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Madras High CourtWP(MD)/17115/2014disposed of

S.Abudhakeer v. The Special Secretary To

2023-03-06Honourable Mr Justice B.Pugalendhi8 pages

BEFORE THE MADURAI BENCH OF MADRAS HIGH COURT DATED: 06.03.2023 CORAM :

THE HONOURABLE MR.JUSTICE B.PUGALENDHI W.P(MD)No.17115 of 2014 and M.P(MD).No.1 of 2014 S.Abudhakeer ... Petitioner Vs.

1.The Special Secretary to Government, Finance (Salaries) Department, Government of Tamil Nadu, Chennai.

2.The Manager, Star Health and Allied Insurance Company Limited, Tamilnadu Government Employees, New Health Insurance Scheme, No.2, Harrington Road, KRM Center, Shopper's Shop, 6th Floor, Chetpet, Chennai-600 031. ... Respondents PRAYER: Writ Petition filed under Article 226 of the Constitution of India, praying this Court to issue a Writ of Certiorarified Mandamus, to call for the records pertaining to the order made in Ref. File No.4194 dated 26.09.2014 issued by the second respondent and quash the same 1/8

and consequently, direct the respondents to reimburse a sum of Rs.1,36,510.58/- to the petitioner within the time stipulated by this Court. For Petitioner : Mr.Prithivraj For R1 : M/s.Christry Theboral Additional Government Pleader For R2 : Mr.T.Antony Arul Raj

O R D E R

This writ petition has been filed challenging the order passed in Ref. File No.4194 dated 26.09.2014 by the second respondent and quash the same and consequently, direct the respondents to reimburse a sum of Rs.1,36,510.58 to the petitioner within the time stipulated by this Court.

2. The petitioner is working as B.T Assistant at Al-ameen High Shool, K.Pudur, Madurai. In the year 2011, the he was infected with a mysterious fever and he took treatment at Bhuvaneswari Hospital Madurai as inpatient from 08.12.2011 to 12.12.2011. Thereafter, he was admitted in the Vadamalaiyan Hospital, wherein he was taking treatment as inpatient from 13.12.2011 to 22.12.2011. While so, the petitioner's son was admitted in the very same hospital on 29.11.2012 and he was treated as inpatient from 29.11.2012 to 04.12.2013.

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3. The grievance of the petitioner is that the claim for reimbursement of his medical expenses was rejected by the second respondent by stating that the treatment underwent by the petitioner and his son is not in the list of network hospitals and in the Vadamalyan hospital, the petitioner has not utilized the scheme properly and already he had paid the money. Therefore, the second respondent stated that there is no reimbursement of the amount. Aggrieved over the same, the present writ petition has been filed.

4. The learned counsel for the petitioner submitted that though the petitioner was admitted in the Bhuvaneswari Hospital, it may be a non net work hospital, subsequently, the petitioner undertook treatment in Vadamalaiyan hospital, wherein the petitioner was admitted in a unconscious condition. Therefore, at the instance of the hospital, the petitioner's family members paid necessary fees. At the time of the claiming the medical expenses, the petitioner came to know that the petitioner is not entitled for reimbursement, since the petitioner has not followed the procedure.

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5. The learned counsel for the second respondent submitted that as per the contract, the second respondent is not liable to reimburse, since the petitioner took treatment in a non network hospital, namely, Bhuvaneshwari Hospital. The petitioner is entitled for reimbursement for taking treatment in the Vadamalayan hospital, which is a network hospital, if he has followed the procedures for cashless treatment as stated in G.O.Ms.No.174 Finance (Salaries) Department dated 28.04.2008. He further submitted that the petitioner has approached the Insurance Company after expiry of three years. Therefore, the petitioner's claim was rejected.

6. This Court has considered the rival submissions and also perused the materials placed on record.

7. The petitioner has claimed medical expenses for the treatment undergone by the petitioner before the Bhuvaneswari hospital and the Vadamalayan Hospital and also for his son, namley Sheik Dawood, who was infected with Dengue fever that he was also admitted in the Vadamalayan Hospital from 29.11.2012 to 04.12.2013. As already pointed out by the learned counsel for the second respondent, the 4/8

petitioner's son took treatment for Dengue Fever in the Vadamalayan hospital, which is a network hospital, even then the petitioner is not entitled for any reimbursement of medical expenses, since the new health insurance scheme was implemented by the second respondent only from 11.06.2008 to 10.06.2012 and the petitioner's son took treatment after expiry of the scheme.

8. The learned counsel for the second respondent has already pointed out that the Bhuvaneswari Hospital is a non network hospital and as per the contract, the second respondent is not liable to pay any amount for the treatment taken before a non-network hospital. However, the petitioner can claim reimbursement, if the petitioner used the clashless scheme before the Vadamalayan hospital. In this case, the petitioner has already paid the amount before the Vadamalayan hospital. Therefore, he cannot claim any reimbursement of the amount.

9. The petitioner was admitted in the Vadamalayan hospital in an unconscious condition for treatment. Therefore, the reason stated by the second respondent is not acceptable. The relatives would be particular about the treatment to be provided and and cannot bargain on the 5/8

available scheme with a private hospital. The Insurance Company can very well ascertain from their network hospital, namely, Vadamalayan whether any treatment was provided as claimed by the petitioner.

10. Considering the fact and the circumstances of this case, this Court dispose of this writ petition with a direction to the petitioner to approach the District Level Empowered Committee along with his entire medical records, within a period of four weeks from the date of receipt of a copy of this order and the District Level Empowered Committee shall consider the petitioner's case and pass necessary orders within a period of 12 weeks thereafter. No Costs. Consequently, the connected miscellaneous petition is closed.

06.03.2023 NCC :Yes/No Index :Yes/No Internet : Yes/ No tta 6/8

To 1.The Special Secretary to Government, Finance (Salaries) Department, Government of Tamil Nadu, Chennai.

2.The Manager, Star Health and Allied Insurance Company Limited, Tamilnadu Government Employees, New Health Insurance Scheme, No.2, Harrington Road, KRM Center, Shopper's Shop, 6th Floor, Chetpet, Chennai-600 031.

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B.PUGALENDHI,J tta Order made in W.P(MD)No.17115 of 2014 Dated : 06.03.2023 8/8