P.Balasaravanan v. The District Collector
IN THE HIGH COURT OF JUDICATURE AT MADRAS
DATED : 07.11.2023 CORAM :
THE HON'BLE Ms. JUSTICE R.N. MANJULA and WMP.Nos.18016 of 2021 & 19134 of 2022 P.Balasaravanan ... Petitioner
Versus
1.The District Collector, District Collectorate, Nagapattinam District - 611 003.
2.United India Insurance Co.Ltd., Rep.by its Divisional Manager, PLA Rathna Tower, 5th Floor, 212, Anna Salai, Chennai - 600 006.
3.The District Level Empowered Committee, Rep. by the District Collector, Nagapattinam District.
... Respondents PRAYER: Writ Petition filed under Article 226 of the Constitution of India, praying for issuance of Writ of Certiorarified Mandamus, to call for the records from the file of the second respondent pertaining to the impugned order dated 19.01.2018 rejecting the medical reimbursement of the writ petitioner and quash the same and consequently direct the respondents to reimburse the medical claim of the petitioner. For Petitioner :
Mr. R. Rajasekar For Respondents :
Mr. T. Arunkumar,AGP (for R1 & R3) :
Mr. P. Sankaranarayanan, (for R2) Page No.1 /14
O R D E R
This Writ Petition has been filed seeking issuance of Writ of Certiorarified Mandamus to call for the records from the file of the second respondent pertaining to the impugned order dated 19.01.2018 rejecting the medical reimbursement of the writ petitioner and quash the same and consequently direct the respondents to reimburse the medical claim of the petitioner.
2.Heard Mr. R. Rajasekar, learned counsel for the petitioner and Mr. T. Arunkumar, learned Additional Government Pleader appearing for the first and third respondents as well as Mr. P. Sankaranarayanan, learned counsel appearing on behalf of the second respondent. 3.The case of the petitioner is that the petitioner initially joined in the Revenue Department Nagapattinam District as a Junior Assistant in the year 2003. Presently, he is working as a Head Clerk at the Sub-Registrar Office, Chembanar Kovil, Mayiladuthurai District. In the year 2014, the petitioner had undergone a check-up at KKR ENT Hospital and Research Institute in order to determine the reason behind a sudden change in his voice. Page No.2 /14
Thereafter, he came to know that he was diagnosed with Carcinoma Larynx T1 NO MO, a malignant tumor discovered throughout the full length of his right vocal chord. Due to the emergent need of treatment of radiation therapy for his laryngeal cancer, he was admitted to the Kauvery HCG Cancer Centre in Chennai, where the petitioner was offered more advanced treatment by using the 3D CR7 technology, for this purpose, the petitioner has spent huge sums of money. Being an employee in a Government office, paying monthly premiums directly from his salary for the State Health Insurance Scheme, 2012, he sought reimbursement for the amount incurred for the medical expenses before the second respondent.
The second respondent summarily rejected the request of the petitioner by stating that the treatment which was undergone by the petitioner is a non-network hospital and the same has not been covered under the scheme. The petitioner approached the respondents through proper channel and made a representation dated 16.11.2016 to reimburse the medical expenses incurred by him. Till date, the petitioner's request was not considered by the respondents. Hence, the petitioner has come up with the present Writ Petition.
4.The learned counsel for the petitioner submitted that the claim of Page No.3 /14
the petitioner should not have been denied for the simple reason that the petitioner took the treatment outside the networking hospital. Further, the learned counsel for the petitioner relied on the judgment of the Division Bench of this Court in W.A(MD).No.1382 of 2017, dated 09.11.2017, wherein it is held as follows:- "35.It is to be pertinently pointed out that -Right to Health- is an integral part of the Right to Life and the Government is under a Constitutional obligation to provide health welfare facilities. If a Government servant underwent a requisite treatment for his ailment and if necessary proof is produced, then it is the primordial duty of the State Government to bear the expenses incurred thereto and reimburse the same.
Just because the Government servant had underwent the treatment at an unapproved Hospital, the expenses incurred thereto cannot be denied by the State Government notwithstanding the fact that the Government servant is a member of the scheme introduced by the Government. Also that the individual Government servant/patient or his family members is/are the proper persons to take a final decision as to where the treatment in question is to be provided, as opined by this Court.
36. It cannot be brushed aside that the State Government is to satisfy the Constitutional obligation to bear/refund the expenses incurred by a Government servant while in service or after retirement from service, of course, based on the policy of the Government. In emergency cases, the treatment that is required will be immediate/forthwith and if one has to comply with the procedure, ultimately, -waiting- in this regard may prove disastrous and fatal.
37.It is to be aptly pointed out that a human being is to take care of himself and in this regard, the Page No.4 /14
individual concerned is the best Judge suited to take a final call/decision. In reality, the self preservation of one-s life is enjoined under Article 21 of the Constitution of India, as an inviolable right, in the considered opinion of this Court.
