Krishnaveni. R v. The Government Of Tamil Nadu
BEFORE THE MADURAI BENCH OF MADRAS HIGH COURT DATED : 08.07.2024
CORAM
THE HONOURABLE MS.JUSTICE R.N.MANJULA W.P.(MD).No.15019 of 2024 R.Krishnaveni ... Petitioner Vs
1. The Government of Tamil Nadu, Rep. by its Secretary, Health Department, Fort St. George, Chennai - 600 009.
2. The Regional Manager, United India Insurance Co., Ltd., Ground Floor, Silingi Building, 134, Greams Road, Chennai - 600 006.
... Respondents Prayer : Writ Petition filed under Article 226 of the Constitution of India, praying this Court to issue a Writ of Mandamus, directing the Respondents to 1/9
grant medical reimbursement for a sum of Rs. 99,799/- to the petitioner by considering the petitioner representations, dated 01.09.2022 and 03.08.2023 and make payment along with interest @ 12 percent within the time stipulated by this Court.
For Petitioner : G.Sailendrababu for M/s. Isaac Chambers For Respondents : Mr.J.Ashok (R1) Additional Government Pleader Mr.A.Shajahan (R2) Standing Counsel
ORDER
Heard G.Sailendrababu, learned counsel for the petitioner, Mr.J.Ashok, learned Additional Government Pleader, for the first respondent and Mr.A.Shajahan, learned Standing Counsel for the second respondent.
2. This Writ Petition has been filed for a direction to the Respondents to grant medical reimbursement for a sum of Rs.99,799/- to the petitioner by considering the petitioner's representations, dated 01.09.2022 and 03.08.2023 and make payment along with interest. 2/9
3. By consent of both parties, this Writ Petition is taken up for final disposal at the stage of admission itself.
4. The petitioner is a beneficiary of New Health Insurance Scheme, 2021. The petitioner has applied for medical reimbursement for a sum of Rs. 99,799/- in view of the medical treatment taken by her husband. Since the petitioner has been disbursed with a partial amount of Rs.16,380/-, towards reimbursement, she sent a representation to the second respondent on 01.09.2022 and the same is pending without any orders. Hence, this petition has been filed.
5. It appears that the credit for Rs.16,380/- has also been given to the petitioner without any proceedings or without citing any reasons by the respondents. The persons, who are beneficiaries of New Health Insurance Scheme, when applied for whole of medical expenses, and when it is admitted partially, the individuals are entitled to know the reason for which the rest of their claim has been withdrawn or rejected. In none of the cases of medical 3/9
reimbursement, such a procedure is followed neither by the Government authorities nor by the Insurance Companies.
6. When the Government servants get allured to join in the Scheme with high hopes that their medical expenses will be covered under the Scheme. But they end in disappointment, when actually go for medical reimbursement. After spending hefty sum in private Hospitals, which are considered as Network Hospitals under the Scheme, the beneficiaries are given with very meager sum as reimbursement. In all cases, the beneficiaries are kept at dark about the calculation as to the permissible limit of reimbursement. This has been made at some level by someone and the amount so arrived by someone is being credited in the account of the beneficiaries.
7. Even though the Scheme is a comprehensive one, none of the beneficiary is allowed to know about the nuances and the limits of their entitlement under the Scheme. In several other cases, even the orders passed by the District Level Empowered Committee is not speaking and not in consultation made between the four members of the Committee. It appears that 4/9
the Scheme serves the best interest of Private Hospitals, which have been included as Network Hospitals under the Scheme.
8. Before the advert to this Scheme, the Government servants are used to rely on the benefits under Tamil Nadu Medical Attendance Rules for the treatment/line of management given to any specific disease covered under the said Rules. For other types of treatment and which they do not have the wherewithal to spend, they would choose Government Hospitals and get the treatment done. When the Insurance Scheme was first floated by having the partnership with Star Health Insurance, the beneficiaries found that their Scheme covered the sizable portion of the money spent on medical expenses. It appears the Scheme has gradually lost its purpose and the Government Servants are made to run from pillar to post without even knowing their entitlement and how they could get the maximum benefit for the treatment taken in the private Hospitals.
Even though it is presumed that the beneficiaries join the Scheme by being informed fully, it is not so in reality, no order even is passed elaborating the reasons for rejection. In the absence of any order, it is very difficult to express the grief by challenging the same before different level of appeal remedy available in the Scheme.
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9. In fact, the Insurance Company engages the services of some third party agents to interact with the claimants and the claimants do not even know where these agents are seated. Because all that they do is only through mail communication. No broader consultation is takes place with the representatives of the Government Servants before any decision is taken to enrol them under the Scheme. The Insurance companies get the benefits because they easily get the whole lots of Government servants of the State without any efforts but joined by designing a standard form of Contract. The other end beneficiaries are the accredited private Hospitals, who are considered as network Hospitals, which attract lot of Government servants, who believe to have been protected under the Scheme.
If the Insurance Scheme also covers the same disease/treatment covered under the Rules with same limit of coverage, it is unnecessary to have such a Scheme in the first place. The claimants do not know how the bargain is done on their behalf with the insurance companies or the Hospitals and what are the concerns addressed while finalising the Scheme with such parties.
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10. The case in hand is also one such case, where the petitioner did not know about the reason for withholding the rest of her claim for medical reimbursement.
11. In view of the above reasons, the respondents are directed to consider the claim of the petitioner strictly in spirit of the Scheme and pass a speaking order by informing the petitioner about the appeal remedy as well within a period of two weeks from the date of receipt of copy of this order.
12. With the above direction, this writ petition is disposed of. No costs.
08.07.2024 NCC : Yes / No Index : Yes / No Internet : Yes PNM 7/9
To
1. The Secretary, Government of Tamil Nadu, Health Department, Fort St. George, Chennai - 600 009.
2. The Regional Manager, United India Insurance Co., Ltd., Ground Floor, Silingi Building, 134, Greams Road, Chennai - 600 006.
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R.N.MANJULA, J.
PNM ORDER IN W.P.(MD).No.15019 of 2024 08.07.2024 9/9