Rama Subbiah v. The Director Of Pension,
IN THE HIGH COURT OF JUDICATURE AT MADRAS
DATED: 17.12.2018
CORAM:
THE HONOURABLE Dr. JUSTICE S.VIMALA W.P.No.32618 of 2018 and W.M.P.No.37821 of 2018 Rama Subbaih Rep. by his son R.Balasubramanian ... Petitioner versus
1. The Director of Pension, 259, Anna Salai, 3rd Block - 2nd Floor, DMS Campus, Teynampet, Chennai - 600 041.
2. United India Insurance Co. Ltd., Divisional Office Co. Ltd., P.L.A. Rathna Towers, 5th Floor, 212, Anna Salai, Chennai - 600 006.
3. District Collector of Tuticorin, Office of the District Collector, Tuticorin.
4. The Treasury Officer, Thoothukudi District Treasury, Thoothukudi.
... Respondents Writ Petition filed under Article 226 of the Constitution of India, praying for the issuance of writ of certiorarified mandamus, to call for the records of the 2nd respondent communicating the rejection of medical reimburse amount vide letter dated 13.08.2018, in serial No.7 to the District Collector of Tuticorin, quash the same and further direct the 2nd to pay the medical claim reimbursement of Rs.2,63,154/- as it is in compliance of G.O.No.477, dated 30.09.2009 with 9% interest from the date of remittance of amount to the hospital by the petitioner, i.e. from 11.10.2018, within the time frame that may be stipulated by this Court.
For Petitioner : Mrs.Sangeetha Rajkumar For Respondents: Mr.A.N.Thambidurai, Special Government Pleader for R1,R3 and R4 Mr.T.Ravichandran for R2
ORDER
The petitioner's father is aged about 89 years old. When his father visited to Chennai on 05.10.2017, he suddenly fell severely ill on 11.10.2018 and hence, he had to be rushed to the St. Isabel Hospital in an unconscious state and was discharged on 03.11.2017 after 24 days. On discharge, the medical bills amounted to more than Rs.5 lakhs. However, the petitioner's father was claiming the actual medical expenditure in the St. Isabel Hospital to the tune of Rs.2,63,154/- under the Tamil Nadu, New Health Insurance Scheme, 2014, Pensioners/Family Pensioners Card ID Card No.TUT/T/NHISP14/0366271.
1.1. The petitioner's father filed a petition claiming only the exact amount that was spent towards medical expenses. But, the said claim petition was rejected, saying that the Hospital, by name, St. Isabel Hospital was not covered in the network hospital that was mentioned in the policy and therefore, his claim cannot be considered in the light of G.O.Ms.No.171 dated 26.06.2017. This is the order passed by the United India Insurance Company Ltd., on 13.08.2018, which is under challenge in this writ petition.
2. The learned counsel appearing for the petitioner submitted that the refusal of reimbursement of medical expenses after the petitioner having parted with money is unjustified. It is also submitted that GO has been amended including the provision for reimbursement of medical expenses in respect of treatment taken in a non-network hospital, if the treatment is emergent.
3. The averments stated in the petition would disclose that the petitioner's father is aged 89 years and when it is stated that the petitioner's father was in hospital for breathing trouble, the implication is, the treatment is emergent. Moreover, the treatment had continued for 24 days. Therefore, the petitioner's father is entitled to get reimbursement of medical expenses in terms of amended G.O.Ms.No.222 Finance (Pension) Department dated 30.06.2018, which reads as under:
"14. Procedure to be followed by the Beneficiaries for availing Medical Assistance under this Scheme:
(1) to (3) .....
(4) In case, a Pensioner/Family Pensioner undergoes emergency treatments/surgeries not covered under this Scheme in either Network Hospital or Non-Network Hospital, no claim can be filed under the Health Insurance Scheme. However, they shall be eligible for claim to the
extent permissible under the Tamil Nadu Medical Attendance Rules and the G.O.Ms.No.1023, Health and Family Welfare Department, dated 17.06.1980. It may be noted that the Tamil Nadu Medical Attendance Rules requires that treatment in private hospitals should not be resorted to except in cases of emergencies. Clause 2(3) of the aforesaid Government Order states that in genuine cases of emergency, the claims will be restricted to the expenditure that would have been incurred had the patient taken treatment in a Government Hospital excepting diet charges. For claims under Tamil Nadu Medical Attendance Rules, the Beneficiaries may apply to the authority in the department in which the Government employee last served who is competent to process and forward pension proposal to the Accountant General, Tamil Nadu. The Head of Office shall process the claims and pay the eligible claims under the Tamil Nadu Medical Attendance Rules."
4. Under such circumstances, the second respondent is directed to consider the claim of the petitioner in the light of the amended G.O. which covers the treatment in the non-network hospital and to pass orders within a period of four weeks from the date of receipt of a copy of this order.
5. With the above direction, the writ petition is disposed of.
No costs. Consequently, connected miscellaneous petition is closed.
Sd/-- Assistant Registrar(CS ) //True Copy// Sub Assistant Registrar ogy To
1. The Director of Pension, 259, Anna Salai, 3rd Block - 2nd Floor, DMS Campus, Teynampet, Chennai - 600 041.
2. United India Insurance Co. Ltd., Divisional Office Co. Ltd., P.L.A. Rathna Towers, 5th Floor, 212, Anna Salai, Chennai - 600 006.
3. District Collector of Tuticorin, Office of the District Collector, Tuticorin.
4. The Treasury Officer, Thoothukudi District Treasury, Thoothukudi.
+1cc to Mr. P.G.Santhosh Kumar, Advocate SR.No.88476 W.P.No.32618 of 2018 A.SK(25/01/2019)