Case Title: C Mani v Principal Secretary to Government of Tamil Nadu
Case No: W.P.(MD)No.25304 of 2018
Decided on: 05th December,2023
CORAM: THE HON’BLE MR. JUSTICE S.M. SUBRAMANIAM AND THE HON’BLE MR. JUSTICE V. LAKSHMINARAYANAN
Introduction
The Madras High Court issued an order that selection of a non-network hospital for treatment should not be the sole determinant for the denial of medical reimbursement.
Facts of the Case
The petitioner has retired from the Principal District Court in Pudukkottai on September 30, 2010, while serving in the capacity of Chief Administrative Officer. He is a member of the Medical Health Scheme and a State pensioner. He consistently paid his subscription under the plan. From April 3, 2016, until April 9, 2016, the petitioner received care as a patient at BRS Hospital in Chennai, where he underwent surgery for a left kidney tumor (cancer). For medical expenditures, the petitioner paid out a total of Rs. 1,24,576. A request for medical reimbursement was made through an application. The petitioner’s medical claim was rejected by the second respondent claiming that the treatment was received in a facility that is not part of the network, making the petitioner ineligible for medical reimbursement.
Respondents 1 to 6 claimed that treatment from a network hospital alone will determine the outcome of the medical claim. The response argued that the claim should be rejected since the hospital where the petitioner sought treatment is not considered a network hospital.
Courts analysis and decision
The court ruled that regarding the treatment received in a non-network institution, there are no longer any res-integra concerns with regard to the medical claim settlement and asserted that courts have issued multiple rulings to resolve medical reimbursement claims rather than rejecting them on the grounds that the hospital is not included in the network of hospitals.
The court set aside the impugned order passed by the 2nd respondent dating 02.04.2018. And the 7th respondent was required to settle the petitioner’s eligible medical reimbursement claim under the scheme within six (6) weeks of receiving a copy of this order. Respondents 1 to 6 are responsible for making sure the 7th respondent makes the payment within the time frame we have specified in this order.
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Written by- Rupika Goundla
