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2017 DIGILAW 998 (MAD)

S. Kulasekarapandian v. Special Secretary to Government Finance (Salaries) Department Government of Tamilnadu, Chennai

2017-04-11

P.VELMURUGAN, T.S.SIVAGNANAM

body2017
ORDER : T.S. SIVAGNANAM, J. The petitioner, who is working as Superintendent in the Principal District Court, Ramanathapuram, has filed this writ petition challenging the order, dated 11.09.2015, passed by the third respondent, rejecting his claim for reimbursement of the charges, which he has incurred for the medical treatment rendered to his wife. 2. The petitioner's case is that on 15.05.2014, his wife developed severe stomach pain and it was found that there was a stone in her kidney. After taking some medicine, she appeared to be alright. However, after two weeks, the problem relapsed. Therefore, she was rushed to Abiman Kidney Centre, Madurai and on diagnosis, it was found that the stone, which was formed in the Kidney, had moved to her urinary track and immediately, surgery was advised to be done. Therefore, due to the serious condition of the petitioner's wife, the petitioner was left with no other option except to permit the Hospital to carry on the surgical procedure and he had paid a sum of Rs.71,206/-. 3. The petitioner has a family health coverage administered by the sixth respondent and the treatment, which was given to the his wife, is one of the approved treatments to be entitled for reimbursement. But, the sixth respondent returned the claim made by the petitioner on the ground that the hospital, where the treatment was administered, is a non-network hospital. Therefore, representations were made to the fifth respondent as well as the fourth respondent and since there was no response to those representations, the petitioner represented to the third respondent, who has rejected the petitioner's claim by the impugned order. 4. The petitioner pleads that due to the emergency situation, he had arranged operation in the said Kidney Centre and since the surgical procedure, which was performed on his wife, was an approved as per the Health Scheme administered by the sixth respondent, he is entitled for reimbursement. 5. The counter affidavit filed by the third respondent on behalf of the other respondents proceeds on the basis that the hospital, where the treatment was administered, is a non-network hospital and as per G.O.(Ms) No. 243, Finance (Salaries) Department, dated 29.06.2012, the hospitals approved by the Insurance Company/Third Party Administrator under the Scheme alone should be approached for availing the benefits. Therefore, the third respondent would state that the impugned order is perfectly correct. 6. Heard Mr. Therefore, the third respondent would state that the impugned order is perfectly correct. 6. Heard Mr. P.R. Prithiviraj, learned counsel appearing for the petitioner and Mr. S. Chandrasekar, learned Government Advocate appearing for the respondents 1 to 5 and carefully perused the materials placed on record. 7. The very same reason for rejection of the medical reimbursement as claimed by the petitioner was considered by this Court in several other cases, where an identical stand was taken by the Insurance Company/Third Party Administrator of the Health Scheme and all those writ petitions were allowed holding that there is no justification to refuse reimbursement on the ground that the hospital is not a network hospital. One such a case is N. Karunanithi v. Commissioner of Treasuries & Accounts, reported in (2010) 2 MLJ 845 . In the said decision, the Court has referred to the other decisions rendered earlier, which includes the decision of the Division Bench of this Court. At this stage, it would be useful to refer to the operative portion of the order, which reads as follows: “6. This Court also issued direction to reimburse the permissible medical expenses without reference to the objections raised, after referring to a number of judgments on this point, in W.P.No.26040 of 2005 dated 01.04.2008. Relevant paras 8 to 10 of the said judgment are extracted here under: "8. Similar issue, with regard to the treatment taken in the unlisted hospitals, mode of treatment not included in the Government Orders and belated applications submitted and whether the same are to be considered or not, came up for consideration before this Court in the following Judgments passed by me as well as by other Learned Judges:- (a) K. Subramanian K.V. Special Commissioner and Commissioner of Treasuries and Accounts reported in 2006 (2) MLJ 267 ; (b) C. Nagamuthu v. State of Tamil Nadu in 2006 (2) MLJ 747 ; (c) G. Elavazhagan v. Commissioner of Treasuries and Accounts, reported in (2006) 4 MLJ 627 ; (d) E. Ramalingam v. Director of Collegiate Education, reported in 2006 (3) MLJ 641 [D.Murugesan, J]; (e) K. Balaswami v. Director of Pension, reported in 2007 (3) MLJ 385 [P. Jothimani, J]; (f) K.Mani v. Secy to Govt., Health & Family Welfare Dept. reported in 2007 (3) MLJ 34 [P.Jothimani, J] (g) K. Sundararaj v. Mgmt. reported in 2007 (3) MLJ 34 [P.Jothimani, J] (g) K. Sundararaj v. Mgmt. Of T.N.S.T. Corporation (Madurai) Ltd, reported in 2006 4 MLJ 1183 [P. Jothimani, J]; and (h) Division Bench Judgment of this Court in W.A.No.280 of 2005, dated 04.07.2005. 