Madras High CourtWP/3198/2021disposed of

V.Varadharaj v. The Director Of Medical And Rural Health Service

2024-01-12Honourable Ms Justice R.N.Manjula6 pages

0IN THE HIGH COURT OF JUDICATURE AT MADRAS DATED : 12.01.2024

CORAM

THE HONOURABLE MS.JUSTICE R.N.MANJULA W.P. No.3198 of 2021 V.Varadharaj ...

Petitioner Vs.

1 The Director of Medical and Rural Health Service, Directorate, Anna Salai, Teynampet, Chennai.

2 The Deputy Director of Medical and Rural Health Service and Family Welfare, District Family Welfare Bureau, Taluk Office, Vellore.

3 The District Level Empowered Committee Headed by the District Collector, Vellore District.

4 The District Collector Tirupattur District.

5 The Treasury Officer Sub- Treasury, Tirupattur.

6 The Assistant Engineer Highway Department, Construction and Maintenance, Tirupattur, Vellore District.

7 The Branch Manager United India Insurance Co. Limited, Regional Office- Silingi Buildings, 134, Greams Road, Chennai 600 006.

8 The Branch Manager, MD India Health Insurance, TPA Private Limited, Guna Complex, New D.No. 443 and 445, Old D.No. 304 and 305, Anna Salai Teynampet, Chennai 600 018.

... Respondents Writ Petition is filed under Article 226 of the Constitution of India to issue a Writ of Mandamus, directing the Respondents to pay the medical bill of Rs.42,301/- to the petitioner payable under New Health Insurance Scheme 2016 for reimbursing Medical Expenditure incurred by the petitioner towards the treatment of her wife dated 14.12.2018 with the interest at the rate of 12 percent.

For Petitioners :

Mr.M.Arun For Respondents For R1 to R6 :

Mr.Yogesh Kannadasan, Special Government Pleader For R7 :

Mr.P.Sankaranarayanan For R8 :

No appearance

ORDER

The petitioner who is working as a Road Inspector in the Highways Department, is covered under the New Health Insurance Scheme, 2016 which was introduced for the welfare of the State of Tamil Nadu Government Employees and their family members. The petitioner's wife was admitted in CMC Hospital, Vellore as inpatient for lower abdominal pain. Due to her medical condition viz., Ruptured Right Ovarian Ectopic Pregnancy, she was advised to undergo a surgery. In this regard, a claim was made by the petitioner under the scheme and the same was returned on the ground that Ectopic Pregnancy is not included under the policy.

2. Mr.P.Sankaranarayanan, learned counsel for the 7th respondent submitted that since the surgery undergone by the petitioner's wife is not covered under the scheme, he has to get medical benefits under some other schemes.

3. Mr.Yogesh Kannadasan, learned Special Government Pleader appearing for the Respondents 1 to 6 submitted that the eligibility of the claim has to be decided by the District Level Committee headed by the

District Collector and the respondents 7 and 8 cannot simply reject the same on the ground that the surgery undergone by the petitioner is not included in the scheme.

4. The learned counsel for the petitioner also relied on the Judgement of this Court made in W.P.(MD).Nos.13429 of 2013 batch case, dated 28.05.2019 wherein this Court after having dealt and referred with various Judgment and citations, held thus:

"18. In Star Health and Allied Insurance Company case cited above (2010-2-LW 90), it has been held that, when there has been agreement between the Insurance Company and the State Government and the said agreement is nothing but a contract, the party to the contract will be abide by only on the condition of the contract and not beyond that. It means that, the Insurance company, if at all liable to pay reimbursement of medical claim such liability is only in consonance with the terms of the contract and not beyond that. While holding so, the Division Bench has further held that, in cases where the Insurance Company is not liable to pay, it is for the Government to pay, of course on the basis of the Tamil Nadu Medical Attendance Rules."

5. It is submitted that the respondents 7 and 8 have placed the

eligibility of the claim before the 3rd respondent in order to arrive at a conclusion about the applicability of the scheme for the claim made by the petitioner. The petitioner did not prefer any appeal before the 3rd respondent and to get his recommendation in this regard.

6. Hence, the petitioner is at liberty to make a fresh representation along with relevant medical records to the 3rd respondent. On receipt of the same, the 3rd respondent is directed to consider it and pass appropriate orders within a period of two weeks from the date of receipt of a copy of this order.

7. With the above direction, this Writ Petition is disposed of. No costs.

12.01.2024 Index: Yes / No Speaking order / Non-speaking order vum R.N.MANJULA ,J.

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