Case Note & Summary
The petitioner, P. Ravi, a Head Constable serving in the Tamil Nadu Police Department, filed a writ petition under Article 226 of the Constitution of India seeking a writ of mandamus to direct the United India Insurance Company Limited (respondent 3) and MD India Healthcare Services (TPA) Pvt Ltd (respondent 4) to reimburse a sum of Rs.2,72,406/- towards his medical claim under the Government of Tamil Nadu New Health Insurance Scheme 2021 (NHIS 2021). The petitioner was a beneficiary of the scheme introduced vide G.O.Ms.No.160, Finance Department, dated 29.06.2021. He underwent Aorto Bi-Iliac Bypass surgery with bifurcation grafting at Velammal Medical College Hospital, Madurai, an empanelled network hospital under the scheme. The ailment was a listed disease covered under the scheme, which provides coverage up to Rs.5,00,000/- per employee. Despite being eligible for cashless treatment, the hospital raised a total bill of Rs.3,73,494/-. The insurance company sanctioned only Rs.1,01,088/- and denied the balance of Rs.2,72,406/-. The petitioner made a representation on 26.08.2022 seeking reimbursement, but it was not considered. The court considered the submissions of the petitioner, the respondents, and the amicus curiae. The court held that the denial of cashless treatment does not extinguish the petitioner's right to reimbursement under the scheme. The court directed the insurance company and TPA to reimburse the amount of Rs.2,72,406/- with interest at 6% per annum from the date of representation (26.08.2022) till the date of payment, within eight weeks. The court also directed the hospital to cooperate in providing necessary documents.
Headnote
A) Health Insurance - Reimbursement - Cashless Facility Denial - New Health Insurance Scheme 2021, G.O.Ms.No.160, Finance Department, dated 29.06.2021 - Petitioner, a government employee, underwent Aorto Bi-Iliac Bypass surgery at an empanelled network hospital. The insurance company and TPA denied cashless treatment but the court held that the denial does not extinguish the right to reimbursement. The court directed the insurance company and TPA to reimburse Rs.2,72,406/- with 6% interest from the date of representation (26.08.2022) till payment. (Paras 2-10) B) Health Insurance - Interest on Delayed Payment - New Health Insurance Scheme 2021 - The court awarded interest at 6% per annum on the reimbursable amount from the date of the petitioner's representation (26.08.2022) till the date of actual payment, as the delay in reimbursement was unjustified. (Para 10) C) Writ Jurisdiction - Contractual Claims - Article 226 of the Constitution of India - The court entertained the writ petition for reimbursement under a government health insurance scheme, holding that the scheme creates a public law obligation and the writ remedy is maintainable for enforcement of such obligations. (Para 1)
Issue of Consideration
Whether the petitioner is entitled to reimbursement of medical expenses under the New Health Insurance Scheme 2021 despite the denial of cashless treatment by the insurance company and TPA.
Final Decision
The court allowed the writ petition and directed respondents 3 and 4 to reimburse the petitioner a sum of Rs.2,72,406/- with interest at 6% per annum from the date of representation (26.08.2022) till the date of payment, within eight weeks from the date of receipt of a copy of the order.
Law Points
- Reimbursement entitlement under health insurance scheme
- Cashless facility denial does not bar reimbursement
- Scheme coverage for listed diseases
- Interest on delayed payment
- Writ jurisdiction for contractual claims
