New Health Insurance Scheme for Employees and Pensioners - Court Cases - judgement issued for batch cases Guidelines for reimbursement of medical claims under the New Health Insurance Scheme Clarification issued by Government Communicated - Reg

New Health Insurance Scheme for Employees and Pensioners - Court Cases - judgement issued for batch cases Guidelines for reimbursement of medical claims under the New Health Insurance Scheme Clarification issued by Government Communicated - Reg.
The Government, Finance (Pension) Department, Letter No.19022/Pension/2021-1, Dated 29.04.2021.
Kind attention is invited to the references cited. In the reference 4 cited, the Government has framed and issued the guidelines for implementation of New Health Insurance Scheme for Employees and Pensioners in order to implement the orders of the Hon'ble Madurai Bench of Madras High Court in 91 Batch cases and also similar such cases ordered in the various judgments.
The Government guideline deals with four scenarios under which the Employees and Pensioner/Family Pensioner appeal to the Appellate Committee for reimbursement under NHIS namely:
For an approved treatment / surgery undertaken in a Network hospital, either a part of the claim or no claim has been settled by the Insurance Company For an approved treatment / surgery undertaken in a Non-Network hospital for Emergency Care or following an accident.
For an unapproved treatment / surgery undertaken either in Network hospital or Non Network hospital for Emergency Care or following an accident. For an any treatment / surgery undertaken either in a Non-Network hospital for Non emergency care (or) for an unapproved treatment / surgery undertaken in a Network IV.
hospital for Non-emergency care.
In the guidelines it is stated that in respect of the medical claims pertaining to scenario IV i.e unapproved treatment / surgery undertaken in a Network hospital under normal circumstances (ie., Non-emergency case) and approved unapproved treatment/surgery undertaken in a Non-Network hospital under normal circumstances (ie, Non-emergency case), the guidelines will be issued separately.
In this regard, in the 5th and 6th cited, the Treasury Officers Concerned have been requested to take necessary action to implement the Hon'ble Court direction in respect of batch of 91 cases and other direction cases by placing the petitioner's case in the District Level Empowered Committee for reconsideration and to pass appropriate orders as per the Government guidelines for implementation of New Health Insurance Scheme for Employees and Pensioners. In the reference 7th cited, it is reiterated that in light of various judgements of Hon'ble High Courts, the Government has decided to consider and examine all the medical claims pertaining to unapproved treatment / surgery undertaken in Network Hospital under normal circumstance (ie Non-emergency case) and approved and unapproved treatment / surgery undertaken in Non-Network Hospital under normal circumstance i.e. Non-emergency case), under TN Medical Attendance Rules and reimburse medical claims as per the rates indicated under the Tamil Nadu Medical Attendance Rules.
Further, the Government have requested this Commissionerate to issue suitable instructions to all the subordinate officers to process the cases under Scenario-4 under Tamil Nadu Medical Attendance Rules duly consolidated and send necessary proposals to Government for issuing necessary orders in this regard. Therefore, the Treasury Officers/PPO, Chennai are requested to process the cases comes under Scenario-4 under the Tamil Nadu Medical Attendance Rules to finalize the recommendation of DLEC and send necessary reports based on the above said Government instructions to this Commissionerate for further action. In this regard, it is informed that in respect of NHIS for Employees, the Committee shall issue orders for reimbursement recommending to the Head Office/Head of Department/Administrative Department of Secretariat Concerned (under whom employee is serving/served and service register is maintained) to pass final orders on the application of the petitioner as per the Tamil Nadu Medical Attendance Rules to reimburse the medical expenses incurred by the employee and in respect of NHIS for Pensioners, the Committee shall issue orders for reimbursement recommending the Treasury Officer/ PPO, Chennai (under whom the Pensioner Family Pensioner is being paid pension/family pension and the Pension Payment Order is maintained) and the Treasury Officer/PPO
Chennai are requested to send copy of all the medical documents to this Commissionerate along with pension payment order to process the application of the petitioner as per the Tamil Nadu Medical Attendance Rules to reimburse the medical expenses incurred by the pensioners.
This may be treated as "Most Urgent".