Case Title: C Mani v Principal Secretary to Government of Tamil Nadu
Summary
The Madras High Court has reaffirmed that a medical claim cannot be denied solely based on the treatment being administered at a non-networking facility, as noted by Justices SM Subramaniam and V Lakshminarayanan. The court stated that the treatment completed at a non-network hospital is no longer a res-integra issue in relation to the settlement of the medical claim. The court revoked the order and instructed the insurance company to resolve the eligible medical reimbursement under the scheme within six weeks. The case highlights the importance of addressing disputes regarding the genuinity of treatment in medical claims.
About the case
Madras High Court recently reaffirmed that a medical claim could not be denied solely on the basis that the treatment was administered in a non-networking facility.
The medical claim could not be rejected when there was no dispute regarding the treatment and the treatment was determined to be genuine, as noted by Justices SM Subramaniam and V Lakshminarayanan.
“The treatment completed at a non-network hospital is no longer a res-integra issue in relation to the settlement of the medical claim.” Several orders have been issued by the courts to resolve the medical reimbursement claim and not to deny it solely on the basis that the hospital is not included in the network of hospitals, the court stated.
One C Mani, who had retired from the position of Chief Administrative Officer at the Principal District Court in Pudukkottai, was a member of the Medical Health Scheme and was paying his subscriptions on a regular basis. The court was currently hearing his petition. In order to address a left renal tumor, Mani underwent surgery and incurred a cost of Rs. 1,24,576. Allegedly, the Director of Health and Rural Services denied his application for medical reimbursement due to the fact that the treatment was administered at a non-network facility.
The Insurance company notified that the Director of Health and Rural Services had issued the order of rejection and emphasized that the medical claim could only be resolved if treatment was administered at a network hospital. The rejection was justified due to the fact that the hospital in which Mani received treatment was a non-network hospital.
In response, the court noted that there was no justification for declining medical reimbursement solely on the basis that the treatment was administered at a non-network facility when there was no dispute regarding the genuinity of the treatment.
The court therefore determined that it was appropriate to revoke the impugned order and instructed the insurance company to resolve the eligible medical reimbursement under the scheme within six weeks.
