1. This proceeding has been initiated with the following prayers:-
'In the premises, it is therefore humbly prayed that your Lordship would be graciously be pleased admit this petition, call for the records, issue a Rule calling upon the Respondents to show cause as to why a writ in the nature of Mandamus or any other appropriate writs or orders or direction directing the official respondents to make payment/reimbursement of the said pending medical expenses bill submitted by the insured persons which is about 6 crores and or any other appropriate writs and/or directions or orders should not be issued against them as sought for by the petitioner in the instant Writ Petition and upon perusal of the records and upon hearing both the parties your Lordship would further be pleased to make the Rule absolute by issuing a writ of mandamus or any other appropriate writ of mandamus or any other order or direction(s) directing the Respondents to process and settle all the outstanding medical expenses reimbursement bills of the claimant, insured persons and to make the payment as per the Mizoram Health Care Scheme in a definite time frame/or pass any other or further order or direction as your Lordship may deem fit and proper in the circumstances of the case for the interests of justice and fair play.'
2. Heard Mr. P.C. Prusty, learned counsel for the petitioner. Also heard Mr. Lalsawirema, learned Govt. Advocate for respondent Nos. 1 to 8 and Mr. A.R. Malhotra, and learned counsel for the respondent No. 10.
3. It needs to be mentioned here that respondent No. 9 did not participate in this proceeding in spite of notice of this proceeding having been served upon it which is why that it runs ex-parte against respondent No. 9 (M/s Reliance General Insurance Company Limited, Mumbai).
4. The facts which are narrated in the writ petition under consideration and which are necessary for disposal of the present proceeding are that the State of Mizoram (respondent No. 1) initiated a scheme called 'Mizoram State Health Care Scheme' (in short, the MSHCS) in 2008 to provide health insurance cover in the form of reimbursement of medical expenses for particular class of bonafide Indian citizens residing within the territorial jurisdiction of State of Mizoram.
5. As per the scheme, medical expenses up-to one lac, incurred in connection with certain kinds of ailments in certain hospitals during the policy period by each family, entitled to the benefit under the scheme, of course, subject to maximum of five, would be borne by Insurance Company. However, each family was to pay Rs. 100/– per year (policy year) as premium in case of people living below the poverty line whereas each family were to pay Rs. 200/- per year as premium in case they are categorized as Above Poverty Line (APL).
6. It has been stated that Mizoram State Health Care Society, hereinafter referred to as Society, was formed to facilitate the formation and implementation of aforesaid schemes. Respondent Nos. 4 and 5 were made the Members Secretary and Chief Executive Officer of the Society respectively. In due course, the scheme was widely published and a large number of people within the eligible criteria in the state of Mizoram approached the Government and paid the premium, prescribed, to get the benefit under the scheme aforementioned.
7. It has been stated that as many as 79,019 number of families residing in the State of Mizoram paid the premium and enrolled as themselves as subscribers under the scheme for which the Government of Mizoram collected Rs. 83,21,200/- only in respect of policy year 2008-2009 as being premium from the families aforesaid. The families who paid premium as aforesaid formed a society under the name and style 'Mizoram Health Care Scheme Insured Persons Association' and same was duly registered under the 'Mizoram Societies Registration Act, 2005'.
8. On 28.03.2008, the State of Mizoram entered into an agreement with respondent No. 9 to implement the scheme aforementioned. As per clause No. 1.10 of the agreement, the Govt. of Mizoram was to pay respondent No. 9 Rs. 28,93,88,192/- plus service tax @12.36% as being 95% of premium amount and remaining 5% were to be paid at the end third quarter of the policy period. It has been stated that the State of Mizoram had paid the aforesaid amount in satisfaction of the obligations arising out of the agreement dated 28.03.2008.
9. The policy period under the scheme above commenced from 01.04.2008 and it ended on 31st March, 2009. During the policy period beginning from 1.04.2008, as stated above, 79019 number of families paid the premium and got themselves insured under the scheme for which Government of Mizoram had collected Rs. 83,21,200/- as being premium to cover the health risk to the persons insured under the scheme for the policy period aforesaid.
10. During the policy period, more than 28571 medical bills were submitted by the beneficiaries to the respondent No. 9 seeking reimbursement of medical expenses. Although respondent No. 9 had paid Rs. 16,93,09,992/- in satisfaction of medical bills submitted to it yet a large number of medical bills, to be prcised 8917, seeking reimbursement of medical expenditures incurred by person insured have not been settled although several years had passed by in the meantime.
