WP/31521/2022 of M.Muthusamy Vs The Joint Director cum Grievance Redressal Office on 28 September 2026

ORDER

The present writ petition has been filed under Article 226 of the Constitution of India, praying for issuance of a Writ of Mandamus, directing the respondents to pay the petitioner a sum of Rs.4,12,590/-, together with the sanctioned amount of Rs.74,096/-, towards reimbursement of medical expenses under the Government of Tamil Nadu Health Insurance Scheme, 2018 for pensioners, as per G.O.Ms.No.222, Finance (Pension) Department, dated 30.06.2018, without any further delay.

2. The learned counsel for the petitioner would submit that she is the spouse of the pensioner and that she was admitted in Gem Hospital Institute of Gastroenterology and Laparoscopy, Coimbatore, for hernia operation on 15.12.2020. It is her submission that she has spent a sum of Rs.5,59,686/- towards her medical expenses. It is the further submission of the petitioner that she is eligible to have medical reimbursement as per the New Health Insurance Scheme 2018 for pensioners (including spouse/family pensioners) as per G.O.Ms.No.222, Finance (Pension) Department, dated 30.06.2018.

3. The learned counsel would submit that, according to the above G.O., the maximum limit at the ceiling criteria for the block period of four years for the surgery undertaken by the patients under Annexure-I A, wherein under Serial No.54, the surgery for various hernias are referred to. By placing reliance upon the above surgery, the learned petitioner counsel would submit that the petitioner is entitled for a maximum reimbursement up to the amount of Rs.7,50,000/- [Rupees seven lakhs fifty thousand only], whereas, in the case in hand, though the petitioner has spent only five lakhs and all, the respondent has settled initially for a sum of Rs.74,000/-. Therefore, it is also her contention that the District Treasury Officer/3rd respondent has already recommended her case to settle the remaining amount as per the letter dated 25.08.2021 to the insurance company, namely, the United India Insurance Company Ltd.,/4th respondent herein. But, in spite of such recommendations, the 4th respondent has not settled the balance amount to the petitioner. Hence, the learned counsel for the petitioner prays to issue a writ of mandamus.

4. In support of her contention, she also relies upon the judgment of this Court in W.P.(MD) No.19354 of 2021, dated 28.02.2022 [K.A. Jeya Sheela vs. The Secretary to Government, Finance (Pension) Department, and others].

5. This contention was totally objected to by the learned Standing Counsel appearing for the 4th respondent and would contend that the petitioner had taken treatment for UMBILICAL Hernia at Gem Hospitals, Institute of Gastroenterology and Laparoscopy, Coimbatore, for which an initial sum of Rs.73,000/- was approved on a cashless basis and thereafter, on the recommendations of the District Level Empowered Committee, a further sum of Rs.74,096/- was reimbursed to the petitioner. Thus, in all, a sum of Rs.1,47,096/- was paid to the petitioner.

6. It is the submission of the learned Standing Counsel for the 4th respondent that the amount would be settled as per the package rate and, apart from the package rate, the petitioner is also entitled for a mesh cost, stapler charges and consumable items. Except the above amount, the petitioner is not entitled for any other amount. Therefore, the prayer sought for by the petitioner to settle the remaining amount does not arise. Hence, prays to dismiss the present writ petition.

7. However, the learned Special Government Pleader would contend that the petitioner's claim has been considered by the District Collector in line with the guidelines of G.O.Ms.No.222, Finance (Pension) Department, dated 30.06.2018, and that it was forwarded by the Treasury Officer and the Treasury Officer, in turn, forwarded it to the insurance company. If at all any amount is due, it is the insurance company to settle the petitioner. Hence, prays to pass appropriate orders.

8. I have given my anxious consideration on either side's submission.

9. The main contention put forth by the learned Standing Counsel for the 4th respondent is that, notwithstanding the total expenditure, the amount which the claimant is eligible for is only in accordance with the package charges. In this regard, he also relies upon certain Excel sheets.

10. However, the learned petitioner's counsel would invite the attention of this Court in respect of the guidelines provided for reimbursement of the mediclaim amount, wherein under Clause 10, Medical Assistance, (3) Ceiling Criteria has been defined. Similarly, Clause 11(1), the settlement of claims by Insurance Company/Third Party Administrator [TPA], has been dealt with. Paragraph Nos.10(3) and 11(1) of the said Government Order read as under: “10. Medical Assistance.-

(3) Ceiling Criteria: The benefit will be on floater basis i.e. the total coverage upto Rupees Four Lakh in respect of all Eligible Medical Expenses incurred towards approved treatments and surgeries as in the Annexure-I and Rupees Seven Lakh and Fifty Thousand in respect of specified treatments and surgeries as in the Annexure-I A to these Guidelines can be availed of individually or collectively by the Pensioner, his/her spouse and eligible dependent during the said block of four years with no restriction on the number of times of availing. In any case, maximum limit of assistance admissible per Pensioner (including spouse and eligible dependent) / Family Pensioner shall not exceed Rupees Seven Lakh and Fifty Thousand.”

