Medical Reimbursement Cannot Be Rejected Merely Because Treatment Was In A Non-Network Hospital: Madras High Court

Justice SM Subramaniam and Justice V Lakshminarayanan noted that when there was no dispute with respect to treatment and the treatment was found to be genuine, there was no reason to reject the medical claim.

“The issues regarding the settlement of the medical claim are no more res-integra in respect of the treatment undertaken in a non-network hospital. Several orders have been passed by the Courts to settle the medical reimbursement claim and not to reject the same merely on the ground that the hospital is not falling under the list of network hospitals,” the court said.

The court was hearing the plea of one C Mani, who had retired from the post of CChief Administrative Officer in Principal District Court, Pudukkottai and was a member of Medical Health scheme, paying subscription regularly. Mani took treatment by undergoing surgery for a left renal tumour for which he spent a sum of Rs. 1,24,576/-. It was alleged that when he applied for medical reimbursement, the Director of Health and Rural Services rejected it saying that the treatment was in a non-network hospital.

The Insurance company informed that the order of rejection was passed by the Director of Health and Rural Services and reiterated that the medical claim could be settled only when treatment was undertaken in a network hospital and since the hospital in which Mani had taken treatment was a non-network hospital, the rejection was appropriate.

To this, the court observed that when there was no dispute regarding the genuneity of the treatment, there was no reason to reject medical reimbursement merely on the ground that treatment was undertaken in a non-network hospital.

The court thus deemed it fit to set aside the impugned order and directed the Insurance company to settle the eligible medical reimbursement under the scheme within 6 weeks.

Counsel for the Petitioners: Mr.P.Ganapathi Subramanian

Counsel for the Respondents: Mr.S.Shanmugavel, Additional Government Pleader, Mr.A.Shajahan

Citation: 2023 LiveLaw (Mad) 389

Case Title: C Mani v Principal Secretary to Government of Tamil Nadu

Case No: W.P.(MD)No.25304 of 2018