(Prayer: Writ Petition is filed under Article 226 of the Constitution of India, praying to issue a Writ of Certiorarified Mandamus, to call for the records of the second respondent vide its letter dated 20.04.2016 and quash the same and direct the second respondent reimburse the medical claim of the petitioner for a sum of Rs.1,66,595/- (Rupees One Lakh Sixty Six Thousand Five Hundred and Ninety Five Only) along with 24% p.a interest, within the time frame as may be fixed by this Court.)

1. Heard the learned counsel for the petitioner and the learned Government Advocate appearing on behalf of the respondents 1,3 and 4 and the learned Standing Counsel for the second respondent and perused the records.

2. The petitioner, by the present writ petition, has assailed the action of the second respondent in issuing impugned proceedings dated 20.04.2016 by which the claim for reimbursement of medical expenses submitted by her has been rejected by the second respondent on the ground that the petitioner had obtained treatment in a non-network hospital and thus, she is not entitled for reimbursement.

3. Petitioner contends that she had served as Record Clerk in the office of the Inspector General of Prison, Government of Tamil Nadu, Egmore, Chennai and took Voluntarily Retirement from the service with effect from 09.08.2001; that on being relieved from service, she was made eligible/entitled to avail all the retirement benefits for the service rendered by her with the Government of Tamil Nadu.

4. Petitioner contends that the first respondent had made a provision for medical insurance under the Tamil Nadu Government Pensioners Health Fund Scheme, 1995; and the amount payable for providing insurance coverage was recovered on monthly basis.

5. It is the further case of the petitioner that on 17.08.2015, she had met with a road accident, which resulted in severe injuries to her right leg and while she was lying on the road side with severe pain and become unconscious, she was taken to the nearby hospital for first aid and then shifted to M/s.Agada Hospital, T.Nagar, Chennai and was admitted in casualty for emergency treatment.

6. It is the further case of the petitioner that the Doctors at the said hospital after diagnosis, had found that right femur had got fracture and was advised to undergo immediate surgery and accordingly, surgery was performed on 18.08.2015; and that the surgery performed was “open reduction internal fixation using distal femoral locking compression plate and screw”; that the petitioner was treated as inpatient on 25.08.2015 and was discharged; that at the time of discharge, the petitioner had settled the hospital bills amounting to Rs.1,66,595/- (Rupees One Lakh Sixty Six Thousand Five Hundred and Ninety Five Only) by herself.

7. Petitioner further contends that the petitioner having incurred the aforesaid expenses for getting herself treated for the injuries sustained by her in an accident, had approached the respondent authority and submitted a representation on 09.09.2015 enclosing therewith the hospital bills and sought for reimbursement of the said medical expenses incurred as she is covered by the Health Fund Scheme of the respondent.

8. It is the further case of the petitioner that the aforementioned representation submitted by the petitioner was forwarded by the third respondent to the District Level Empowered Committee for its decision on 21.09.2015 as well as to the Joint Director of Medical and Rural Health Services (DMS) ie., fourth respondent; and that the District Level Empowered Committee in its meeting held on 19.02.2016 after perusing the documents submitted by her seeking reimbursement, had declared that since, she had taken treatment at a hospital which is not in the approved list ie., non network hospital and that the treatment taken by her is not a life saving treatment and directed the petitioner to approach the second respondent.

9. It is the further case of the petitioner that she had approached the second respondent thereafter on 07.03.2016 and submitted her claim for reimbursement and the second respondent by its letter dated 23.03.2016 had intimated that as per the G.O.Ms.No.171 dated 26.06.2014 issued by the Government of Tamil Nadu, the procedure for taking treatment under NHIS – 2014 emphasis that the payment will be made to the hospitals only for approved treatment procedures mentioned in the said G.O and rejected the claim of the petitioner as the hospital in which the petitioner had availed the treatment is not an approved hospital under the scheme.

10. Petitioner further contends that thereafter once again on 09.09.2015, she had approached the second respondent and gave another representation to reconsider the request for reimbursement and the same was forwarded to the District Level Empowered Committee for consideration on 21.09.2015; and that the District Level Empowered Committee (DLEC) vide its letter dated 07.03.2016 recommended for reimbursement; and that the petitioner thereafter on the basis of the aforementioned recommendation, approached the second respondent for reimbursement.