38.No doubt, a patient as a lay human being cannot pick and choose the method/mode of surgery. It is for the Doctors/Medical experts to determine and suggest a right course of action as to what/which kind of surgery/treatment is suitable, of course, taking into consideration the nature of the ailment and the status/condition of the concerned patient.
39.Although financial resources are required for providing medical facilities to the needy, ultimately, the State Government has the constitutional obligation to provide enough medical services to the public. On account of financial constraints, the Constitutional obligation to provide medical services/facilities to the people cannot be avoided."
5.However, the learned Additional Government Pleader appearing for the first and third respondent and the learned counsel appearing for the second respondent has submitted that the petitioner has taken treatment in the hospital which does not fall under the accredited list of hospitals. He can always make the claim for reimbursement under Tamil Nadu Medical attendance Rules.
6.The learned counsel appearing for the second respondent has also Page No.5 /14
relied on the judgment of this Court held in Star Health and Allied Insurance Co.Ltd Vs. A.Chokkar and Ors., dated 26.02.2010, in support of rejecting the claim of the petitioner. For the sake of convenience, the relevant portion of the said judgment is extracted hereunder:- "24. In the present case, what we have to decide is whether the State is bound to reimburse the claim, whether the insurance company is bound to indemnify the beneficiary for the claim made by him.
As held in the decisions referred to above, the insurance company is strictly bound to strictly by the terms of contract and cannot be asked to settle a claim which does not fall within the terms of the contract and therefore the claim made by the beneficiaries in respect of treatments that were taken in a non-network hospital or for reimbursement of the claim made the insurance company is not liable. For this reason, the insurance company had made it clear that only if the beneficiary took treatment in a network hospital they would settle the claim and more importantly the facility itself is a cashless facility. The insurance company cannot pay cash and if we issue direction to the insurance company to reimburse the claim, we would be virtually re-writing the contract which we are not entitled to.
25. The Tamil Nadu Medical Attendance Rules ("the Rules" in short) clearly lay down the rules regarding dependents and who is entitled to medical concessions under the Rules. It also defines who is a well to do person. The Rules lay down the manner in which claims can be made. According to the learned Advocate General, these Rules are still in force and therefore when it is a claim not covered by the present Insurance Scheme, the Government Servants have the right to make their claims under the Rules. Therefore, as regards Category-A, where treatment has been Page No.6 /14
taken in a non-network hospital, the insurance company cannot be asked to cover the expenses, since the scheme itself makes the network hospitals as intrinsic. However, the petitioners/claimants were also not no remediless and that is why we will issue directions to the claimants to make an application under the Rules or go before the Redressal Committee.
26. Before taking up the individual cases, we must record that there are certain situations which may arise and in fact which have arisen, for which the Government must issue clear guidelines. This the Government has to do, since it has made the Scheme obligatory for everyone and there is automatic deduction of premium to an extent of Rs. 25/- per month. The directions are as follows:
(i) The State shall make it clear that if for some reason, which is satisfactory, the claimant is unable to take treatment in a network hospital but has been advised or had to go to a non-network hospital, then his claim would be considered under the Rules. (ii) If the claimant has been advised some procedure which is not covered by the Scheme, there again, it must be made clear that he can apply under the Rules.
(iii) To safeguard duplication of payments, the Government can make sure and when they apply under the Rules, that the claimant himself certifies that he has not made claim under the Scheme or viceversa. (iv) The State shall inform every network hospital that if it receives complaints from claimants that money was demanded for admission or for treatment, then that hospital will be removed from the network. This warning is necessary, since, at times of crisis, the claimants will not be in a position to argue with the hospital that this is a "cashless" Scheme. We Page No.7 /14
are aware that there is an officer of the Star Health Insurance Company at every network hospital to ensure that hospitals adhere to the terms of the Scheme but, yet, it is better to make this position clear to the hospitals, since one of the questions that has arisen before us is that whether the claimants will be entitled to reimbursement if, by mistake, they pay cash.
27. Now coming to the individual cases, in all the case, whatever may be the category, the petitioners/claimants have paid the amount. The scheme is a 'cashless' one and, therefore, it is only the Government which have to make the payment under the Rules. The Redressal Committee is empowered to decide the following circumstances, namely, any difficulty in availing treatment, non-availability of facilities, bogus availment of treatment for ineligible individuals, etc. It is really not clear what other complaints would be covered under the umbrella "etc.". But, however, since the Paragraph relating to 'Redressal of Grievances' starts with the sentence "The Hospitals shall extend treatment to the beneficiaries under the Scheme on a cashless basis", it is evident that the Committee cannot direct payment of cash.
