"State Health Scheme Not Charity", Govt. Cannot Reject Reimbursement Claims Of Employees & Pensioners On Technical Grounds: Madras HC

"[…] these schemes are compulsory scheme for everyone i.e., every employee/pensioner and whether they are willing or not, they have been compelled to contribute towards this scheme, hence their genuine claim for medical reimbursement cannot be easily brushed aside by projecting technical reasons."

Background

The issue raised in the writ petitions before the court was the entitlement of the writ petitioners, who are either Government employees or pensioners of the State Government and its undertakings or their family members / legal heirs / next kith and kin, to get medical reimbursement under the New Health Insurance the scheme implemented by the State Government from time to time.

The State Government originally was having a scheme called "Tamil Nadu Government Employees Health Fund Scheme, 1992", which because of its inefficiency was replaced by new scheme in 2008 which continued for its block years till 2012 and it was extended till 2016and the scheme was to be administered through the third party administrator under the control of United India Insurance Company, Chennai. Every employee of the State Government and Public sector undertakings would pay premium of Rs.150/- per month to the State Government and the said amount would be deducted from their salary. The 2012 scheme was made compulsory for all Government employees. In turn, the State Government entered into an agreement with United India Insurance Company Ltd., Chennai and accordingly, the annual premium of Rs.1,860 would be paid by the State Government to the Insurance company as a yearly premium for the employee, under which the employee, as well as his family, would be covered under the Insurance scheme 2012. The scheme was again extended in 2016 and will continue till 2020. The very same insurance company namely United India Insurance Company Ltd., Chennai is the insurance company, with whom the State Government entered into an agreement, according to which, from 01.07.2016 onwards the scheme would be implemented as a cashless model for the approved treatments/surgeries in the hospitals approved by the United India Insurance Company / third-party administrator and the employee and their eligible family members would be covered under the scheme and shall avail financial assistance on cashless basis up to the limit of Rs.4,00,000/- in a block period of four years. However, the assistance shall be up to Rs.7,50,000/- for specified illness listed in Annexure-II A of the scheme.

State Health Scheme Not Charity

Bench of Justice R. Suresh Kumar found that the District Level Empowered Committee has rejected the claim of petitioners for reimbursement in one line without giving any plausible or acceptable reason like the treatment taken in non network hospital or for the non-listed disease. It said that even if it is assumed that the treatment has been taken in non-network hospital, it is the duty of the District Level Empowered Committee or at least at the State Level high power committee to go in to the claim of such employee/pensioner and to see whether the treatment had been taken in a non-network hospital for any plausible reason like emergency or immediate non-availability of the network hospital in the locality.

"With this measure to protect its employees and former employees, the State Government in fact introduced the scheme, not as a charity, but as an enabling procedure, because, the State Government has not paid any money to the Insurance Company for reimbursement, but only the contribution to be made by the employee and the pensioner, by way of premium subscription paid by them every month…"

Right to Health Part of Right to Life

Court said right to health is part of right to life and state should assure protection cover as far as good health of its subjects goes.

"The scope of Right to Life enshrined in the Constitution under Article 21 has been expanded, which includes, Right to Health, which is an integral part of Right to Life. Since Right to Health is part of Right to Life under Article 21 of the Constitution, it is obligatory on the part of the State to take all possible efforts and measures to give quality medical facilities to its citizens."

It observed further:

"It is not only from the angle of, "The Right to Life" which includes Right to Health, but also from the point of view of the State to give adequate facilities to have the protection cover for every citizen from health issues, the State must provide all such facilities on their own."

State Means Freedom From Hunger Apart Other Things

Quoting Saint Thiruvalluvar, Court said that the freedom from hunger and disease as well as from the threat of enemies invasion is a State that is desired for a prosperous nation.

"In order to achieve the said avowed goal as quoted by Saint Thiruvalluvar, the State Government, being the welfare State, must be in a position to protect its citizens, especially, in the present context, its employees and erstwhile employees, from all health issues. Therefore the obligation of the State Government and their duty towards achieving this goal cannot be abdicated on any flimsy or technical reasons."

Court said that the State Government's obligation cannot be easily given up or washed away in the manner it has been done in these cases and it is of the considered view that, none of the impugned orders passed in the batch of cases before it, are sustainable.

It relied on a number of judgments besides judgment of Supreme Court in Shiva Kant Jha v. Union of India reported in (2018) 5 MLJ 317 (SC) wherein Apex Court held that "the right to medical claim cannot be denied merely because the name of the hospital is not included in the Government Order. The real test must be the factum of treatment. Before any medical claim is honoured, the authorities are bound to ensure as to whether the claimant had actually taken treatment and the factum of treatment is supported by records duly certified by Doctors / hospitals concerned. Once it is established, the claim cannot be denied on technical grounds."

Directions

Court passed the following directions:

• All the impugned orders in the respective writ petitions in this batch of cases, are quashed.
• The writ petitions where impugned orders are quashed as well as the writ petitions where mandamus sought for, are hereby remanded with directions to the concerned District Level Empowered Committee, before whom, these matters shall be placed and the Committee shall reconsider every individual case.
• While reconsidering, the Committee shall not reject any claim merely on the reason of non-network hospital or non listed disease.
• The Committee, wherever possible, shall give suitable direction to the Insurance Company to reimburse the claim made by the respective claimant / employee / pensioner.
• If the Committee finds some cases where the Insurance Company cannot be directed to reimburse, in those cases, suitable orders shall be passed directing/recommending the State authorities to reimburse the claim under Medical Attendance Rules.
• Once such orders are passed, the Insurance Company shall immediately reimburse the medical claim with 6% interest from the date of due till date of payment, within a period of thirty days from the date of receipt of such order to be passed by the Empowered Committee of the District concerned.
• On receipt of such orders/recommendation from the Empowered Committee, the Sanctioning authority / State authority / High Power Committee in the State Level shall pass necessary orders allowing the medical reimbursement claimed by the individual claimant/employee/ pensioner under the Medical Attendance Rules.
• While ordering medical reimbursement under Medical Attendance Rules, the rate approved, accepted or quoted by the Insurance Company under the Medical Insurance Scheme shall be taken as the rate and by calculating the reimbursement on the said rate, the reimbursement claim shall be immediately sanctioned and the amount shall be reimbursed to the claimant with 6% interest form the date of due till date of payment, within a period of thirty days from the receipt of the recommendation /order from the District Empowered Committee.

Petitioners were represented by advocate T.Lajapathi Roy and respondents by AAG B.Pugalendi assisted by S.Srimathy.

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