The petitioner who has taken treatment for Coronary Arteries Disease is said to have spent an amount of Rs.3,45,952/-. But, he was Page No.2 of 9 https://www.mhc.tn.gov.in/judis W.P.No.34565 of 2019given reimbursement of only Rs.1,65,000/-. The petitioner's application for full reimbursement has not been considered. Hence, the petitioner is before this Court.4. The learned counsel for the petitioner submitted that only from the counter filed by the second respondent Insurance Company, the petitioner came to know that the medical bills have not been received by the Insurance Company. 5. The learned counsel for the fourth respondent Hospital submitted that the medical bills have already been submitted to the second respondent. But, they have not taken a decision so far. 6. The learned counsel for the second respondent submitted that as per the pre-authorisation approval, a sum of Rs.1,65,000/- has been paid to the Hospital. 7. So far as the petitioner is concerned, he has taken treatment Page No.3 of 9 https://www.mhc.tn.gov.in/judis W.P.No.34565 of 2019from the network hospital. No doubt the petitioner has taken treatment after 2018 and hence, he is governed by the New Health Insurance Scheme 2018. So far as the petitioner is concerned, he does not know what is the outer limit for his claim and what are the eligible medical expenses that can be reimbursed. Unless an order is passed by the respondents by considering the claim of the petitioner, he may not even know whether his claim has been rejected or partly allowed or fully allowed. 8. In this regard, clear guidelines have already been given in the judgment of this Court made in a batch of Writ Petitions in W.P.(MD) Nos.13429 of 2013 etc.,dated 28.05.2019 (S.Marimuthu Vs. The Government of Tamil Nadu and others), as under:"80. In order to reconsider all these claim made by the respective writ petitioners for medical reimbursement, by remitting the matters back, the following directions are issued:(i) All the impugned orders in the respective writ petitions in this batch of cases, are hereby quashed.(ii) The writ petitions where impugned orders are Page No.4 of 9 https://www.mhc.tn.gov.in/judis W.P.No.34565 of 2019quashed as well as the writ petitions where mandamus sought for, are hereby remanded with directions to the concerned District Level Empowered Committee, before whom, these matters shall be placed and the Committee shall reconsider every individual case.(iii) While reconsidering, the Committee shall not reject any claim merely on the reason of non network hospital or non listed disease.(iv) The Committee, wherever possible, shall give suitable direction to the Insurance Company to reimburse the claim made by the respective claimant / employee / pensioner.(v) If the Committee finds some cases where the Insurance Company cannot be directed to reimburse, in those cases, suitable orders shall be passed directing / recommending the State authorities to reimburse the claim under Medical Attendance Rules.(vi) Once such orders are passed, the Insurance Company shall immediately reimburse the medical claim with 6% interest from the date of due till date of payment, within a period of thirty days from the date of receipt of such order to be passed by the Empowered Committee of the District concerned.(vii) On receipt of such orders / recommendation Page No.5 of 9 https://www.mhc.tn.gov.in/judis W.P.No.34565 of 2019from the Empowered Committee, the Sanctioning authority / State authority / High Power Committee in the State Level shall pass necessary orders allowing the medical reimbursement claimed by the individual claimant / employee / pensioner under the Medical Attendance Rules.(viii) While ordering medical reimbursement under Medical Attendance Rules, the rate approved, accepted or quoted by the Insurance Company under the Medical Insurance Scheme shall be taken as the rate and by calculating the reimbursement on the said rate, the reimbursement claim shall be immediately sanctioned and the amount shall be reimbursed to the claimant with 6% interest form the date of due till date of payment, within a period of thirty days from the receipt of the recommendation / order from the District Empowered Committee."9. For the medical expenses incurred by the petitioner in the year 2019, so far the settlement has not been made. As the petitioner was not aware of his first level disposal of his application, he may not be able to address his grievance before the District Level Empowered Committee as well. It appears that the petitioner's claim has been rejected on the ground Page No.6 of 9 https://www.mhc.tn.gov.in/judis W.P.No.34565 of 2019that the package charges for the treatment taken by the petitioner has already been settled. So, the petitioner ought to have filed an appeal before the District Level Committee.10. It appears that the Insurance Company itself has placed papers before the District Level Empowered Committee. The District Level Empowered Committee is the appellate authority who has to take a decision on the papers placed before it by considering the claim as an appeal. Hence, the fifth respondent is directed to dispose the claim of the petitioner by considering it as an Appeal.11. In view of the above stated reasons, this Writ Petition is disposed and the fifth respondent is directed to dispose the claim of the petitioner by considering it as an Appeal and pass a speaking order within a period of four weeks from the date of receipt of a copy of this order. No costs. Index: Yes / No 06.03.2025Speaking / Non-speakingPage No.7 of 9 https://www.mhc.tn.gov.in/judis W.P.No.34565 of 2019Neutral Citation : Yes / No gskPage No.8 of 9 https://www.mhc.tn.gov.in/judis W.P.No.34565 of 2019R.N.MANJULA , J. gskTo1.The Secretary to Government, Finance (Pension) Department, Government of Tamil Nadu, Fort St.George, Chennai 600 009. 2.The United India Insurance Co.Ltd., No.24, Whites Road, Chennai 600 014. 3.M.D.India Health Care Services (TPA) Pvt. Ltd., No.27, Lakshmi Towers, 3rd Floor, Dr.Radhakrishnan Salai, Mylapore, Chennai 600 004. W.P.No.34565 of 20194.Madras Medical Mission, 4-A, Dr.JJ Nagar, Mogappair, Chennai - 600 037. 5.The District Collector, District Level Empowered Committee, Collectorate, Singaravelar Maaligai, 62, Rajaji Salai, Chennai 600 001.06.03.2025Page No.9 of 9