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Synopsis

The Madras High Court recently observed that each and every step in the treatment of Covid-19 during the pandemic years, especially 2020, should be considered critical care for the purpose of medical insurance payment or reimbursement of the medical bill. 

The bench of Justice Battu Devanand said, "COVID-19 symptoms range from asymptomatic to deadly... As such to classify the medical assistance provided into critical or non-critical categories would be a farce, as in 2020, the whole pandemic situation was burning the country in chaos...Thus, each and every step in the treatment should be considered critical".

Court held that anyone who is deprived of such medical care or insurance or reimbursement related to such medical care is directly being deprived of their Right to Life under Article 21 of the Indian Constitution.

Court made the observations while passing orders in a writ petition filed by a retired Secondary School Teacher. The petitioner was infected with Covid-19 in 2020. At the time, she was 73 years old having Type-II diabetes. She had also undergone Corollary Artery Bypass Grafting (CAVG) open heart surgery in the year 2016.

Though the petitioner was a beneficiary and insured under New Health Insurance Scheme (NHIS) for employees and pensioners formulated by the Finance (Pension) Department and was paying Rs.350 per month as a premium, the United India Insurance Company Ltd. held her not entitled to the reimbursement of the expenditure amounting to Rs.2,62,596 incurred by her for her treatment on the ground that it was non-critical care and it was taken in a non-network hospital.

Court held the ground taken by the Insurance company "inhuman, irrational, unreasonable, unjust and violative of the right to life guaranteed under Article 21 of the Constitution of India".

Court opined that United India Insurance Company Ltd should have considered the claim of the petitioner with reasonableness and with utmost care.

"It is not fair for the Respondent No.4 (United India Insurance Company Ltd) to include such clauses and imposing such conditions in the terms and conditions of the policy/scheme, which are against the public interest," said the court.

"...during the pandemic period, as there was a great demand for admission in the hospitals for COVID-19, the public including the Government employees and pensioners were left with no other option but to take treatment in private hospitals, which are not covered under the network hospitals listed under the different Health Insurance Schemes," court added. 

Therefore, in view of the June 6, 2022 directions issued by the State Government to clear the claims of the eligible expenses incurred by the Government employees (present and retired) under non-critical Covid care treatment undertaken in a non-network hospital, court directed the petitioner to re-submit her claim.

Further, court directed the United India Insurance Company Ltd to settle the same in given timeframe

Moreover, taking into account the age and health conditions of the petitioner, for the inconvenience and hardship being suffered by her, court directed the respondents to pay her Rs.25,000 as cost. 

Case Title: S.Porkamalam v The State of Tamil Nadu and Others