S.Gopalakrishnan v. The Principal Secretary To
IN THE HIGH COURT OF JUDICATURE AT MADRAS
DATED : 21.04.2022
CORAM
THE HON'BLE MR. JUSTICE P.D. AUDIKESAVALU W.P. No. 23845 of 2018 S.Gopalakrishnan (deceased) G.Prema ... Petitioner (Petitioner substituted vide order dated 21.04.2022 in W.M.P. No. 10096 of 2022) -vs1. The Principal Secretary to Government of Tamil Nadu, Department of Finance (Pension), Secretariat,
2. The Principal Secretary/Commissioner of Treasuries Accounts, Integrated Office Complex for Accounts Department, Nandanam, Anna Salai, Chennai - 600 003.
3. The Director of Pension, DMS Campus, 3rd Block, 2nd Floor, 259, Anna Salai,
4. The Director of Medical and Rural Health Services/ Member Secretary - SLEC for NH & S, DMS Compound, Chennai - 600 005.
5. The District Collector/Chairman Health Fund Scheme, Tiruvarur District.
6. The District Treasury Officer, Tiruvarur.
7. The Divisional Manager, United India Insurance Company Limited, ... Respondents
Prayer:- Writ Petition filed under Article 226 of the Constitution of India, 1950, praying to issue a Writ of Mandamus, directing the Respondents to reimburse the sum of Rs. 2,53,434/- (Rupees Two Lakh Fifty Three Thousand Four Hundred and Thirty Four only) towards the medical expenses meted for the Petitioner's wife with 12% interest per annum. For Petitioner :
Mr. D.Baskar For Respondents:
Mrs. C.Sangamithirai, Special Government Pleader (for R1 to R6) Mr. T.Shanmugam (for R7)
O R D E R
Heard Mr. D.Baskar, Learned Counsel for the Petitioner, Mrs. C.Sangamithirai, Learned Special Government Pleader appearing for the First to Sixth Respondents and Mr. T.Shanmugam, Learned Counsel for the Seventh Respondent and perused the materials placed on record, apart from the pleadings of the parties.
2.
The Original Petitioner viz., S.Gopalakrishnan, who was receiving pension on retirement from service as Deputy Registrar of Co-operative Societies in the State Government, has availed the benefits of the New Heath Insurance Scheme, 2014, for Pensioners of the Government of Tamil Nadu in G.O. Ms. No. 171, Finance (Pension) Department dated 26.06.2014, which also covers his dependants, by making periodical contributions towards insurance premia from his pension. It is the case of the Original Petitioner that his wife, viz., G.Prema, had suffered injuries in an accident that had taken place on 20.10.2016 for which she was admitted at Soundarapandian Bone and Joint Hospital and Research Institute Private Limited, Anna Nagar, Chennai for treatment and surgery and he had incurred medical expenses of Rs. 2,53,434/- in that regard.
The claim made by the Original Petitioner to the Seventh Respondent, which is the Insurance Company to grant the benefits under the New Health Insurance Scheme, 2014, was rejected by Proceedings in O. Mu. No. 16704/KaPi1/3/ 2017 dated 02.04.2018 by the Fourth Respondent stating that the treatment was taken in a non-network hospital. The Petitioner has filed this Writ Petition seeking a direction to the Respondents to make payment of the said sum of Rs. 2,53,434/- towards reimbursement of medical expenses with interest at the rate of 12% per annum from the date of making the claim till actual payment.
3.
Since the Original Petitioner died on 12.10.2021 after the filing of the Writ Petition, his wife, viz., G.Prema, in respect of whom the claim for reimbursement of medical expenses was made, has been substituted as the Petitioner in the Writ Petition in his place by order dated 21.01.2022 in W.M.P. No. 10096 of 2022 passed by the Court.
4.