11. It is further contended by the Petitioner that despite the DLEC on 07.03.2016 recommending for reimbursement, the second respondent had rejected the claim for reimbursement summarily on 20.04.2016 by the impugned proceedings which action of the respondents 1, 3 and 4 and the second respondent through whom an employee is covered under the Health Fund Scheme, is challenged.

12. Per contra, learned Government Advocate appearing on behalf of the respondents 1, 3 and 4 submits that since, the claim of the petitioner has been rejected by the second respondent under the impugned proceedings dated 20.04.2016 and the Hon’ble Division Bench of this Court by its decision dated 28.05.2019 in W.P.(MD).No.13429 of 2013 and batch had set aside the order impugned therein whereby the claim for medical reimbursement has been rejected, and remanded the matter back to the District Level Empowered Committee to reconsider every individual case. Learned Government Advocate would also submit that the Hon’ble Division Bench of this Court further directed that the Committee, while reconsidering, shall not reject any claim merely on the reason of treatment being availing in a non network hospital or for a non listed disease.

13. The learned Government Advocate further submits that since, the petitioner also stands on the same footing as considered by the Hon’ble Division Bench of this Court in the aforesaid case, this Court may set aside the impugned proceedings, and direct the petitioner to submit a fresh representation to the District Level Empowered Committee along with all the supporting bills; and that the District Level Empowered Committee be directed to decide the claim for medical reimbursement in terms of the direction contains in the aforesaid order of this Court.

14. The learned Standing Counsel for the second respondent by placing reliance on the decision of this Court in W.A.(MD).No.480 of 2019 and batch dated 26.02.2010 would contend that as per the agreement entered into by the second respondent with the State Government, the Insurance Company would be liable for reimbursement, only if treatment is availed in the net work hospital.

15. I have taken note of the respective contentions as urged.

16. At the outset, it is to be noted that the Hon’ble Supreme Court in the case of Shiv Kant Jha Vs, Union of India reported in (2018) 16 SCC 187 had held as under:-

                   “17. It is a settled legal position that the government employee during his lifetime or after his retirement is entitled to get the benefit of the medical facilities and no fetters can be placed on his rights. It is acceptable to common sense, that ultimate decision as to how a patient should be treated vests only with the doctor, who is well versed and expert both on academic qualification and experience gained. Very little scope is left to the patient or his relative to decide as to the manner in which the ailment should be treated. Speciality hospitals are established for treatment of specified ailments and services of doctors specialised in a discipline are availed by patients only to ensure proper, required and safe treatment. Can it be said that taking treatment in speciality hospital by itself would deprive a person to claim reimbursement solely on the ground that the said hospital is not included in the government order. 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. Clearly, in the present case, by taking a very inhuman approach, the officials of CGHS have denied the grant of medical reimbursement in full to the petitioner forcing him to approach this Court.”

17. Further, though on behalf of the second respondent, it was sought to be contended that since the agreement provides for reimbursement if only the treatment is taken in the network hospital, the said contention of the second respondent would not be valid in the light of the decision of the Hon’ble Division Bench of this Court dated 28.05.2019 wherein this Court had held that the claim cannot be rejected on the ground of treatment being availed in the non-network hospital.

18. Since, the aforesaid decision of the Hon’ble Division Bench of this Court binds this Court and as the petitioner’s claim for reimbursement had been rejected earlier i.e., prior to the order of the Hon’ble Division Bench of this Court dated 28.05.2019, this Court is of the view that the impugned proceedings as issued by the second respondent refusing for reimbursement of the medical claim of the petitioner cannot be sustained.

19. Accordingly, the impugned proceeding of the second respondent dated 20.04.2016 is set aside and the matter is remitted back to the District Level Empowered Committee to consider the claim of the petitioner for reimbursement of medical expenses incurred by her for availing treatment for the injuries suffered by her in an accident.

20. However, due to the passage of time, the petitioner is directed to approach the District Level Empowered Committee and submit a fresh representation enclosing therewith all the supporting medical bills in respect of her claim and the District Level Empowered Committee is directed to take further action in terms of the direction contained in the order of this Court dated 28.05.2019 in W.P.(MD).No.13429 of 2013 and batch, as expeditiously as possible preferably within a period of eight weeks from the date of petitioner submitting her representation.

Accordingly, this Writ Petition is disposed of. Consequently, connected Miscellaneous Petition is closed. No costs.