Jothi. M (Bt Asst.,) v. School Education Department
BEFORE THE MADURAI BENCH OF MADRAS HIGH COURT DATED : 22.11.2023
CORAM
THE HONOURABLE MR.JUSTICE R.VIJAYAKUMAR M.Jothi ... Petitioner Vs.
1.The Chief Educational Officer, Sivagangai District, Sivagangai.
2.The Director, Directorate of Medical and Rural Health, DMS Complex, Anna Salai, Chennai.
3.The General Manager, United India Insurance Company Limited, No.19, Nungampakkam High Road, Chennai.
4.MD India Health Insurance TP A Private Limited, Guna Complex, No.443 and 445, Anna Salai, Teynampet, Chennai.
5.The Officer Incharge, Administrative Office, Appolo Hospital, Madurai.
... Respondents 1/7
Prayer : Writ Petition filed under Article 226 of the Constitution of India, praying this Court to issue a Writ of Mandamus, directing the third and fourth respondents to pay the remaining amount of Rs.1,96,435/- as reimbursement of medical bills to the petitioner with appropriate interest, based on the petitioner's representation, dated 02.09.2022.
For Petitioners : Mr.P.Muthu Vijaya Pandian For R-1 & R-2 : Mr.V.Om Prakash Government Advocate For R-3 : Mr.C.Karthik For R-4 : No appearance For R-5 : Mr.V.Ramakrishnan
ORDER
The present writ petition has been filed by a B.T Assistant Teacher seeking a Mandamus directing the Insurance Company to reimburse the medical expenses incurred by her husband at Apollo Hospital, Madurai.
2. It is the case of the writ petitioner that her husband, namely, A.Palanisamy was admitted to Apollo Hospital, Madurai and he underwent a heart surgery on 25.12.2021 and he was discharged on 04.01.2022. According to the writ petitioner, they have incurred a sum of Rs.4,93,769/- as expenses for 2/7
the said surgery and other procedures. When they made a claim to the third and fourth respondents herein under the new Health Insurance Scheme, the respondents have reimbursed only a sum of Rs.2,97,334/-. Since the balance amount of Rs.1,96,435/- remained unpaid, the present writ petition has been filed.
3. According to the learned Counsel appearing for the writ petitioner, when the petitioner's husband has incurred an expense of Rs.4,93,769/-, the entire amount ought to have been reimbursed by the respondents 3 and 4 under the new Health Insurance Policy. They have no descretion whatsoever to reject certain claims.
4. Per contra, the learned Counsel appearing for the Insurance Company placed on record the Package Rate List for Tamil Nadu New Health Insurance Scheme and contended that the petitioner's husband has undergone valve replacement surgery and the package rate for the said surgery as approved by the Government is Rs.1,91,100/- which has been reimbursed and the petitioner has been reimbursed a sum of Rs.52,852/- under the head of Valve cost. The petitioner has also been reimbursed a sum of Rs.30,576/- towards conservative 3/7
Management without angiogram and the entire pharmacy expenses namely to an extent of Rs.22,806/- has also been reimbursed. Therefore, whatever that is applicable to the writ petitioner as per the package rate has been reimbursed.
5. I have carefully considered the submissions made on either side and perused the materials available on record.
6. The primary contention of the writ petitioner is that when the petitioner's husband had incurred a sum of Rs.4,93,769/-, the entire amount should have been reimbursed. However, the learned Counsel appearing for the respondent had pointed out that the reimbursement is based upon the package rate that have been arrived at between the Government of Tamil Nadu and the Insurance Company. Whatever the maximum rates that have been prescribed under the package rate list have been disbursed to the writ petitioner and none of the amount has been retained or rejected. Therefore, the claim of the writ petitioner has been satisfied in full as per the insurance policy. In case, if some portion is not covered by the insurance policy, it is for the petitioner to approach the Government under the Medical Attendance Rules 4/7
for reimbursement of the balance amount. Therefore, there are no merits in the writ petition.
7. This writ petition stands dismissed with the above said observations. There shall be no order as to costs.
22.11.2023 NCC : Yes / No Index : Yes / No Internet : Yes BTR To 1.The Chief Educational Officer, Sivagangai District, Sivagangai.
2.The Director, Directorate of Medical and Rural Health, DMS Complex, Anna Salai, Chennai.
3.The General Manager, United India Insurance Company Limited, No.19, Nungampakkam High Road, Chennai.
5/7
4.MD India Health Insurance TP A Private Limited, Guna Complex, No.443 and 445, Anna Salai, Teynampet, Chennai.
5.The Officer Incharge, Administrative Office, Appolo Hospital, Madurai.
6/7
R.VIJAYAKUMAR, J.
BTR 22.11.2023 7/7