Karthihai Balan.S v. The Senior Divisional Manager
BEFORE THE MADURAI BENCH OF MADRAS HIGH COURT DATED : 21.03.2022
CORAM
THE HONOURABLE MR.JUSTICE S.M.SUBRAMANIAM S.Karthihai Balan ... Petitioner -vs1.The Senior Divisional Manager, United India Insurance Company Limited, Divisional Office, Vth Floor, P.L.A. Rathna Towers, 212, Anna Salai, Chennai-600 006.
2.The Chairman Cum Managing Director, Tamil Nadu Generation and Distribution Corporation Limited (TANGEDCO), NPKRR Maligai, 144, Anna Salai, Chennai-600 002.
3.The District Collector, Virudhunagar District, Virudhunagar.
4.The Joint Director of Medical and Rural Health Services and Family Welfare, Ramamoorthi Road, Opposite to Government Hospital, Virudhunagar, Virudhunagar District.
... Respondents Prayer:- Petition filed under Article 226 of the Constitution of India praying for issuance of Writ of Certiorarified Mandamus to call for the records of the 1st respondent in his proceedings dated 09.12.2021 and quash the same and consequently direct the respondents herein to reimburse the amount of Rs.3,85,022/- with interest for the treatment taken by the petitioner and his wife within time limit as stipulated by this Court. For Petitioner :
Mr.AL.Kannan for Mr.K.Hemakarthikeyan For R1 :
Mr.A.Shajahan For R2 :
Mr.S.Arivalagan, Standing Counsel For RR3 & 4 :
Mr.N.Satheesh Kumar, Additional Government Pleader 1/3
O R D E R
The order of rejection dated 09.12.2021, rejecting the claim of the writ petitioner for medical reimbursement in respect of the treatment taken for COVID-19 is under challenge in the present writ petition.
2.The petitioner is a pensioner of TANGEDCO. He is a member of the Health Insurance Scheme and in respect of COVID-19 cases, a separate order has been passed restricting the claim in respect of the treatment provided for critical cases.
3.In the present case, the application submitted by the writ petitioner for reimbursement was processed by the Service Provider and the treatment taken is non-critical in nature and more so in non-network hospital. Therefore, the United India Insurance Company rejected the claim relying on the terms and conditions stipulated in G.O.Ms.No.280, Finance (Salaries) Department, dated 24.06.2020. As far as the Government Order issued in G.O.Ms.No.280 is concerned, in respect of critical treatment, medical reimbursement is permitted. 4.As far as non-critical treatment is concerned, only cashless service is provided and in respect of such cases, the infected person has to get treatment in the empanelled hospital by adopting the cashless procedures.
In the present case, the petitioner has taken treatment in a non-network hospital and further more, the treatment taken was not considered as critical in nature. In this regard, the learned Additional Government Pleader relied on the discharge summary and the reimbursement application wherein it is stated that critical care ICU non-ventilated treatment has been given. Therefore, the petitioner has not taken treatment for critical and he was treated as non-critical patient and provided treatment by staying in a quarantine home. Therefore, the petitioner is not entitled for medical reimbursement under the scheme specially constituted for COVID-19 infected cases.
5.This Court is of the considered opinion that lakhs and lakhs of persons were infected due to COVID-19 pandemic. There is a possibility of submitting applications in thousands and therefore, the authorities competent are expected to be cautious in processing such applications. While processing application for medical reimbursement cases, the terms and conditions stipulated under the scheme are to be scrupulously followed. In the event of any doubt in respect of the treatment provided by private hospital, the genuinity must be verified, if necessary, by conducting an enquiry or asking the applicant to produce sufficient evidence. Thus, in order to avoid false claims, the authority competent must be vigilant and cautious for considering the application, as it involves public money. Thus, the petitioner in this case has not established that he has taken treatment for critical and further, the discharge summary and the application itself reveals that he has taken treatment for infection and the percentage of lung infection 2/3
is 5 to 10% and thus, the petitioner is not entitled for the relief. 6.This apart, the petitioner is a retired employee from TANGEDCO and not a Government pensioner drawing pension from the Treasury. Thus, the Government Order issued in G.O.Ms.No.280 is not applicable to the petitioner and as far as TANGEDCO is concerned, there is a separate scheme and the said scheme provides only cashless treatment for COVID-19 infected cases. 7.With the above observations, this Writ Petition stands dismissed. However, there shall be no order as to costs. Sd/- Assistant Registrar (T & P) // True Copy // / /2022 Sub Assistant Registrar(CS) To 1.The Chairman Cum Managing Director, Tamil Nadu Generation and Distribution Corporation Limited (TANGEDCO), NPKRR Maligai, 144, Anna Salai, Chennai-600 002.
2.The District Collector, Virudhunagar District, Virudhunagar.
3.The Joint Director of Medical and Rural Health Services and Family Welfare, Ramamoorthi Road, Opposite to Government Hospital, Virudhunagar, Virudhunagar District.
+1 CC to M/s.A.SHAJAHAN, Advocate ( SR-13395[F] dated 22/03/2022 ) +1 CC to M/s.K.HEMAKARTHIKEYAN, Advocate ( SR-13657[F] dated 23/03/2022 ) +1 CC to M/s.SPL GP ( SR-13503[F] dated 22/03/2022 ) 21.03.2022 RS(29.03.2022) 3P-7C 3/3