United India Insurance Co. Ltd., v. D. Babu,
BEFORE THE MADURAI BENCH OF MADRAS HIGH COURT Dated : 03.06.2025
CORAM
THE HONOURABLE MR.JUSTICE G.R.SWAMINATHAN AND THE HONOURABLE MR.JUSTICE K.RAJASEKAR & C.M.P.(MD)No.615 of 2023 United India Insurance Company Limited, No.27, Lakshmi Towers, 3rd Floor, Dr.Radhakrishnan Salai, Mylapore, Chennai-600 004.
... Appellant / Respondent No.5 Vs 1.D.Babu ... 1st Respondent / Writ Petitioner 2.The Secretary to Government, Family Welfare & Health Department, Fort.St.George, Chennai-9.
3.The Director of Pension, 259, Anna Salai, 3rd Block, 2nd Floor, DMS Campus, Teynampet, Chennai-600 006.
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4.The District Collector, Thanjavur District, Thanjavur.
5.The District Treasury Officer, Court Road, Thanjavur. ... Respondents 2 to 5 / Respondents 1 to 4 PRAYER: Writ Appeal filed under Clause 15 of Letters Patent, praying this Court to set aside the order dated 20.06.2022 made in W.P.(MD)No. 20110 of 2018 on the file of this Court.
For Appellants : Mr.A.Shajahan For Respondents : Mr.A.Kannan Additional Government Pleader for R2 to R5 : No appearance for R1
ORDER
(Order of the Court was made by G.R.SWAMINATHAN, J.) This writ appeal is directed against the order dated 20.06.2022 made in W.P.(MD)No.20110 of 2018. The said writ petition was filed by one Babu, the first respondent herein. Even though notice has been served on him, he has not chosen to enter appearance. His name is however printed in the cause list. The said Babu had taken treatment for 2/6
Pustular Psoriasis from 21.07.2016 to 27.07.2016 with one Dr.Uma Devi. According to him, he had incurred medical expenditure to the tune of Rs.16,619.57/-. He sought reimbursement from the appellant insurance company.
2. It is not in dispute that the writ petitioner is a pensioner. He is a member of the New Health Insurance Scheme, 2014. The Government of Tamil Nadu had entered into an agreement with the United India Insurance Company and the members of the scheme are governed by the terms and conditions set out in the scheme. Admittedly, Pustular Psoriasis is not covered under the Scheme. The clinic where the writ petitioner took treatment is also not a Network hospital (MVK Hospital, South Rampart, Thanjavur). The writ petitioner also did not suffer from any medical emergency. Therefore, the insurance company could not have been saddled with any liability. At the same time, in order to address such cases, the Government had issued the executive instructions. Copy of the letter dated 01.11.2019 issued by the Principal Secretary to Government, Finance Department has been enclosed in the typed set of papers.
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3. Clause IV of the guidelines for claims under New Health Insurance Schemes for employees, pensioners / family pensioners reads as follows:- "IV. For any treatment / surgery undertaken in a NonNetwork Hospital for Non-emergency care (or) for an unapproved treatment / surgery undertaken in a Network Hospital for Non-emergency care."
4. In terms of the said guidelines, the Government issued Letter No.19022/Pension/2021-1, dated 29.04.2021 and Paragraph No.3 of the said letter reads as follows:- "3. I am to inform that in light of various Judgments of Hon'ble High Courts, the Government has decided to consider and examine all the medical claims pertaining to unapproved treatment / surgery undertaken in Network Hospital under normal circumstances (ie. Non-emergency case) and approved and unapproved treatment / surgery undertaken in NonNetwork Hospital under normal circumstances ie., Non-emergency case), under TN Medical Attendance Rules and reimburse medical claims as per the rates indicated under the Tamil Nadu Medical Attendance Rules." 4/6
5. We are clearly of the view that the case of the writ petitioner will have to be dealt with under Tamil Nadu Medical Attendance Rules and his reimbursement will have to depend on the rates indicated in the said Rules. Since this aspect of the matter has not been taken note of, we set aside the order passed by the learned single Judge. The writ appeal is allowed. The writ petitioner is permitted to lodge a fresh claim under Tamil Nadu Medical Attendance Rules. As and when such claim is lodged, it shall be dealt with and disposed of within a period of twelve weeks thereafter. No costs. Consequently, connected miscellaneous petition is closed.
(G.R.S., J.) (K.R.S., J.) 03.06.2025 Index : Yes / No Internet : Yes / No NCC : Yes / No rmi To 1.The Secretary to Government, Family Welfare & Health Department, Fort.St.George, Chennai-9.
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G.R.SWAMINATHAN, J.
AND K.RAJASEKAR, J.
rmi 2.The Director of Pension, 259, Anna Salai, 3rd Block, 2nd Floor, DMS Campus, Teynampet, Chennai-600 006.
3.The District Collector, Thanjavur District, Thanjavur.
4.The District Treasury Officer, Court Road, Thanjavur.
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