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Madras High CourtWP/8342/2021disposed of

V.Lakshmanan v. The State Of Tamil Nadu

2022-06-16Honourable Mr Justice D. Krishnakumar3 pages

IN THE HIGH COURT OF JUDICATURE AT MADRAS

DATED: 16.06.2022

CORAM:

THE HON'BLE MR. JUSTICE D.KRISHNAKUMAR W.P.No.8342 of 2021 V.Lakshmanan

...Petitioner

Vs.

1.The State of Tamil Nadu Rep. by Secretary to Government, Finance (Pension) Department, Chennai - 600 009.

2.United India Insurance Company Ltd., Divisional Office: 010600, 5th Floor, PLA Rathna Tower, 212, Anna Salai, Chennai - 600 006.

...Respondents

Prayer: Writ Petition filed under Article 226 of the Constitution of India praying for issuance of a Writ of Mandamus, directing the first respondent to issue orders to the second respondent to sanction the balance amount of Rs.2,67,173 (Rupees Two Lakhs Sixty Seven Thousand and One Hundred and Seventy Three only) eligible medical cashless insurance to the petitioner within a time frame stipulated by this Court. For Petitioner : Mr.D.Daniel For R1 : Mr.S.Rajesh Government Advocate For R2 : Mr.P.Sankaranarayanan

O R D E R

This writ petition has been filed to direct the first respondent to issue orders to the second respondent to sanction the balance amount of Rs.2,67,173 (Rupees Two Lakhs Sixty Seven Thousand and One Hundred and Seventy Three only) eligible medical cashless insurance to the petitioner.

2. The case of the petitioner in brief:

The petitioner herein and his wife were retired Government employees and the medical insurance identity card has been issued in the name of the petitioner's wife. Even though they were subscribing members of the New Health Insurance Scheme, 2016-2018, issued by the first respondent in G.O. (Ms).No.391 dated 10.12.2018 for the block of four years from 01.07.2016 - 30.06.2020. the said scheme was extended by the first respondent in G.O.(Ms).No.441 dated 03.12.2020. As per the new scheme, the subscriber is eligible for claiming cashless treatment upto Rs.7,50,000/-. The petitioner was admitted in the Madras Medical Mission for Coronary surgery and the procedure was performed successfully. The hospital authorities charged gross amount of Rs.5,41,182/- towards surgery and other related costs such as medicines and room charges.

The petitioner claimed eligible amount of Rs.7,50,000/- as per the scheme norms. But the second respondent rejected the petitioner's claim and sanctioned only Rs.2,45,000/-. The second respondent not acting on the scheme provisions rejected the claim for the medical insurance amount upto Rs.7,50,000/-. The petitioner had clear the bill through his credit card payment amounting Rs.3,25,000/-. All his efforts to get the eligible balance of Rs.2,67,173 has not yielded any result. Hence, this writ petition.

3. The learned counsel for the petitioner submitted that the petitioner is entitled for the balance of eligible insurance payment amount of Rs.2,67,173/- (Rupees Two Lakhs Sixty Seven Thousand and One Hundred and Seventy Three only) for his medical treatment.

4. According to the 2nd respondent, as per the scheme, the maximum eligibility for the payment of surgery is Rs.4,00,000/- (Rupees Four Lakhs only) whereas the bill amount is Rs.5,41,182/- (Rupees Five Lakhs Forty One Thousand and One Eighty Two only). Therefore, there is no such request made by the hospital for claiming that the amount of Rs.5,41,182/- (Rupees Five Lakhs Forty One Thousand and One Eighty Two only) whereas the maximum limit for the surgery is Rs.4,00,000/- (Rupees Four Lakhs only). Therefore, the 2nd respondent/insurance company is not liable to pay the said amount. Further it is stated that the petitioner has to seek his remedy before the Appellate Authority, without exhausting the appeal remedy, the petitioner has approached this Court.

5. The learned Government Advocate appearing for the 1st respondent submitted that the petitioner is having the remedy before the Appellate Authority.

6. According to the 1st respondent, as per the National Health Insurance Scheme, the hospital has directly sent the claim bill to the 2nd respondent/insurance company prior to the treatment. Therefore, based on the said bill only they have settled the amount. Hence, this dispute is between the hospital and the writ petitioner. Therefore, the petitioner's grievance as against the hospital, and the petitioner shall seek his remedy, before the Appellate Authority.

7. In view of the above, the petitioner is directed to seek his remedy before the Appellate Authority by way of filing an appeal by impleading the hospital as party in the said proceedings and whatever observation made in the order, would not influence upon the Appellate Authority, on the hearing of the appeal.

8. With the above direction, the writ petition stands disposed of. No costs.

Sd/- Assistant Registrar(CS-V) // True Copy // Sub Assistant Registrar ata To The Secretary to Government, Finance (Pension) Department, Chennai - 600 009.

+1cc to Mr.D.Daniel, Advocate SR.No.36881 +1cc to Mr.P.Sankaranarayanan, Advocate SR.No.36637 +1cc to the Government Pleader, SR.No.37182 W.P.No.8342 of 2021 GSM(CO) CB(13/07/2022)