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2019 DIGILAW 1315 (MAD)

M. Somasundaram v. Director of Pension

2019-04-26

S.M.SUBRAMANIAM

body2019
JUDGMENT : 1. The relief sought for in the present writ petition is for a direction to direct the first and fourth respondents to reimburse the medical expenditures of the writ petitioner to the tune of Rs.1,90,071/- along with interest at the rate of 9% per annum. 2. The learned counsel for the writ petitioner states that the writ petitioner met with an accident and sustained serious injury of hip fractures. The writ petitioner was admitted in the nearby Appollo Specialty Hospital at Tiruchirappalli. 3. The writ petitioner is a State pensioner and a member of the New Health Insurer Scheme 2014. The writ petitioner is subscribing under the Scheme and therefore, he is eligible to avail the benefit of medical reimbursement. 4. The writ petitioner underwent a major surgery of replacement of hip and accordingly, incurred the medical expenditure of Rs.1,90,071/-. The writ petitioner submitted an application, seeking medical reimbursement and the respondents have not considered the case of the writ petitioner for medical reimbursement. 5. The learned counsel appearing on behalf of the respondent-Insurance Company admits that the Hospital in which the writ petitioner has taken treatment is not an approved Hospital and as per the Government Orders in respect of unapproved Hospitals, the claims cannot be settled by the Insurance Company and in this regard, the Division Bench of this Court directed to settle the medical reimbursement claim by the Government itself. 6. In other words, the learned counsel for the respondents states that in respect of the medical reimbursement claims made with reference to the unapproved hospitals, the Government has to settle the amount and not the Insurance Company. 7. However, it is subsequently admitted by the learned counsel for the fifth respondent that the Appollo Specialty Hospital, Tiruchirappalli was included in the list of approved hospitals by the Government. 8. The learned counsel for the writ petitioner also states that the Appollo Specialty Hospital was included as an approved Hospital under the Scheme on 8.5.2017 itself. It is relevant to record, even today, the application submitted by the writ petitioner is pending and no order has been passed. 9. Under these circumstances, this Court of the considered opinion that the reason stated by the respondent that the said hospital is not listed out in the Government Order, cannot be accepted. 10. This apart, the medical reimbursement claims cannot be denied on such flimsy grounds. 9. Under these circumstances, this Court of the considered opinion that the reason stated by the respondent that the said hospital is not listed out in the Government Order, cannot be accepted. 10. This apart, the medical reimbursement claims cannot be denied on such flimsy grounds. The authorities are bound to consider the genuinity of the treatment taken by the employees and not the hospital in which they have taken treatment. The Courts have time and again held that medical facility is an integral part of an employee under Article 21 of the Constitution of India and the writ petitioner, like pensioner, is availing the medical facility with a fond hope that he will get reimbursement of such claims. 11. This apart, the writ petitioner is a regular subscriber of the Health Fund Scheme. Under these circumstances, the claim of the writ petitioner cannot be rejected merely on the ground that the hospital was not included in the list of approved hospital. However, in the present case on hand, the hospital was included in the list of approved hospital on 8.5.2017. 12. As far as the medical reimbursement claims are concerned, the same cannot be rejected on flimsy grounds as the writ petitioner, like pensioner, is purely depending on the claims of medical reimbursement. This apart, the writ petitioner met with an accident and immediately admitted in the nearby hospital. Thus, the genuinity of urgency is also to be considered by the authorities concerned. 13. Admittedly, the writ petitioner underwent a surgery and paid the medical expenses to the hospital. Thus, the respondents are bound to settle the medical reimbursement claim of the writ petitioner under the Scheme. 14. This being the factum, the fourth respondent-Insurance Company is directed to settle the medical reimbursement claim of the writ petitioner as per his eligibility under the Scheme, within a period of twelve weeks from the date of receipt of a copy of this order. 15. Accordingly, the writ petition stands allowed. However, there shall be no order as to costs.