11. In that connection, it has been stated that as per the agreement, respondent No. 9 was to settle the medical bill within a period of 7 days once the bills, complete in all respect, are submitted to the authority concerned. The petitioner has submitted that the State had incurred huge expenditures in order to meet the objective under the scheme, the details of which are reflected in paragraph 15 of the writ petition which are reproduced below-
'15. That the petitioner begs to submit that the State exchequer has incurred expenditure to make the objective of the scheme by making payments in three installments as described below:
I) Vide Letter No. B.16011/00/03-HFW dated 7.4.2008 from the Respondent No. 8, a sum of Rs. 2740.19 lakhs was sanctioned for payment as premium to Respondent No. 9 RGICL.
II) Vide Letter No. B.16011/18/2008-HFW dated 5.6.2008 from the Respondent No. 7 an amount of Rs.22.00 lakhs was sanctioned as Grant-in-Aid to the Mizoram Health Care Society as 1st installment for the implementation of the Scheme.
III) Vide Letter No. B.16011/18/08-HFW/Pt dated 6.11.2008 from the Respondent No. 8 a sum of Rs. 2228.82/- lakhs was sanctioned as Grant-in-Aid of the Mizoram Health Care Society.
Copies of the abovementioned letter dated 7.4.2008, 5.6.2008 and 6.11.2008 are annexed hereto and marked as Annexures-11, 12 and 13 respectively.'
12. It is also the case of the petitioners that as per information, collected under the RTI Act at Annexure-15 to the writ petition, out of Rs.50 crores plan fund under the Health Care Scheme, Rs. 10 crores was invested in Bajaj Allianz whereas another 10 crores was deposited in Axis Bank, Aizawl in the account of the Health Care Society. Annexure-15 further reveals that the amount in the bills which are yet to be settled comes to Rs. 6 crores.
13. The policy holders under the scheme whose bills have not yet been settled by respondent No. 9 had approached the Government seeking its intervention in settling their medical bills. The Government has done its best to secure the payment against the medical bills and sat in conference with the respondent No. 9 both formally and informally in order to settle the claim of policy holders aforesaid.
14. But the respondent No. 9 did not do enough till date to satisfy all the claims of the policy holders who claimed the reimbursement of their medical expenses incurred during the policy period in accordance with the terms and conditions of the scheme under consideration. Having found no other way out, they approached this court seeking relief as aforesaid.
15. The respondent No. 1 to 8 having filed common counter affidavits, submitted that for the welfare of common people living in the State of Mizoram, the scheme aforesaid was brought into existence and in that connection, it entered into an agreement with respondent No. 9 on 28.03.2008. As per terms and conditions, the policy period started from 1.04.2008 and it was to end on 31.03.2009.
16. The terms and conditions of the said agreement further required that state of Mizoram was to pay 95% of the premium amount before commencement of the policy and remaining amounts were to be paid at the end of third quarter of the policy period. In satisfaction of such condition in the agreement, the State of Mizoram had paid 95% of the total premium within the stipulated period.
17. Though during the policy period a large number of bills have been submitted by policy holders seeking reimbursement of their medical expenditures incurred in connection with deceased enlisted in the scheme and that too in the approved hospitals during the policy period, the respondent No. 9 had cleared bills amounting to Rs. 16,93,09,992/- only leaving a large number of bills yet to be settled.
18. In such a situation, State Government, represented by concerned minister, had initiated several measures in order to settle the claims of the policy holders whose bills have not yet been settled. Unfortunately, respondent No. 9 did not show enough interest in settling the claims of remaining policy holders causing huge problems to the policy holders in general and to the Government in particular.
19. Referring to the contention made in paragraph 21 of the writ petition, it has been stated that out of 50 crores in the plan fund, meant for Health Care Scheme, Rs. 10 crores has been invested in Bajaj Allianz Life Insurance Corporation Limited whereas Rs. 10 crores has been invested with Axis Bank for further implementation of Mizoram Health Care Schemes during the policy period between 2010 and 2011.
20. The respondent No. 1 to 8, however, in their common counter affidavit take the stand that State respondents are no way responsible for non-settling of the bills of the policy holders who claimed reimbursement of the expenses they incurred during the period under consideration. But in spite of not being responsible for non-payment of their dues, the State respondents have done everything possible to see that the medical claims of the all policy holders are settled sooner than later.
21. The respondent No. 10 too has also entered appearance and filed counter affidavit. In its counter affidavit, the respondent No. 10 has stated that it received an amount to the tune of Rs. 10 crores along with proposals for life insurance from individual persons from the State of Mizoram. On the receipt of the proposal forms along with necessary documents, the respondent No. 10 issued 17 policies of life insurance which are to be paid out of the funds granted to the Mizoram Health Care Society. After issuance of policies, in favour of Mizoram Health Care Society, the respondent No. 10 came to know that CBI had registered a case under various provisions of Indian Penal Code for improper utilization of Government money.
22. As in the meantime, the renewal premium for 17 policies was not paid, all those policies got lapsed. Out of those 17 policies, 13 policies of life insurance were terminated in accordance with terms and conditions of the policies since policies were not revived within the revival period. The remaining 4 policies were surrendered by the Mizoram Health Care Society being the assignee of aforesaid policies.
