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Madras High CourtWP(MD)/18144/2021allowed

Jabamalai Mary.A v. The State Of Tamil Nadu

2022-02-28Honourable Mr Justice S.M. Subramaniam4 pages

BEFORE THE MADURAI BENCH OF MADRAS HIGH COURT DATED : 28.02.2022

CORAM

THE HONOURABLE MR.JUSTICE S.M.SUBRAMANIAM and W.M.P(MD).Nos.14992 & 14993 of 2021 A.Jabamalai Mary ... Petitioner Vs.

1.The State of Tamil Nadu, Rep.by its Secretary, The Department of Finance (Salaries), Fort St.George, Chennai-600 009.

2.The District Collector, The District Level Empowered Committee, District Collector's Officer, Dindigul, Dindigul District-624 004.

3.The Chairman, Medical Board, Government Head Quarters Hospital, Dindigul District-624 001.

4.The Block Educational Officer, Sanarpatty Union, Dindigul-624 304, Dindigul District.

5.The Divisional Manager, United India Insurance Company Limited, Divisional Office VI, No.212, Pala Rathna Towers, 5th floor, Anna Salai, Chennai-600 005. ... Respondents Petition filed under Article 226 of the Constitution of India praying for issuance of Writ of Certiorarified Mandamus, calling for the records relating to the impugned proceedings issued by the 5th respondent Insurance Company in REF:010600/P042/2020-21 dated 19.01.2021 and the consequential proceedings issued by the 2nd respondent District Collector in Pa.Mu.No.26022/2019/F2 dated 08.02.2021, quash the same and further direct the respondents herein to reimburse forthwith the Medical Expenses to the tune of Rs.3,21,235/- to the petitioner towards the treatment undergone by her son for Chromic Clacific Pancreatitis at Lakeshore Hospital, Nettoor, Kochi, Kerala State with interest. 1/4

For Petitioner : Mr.P.Muthuvel for M/s.Isaac Chambers For Respondents : Mr.N.Satheesh Kumar Additional Government Pleader for RR1 to 4 Mr.A.Shajahan for R5 ******

O R D E R

The order passed by the fifth respondent/United India Insurance Company Limited rejecting the claim of the writ petitioner for medical reimbursement is under challenge in the present Writ Petition.

2. The petitioner, admittedly, is the member of the New Health Insurance Scheme. Therefore, she is eligible for medical reimbursement. The petitioner's son underwent treatment in a nonnetwork hospital and further, as per the Government Order, the petitioner had not established the emergency care. Therefore, the Insurance Company has rejected the claim of the petitioner. However, the District Level Empowered Committee, in its proceedings dated 27.11.2019, categorically recommended the case of the petitioner by stating that it is found genuine, and further, forwarded the recommendation to the United India Insurance Company to pay medical reimbursement claim of the writ petitioner, as per the Scheme.

3. The learned counsel appearing for the Insurance Company strenuously contended that the decision of the District Level Empowered Committee is erroneous and not in accordance with the New Health Insurance Policy. Therefore, the impugned order is in consonance with the Government Order. Under these circumstances, the decision of the District Level Empowered Committee cannot be taken into consideration.

4. It is made clear that the District Level Empowered Committee is the Competent Committee to decide the issues regarding the genunity of the claim. Further, the Representative of the Insurance Company is also the Official member of the District Level Empowered Committee, as per the Policy. While so, if at all any objection, the Insurance Company has to raise such objection before the Committee itself. Once the Committee recommended the case as genuine, the Insurance Company cannot turn around and decline settlement of the medical reimbursement claim and take an independent decision overlooking the decision taken by the District Level Empowered Committee. The policy does not contemplate or provide any such power to the Insurance Company, in view of the fact that the Authorised Representative is the Official member of the Committee. Therefore, the Insurance Company cannot take a decision contrary to the decision taken by the District Level Empowered 2/4

Committee. However, there is an option for the Insurance Company to approach the State Level Empowered Committee as the Scheme contemplates an appeal as against the order passed by the District Level Empowered Committee. Thus, the Insurance Company is at liberty to approach the State Level Empowered Committee for redressal of their grievances. Beyond such remedy, the Insurance Company is at liberty to approach the Government in terms of the contract, for reimbursement of money paid by the Insurance Company. Under these circumstances, if the Insurance Company is able to establish that they have settled the claim over and above the Scheme, then as per the terms and conditions of the Contract between the Insurance Company and the Government, the Government has to refund the amount to the Insurance Company.

However, those disputes are to be resolved between the Insurance Company and the Government. As far as the New Health Insurance Scheme is concerned, once the District Level Empowered Committee recommended the case, the Insurance Company has to pay the money or file an appeal or approach the Government, if any grievance exists.

5. More precisely, the recommendation of the District Level Empowered Committee is binding on the Insurance Company, as per the Scheme and the Insurance Company cannot take an independent or unilateral decision overlooking the decision taken by the District Level Empowered Committee, wherein the Representative of the Insurance Company is also an official member.

6. This being the factum, in the present case, the son of the petitioner underwent treatment in a non-network hospital. However, the treatment underwent is in the list of treatments provided in the Government Policy. Thus, the order impugned passed by the fifth respondent in proceedings No.REF:010600/P042/2020-21 dated 19.01.2021 and the consequential proceedings issued by the second respondent in proceedings No.Pa.Mu.No.26022/2019/F2 dated 08.02.2021 are quashed. The fifth respondent/United India Insurance Company Limited is directed to settle the medical reimbursement claim of the writ petitioner, as per her eligibility within a period of eight weeks from the date of receipt of a copy of this order.

6. Accordingly, the Writ Petition stands allowed. No costs. Consequently, connected miscellaneous petitions are closed. Sd/- Assistant Registrar (CSIII) // True Copy // / /2022 Sub Assistant Registrar(CS) 3/4

To 1.The Secretary, The Department of Finance (Salaries), Fort St.George, Chennai-600 009.

2.The District Collector, The District Level Empowered Committee, District Collector's Officer, Dindigul, Dindigul District-624 004.

3.The Chairman, Medical Board, Government Head Quarters Hospital, Dindigul District-624 001.

4.The Block Educational Officer, Sanarpatty Union, Dindigul-624 304, Dindigul District.

5.The Divisional Manager, United India Insurance Company Limited, Divisional Office VI, No.212, Pala Rathna Towers, 5th floor, Anna Salai, Chennai-600 005.

+1 CC to M/s.SPL GP ( SR-9197[F] dated 01/03/2022 ) +1 CC to M/s.ISAAC CHAMBERS, Advocate ( SR-9302[F] dated 01/03/2022 ) +1 CC to M/s.A.SHAJAHAN, Advocate ( SR-9364[F] dated 01/03/2022 ) ORDER MADE IN 28.02.2022 KVL/12.03.2022/4P/9C 4/4