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2025 DIGILAW 2184 (MAD)

P. Duraisamy v. Collector, Salem

2025-04-17

C.V.KARTHIKEYAN

body2025
ORDER : 1. The writ petition has been filed in the nature of a Certiorarified Mandamus calling for the records relating to the letter of rejection of claim in Ref.No.010600/CRS-51/1/2023, dated 21.09.2023, on the file of the 5 th respondent and quash the same. Petitioner seeks reimbursement of the medical expenses of Rs.85,114/- incurred by the petitioner for the medical treatment of his wife at G. Kuppusamy Naidu Hospital, Coimbatore. 2. This Court had heard both the learned counsel for the petitioner and the learned counsel for the respondents and had passed the following order on 12.02.2025. 1. This writ petition has been filed for issuance of a writ of certiorarified mandamus calling for records relating to the letter of rejection of claim in Ref:010600/CRS-51/1/2023 dated 21.09.2023 on the file of the 5 th respondent and quash the same and direct the respondents to reimburse the medical expenses of Rs.85,114/- incurred by the petitioner for the medical treatment of his wife at G. Kuppusamy Naidu Memorial Hospital, Coimbatore. 2. In the affidavit filed in support of the writ petition it had been stated by the petitioner, P.Duraisamy that he had retired as Head Master in Government Elementary School on 31.08.2005. He had also joined Government NHIS Medical Insurance and had been paying Rs.180/- as a monthly premium every month in Card No. SLM/T/NHISP14/0263991 and PPO No. C191828/EDP/EDN. It had been further claimed that his wife Kalavathi who is aged about 63 years had been affected with sudden Paralysis and Stroke on 22.11.2016 and she was admitted in G. Kuppusamy Naidu Memorial Hospital, Coimbatore and medical expenses incurred Rs.4,25,130/- had been incurred for her treatment. Thereafter a claim was made and the writ petition had been filed and it is contended a total sum of Rs.2,00,000/- had been paid to the petitioner and with respect to the balance, the petitioner had filed W.P.No.35826 of 2023 which is now pending. 3. It is stated that quite independent of the earlier treatment, the wife of the petitioner had suffered viral infection and had been admitted in G. Kuppusamy Naidu Hospital, Coimbatore on 04.06.2022. She had been treated as inpatient till 30.06.2022. The medical expenses amounted to Rs.85,114/-. 3. It is stated that quite independent of the earlier treatment, the wife of the petitioner had suffered viral infection and had been admitted in G. Kuppusamy Naidu Hospital, Coimbatore on 04.06.2022. She had been treated as inpatient till 30.06.2022. The medical expenses amounted to Rs.85,114/-. It had been contended that the petitioner had raised a claim for reimbursement for that particular medical claim but though it had been forwarded by the Treasury Officer, Salem, the 5th respondent had passed the impugned order rejecting the claim on the basis that the treatment was taken in a non-network hospital and that the treatment afforded for that particular illness is not covered under the insurance scheme. This particular order is now challenged in the present writ petition. 4. The learned counsel for the petitioner claims that with respect to the stand of the 5th respondent that treatment was given in a non-network hospital cannot be sustained by this Court since there are earlier precedents in this regard that in times of emergency the petitioner cannot be searching whether the particular hospital where she or he is admitted for treatment is a nonnetwork covered hospital or not. In this connection, the learned counsel for the petitioner placed reliance on the judgment of the learned single Judge of this Court reported in N. Raja Vs. The Government of Tamil Nadu Rep. by its Secretary, Adi Dravidar Welfare Department, Fort St. George, Chennai and others, 2016 (3) CTC 394 . The learned counsel also placed further reliance on the judgment of the Hon'ble Supreme Court reported in Shiva Kantjha Vs. Union of India , (2018) 16 SCC 187 . The observations made by the Courts earlier is that if the treatment is emergent in nature then the patient cannot be expected to determine whether the hospital for the aforesaid treatment is a network hospital or not. 5. In the instant case, the learned counsel for the respondents contended that the petitioner would have to make a case that the treatment for which she took is an emergent treatment. It is further contended that for viral infection the medical insurance is not covered. 5. In the instant case, the learned counsel for the respondents contended that the petitioner would have to make a case that the treatment for which she took is an emergent treatment. It is further contended that for viral infection the medical insurance is not covered. But however it must be noted that the wife of the petitioner is already suffering from decompression craniotomy and in the discharge summary it is stated that she is suffering from restricted mobility for the past six years and for that particular ailment she had actually taking treatment from the very same hospital. For that particular treatment, partial reimbursement of the medical expenses had also been done by the 5th respondent. Therefore the objection that the treatment taken at G.Kuppusamy Naidu Memorial Hospital, Coimbatore has to be rejected. 