Kalaiarasi.A v. The Secretary To Government

BEFORE THE MADURAI BENCH OF MADRAS HIGH COURT DATED:13.04.2022

CORAM:

THE HONOURABLE MR.JUSTICE S.M.SUBRAMANIAM A.Kalaiarasi ... Petitioner Vs.

1.The Secretary to Government Finance Department, Secretariat, Chennai-600 009.

2.The Joint Director of Health Services, Tirunelveli District at Tenkasi, 3.The Treasury Officer, District Treasury, Tenkasi, 4.MD India Health Insurance TPA Private Ltd., Represented by its Regional Manager, Guna Complex, D.No.443 and 445, Anna Salai, Teynampet, Chennai-18.

5.United India Insurance Company Ltd., Represented by its Divisional Manager, Division VI, B L A, Rathina Towers, 2nd Floor, 212, Annasalai, Chennai-6.

... Respondents (R5 impleaded vide order dated 13.04.2022 in W.M.P(MD)No.5202 of 2022) PRAYER: Writ Petition under Article 226 of the Constitution of India, to issue a Writ of Certiorarified Mandamus, to call for the records relating to the proceedings impugned order in Na.Ka.No.5917/K5 1/2018 dated 05.02.2021 of the 2nd respondent herein and quash the same and consequently direct the respondents to reimburse the medical expenses of Rs.2,02,049/- to the petitioner with adequate interest.

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For Petitioner : Mr.T.Pon Ramkumar For R1 to R3 : Mr.N.Satheesh Kumar Additional Government Pleader For R4 : Mr.A.Shajahan

ORDER

The order of rejection rejecting the medical reimbursement claim of the writ petitioner by the second respondent is under challenge in the present writ petition.

2.The petitioner is working as a Headmaster in the Education Department. The petitioner is the member of the New Health Insurance Scheme and she is eligible for cashless treatment including the family members. The husband of the writ petitioner is a diabetic and suffering from kidney related ailments. The husband of the writ petitioner admitted in the hospital and underwent operation. Thus, the petitioner filed an application seeking medical reimbursement claim.

3.The claim was recommended by the District Level Empowered Committee. The learned Additional Government Pleader appearing for the respondents 1 to 3 also confirmed that the District Level Empowered Committee considered the claim and recommended for settlement of eligible medical reimbursement claim. However, the Insurance Company has taken a different stand and rejected the claim of the writ petitioner on the ground that the petitioner is not eligible.

4.The learned counsel appearing for the Insurance Company made a submission that the emergency circumstances were not established by the writ petitioner.

5.This Court is of the considered opinion that once the said emergency circumstances were accepted by the District Level Empowered Committee, the Insurance Company cannot sit on appeal and take a independent decision, as the representative of the Insurance Company is also a member in the District Level Empowered Committee. If at all any objection, the Insurance Company ought to have raised before the Committee itself. Once the District Level Empowered Committee recommended the case wherein the Insurance Company representative is also a member, thereafter, if they are aggrieved, then they have to prefer an appeal before the State Level Empowered Committee. However, the Insurance Company cannot sit on appeal in respect of the recommendations of the District Level Empowered Committee. In other words, the Insurance Company cannot act as a appellate authority in respect of the recommendations made by the District Level Empowered Committee. Their remedy is before the State 2/4

Level Empowered Committee and such an appeal is to be filed only after settle the amount as per the recommendations of the District Level Empowered Committee. The medical treatment being an integral part of Article 21 of the Constitution of India, the right of medical reimbursement need not be denied on certain flimsy grounds. 6.In the present case, the District Level Empowered Committee recommended the case of the writ petitioner. Thus, the United India Insurance Company has to settle the medical reimbursement claim and if they are aggrieved from and out of the recommendations made by the District Level Empowered Committee, they are at liberty to prefer an appeal before the State Level Empowered Committee and thereafter, if necessary approach the Government for redressal of their grievances. However, the member of the Health Funds Scheme cannot be denied on such grounds, when the case was considered by the District Level Empowered Committee.

7.This being the factum, the second respondent is directed to settle the medical reimbursement claim of the writ petitioner as per the recommendations of the District Level Empowered Committee within a period of eight weeks from the date of receipt of a copy of this order. Accordingly, the impugned order passed by the second respondent in Na.Ka.No.5917/K5 1/2018 dated 05.02.2021 is quashed and the writ petition is allowed. If at all they are aggrieved, they are at liberty to approach the State Level Empowered Committee. No costs.

Sd/- Assistant Registrar (CS-II) // True Copy // / /2022 Sub Assistant Registrar(CS) Ns To 1.The Secretary to Government Finance Department, Secretariat, Chennai-600 009.

2.The Joint Director of Health Services, Tirunelveli District at Tenkasi, 3/4

3.The Treasury Officer, District Treasury, Tenkasi, +1 CC to M/s.A. SHAJAHAN, Advocate ( SR-18746[F] dated 13/04/2022 ) +1 CC to M/s.SPL.GP. ( SR-19182[F] dated 18/04/2022 ) +1 CC to M/s.T. PON RAMKUMAR, Advocate ( SR-19081[F] dated 18/04/2022 ) 13.04.2022 RK(04/05/2022) 4P 7C 4/4