M. Ajith Kumar v. The Secretary
BEFORE THE MADURAI BENCH OF MADRAS HIGH COURT DATED : 16.10.2024 CORAM :
THE HONOURABLE MR.JUSTICE N.SATHISH KUMAR W.P.(MD)No.24191 of 2024 M.Ajith Kumar ... Petitioner Vs.
1.The Secretary, Health & Family Welfare Department, Government of Tamil Nadu, Fort St.George, Chennai.
2.The Project Director, Tamil Nadu Health Systems Project (TNHSP), 3rd Floor, DMS Annex New Building, 259 Anna Salai, Teynampet, Chennai-600 006.
3.The Authorized Officer, CMCHIS Project Office, Chief Minister's Comprehensive Health Insurance Scheme, No.226, OM Sakthi Towers, Kilpauk Garden Road, Kilpauk, Chennai-600 010.
4.Star Health & Allied Insurance Co.Ltd., Rep. by its General Manager, Having Office at 935, 2 & 3rd Floor, G.K.S.Towers, Poonthamalli Highways, Chennai-600034.
5.M/s.United India Insurance Company, Rep. by its Branch Manager, Having Office at Divisional Office VI, 1/5
5th Floor, P.L.A.Rathna Towers, 212, Anna Salai, Chennai-600 006.
6.Preethi Hospitals (P) Ltd., Rep. by its General Manager, Having Office at No.50, Melur Main Road, Uthangudi, Madurai-625 107.
... Respondents PRAYER: Writ Petition filed under Article 226 of the Constitution of India, praying this Court to issue a Writ of Mandamus, directing the respondents to provide reimbursement to the sum of Rs.5,00,000/- for the medical expenses incurred by the petitioner in accordance with the Chief Minister Comprehensive Health Insurance Scheme along with interest in favour of the petitioner on the basis of the petitioner's representation dated 29.08.2024. For Petitioner : Mr.M.Pozhilan For R1 : Mr.A.Kannan, Additional Government Pleader For R5 : Mr.I.Robert Chandrakumar
ORDER
By consent of both sides, the Writ Petition is taken up for final disposal at the stage of admission itself.
2.Mr.A.Kannan, learned Additional Government Pleader takes notice for the 1st respondent and Mr.I.Robert Chandrakumar, learned counsel takes 2/5
notice for the 5th respondent. Considering the nature of order proposed to be passed in this Writ Petition, notice to other respondents is dispensed with. 3.According to the petitioner, he met with an accident and was admitted in the 6th respondent Hospital, where he has undergone surgery, for which, a sum of Rs.12 Lakhs has been spent. Since his family is covered under the Health Insurance Scheme as per G.O.(Ms)No.16, Health and Family Welfare (EAPL-1) Department, dated 08.01.2022, he sent a representation dated 29.08.2024 to the respondents, seeking reimbursement. Since the same has not been considered so far, the petitioner is before this Court. 4.The learned counsel appearing for the petitioner would submit that the District Collector has conducted enquiry in this regard and forwarded the enquiry report to the 2nd respondent, stating that the petitioner has not obtained pre-authorization approval before surgery from the concerned Insurance Company.
5.At the outset, this Court is of the view that this issue is no longer res-integra. Whether the pre-authorization approval is obtained or not, is no significance. Once the petitioner is covered under the scheme, merely on the 3/5
basis of not obtaining pre-authorization approval, medical reimbursement cannot be rejected. It is relevant to note that when a person is suffered with severe injury in an accident and undergoing treatment, it cannot expect that such person has to get pre-authorization approval from the concerned Insurance Company before surgery, particularly, when the person is injured and admitted in ICU. In such view of the matter, the 2nd respondent is directed to consider the issue and pass appropriate orders in this regard by releasing the amount, which is applicable to the petitioner, within a period of one month from the date of receipt of a copy of this order.
6.With the above direction, this Writ Petition is disposed of. No costs.
16.10.2024 NCC : Yes / No Index : Yes / No Internet : Yes / No Yuva 4/5
N.SATHISH KUMAR, J.
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