23. In due course, an amount to the tune of Rs. 11,20,43,289.80p was paid to Mizoram Health Care Society against all the 17 policies and as such, at the moment, nothing is left to be paid from the side of respondent No. 10. Therefore, respondent No. 10 urges this court to dismiss the proceeding as far as respondent No. 10 is concerned since it has nothing to do with the claims made by the policy holders in this writ proceeding.
24. I have considered the arguments advanced by learned counsel for the parties having regard to the pleadings of the parties. On the perusal of pleadings of the parties, I have found that the petitioners, being the member of the Mizoram Health Care Scheme Persons Insured Association, had paid the required premium and got themselves insured under the scheme aforesaid.
25. As per terms and conditions of the scheme, the Government of Mizoram has paid 95% of total premium amount well ahead of policy period as required under the agreement. As such, the petitioners are entitled to claim reimbursement of medical expenditures which the incurred in treating the specified deceases in approved hospitals during the policy period starting from 1.4.2008 to 31.03.2009 provided they made claim in accordance with terms and conditions of the policy.
26. It is the specific claim of the petitioners herein which is also not objected to by the state respondents that the former submitted medicals bills complete in all respect, to the concerned authority in time. But the respondent No. 9 despite being under compulsion to settle, within the specified period, all the valid claims seeking reimbursement of medical expenses incurred during the policy period, did not settle a large number of bills so submitted till date.
27. Though the respondent No. 1 to 8 made all efforts to settle all the valid medical bills, such efforts too till date could not yield the desired result. I have found that under the agreement in question, the respondent No. 9 was to settle all the valid claims within the definite time frame. Unfortunately, in spite of passing over several years since the time of submission of medical bills aforementioned, a good number of bills claiming reimbursement of expenses ranging between 5 to 6 crores remain outstanding. This is quite sad and unfortunate.
28. We have already found the scheme, above, was initiated for the welfare of the most vulnerable sections of the society in order to shield them from some adverse situations. What is, however, very important to note is that a huge amount of public money was spent to attain objective aforementioned. But such efforts are greatly hampered due to unpardonable conduct on the part of respondent No. 9.
29. These are also the testimonies of some hugely humane schemes being hijacked by some companies/institutions/organisations who always talk tall whenever services to the humanity come. In view of the above, I am of the considered view that the respondent No. 9 needs to be directed to examine all the outstanding medical bills and to make payment against all the valid bills within a definite time frame.
30. In the result, the respondent No. 9 is directed to examine all the outstanding medical bills in accordance with terms and conditions of the policies initiated under the scheme under mentioned and thereafter make payment against all the valid bills within a period of 6 months from the date receipt of copy of this order.
31. Here, I make it clear that in the event of the failure of the respondent No. 9 to pay the insured persons of their valid medical bills, the respondent No. 9 would be liable to pay simple interest on the amount due to the each insured persons @ 6% from the date of this order.
32. Before I part with record, it needs to be stated that though the state respondents have claimed that they did not any responsibility in realizing the medical dues to the petitioners, such claim is found unacceptable for several valid and legitimate reasons. In that connection, it may be pointed out that apart from having constitutional obligation in ensuring the well being of its people, it has a contractual obligation as well.
33. We have already found that it is the state respondents who had motivated the people in the state of Mizoram to come forward to take advantage of the benefits under the Scheme in question and on their coming forward and on their accepting the offers, the state respondents had collected huge premium from the targeted people with p
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romise to provide them medical security within the policy period. Thus, in my considered opinion, the state respondents have an obligation to see that the promises, they made, is realized in letter and sprit. 34. Since the promise to provide medical security to its people has not been fully realized inspite of policy holders paying required sum as premium, the state respondents cannot avoid its contractual obligation aforesaid. In the compectus of above discussion, in my considered opinion, the state respondents cannot leave the ground saying that they have no responsibility in settling the outstanding medical bills submitted by the persons who were so insured under the scheme under consideration. 35. Since I have found reasons to hold that the respondent No. 9 was mainly responsible for not honoring the medical bills, submitted by the petitioners herein and since I have already found that the State respondents have done something very seriously to settle the bills, submitted by the petitioners seeking reimbursement of expenses, incurred in connection with treating their specified disease in the approved hospitals, I refrain from passing any orders/directions against the State respondents as of now. 36. I have already found that the respondent, No.10 categorically claims that in regard to prayers, made by the petitioners in this proceeding, it has no role to play and as such wants this proceeding to be dismissed as far as respondent No. 10 is concerned. In view of materials on record, I am in quite in agreement with the stand taken by the respondent No 10. Hence this proceeding stands dismissed as against the respondent. No 10. 37. With the above observations and directions this proceeding is disposed of. Order accordingly.