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Synopsis

The Kerala High Court has ruled that medical reimbursement cannot be denied merely because an insured individual underwent treatment in a hospital not approved by the insurer, particularly in cases of emergency.

The court, presided over by Justice C.S.Dias, directed the Employees’ State Insurance Corporation (ESI) to process and reimburse the petitioner’s claim for her husband’s emergency liver transplantation expenses.

The petitioner, an insured employee covered under the ESI e-Pehchan card approached the court seeking reimbursement of expenses for her husband’s treatment, who was suffering from stage C cirrhosis. Her husband was initially treated for liver disease at an ESI hospital, where he was referred to the Medical College Hospital, Thrissur, for liver transplantation approval. The Technical Committee and Authorization Committee for Transplantation of Organs sanctioned the procedure. However, as the patient’s condition worsened, he underwent an emergency liver transplantation at Aster Medicity, a private hospital, since ESI hospitals lacked the required facilities. The petitioner paid for the procedure and subsequently submitted her claim to the ESI for reimbursement, along with an emergency certificate. Despite repeated representations, the ESI rejected the claim, citing procedural deficiencies, including the absence of an emergency certificate in the prescribed format and an internal ethics committee report.

Citing the Supreme Court’s verdict in the case of Shiv Kant Jha Vs. Union of India (2018), the High Court noted : “The right to medical claim cannot be denied merely because the name of the hospital is not included in the Government Order. The real test must be the factum of treatment. 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. Once, it is established, the claim cannot be denied on technical grounds. Clearly, in the present case, by taking a very inhuman approach, the officials of the CGHS have denied the grant of medical reimbursement in full to the petitioner forcing him to approach this Court.”

The court found that ESI hospitals did not have facilities for liver transplantation, necessitating the patient’s treatment at the private hospital and that the emergency certificate provided by Aster Medicity confirmed the critical nature of the surgery, showing a 50-60% mortality risk.

The court rejected the ESI's objections observing that, “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.”

Accordingly, the court directed the ESI to process and reimburse the petitioner’s claim within 60 days.

 

Cause Title: Suma Sunilkumar v. State Medical Officer [WP(C) No. 21799 of 2024]

Appearance: Advocates K.S. Bharathan, Aadithyan S. Mannali, Aleena Sony, Vishal L. (Counsel for Petitioner); and Advocates T.V. Ajayakumar, P. Jayabal Menon, Rimju P.H., Jothis Chacko, Rekha Agarwal, Senior Government Pleader Deepa Narayanan (Counsel for Respondents)