9. The Supreme Court has recognised the right to health as Fundamental Right under Article 21 of the Constitution of India in the decision in State of Punjab and others v. Mahinder Singh Chawla and others, reported in AIR 1997 SC 1225 and again in the case of Paschin Banga Khet Mazdoor Samity and others v. State of W.B. And another reported in AIR 1996 SC 2426 . 10. In the light of the above referred decisions of this Court as well as the Judgments of the Supreme Court, I hold that the impugned order passed by the third respondent is unsustainable, and therefore, the same is set aside and the Writ Petition is allowed. The respondents are directed to sanction the permissible amount as claimed by the petitioner without reference to the objections raised and payment shall be made by the respondents within a period of four weeks from the date of receipt of copy of this order. No costs. Consequently, the concerned miscellaneous petition is closed." 7. In the order dated 04.07.2005 in W.P.No.280 of 2005, this Court (Division Bench) held that the mode of treatments listed in the concerned Government order are only illustrative and not exhaustive. Para 3 to 6 of the said judgment which are relevant, are extracted herein below:- "3. The said request was however, rejected by the Government on the ground that the treatment undergone by the petitioner was not covered under G.O.Ms.No.437 of Home Department, dated 11.03.1995 and he was entitled for medical reimbursement only in respect of open heart surgery and not closed heart surgery. 4. Learned single Judge rejected the objection of the Government holding that the reason given by the Government cannot hold good as in the modern medical treatment, new inventions are introduced and merely because one of the mode of treatment is not included in the list of treatments, there can no denial of medical reimbursement. 5. Learned Special Government Pleader contends that para 3 of the Government order has enlisted only certain categories of treatments as eligible for financial assistance. 5. Learned Special Government Pleader contends that para 3 of the Government order has enlisted only certain categories of treatments as eligible for financial assistance. Under Category-I, only open heart surgery is contemplated and admittedly, the petitioner having undergone closed heart surgery is not entitled for reimbursement. He also contends that the reason given by the learned single Judge that scientific advancement would entitle reimbursement even apart from the categories enlisted in the Government Order cannot be sustained. 6. We do not find any ground to interfere with the order of the learned single Judge. It is admitted that the petitioner had undergone treatment for his heart ailment and the Government Order, which is dated 17.03.1995 has not been updated to include other variations of the same surgery for the same ailment. Advancement in medical science has opened closed heart surgery with reference to the same ailment and there is no jurisdiction for the State to refuse to grant medical reimbursement for closed heart surgery, which is performed dealing with the same ailment. Mere default on the part of the Government in not updating the list of treatments cannot be put against the claimant." 8. Thus, in the light of the above referred pronouncement, the reason assigned in the impugned order by the third respondent to reject the reimbursement claim is not sustainable. 9. Further, in the instant case, the petitioner's wife was given emergency treatment on account of severe stomach pain. This aspect has not been disputed by the respondents. In such circumstances, the respondents are bound to consider the petitioner's reimbursement claim in accordance with the policy. 10. Accordingly, the writ petition is allowed and the impugned order in Na.Ka.No.57305/Kabi 1/3/15, dated 11.09.2015, passed by the third respondent is quashed. The respondents 3 to 6 are directed to consider the petitioner's reimbursement claim and reimburse the amount, to which he is entitled to as per the Scheme, within a period of three weeks from the date of receipt of a copy of this order. No costs. Consequently, connected miscellaneous petition is closed.