28. Therefore, if the claimants have made payments whether for a procedure not covered or whether at a non-network hospital or they have paid when they have been treated for a covered procedure in a network hospital, their only remedy is to approach the Government under the Rules. If, however, before they take treatment they are informed that a particular procedure is not covered, then at that stage, they may approach the Redressal Committee where the medical expert can decide whether that procedure is covered or not. The Redressal Committee may also go into the complaints regarding nonavailability of facility at a network hospital, which may be available in favour of the claimant when he Page No.8 /14
applies under the Rules. Otherwise, we do not think that the Redressal Committee can do much in any one of these cases, since all the petitioners/claimants before us would have made payments. But, if there is a petitioner who has not settled the claim and has come before us, then, in the event, that it is for a procedure that is not covered, he may approach the Redressal Committee. In view of the fact that there are the above lacunae in the Scheme, the Government shall not deny any claim validly made under the Rules only because the claimant is a member of the Scheme.
29. With the above directions and observations, all the writ petitions are disposed of. W.A.No. 480/2009 is allowed and the order of the learned Single Judge is set aside. No order as to costs. Connected M.Ps. are closed."
7.The Tamil Nadu Government sponsored the New Health Insurance Scheme for Government servants only in the year 2008. The erstwhile scheme was called as the Employees Health Fund Scheme and it was in force from 1991 to 1995. Under this, the State Government provided free medical treatment in Government Medical Institutions to Government servants and pensioners by having ties with Private Insurance Companies. The petitioner is also a member of such a scheme and he has been making contributions, hence, the said fact was not denied. The only reason for denying the reimbursement claim of the petitioner is that the hospital in which the petitioner had taken treatment is not under the accredited list of Page No.9 /14
hospitals.
8.The essential facts which has to be appreciated is whether the treatment alleged to have been undergone by the Government servant or his family members who are eligible for reimbursement have really taken the treatment or whether the medical reimbursement is allowed for the alleged treatment. The list of accredited hospitals are to the benefit of the Government servants and it is a first line information to them about the best hospitals where they can have a better access, facility and treatment. But this act should be made more cumbersome to deny the benefit even when the beneficiary chooses to take treatment at a hospital of his own choice, but for the disease or the type of the treatment for which reimbursement is permitted.
9.In the case at hand, the learned counsel for the petitioner submitted that the petitioner needed an emergency treatment and he had taken immediate treatment at Kauvery HCG Cancer Centre, Hospital in Chennai. If the opted hospital does not find place in the accredited list, that can be viewed at the worst as an irregularity.
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10.The object of the scheme is to ensure availability of better medical facility and service available to the employees/pensioners covered through any Insurance Schemes sponsored by the government or directly by the Government itself. It is advisable for a beneficiary to take treatment in the accredited hospitals, to avail future compensation. However, the rule cannot be viewed so narrowly for denying the reimbursement for the treatment taken outside the purview of the listed hospitals. 11.It is always open to the Government to refer the medical papers and the beneficiary to an Expert Committee, if it is so felt by Government to assess the genuineness and necessity of the treatment taken by the Government servant on a case to case basis and give proper recommendation to the second respondent for reimbursement. 12.
So in my considered view, the Government has to reconsider the claim made by the petitioner in the light of the above observation and also in the light of the observations made by the learned Division Bench of this Court in W.A (MD) No.1382 of 2017 dated 09.11.2017. Page No.
13.It is learnt that at the time of filing the application for reimbursement the District Collector, Nagapattinam had the jurisdiction and after bifurcation, it fell under Mayiladuthurai District. Therefore, the first and third respondents are directed to forward the claim application to the Mayiladuthurai District.
14.In the result, this Writ Petition is allowed and the impugned order passed by the second respondent / United India Insurance Company Ltd., vide letter dated 19.01.2018 is set aside and respondents 1 and 3 are directed to forward the claim of the petitioner to the District Collector, Mayiladuthurai District, within two weeks who in turn shall consider the claim of the petitioner by taking into consideration of the object of the Scheme and give appropriate recommendation within a period of two weeks to the second respondent and the second respondent on receipt of the same shall pass necessary orders for reimbursement of the medical expenses, within a period of two weeks from the date of order of receipt of the recommendation. Consequently, the connected miscellaneous petitions are closed. No costs.
07.11.2023 Page No.12 /14
Index : Yes/No Speaking / Non-Speaking order klt To:
1.The District Collector, District Collectorate, Nagapattinam District - 611 003.
2.The Divisional Manager, United India Insurance Co.Ltd., PLA Rathna Tower, 5th Floor, 212, Anna Salai, Chennai - 600 006.
3.The District Collector, District Level Empowered Committee, Nagapattinam District.
Page No.13 /14
R.N. MANJULA, J.
klt and WMP.Nos.18016 of 2021 & 19134 of 2022 07.11.2023 Page No.14 /14