(Prayer: Petition filed under Article 226 of the Constitution of India, praying for the issuance of a Writ of Certiorarified Mandamus, calling for the records connected with impugned order passed by the 3rd respondent in his proceedings O.Mu.No.163/1/2016 M1 dated 20.7.2016 and quash the same and consequently direct the respondents to Reimburse Rs.1,15,569/- (Rupees one Lakhs fifteen thousands five hundred and sixty nine only) being the actual medical expenditure incurred by the petitioner for the treatment given to the petitioner's husband for the brain problem diagnosed as OLD CVA/Multiinfarcstate/SeverCystitis/Prostatomegaly undergone by the petitioner's husband in LAKSHMANA Multi Speciality Hospital, Madurai, within a specified period that may be fixed by this Hon'ble Court.)
1. The petitioner retired from service as P.G. Assistant on 30.04.2012; after retirement, she is receiving pension till date and from the pension, she is contributing Rs.150/- per month towards Pensioners Health Fund Scheme; deduction of Rs.150/- is made compulsorily; as per the New Health Insurance Scheme for Pensioners and as per G.O.462, dated 27.12.2013, the petitioner is entitled to claim a sum of Rs.2,00,000/- for the Block year 01.07.2014 to 30.06.2018; the petitioner admitted her husband at Lakshmana Multi Speciality Hospital for Brain problem on 23.03.2016 and got him discharged on 01.04.2016; in that process, she incurred expenditure of Rs.1,15,569/- towards the treatment of her husband; representation dated 29.04.2016 was submitted to the 3rd respondent along with the medical bills and other documents, claiming reimbursement of the said amount; the 3rd respondent has rejected the same on the ground that the hospital in which the petitioner's husband was treated, is not a net-worked or approved hospital under the scheme and therefore, the petitioner has filed this writ petition challenging the rejection of medical reimbursement and claiming the benefits.
2. The impugned order dated 20.07.2016 has been passed on two grounds based on which, the claim of the petitioner has been negatived.
(i) The hospital in which the petitioner's husband took treatment is not an approved hospital under the scheme.
(ii) The treatment under the scheme is a cashless treatment. As the petitioner has already made payment, her request for reimbursement has been ordered to be returned by the District Level Empowered Committee.
3. The contention of the respondent that medical reimbursement would not be granted in cases where treatment is taken in a non-network hospital has been tested and the said contention has been rejected in several cases.
4. In a decision reported in 2016 (3) CTC 394 in the case ofN.Raja vs. The Government of Tamil Nadu, the contention that the petitioner therein was treated in a hospital which is a non listed hospital, was not accepted by this Court and in that case, the Government was directed to sanction and reimburse medical expenses (incurred by the petitioner for his treatment) with 9% interest, from the date of remittance of the amount to the Hospital by the petitioner to till the date of payment. Facts and circumstances of the present case are also similar to the abovesaid decision and therefore, the said decision squarely applies to this case also.
5. So far as the contention that when the petitioner is entitled to get cashless treatment, the petitioner ought not to have paid cash to the hospital and then to ask for reimbursement, it is relevant to consider the averments made in the representation dated 29.04.2016. It is stated that as her husband became mute, having lost the memory power, there was an emergency situation. It is alleged that when the I.D card was shown, the hospital administration replied to her, saying that the Health Insurance Scheme did not cover their hospital and hence, she has to pay the money compulsorily.
5.1. This explanation is plausible and acceptable. If at all the treatment is provided under the cashless scheme, nobody would be inclined to pay the cash and then ask for reimbursement. The payments are made only under coercive circumstances. Therefore, rejection of re-imbursement on the ground that cash is paid in a cashless scheme is unreasonable and it is liable to be set aside.
6. Further, the Government have also issued orders in G.O.No.477, Finance (Pension) Department, dated 30.09.2009, delegating the powers to the Director of Pension, for sanction of assistance, for Specialised surgery / treatment undergone in unaccredited hospitals Specialised surgery / treatment not included in the accredited list and the said G.O is extracted hereunder:-
''FINANCE (PENSION) DEPARTMENT
G.O. No.477, Dated 30th September, 2009
(Puratasi-14, Thiruvalluvar Aandu 2040)
Pension Tamil Nadu Government Pensioners Health Fund Scheme 1995 Specialised surgery / treatment undergone in unaccredited hospitals Specialised surgery / treatment not included in the accredited list - Sanction of assistance - Delegation of powers to the Director of Pension - Orders Issued.
