Medical Reimbursement Cannot Be Denied Because Insured Underwent Treatment In A Hospital Not Approved By Insurer: Kerala HC

The Kerala High Court has reiterated that medical reimbursement cannot be denied because the insured underwent treatment in a hospital not approved by the Insurer.

The Court was considering a Writ Petition against the inaction of the Insurer to provide with the inured amount on the ground that treatment took place at an unapproved hospital.

The single-bench of Justice C.S. Dias observed, "It is well settled that medical reimbursement cannot be denied because the insured underwent treatment in a hospital not approved by the Insurer. In the instant case, the ESI hospitals do not have the facility for liver transplantation. Based on the respondents' recommendation and concurrence, the patient was taken to the 4th respondent for treatment. Therefore, the respondents cannot turn around and say that they were ignorant of the patient's medical condition. The respondents’ insistence on an emergency certificate to process the petitioner’s claim is untenable and hyper-technical."

The Petitioner was represented by Advocate K.S. Bharathan while the Respondent was represented by Advocate T.V. Ajayakumar.

The Petitioner, an insured employee had taken her husband to the ESI hospital for treatment of his liver disease and undergoing treatment for a few days at the said Hospital, the patient was referred to the Medical College Hospital, Thrissur for liver transplantation. By the time, the Authorisation Committee for Transplantation of Organs granted permission to the patient for transplantation as per the provisions of the Transplantation of Human Organs and Tissues Act, his health had already deteriorated. Therefore, he was shifted to another hospital and underwent an emergency liver transplantation. When the Petitioner submitted her claim for reimbursement to the Insurance Company, she didn't receive a favourable reply despite sending several representations to the respondents, including a lawyer notice.

Later, she was informed that her claim could not be processed because she had not submitted the emergency certificate for undergoing the transplantation. Even when she fulfilled the said demand of the Insurance Company, the claim was not processed. The present petition was thus filed claiming the inaction of the respondents to be arbitrary, illegal and unconscionable.

The Court at the outset observed that it is an undisputed fact that the ESI hospital does not have the facility for liver transplantation and only on medical advice, the patient underwent emergency liver transplantation at their hospital.

It referred to Supreme Court's decision in Shiv Kant Jha Vs. Union of India wherein it was held that the right to medical claim cannot be denied merely because the name of the hospital is not included in the Government Order.

The Apex Court had established that the real test must be the factum of treatment. It was observed that 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 and once, it is established, the claim cannot be denied on technical grounds.

"I am satisfied that respondents are to be directed to forthwith process the petitioner’s claim and reimburse her the medical expenses for her husband’s medical treatment," the Court observed.

The Petition was accordingly allowed.

Cause Title: Suma Sunilkumar vs. The State Medical Officer (2024:KER:96495)

Appearances:

Petitioner- Advocate K.S. Bharathan, Advocate Aadithayan Mannali, Advocate Aleena Sony, Advocate Vishal L.

Respondent- Advocate T.V. Ajayakumar, Advocate P. Jayabal Menon, Advocate Rimju P.H., Advocate Jothis Chacko, Advocate Rekha Agarwal

Click here to read/ download Judgement: