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Madras High CourtWP/27674/2017dismissed

N.Palani, S/O. Natesan v. The United India Insurance Co.

2022-03-07Honourable Mr Justice V. Bharathidasan3 pages

IN THE HIGH COURT OF JUDICATURE AT MADRAS

DATED : 07.03.2022

CORAM

THE HONOURABLE MR.JUSTICE V.BHARATHIDASAN W.P.NO.27674 OF 2017 N.Palani S/o.Natesan ... Petitioner

Versus

1. The United India Insurance Co. Ltd., Rep. by the Regional Manager, No.24, Whites Road, Chennai - 600 014.

2. The office of the Insurance Ombudsman (Tamil Nadu and Puducherry), New No.453, Old No.312, 4th Floor, Anna Salai, Teynampet, Chennai - 600 018.

... Respondents PRAYER:- Writ Petition filed under Article 226 of the Constitution of India, praying for the issuance of a Writ of Mandamus, directing the 1st respondent to pay the Medical expenditure of Rs.2,80,760/- (Rupees two lakhs eighty thousand seven hundred and sixty only) to the petitioner in his Medical Policy No. 010600/48/14/41/00000030.

For Petitioner :

Mr.C.S.Vijayakumar For Respondents :

Mr.P.Sankaranarayanan For R1 No appearance For R2

O R D E R

This Writ Petition has been filed seeking a direction directing the 1st respondent to pay medical expenditure to the tune of Rs.2,80,760/- to the petitioner.

2. According to the petitioner, he was a retired school teacher and the Pensioner, and covered under the New Health Insurance Scheme, 2014 floated by the State Government. In the year 2017, he has suffered cardiac disease and admitted in a private hospital for implanting Cardio Verter Defibrillator, for which, he has spent medical expenditure of Rs.5,31,760/-. Accordingly, he has applied to the 1st respondent seeking to reimburse the entire medical expenditure from his medical policy, but the same was denied by the 1st respondent. Subsequently, in the family medical policy taken by his son in the Star Health and Allied Insurance Co. Ltd., he has received part payment of Rs.2,51,000/- out of Rs.5,31,760/-. In the said circumstances, the present Writ Petition has been filed seeking a direction to the 1st respondent to pay remaining medical expenditure.

3. Mr.C.S.Vijayakumar, learned counsel appearing for petitioner would submit that, it is not a private medical claim policy and the petitioner is covered under new health insurance scheme-2014 floated by the State Government for pensioners and their families in G.O.Ms.No.171, Finance Department, dated 26.06.2014. As per the said G.O., the petitioner is entitled for the treatment of cardiac arrest. However, the 1st respondent insurance company did not pay any amount. Hence, he has filed the present Writ Petition seeking a direction to the 1st respondent to pay the remaining medical expenses of Rs.2,80,760/-.

4. Mr.P.Sankaranarayanan, learned counsel appearing for 1st respondent would submit that, as per the G.O., in Annexure-2, only heart disease is covered. So far as the disease suffered by the petitioner is concerned, it is not covered under the said G.O. Hence, the petitioner is not entitled to seek for reimbursement of medical expenditure and also the 1st respondent Insurance company had passed an order rejecting the petitioner's claim by an order dated 09.08.2017. According to the 1st respondent, since the disease suffered by the petitioner is not covered under the G.O., the 1st respondent is not in a position to reimburse the medical expenditure spent by the petitioner.

5. Heard and considered rival submissions made by learned counsel appearing for both sides and perused the records.

6. On perusal of records, it could be seen that, the petitioner is covered under the New Health Insurance Scheme, 2014 floated by the State Government. According to the 1st respondent Insurance Company, the cardiac disease suffered by the petitioner did not cover under the G.O., and his request was already rejected by the 1st respondent as early as in the year 2017. Considering the above dispute, whether the petitioner is entitled to receive the medical expenditure spent for the cardiac treatment suffered by the petitioner, the disputed issue cannot be decided in the Writ Petition. If at all, the petitioner has any grievance over the issue, he can very well approach the civil court to redress his grievance. Accordingly, this Writ Petition is dismissed. No costs.

Sd/- Assistant Registrar(CS IV) //True Copy// Sub Assistant Registrar rpp To 1.

The Regional Manager, The United India Insurance Co. Ltd., No.24, Whites Road, Chennai - 600 014.

2.

The office of the Insurance Ombudsman (Tamil Nadu and Puducherry), New No.453, Old No.312, 4th Floor, Anna Salai, Teynampet, Chennai - 600 018.

+1cc to Mr.P.Sankaranarayanan, Advocate, S.R.No.15924 W.P.NO.27674 OF 2017 BP(CO) PBS/23/05/2022