1. G.O. (Ms) No. 562, Finance (Pension) Department, dated 11.07.1995
2. G.O. (Ms) No. 207, Finance (Pension) Department, dated 22.04.1997
3. G.O. (Ms) No. 378, Finance (Pension) Department, dated 13.10.2005
4. G.O. (Ms) No. 128, Finance (Pension) Department, dated 12.04.2007
5. G.O. (Ms) No. 440, Finance (Pension) Department, dated 13.09.2007
6. G.O. (Ms) No. 458, Finance (Pension) Department, dated 21.09.2007
7. G.O. (Ms) No. 50, Finance (Pension) Department, dated 19.02.2008
1. The Government in their order first read above had constituted a fund called, Tamil Nadu Government Pensioners Health Fund to provide financial assistance to pensioners for undergoing certain specialized treatments / surgeries included in the approved list, in certain accredited list of hospitals under the Scheme. In the Government Order third read above, revised consolidated orders were issued showing list of diseases and list of accredited private hospitals for availing assistance by the pensioners under this scheme. In the Government Order fourth, fifth, and seventh read above, some new hospitals have been approved for availing assistance for the specialities under this scheme.
2. In the Government Order sixth read above, orders were issued that pensioners who undergo specialized advanced surgeries / treatments in respect of diseases which are included in the list approved under the Tamil Nadu Government Pensioners Health Fund Scheme in unaccredited hospitals shall also be eligible for sanction of assistance subject to the certification of the District Medical Officer concerned in the Districts / Director of Medical Education, as the case may be, regarding the existence of facilities and infrastructure for the treatment / surgery in the hospital.
3. The Director of Pension has stated that the pensioners who have taken treatment in unaccredited private hospitals or who have taken treatment for the diseases other than those given in the approved list or who have taken treatment in unaccredited institutions of other States are moving Court and get favourable orders to consider such cases for sanction by Government. In order to implement the Court orders, Government issues relaxation orders, sanctioning the claims and permitting the Director of Pension to admit such claims of unapproved treatments and unaccredited institutions in the case of respective pensioners who won cases and payment is made by Director of Pension accordingly.
4. The Director of Pension has also stated that the Hon ble High Court has observed in various judgements that mode of treatment is at the discretion of the Doctors and the departments cannot insist particular mode of treatment alone can be taken by the patient and that the pensioners cannot be imposed any condition that a particular type of treatment alone should be taken or the treatment should be taken in a particular hospital .
5. The Director of Pension has therefore requested for delegation of powers to him for sanction of assistance under Tamil Nadu Government Pensioners Health Fund Scheme towards treatments not approved and not listed in the G.O.(Ms)No.378, Finance (Pension) Department, dated 13.10.2005 and also for treatments taken in institutions of other States in order to reduce hardship to the pensioners from moving Court often (on rejection of the proposals).
6. The Government, after careful consideration of the request of the Director of Pension in paragraph 5 above, pass the following orders:-
The Director of Pension is delegated with powers to sanction pending claims as well as future claims for medical assistance from the pensioners in respect of ineligible treatments as well as eligible treatments taken in unaccredited institutions, both within the State as well as outside the State, subject to the following procedure: -
In respect of treatments taken in unaccredited hospitals within the State
Procedure prescribed in para 4 (i) (a) of the G.O. sixth read above shall be continued.
In respect of treatments taken in unaccredited hospitals outside the State
The Pension Pay Officer / District Treasury Officer/ Sub-Treasury Officer / Branch Manager of Public Sector Banks after satisfying about the details furnished in the application received in his office shall send the claim direct to the Director of Pension within a week. However, certification from the District Medical Officer / Director of Medical Education need not be insisted in respect of Hospitals outside the State.
7. The other terms and conditions of the scheme shall remain unchanged.
(By order of the Governor)
Principal Secretary to Government''
7. In the said G.O., it has been stated that in respect of treatments taken in unaccredited hospitals within the State, procedure prescribed in para 4(i)(a) of G.O(Ms)No.458, Finance (Pension) Department, dated 21.09.2007 shall be continued. It is pertinent to extract below paragraph 4(i)(a) of G.O.(Ms)No.458:-
''The Pension Pay Officer / District Treasury Officer / Sub-Treasury Officer / Branch Manager of the Public Sector Bank after satisfying himself about the details furnished in the application received in his office, shall consult the District Medical Officer attached to the Government Hospitals under the control of Director of Medical and Rural Health Services in the District and the Director of Medical Education in Chennai as the case may be, who shall certify the existence of facilities and infrastructure for the treatment / surgery undergone in the hospital and through Pension Pay Officer / Treasury Officer / Sub-Treasury Officer / Branch Manager of the bank concerned shall send the claim to Director of Pension within a week.''
8. In the light of the decision in N.Raja's case(supra), the impugned order is set aside and the respondents are directed to sanction and reimburse the medical expenses incurred by the petitioner for the treatment of her husband with 9% interest, from the date of remittance of the amount to the Hospital by the petitioner to till the date of payment, within a period of four weeks from the date of receipt of a copy of this order.
With the above direction, this Writ Petition stands allowed. No costs.