And

11. Settlement of Claims by Insurance Company/Third Party Administrator [TPA].-

(1) The medical assistance shall be on CASHLESS basis for the Eligible Medical Expenses incurred subject to the Ceiling Criteria for approved treatments taken and surgeries undergone during Hospitalisation in any of the empanelled Network Hospitals and no payment for any of the Eligible Medical Expenses need to be made by the Beneficiary. In case, payment has been made by the Beneficiaries either at the instance of the hospital or otherwise for any of the Eligible Medical Expenses, including in a case where pre authorization has been sought but wrongly denied or claim under CASHLESS facility has been restricted, the Insurance Company shall be required to make cash reimbursement of the same, subject to the Ceiling Criteria along with interest at 12% per annum calculated on monthly basis for the period from the date of payment to the hospitals by the Beneficiary and the date of reimbursement of Eligible Medical Expenses upon submission of claims by the Beneficiary after following the process stated in clause 15 of these Guidelines.”

11. While conjointly reading the above provisions harmoniously, what would emerge is that the claimant is entitled to have a maximum ceiling limit within the block period of four years and, if there is any delay, then the claimant is entitled to have interest at the rate of 12% per annum.

12. In the case in hand, the learned counsel has invited the attention of this Court in respect of the Annexure attached to the above guidelines and, according to Annexure-I A, under Serial No.54, the surgeries for various Hernias are defined. Therefore, it is construed that, under the ceiling criteria referred to in Clause 10(3), the petitioner is eligible to have a maximum reimbursement up to the level of Rs.7,50,000/-, whereas the petitioner's total expenditure, according to the document submitted in the writ petition, is only Rs.5,59,686/-.

13. However, it is the specific contention of the learned counsel for the petitioner that the District Treasury Officer/3rd respondent herein had already recommended to the insurance company, namely, the United India Insurance Company Ltd./4th respondent herein, to settle the balance amount in respect of the guidelines. However, the 4th respondent has not settled the same.

14. Considering the fact, and as per the guidelines, the maximum amount entitled for the petitioner for the surgery undertaken, namely, the Hernia, is Rs.7,50,000/-. However, according to the respondent, so far the petitioner was settled a sum of Rs.1,47,096/-. The remaining amount, according to the guidelines, the petitioner is entitled to be reimbursed.

15. At this juncture, the objection raised by the 4th respondent in respect of the package rate is to be considered.

16. In this regard, it is relevant to refer to the judgment relied upon by the learned counsel for the petitioner in K.A. Jeya Sheela case [cited supra], wherein this Court has, in categorical terms, held that any restrictions contrary to G.O.Ms.No.222, Finance (Pension) Department, dated 30.06.2018, would defeat the very purpose and the claimants are entitled to have the reimbursement in accordance with the guidelines.

17. Therefore, this Court is of the firm view that, notwithstanding any indications in G.O.Ms.No.222 in respect of the package rate, the contention put forth by the 4th respondent that they would settle only in accordance with the package rate cannot be accepted at all. However, this Court does not go into that aspect deeper, as the petitioner seeks that her claim had already been rightly considered by the 3rd respondent and has been recommended to the 4th respondent, and that the 4th respondent has not settled the same in terms of G.O.Ms.No.222, Finance (Pension) Department, dated 30.06.2018.

18. Therefore, in such view of the peculiar aspect and in view of the above detailed discussion, this Court finds justification to issue a mandamus to the 4th respondent to disburse the amount as per the recommendations made by the 3rd respondent vide letter dated 25.08.2021, in accordance with the guidelines under Ceiling Criteria and Settlement of Claims, mentioned in G.O.Ms.No.222, Finance (Pension) Department, dated 30.06.2018, within a period of eight weeks from the date of receipt of a copy of this order. It is also relevant to mention that the petitioner is entitled to have 12% interest per annum in accordance with the above guidelines, upon this amount is due.

19. In view of the above, the present writ petition is disposed of. There shall be no order as to costs. 28-09-2026 Index: Yes/No Speaking/Non-speaking order Neutral Citation: Yes/No JRS To

1. The Joint Director cum Grievance Redressal Officer, Rural Health Medical Services, Tirunelveli District.

2. The Commissioner, Treasury and Accounts Department, No.9, Jones Road, Saidapet, Chennai-600 015.

3. The Treasury Officer, District Treasury, Kokirakulam, Tirunelveli-627 009.

4. The Zonal Manager, United India Insurance- Company Ltd., Divisional Office-VI, PLA Rathna Towers, 5th Floor, No.212, Anna Salai, Chennai-06.

5. The Public Prosecutor, High Court of Madras.

C.KUMARAPPAN J. JRS WP No. 31521 of 2022 28-09-2026