A.Vijaya Kumar v. The Director,
IN THE HIGH COURT OF JUDICATURE AT MADRAS
DATED : 25.04.2022
CORAM
THE HON'BLE MR. JUSTICE P.D. AUDIKESAVALU W.P. NO. 28523 OF 2017 A.Vijayakumar ... Petitioner -vs1. The Director, Treasuries and Accounts Department, Chennai - 600 015.
2. The District Collector, Thiruvannamalai District, Thiruvannamalai.
3. The Branch Manager, Tamil Nadu State Transport Corporation, Thiruvannamalai - 606 606.
4. United India Insurance Company, Regional Office, No. 134, 4th Floor Greams Road, Chennai - 600 006.
... Respondents Prayer:- Writ Petitions filed under Article 226 of the Constitution of India, 1950, praying to issue a Writ of Mandamus, directing the Respondents to consider the Petitioner's representation dated 03.07.2017 and 18.07.2017 and subsequently direct the Respondents to claim for reimbursement of medical expenditure a sum of Rs. 5,45,000/- for a treatment undergone. For Petitioner : Mr. V.Thiyagarajan For Respondents: Mrs. C.Sangamithirai, Special Government Pleader (for R1 & R2)
Mr. G.Saravanakumar, Standing Counsel (for R3) Mr. N.Venkatraman for M/s. Nageswaran & Narichania (for R4)
O R D E R
Heard Mr. V.Thiyagarajan, Learned Counsel for the Petitioner, Mrs. C.Sangamithirai, Learned Special Government Pleader appearing for the First and Second Respondents, Mr. G.Saravanakumar, Learned Standing Counsel appearing for the Third Respondent and Mr. N.Venkatraman, Learned Counsel for the Fourth Respondent and perused the materials placed on record, apart from the pleadings of the parties.
2.
The Petitioner, who is working as a driver in the Transport Corporation of the Third Respondent, has availed the benefits of the New Health Insurance Scheme, 2016, of the Government of Tamil Nadu in G.O. Ms. No. 202, Finance (Salaries) Department dated 30.06.2016 by making periodical contributions towards insurance premia from his salary. It is the case of the Petitioner that he had suffered injuries in an accident that had taken place on 08.11.2016 for which he was admitted at Trauma & Orthopaedic Speciality Hospital, Kilpauk, Chennai for treatment and surgery and he had incurred medical expenses of Rs. 5,45,000/- in that regard. Since there was no response from the Fourth Respondent, which is the Insurance Company to grant the benefits under the New Health Insurance Scheme, 2016, for the claim made by the Petitioner for reimbursement of the medical expenses of Rs. 5,45,000/- despite his representations dated 03.07.2017 and 18.07.2017 made to the Respondents in that regard, he has filed this Writ Petition.
3.
The First Respondent has resisted the Writ Petition by filing Counter-Affidavit dated 03.07.2018 stating that the hospital in which the Petitioner had underwent treatment and surgery is not approved under the Scheme. At this juncture, it would be necessary to point out that clause 5(b) of Annexure-I relating to implementation procedures for the New Health Insurance Scheme, 2016 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."
This would obviously mean that the refusal of the Respondents to reimburse the medical expenses incurred by the Petitioner under the New health Insurance Scheme, 2016, is unjustified and cannot be accepted 4.
In such circumstances, this Court without expressing any view on the correctness or entitlement of the claim made by the Petitioner, passes the following order:- (i) it shall be incumbent upon the concerned authorities of the Fourth 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 his 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, he is not precluded from working out his 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 //True Copy// Sub Assistant Registrar vjt To
1. The Director, Treasuries and Accounts Department, Chennai - 600 015.
2. The District Collector, Thiruvannamalai District, Thiruvannamalai.
3. The Branch Manager, Tamil Nadu State Transport Corporation, Thiruvannamalai - 606 606.
4. United India Insurance Company, Regional Office, No. 134, 4th Floor Greams Road, Chennai - 600 006.
Copy to The Registrar (Judicial), Madras High Court, Chennai - 600 104.
+1cc to G.Saravanakumar, Advocate, S.R.No.28516 +1cc to M/s. Nageswaran & Narichania, Advocate, S.R.No.28986 +1cc to Mr.V.Thiyagarajan, Advocate, S.R.No.28730 W.P. No. 28523 of 2017 RP(CO) PM/23/05/2022