(Prayer: Writ petition filed under Article 226 of the Constitution of India for writ of Certiorarified Mandamus calling for the records relating to the impugned order of the fifth respondent made in proceedings in Na.Ka.3149/U2/2017 dated 05.10.2017 as confirmed by the third respondent made in his proceedings in O.Mu.No.16704/Ka.Pi.1/3/2017, dated 02.04.2018 and quash the same and direct the respondents to reimburse the medical expenses incurred by the petitioner in taking treatment for his husband as per her claim made in her application dated 19.06.2017 under the New Health Insurance Scheme 2014.)
1. This writ petition has been filed challenging the proceedings dated 05.10.2017 issued by the fifth respondent which has been confirmed by the third respondent by his proceedings dated 02.04.2018 under which the petitioner's application seeking for reimbursement of medical expenses for her husband has been rejected on the ground that her husband has taken treatment in a non-network hospital.
2. The petitioner was working as Tamil Pandit at Government Boys Higher Secondary School, Kavundapadi, Bhavni, Erode District. She retired from service on attaining superannuation on 31.12.2007. She is a member of the New Health Insurance Scheme 2014 for pensioners (including spouse)/ family pensioners. The petitioner claims that she has been paying subscription charges under the said insurance scheme without committing any default. The petitioner claims that under the said claim, the pensioners (including spouse) / family pensioner can avail medical assistance upto a limit of Rs.2,00,000/- in a block period of four years from 01.07.2014 to 30.06.2018 on cashless basis for the accredited treatments/surgeries. According to the petitioner, her husband Y.R.S.Mani suddenly fell sick on 07.08.2014 and complained of chest pain. According to the petitioner, he was immediately rushed to Abi S.K.Hospital, Gobichettipalayam where he was given first aid and the doctors in the said hospital recommended for the immediate intensive care treatment in an equipped hospital as his condition was very serious. According to the petitioner, the Doctors in the said hospital sent the patient Y.R.S.Mani in an ambulance to Sudha Hospital, Erode. According to the petitioner, during the said emergency situation, the petitioner did not have time or occasion to think about the hospitals approved by the sixth respondent under the New Health Insurance Scheme 2014.
3. According to the petitioner, on admission in Sudha Hospital, Erode, her husband had immediately undergone, “Angioplasty” surgery in the said Hospital. According to the petitioner, only thereafter she came to know that the said Sudha Hospital, Erode is not in the list of Hospitals approved by the sixth respondent and is a non-network Hospital.
4. The petitioner claims that she had spent a sum of Rs.2,68,133/- towards medical bills for her husband's treatment in Sudha Hospital, Erode. The petitioner submitted an application dated 13.04.2015 before the second respondent seeking for reimbursement of the said sum under the National Health Insurance Scheme 2014. The second respondent has also forwarded the application to the fifth respondent for appropriate action. The fifth respondent under the impugned proceedings dated 05.10.2017 has rejected the petitioner's application seeking for medical reimbursement of a sum of Rs.2,68,133/- which the petitioner claims that she has incurred towards medical bills for the treatment given to her husband at Sudha Hospital, Erode. However, the fifth respondent has rejected the petitioner's application only on the ground that the petitioner's husband has taken treatment in a non network hospital and therefore, not eligible to get medical reimbursement. The third respondent has also confirmed the proceedings of the fifth respondent dated 05.10.2017 by his proceedings dated 02.04.2018.
5. Both the proceedings have been challenged by the petitioner in this writ petition on the ground that eventhough the petitioner's husband had taken treatment in a non network hospital, the petitioner is eligible for medical reimbursement as the said treatment was taken only in an emergency situation.
6. Learned counsel for the petitioner also drew the attention of this Court to the decision of a learned Single Judge of this Court in the case of N.Raja vs. The Government of Tamil Nadu rep. by its Secretary and others reported in 2016 (3) CTC 394 involving an identical matter. He also submits that the learned Single Judge has followed the Division Bench judgment of this Court in the case of Star Health and Allied Insurance Co. Ltd vs. A.Chokkar & Another reported in 2010 (2) LW 90 .
7. Learned counsel for the sixth respondent would reiterate the contents of the insurance policy and would submit that only in terms thereof, the petitioner's application has been rejected and therefore, there is no illegality in the same.
8. As rightly pointed out by the learned counsel for the petitioner, it is now settled law as laid down by the various decisions of this Court including the decision relied upon by the learned counsel for the petitioner in the case of N.Raja vs. The Government of Tamil Nadu rep. by its Secretary and others reported in 2016 (3) CTC 394 referred to supra that in emergency situations, for seeking medical reimbursement, there is no necessity for the patient to take treatment only in a network hospital.
9. In the instant case, the petitioner has pleaded that only due to the grave emergency, her husband was treated in a non network hospital namely Sudha Hospital, Erode. There is no contra evidence produced by the respondent to disprove the said contention of the petitioner. Therefore, necessarily the contention of the petitioner that only due to the grave emergency, the petitioner's husband was treated in a non network hospital has to be accepted by this Court.
10. However, with regard to the quantum of the money that has to be paid to the petitioner towards medical reimbursement is concerned, it is for the respondents to consider the same on merits and in accordance with law. Since the impugned proceedings rejecting the petitioner's application seeking for medical reimbursement has been passed in contravention of the settled law which enables the patient to take treatment in a non network hospital in case of grave emergency, the said proceedings will have to be necessarily quashed and the matter will have to be remanded back to the first respondent on merits and in accordance with law within a time frame to be fixed by this Court.
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11. For the foregoing reasons, the impugned proceedings dated 05.10.2017 passed by the fifth respondent and dated 02.04.2018 passed by the third respondent are hereby quashed and the matter is remanded back to the first respondent for fresh consideration on merits and in accordance with law and the first respondent is directed to pass final orders on merits and in accordance with law in the light of the decision rendered by this Court in the case of N.Raja vs. The Government of Tamil Nadu rep. by its Secretary and others reported in 2016 (3) CTC 394 referred to supra within a period of twelve weeks from the date of receipt of a copy of this Order. 12. With the aforesaid directions, this writ petition is disposed of. No costs.