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M. Karunakaran v/s The Manager, MD India Health Care Services (P) Limited & Others

    W.P.(MD).No. 19174 of 2014

    Decided On, 18 August 2015

    At, Before the Madurai Bench of Madras High Court


    For the Petitioner: J. Anandkumar, Advocate. For the Respondents: R1, No Appearance, R2, D. Sivaraman, R3, S.K. Krishnamurthy, Advocates.

Judgment Text

(Prayer: Petition is filed under Article 226 of the Constitution of India for the issue of a Writ of Mandamus, directing the respondents to grant the petitioner medical reimbursement to the tune of Rs.11,12,890/- by considering his representation, dated 25.05.2013.)

The Writ Petition has been filed, praying for issuance of a Writ of Mandamus, directing the respondents to grant the petitioner's medical reimbursement to the tune of Rs.11,12,890/- by considering his representation, dated 25.05.2013.

2. The case of the petitioner is that the petitioner is working as Senior Technical Assistant in the Tamil Nadu State Transport Corporation, Tirupathur Division, Sivagangai District. The petitioner is working for the past 27 years in the respondent Corporation, without any blemish. The Government of Tamil nadu has introduced a Health Insurance Scheme for all the Government employees. The petitioner has joined the said Scheme by paying Rs.150/- premium without fail.

2.1. While the situation stood thus, on 21.10.2012, the petitioner's wife namely Tamaraiselvi had fallen ill and treated for the disease of Brain Anurysm at Vadamalayan Hospital. The petitioner's wife was advised to undergo a brain surgery at nuero hospital. Therefore, the petitioner was forced to perform a surgery and the same was done on 23.10.2012 at Hannah Joseph Hospital, Madurai. For the said surgery, the petitioner had incurred a sum of Rs.11,12,890/- towards medical expenditure. The petitioner made representations for claiming the said medical expenditure to the respondents herein. Since the representations made by the petitioner did not evoke any response, the petitioner is before this Court under Article 226 of the Constitution of India.

3. The learned counsel for the petitioner submitted that having detected the premium amount for the Insurance Scheme, it is not fair on the part of the respondents to deny the medical expenditure incurred by the petitioner in one way or the other. He further submitted that this Court in various judgments has reiterated the fact that the time is essence of the matter for taking treatment for the patients and therefore, the petitioner cannot be forced to go for the net work hospital to perform surgeries. In support of his contention, he placed reliance upon a judgment of this Court in W.P.(MD).No.6299 of 2013 dated 17.04.2013 to state that this Court has directed the respondents therein to reimburse the amount incurred by the petitioner therein. Further, the petitioner's wife suffered from nuero problem for which he cannot be asked to go for treatment only in a listed hospital. The contention of the insurance company that the if a person had taken treatment in a non-network hospital, he/she is not eligible for the respondent reimbursement of medical claim has already been negatived in a number decisions. Therefore, the learned counsel for the Insurance Company cannot take such a ground in this Writ Petition.

4. The learned counsel for the third respondent has filed a counter affidavit inter alia stating that the Tamil Nadu Government has implemented New Health Insurance Scheme, 2012 on 01.07.2012 for the employees of the Government of Tamil Nadu for Rs.4,00,000/- for a block period of four years and issued a G.O.Ms.No.243 (Finance) dated 29.06.2012. Rule 6 of the implementation procedure states as 'the hospitals already in Tamil Nadu Government Employees Health Fund Scheme and approved by the Insurance Company/Third Party Administrator under the New Health Insurance Scheme, 2012 are listed in the Annexure-III. The employees and/or their eligible family members for assistance shall get admitted in any one of the approved hospitals'. Thus, implementation procedure makes it mandatory that the employee or their eligible family members for assistance shall get admitted in approved hospitals.'. Further, the Hannah Joseph Hospital, Madurai is not an approved hospital and therefore, the petitioner is not eligible to get reimbursement under this Scheme. The petitioner is well aware about the procedure mentioned in G.O.Ms.No.243 dated 29.06.2012 to avail cashless treatment at network hospital. Initially, he had approached Vadamalayan Hospital which is a network hospital and presented MD India Healthcare Service TPA Pvt Ltd who in turn has given pre-authorisation approval to the network hospital for Rs.62,890/- vide CCN (claim control number) MDI0008663 on 21.10.2012 which was duly utilised by the employee ( petitioner ) and payment to the hospital was also effected on 21.11.2012. Since the petitioner's wife subsequently took treatment in Hannah Joseph Hospital, Madurai, and it is a non-network hospital, the petitioner is not entitled to get back the medical reimbursement.