During the earlier hearing on 23.02.2022, it had been brought to notice that clause 5(b) of Annexure-I relating to the implementation procedure for New Health Insurance Scheme in G.O. Ms. No. 202, Finance (Salaries) Department dated 30.06.2016 issued by the Government of Tamil Nadu, provides as follows:- "5(b) Claims relating to treatment/surgery included in the approved list undergone in non-network hospital consequent on accidents shall be covered under NHIS, 2016 and settlement made through a suitable mechanism." In view of the same, Learned Counsel appearing for the Seventh Respondent sought time to obtain instructions as to why the Petitioner had not been granted the benefits in terms of the said clause and file report in that regard.
5.
When the matter was taken up for hearing on 07.04.2022, Learned Counsel for the Seventh Respondent, on instructions, stated that the original bills for the medical expenses have already been returned to the Petitioner by the impugned Order in O. Mu. No. 16704/KaPi1/3/2017 dated 02.04.2018 passed by the Fourth Respondent and unless the original bills are resubmitted, the Seventh Respondent would not be in a position to take further action in the matter.
6.
Having regard to the aforesaid submissions made, this Court without expressing any view on the correctness or entitlement of the claim made by the Petitioner, passes the following order:- (i) on receipt of the original bills from the Petitioner or production of its authenticated copies from the concerned hospital with explanation from the Petitioner as to the nonavailability of the original bills by 31.07.2022, it shall be incumbent upon the concerned authorities of the Seventh Respondent to examine the claim made by the Petitioner for reimbursement of the medical expenses in terms of clause 5 (b) of Annexure I relating to the implementation procedure for New Health Insurance Scheme in G.O. Ms. No. 202, Finance (Salaries) Department dated 30.06.2016, without reference to the fact that the Petitioner had undergone treatment in a hospital which had not been included in the list of recognized hospitals for extending such benefit; (ii) if it is found that any details or supporting documents
satisfying the eligibility criteria for the actual amount claimed has not been produced, the deficiencies in that regard shall be informed in writing to the Petitioner requiring the same to be furnished within a time frame of not less than 15 clear working days in that regard; (iii)if the Petitioner is found entitled to the claim made, the eligible amount shall be disbursed within a period of 30 days from the date of passing of that order;
(iv) in the event of not being satisfied with the requirements thereafter, an enquiry shall be conducted affording opportunity of personal hearing to the Petitioner to explain her position in that regard and a reasoned order shall be passed dealing with each of the contentions raised on merits and in accordance with law with details of any deductions made under various heads and the decision taken communicated under written acknowledgment;
(v) if the Petitioner is found entitled to the claim made, the eligible amount shall be disbursed within a period of 30 days from the date of passing of that order;
(vi) if the Petitioner still has any grievance to be redressed in the matter, she is not precluded from working out her rights before the proper forum in the manner recognized by law; and (vii)the report of completion of the aforesaid exercise shall be filed by 30.09.2022 before the Registrar (Judicial) of this Court.
In the result, the Writ Petition is ordered on the aforesaid terms. No costs.
Sd/- Assistant Registrar(CO) //True Copy// Sub Assistant Registrar vjt To
1. The Principal Secretary to Government of Tamil Nadu, Department of Finance (Pension), Secretariat,
2. The Principal Secretary/Commissioner of Treasuries Accounts, Integrated Office Complex for Accounts Department, Nandanam, Anna Salai, Chennai - 600 003.
3. The Director of Pension, DMS Campus, 3rd Block, 2nd Floor, 259, Anna Salai,
4. The Director of Medical and Rural Health Services/ Member Secretary - SLEC for NH & S, DMS Compound, Chennai - 600 005.
5. The District Collector/Chairman Health Fund Scheme, Tiruvarur District.
6. The District Treasury Officer, Tiruvarur.
7. The Divisional Manager, United India Insurance Company Limited,
8. Copy to The Registrar (Judicial), Madras High Court, Chennai - 600 104.
W.P. No. 23845 of 2018 SR(CO) CT 30/05/2022