The United India Insurance v. A.Kanagasabapathi

BEFORE THE MADURAI BENCH OF MADRAS HIGH COURT DATED : 13.02.2025

CORAM:

THE HONOURABLE DR.JUSTICE G.JAYACHANDRAN AND THE HON'BLE MS.JUSTICE R.POORNIMA W.A.(MD).No.1156 of 2018 and C.M.P.(MD).No.8339 of 2018 The United India Insurance Co. Ltd., Division Office VI 5th Floor P.L.A Rathna Towers No.212, Annasalai, Chennai - 600 006.

: Appellant Vs.

1.A.Kanagasabapathi 2.The Principal Secretary to Government (Expenditure), Finance (Salaries) Department, Secretariat, Chennai - 600 009.

3.The Commissioner of Treasuries & Accounts, 2nd Floor, Panagal Building, Jeenish Road, Saidapet, Chennai - 600 015.

4.The District Collector, Virudhunagar District, Virudhunagar.

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5.The District Treasury Officer, District Treasury, Virudhunagar.

: Respondents PRAYER: Writ Appeal is filed under Clause 15 of Letters Patent to set aside the order dated 27.03.2018 passed in W.P.(MD) No.22165 of 2016. For Appellant : Mr.A.Shajahan For Respondents : Mr.S.Balamurugan (for R1) Mr.D.Gandhi Raj Spl. Govt. Pleader (for R2 to R5) ***

JUDGMENT

(Judgment of the Court was delivered by DR.G.JAYACHANDRAN,J.) The appellant, instead of complying with the direction of the learned Single Judge, who was directed to consider the representation of the first respondent/writ petitioner regarding reimbursement, de-hors of the fact that the first respondent/writ petitioner has taken treatment in a non-network hospital and the scheme is only to cover cashless treatment and not reimbursement of the expenses already incurred, has filed the present writ appeal. 2/7

2. The learned Single Judge has passed the above order directing the appellant to consider afresh based on the order of the Division Bench of this Court rendered in W.P.(MD).No.1408 of 2016 in the case of N.Raja vs. The Government of Tamil Nadu, reported in 2016(3) CTC 394.

3. The contention of the appellant, who is the Nodal Officer of the Insurance Company, is that the writ petitioner, who is a pensioner under the Government of Tamil Nadu, has admitted his wife for treatment at Velammal Medical College Hospital, Madurai on account of cardiac disease and on the advice of the doctor, his wife underwent surgery and got discharged on 09.08.2017. He has allegedly spent Rs.1,79,144/- for her treatment. His application seeking reimbursement under the Tamil Nadu New Health Insurance Scheme, though recommended by the District Empowerment Committee, the Insurance Company rejected the same on the ground that the wife of the petitioner has taken the above said treatment in a non-network hospital and therefore, the Insurance Company, who is the appellant herein, is not authorised to reimburse the said claim.

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4.The issue that taking treatment in a non-network hospital will not entail the claimant for reimbursement, has been considered earlier in a batch of writ petitions by the Division Bench of this Court in Star Health and Allied Insurance Co. Ltd. vs. A.Chokkar & another reported in 2010-2-L.W.90. Again, the issue came up for consideration in N.Raja vs. The Government of Tamil Nadu (supra), in which, the learned Single Judge has relied upon that the writ petitioner is the pensioner and has been provided with health security under the scheme, has to be provided with the benefit as per the procedure laid. Even if the Tamil Nadu New Health Scheme 2014, introduced for cashless basis treatment, it does not cover the instance, which is stated above.

The writ petitioner cannot be deprived of the benefit if there is other scheme which covers the treatment. Mere taking treatment in a non-network hospital will not deprive the claimant from seeking reimbursement. The learned Single Judge of this Court in that case, after taking note of the fact that the writ petitioner's reimbursement cannot be negatived by the Insurance Company only on the ground that the treatment was taken in a non-network hospital, had directed the appellant/respondent to quantify the amount to which, the petitioner is eligible and sanction and reimburse the same within a period of six weeks from the date of receipt of a copy of that order.

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5. It is to be noted that the responsibility to reimburse the medical claim is primarily fixed on the Government, who is the former employer of the claimant. The Insurance Company has come into picture to supersede the liability on subscription to the Insurance Company. The appeal is preferred by the Insurance Company and not by the State. This Court considering the said fact earlier, had directed the parties to submit themselves for amicable settlement through Lok Adalat. In fact, it is stated that the parties attended Lok Adalat, but the proposal given by the State is not accepted by the writ petitioner, who is first respondent in the appeal.

6. The learned counsel for the appellant emphasis that the terms of the settlement proposal in the Lok Adalat to be implemented. This Court is unable to endorse the said due. Any mode of dispute or settlement under Section 89 of the Code of Civil Procedure, unless fortified and culminated in a consensus, the proceedings cannot be taken into account by the Courts of adjudication, the matter on merits. The writ appeal, therefore, disposed of directing the appellant to consider the representation of the first respondent/writ petitioner seeking reimbursement of the medical claim and pass appropriate orders as per the law in force. Challenging the said direction in the writ appeal 5/7

is un-merit without passing appropriate orders and therefore, the writ appeal stands dismissed. No costs. Consequently, connected miscellaneous petition is closed.

(G.J., J.) (R.P., J.) skn 13.02.2025 NCC : Yes/No Index : Yes / No Internet : Yes To 1.The Principal Secretary to Government (Expenditure), Finance (Salaries) Department, Secretariat, Chennai - 600 009.

2.The Commissioner of Treasuries & Accounts, 2nd Floor, Panagal Building, Jeenish Road, Saidapet, Chennai - 600 015.

3.The District Collector, Virudhunagar District, Virudhunagar.

4.The District Treasury Officer, District Treasury, Virudhunagar.

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DR.G.JAYACHANDRAN,J.

and R.POORNIMA, J.

skn W.A.(MD).No.1156 of 2018 and C.M.P.(MD).No.8339 of 2018 13.02.2025 7/7