5. The learned counsel for the second respondent was put on notice on the above factual aspects of the matter.

6. Heard the submissions made by the parties concerned and perused the materials available on record.

7. A perusal of the documents would reveal the fact that the petitioner had incurred medical expenditure to the tune of Rs.11,12,890/- for his wife. The treatment taken by the petitioner's wife is not under dispute. The petitioner claim for medical reimbursement was only negatived on the ground that the petitioner's wife has taken treatment in a non-network hospital. It is apt to mention that in various decisions of this Court, it has been held that the trauma undergone by an applicant for performing surgery either for himself or for his family members cannot be described at all. In such event, the petitioner cannot be asked to go to a net work hospital listed out by the insurance company. A person struggling for life or his family members cannot be expected at the golden hours to search for a recognized hospital to save the life of such person for immediate medical facilities. If such is the condition, the very object for which the Scheme is intended will be defeated and no useful purpose would be served for the employees. In an emergent circumstances, the sufferer will take utmost care to save the life of a person alone and he/she cannot asked to go for a listed hospital bearing in mind to get the reimbursement from the insurance company. Further, the issue involved in this Writ Petition is no more res integra. This Court in the order in W.P.No.8449 of 2007 (A.Nagoor Pitchai v. State of Tamil Nadu rep. by the Director, Land and Survey Department, Ezhilagam, Chepauk, Chennai -5 and others) dated 15.09.2013, was pleased to hold as follows:

'8. In regard to the reasons as to the non inclusion of the Hospital in Government Order for denial, this Court cannot brush aside the advancement in modern medical treatment. Speciality Hospitals are established for treatment for specified ailments and services of Doctors specialized in a discipline are availed by patients only to ensure proper, required and safe treatment. Can it be said that taking treatment in Speciality Hospital by itself would deprive the beneficial order of the Government, solely on the ground that the said Hospital is not included in the Government Order. It cannot be so, as the Government Order should be read keeping the purpose for which the same was issued. The right to medical claim cannot be denied merely because the name of the hospital is not included in the Government Order. The real test must be the factum of treatment. Before any medical claim is honoured, the authorities are bound to ensure as to whether the claimant had actually taken treatment and the factum of treatment is supported by records duly certified by Doctors/Hospitals concerned. Once,it is established, the claim cannot be denied on technical grounds as found in the impugned order. Having regard to the above lacunae in the earlier Government Order and issuance of subsequent Government Order including not only the treatment but also the hospital, I am of the view that the petitioner is entitled to claim reimbursement.

6.1. Another learned single Judge of this Court in a decision made in W.P.No.2714 of 2007 (T), (O.A.No.5757 of 2001) dated 4.11.2011 has observed at paragraph Nos.5 and 6 as follows:

'5. When a person is struggling for life and when his family members want to save his life, no body would search for a recognised hospital for future medical reimbursement. It is not the case of the respondents that no surgery was performed. Having admitted that heart surgery was performed, the respondents are not correct in refusing to reimburse the medical expenses.

6. The very purpose of the health scheme is to help the ailing employees particularly when they are faced with major problems such as Heart Surgery, etc. In a similar circumstances, this Court in K.Mani Vs. Secretary to Government, Health and Family Welfare Department, Chennai and Others [2007(3) MLJ 34] and Mr.K.Balaswami Vs. Director of Pension, Chennai and Another [2007(3) MLJ 385], held that medical reimbursement should not be denied on the ground that the petitioner failed to undergo heart surgery in the hospital recognised by Government of Tamilnadu'.

8. In the light of the above, this Court finds that the decisions rendered by this Court squarely apply to the facts and circumstances of the present case and conse

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quently the petitioner is entitled to succeed in this Writ Petition. Before parting with this judgment, once again, this Court emphasises the fact that for the purpose of getting reimbursement of medical expenses, by listing out the network hospitals, a person cannot be denied privilege of taking treatment of his/her beloved ones at a specialised hospital to save a life of a person. Therefore, following the earlier orders, this Court directs the second respondent to forward the proposal for reimbursement of the amount spent by the petitioner for the treatment of his wife, to the third respondent, within a period of two weeks from the date of receipt of a copy of this order. On receipt of the same, the third respondent is directed to reimburse the amount claimed by the petitioner within a period of four weeks from the date of proposal of the second respondent in regard to the sanction of the amount spent by the petitioner for the treatment of his wife. The Writ Petition is allowed, with the above direction. No Costs.