6. The other ground is that the illness suffered is not covered under the Government order but that has to be examined with the existing medical condition of the wife of the petitioner. In this connection, it would only be appropriate that the 2nd respondent/The Joint Director, Medical and Rural Health Services, Salem deputes a medical professional to assess the wife of the petitioner and assess her illness relating to restricted mobility and whether that particular illness would be suspectable to viral infection and whether the viral infection suffered during the period of admission in G. Kuppusamy Naidu Memorial Hospital between 04.06.2022 and 13.06.2022 is a result of such restricted mobility or an independent illness suffered by the wife of the petitioner. 7. A report may be forwarded to this Court by the 2nd respondent. List the matter with the said report on 07.03.2025. The Medical Professional should visit the wife of the petitioner between 24.02.2025 and 28.02.2025 and forward the report to this Court on 07.03.2025. 3. Thereafter, the petitioner had been examined by a Medical Team of Civil Surgeon, Government Hospital, Idappadi, Salem District and Senior Assistant Surgeon, Government Head Quarters Hospital, Mettur Dam, Salem District and the following report was issued by them. As per reference no.2247/A5/2024 dated 28.02.2025 of the Joint Director of Health Services, Salem formed Medical Team comprising of Dr. V. Gokulakrishnan, M.D. (General Medicine), DTCD, Civil Surgeon, Government Hospital, Idappadi, Salem District and Dr. As per reference no.2247/A5/2024 dated 28.02.2025 of the Joint Director of Health Services, Salem formed Medical Team comprising of Dr. V. Gokulakrishnan, M.D. (General Medicine), DTCD, Civil Surgeon, Government Hospital, Idappadi, Salem District and Dr. R. Arun Natesh, MD, (General Medicine), Senior Assistant Surgeon, Government Head Quarters Hospital, Mettur Dam, Salem District for enquiry related to Hon'ble High Court, Madras W.P.No. 146/2024. We, Medical Team visited the petitioner Thiru. P. Duraisamy in his residence at 10/10-22A, Munusamy Goundar Street, Kolathur, Mettur Taluk, Salem District on 01.03.2025 at around 9.30 AM and hereby submitting following medical report. 1. After taking a brief history about the illness of his wife and going through the available records regarding the illness for which she was admitted in G. Kuppusamy Naidu Memorial Hospital, Coimbatore between 04.06.2022 and 13.06.2022, we examined the patient's present condition. 2. As per the available records patient was admitted on 04.06.2022 with fever and drowsiness for 1 day. She is a known case of type 2 DM / old CVA-ICH S/P Decompression Craniotomy / Seizure Disorder. For which she was investigated above illness and her reports were suggestive of Viral Fever. She was treated in ICU from 04.06.2022 to 06.06.2022 in view of Hypotension and Inotrope support. Patient's general condition improved with treatment, shifted to General Ward and discharged on 13.06.2022. 3. Patient at present is conscious, aphasic, bed ridden and needs support for her daily routine. 4. Based on the above assessment we are of the opinion that the illness (Viral Fever) is not a sequelae of her previous illness (Old CVA). We also opine that her comorbidities (Old CVA / Diabetes) would have necessitated her admission in ICU for the treatment of Viral Fever. 4. It is now contended by the learned counsel for the fifth respondent that the treatment for which the petitioner now seeks reimbursement had been very categorically stated by the Medical Board that the illness (Viral Fever) is not a sequelae of her previous illness. But the Medical Team had also opined that her earlier condition would have necessitated her admission in the ICU for the treatment of Viral Fever. If the wife of the petitioner had Viral Fever simplicitor, then there would have been no necessity for her to be admitted in the ICU. But specialised treatment was necessitated for the Viral Fever only owing to her existing condition, namely, comorbidities (Old CVA/Diabetes). If the wife of the petitioner had Viral Fever simplicitor, then there would have been no necessity for her to be admitted in the ICU. But specialised treatment was necessitated for the Viral Fever only owing to her existing condition, namely, comorbidities (Old CVA/Diabetes). It is for this admission in the ICU and the expenses incurred on that particular aspect, the petitioner seeks reimbursement and the same had been rejected by the fifth respondent. 5. I must place on record the very fair statement made by the learned counsel for the fifth respondent stating that the bills submitted the petitioner may now be re-examined by the District Endowment Committee, which is held by the District Collector at Salem. 6. A direction is given that the records of the petitioner must be placed in the meeting of the District Endowment Committee held by the District Collector in accordance with law and guidelines issued for implemention of the New Health Scheme, 2020 for Pensioners including Spouse/Family Pensioners, wherein, it had been stated that the District Endowment Committee may examine the nature of the expenses incurred, the bills produced and take a decision on the claims which could be allowed and permitted. A decision in this regard may be taken within the next meeting of the District Endowment Committee. The meeting of the District Endowment Committee should be convened within a period of eight weeks from the date of receipt of a copy of this order and the responsibility is on the first respondent/The Collector, Salem District, Salem, to so convene the meeting since he is the Chairman of the said Committee. A decision may be taken in the said meeting regarding the permissible claims of the petitioner relating to the treatment undergone by the wife of the petitioner and the expenses incurred by them at the G. Kuppusamy Naidu Hospital, Coimbatore, between 04.06.2022 and 13.06.2022. 7. The writ petition stands disposed of. No Costs. Consequently, connected miscellaneous petition is also closed.