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

Madras High Court ruled in Marimuthu v. Government of Tamil Nadu that medical reimbursement claimed by the employees and pensioners or their family members is not the bonus or bounty. It noted that since it has been made compulsory that, every employee or pensioner of the State Government must join in the Health Insurance Scheme by paying a continuous contribution towards premium every month, the State Government cannot easily abdicate their duty and responsibility by merely rejecting the case of the medical reimbursement claim on technical grounds. "[…] 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...

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

Shayesta Nazir

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