IMPORTANT POINT
Medical reimbursement claims cannot be denied on technical grounds if the treatment was necessary and properly documented, emphasizing the importance of patient care over procedural technicalities.

JUDGMENT :

(C.S. Dias, J.)

The petitioner is an insured employee. The petitioner had taken her husband to the ESI hospital for treatment of his liver disease. After undergoing treatment for a few days at the said Hospital, the patient was referred to the Medical College Hospital, Thrissur. By Ext.P2 slip, the Superintendent of the ESI Hospital advised the patient for liver transplantation and he was referred for approval to the Technical Committee of the 4 th respondent hospital. By Ext.P4 certificate, the first respondent had informed the Superintendent of the ESI Hospital that the Technical Committee had approved and recommended the patient for liver transplantation. In the meantime, by Ext.P5 letter, 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. By this time, the patient’s health deteriorated. He was shifted to the 4 th respondent hospital. He was advised of an emergency liver transplantation. Consequently, the patient underwent the transplantation on 4.10.2023. The petitioner had paid the medical expenses for the transplantation. After the surgery, the petitioner submitted her claim for reimbursement to the third respondent. Despite sending several representations to the respondents, including a lawyer notice claiming reimbursement, the respondents did not send any favourable reply. By Ext.P15 letter, the third respondent informed the petitioner that her claim could not be processed because she had not submitted the emergency certificate for undergoing the transplantation. Immediately, the petitioner submitted Ext.P18 emergency certificate. Even then, the respondents have not paid the reimbursement. The inaction of the respondents is arbitrary, illegal and unconscionable. Hence, the writ petition.

2. The respondents 1 to 3 have filed a counter affidavit. They have admitted that the petitioner is an insured employee. In response to Ext.P12 representation, the third respondent has sent Ext.P13 reply directing the petitioner to submit the medical reimbursement claim, cash-paid bills in original and additional documents in the dispensary. If it is not an elective procedure, an emergency certificate is required. The third respondent had also issued Ext.P15 reply to Ext.P14 lawyer notice stating that the petitioner had not submitted the emergency certificate and only sent a surgery certificate. The petitioner was also intimated to rectify the defects in the claim form, and was granted one year to submit the bills. The petitioner submitted the medical reimbursement claim form only on 27.12.2023. As per Ext.R1(a) letter, the expenditure incurred on private treatment from a non-ESIC or private hospitals could be reimbursed only after ascertaining the emergency and the entitlement as per the CGHS rates. The first respondent has returned the petitioner’s claim due to the non-submission of the emergency certificate and the internal ethical committee report. Therefore, the writ petition may be dismissed.

3. When the writ petition came up for consideration on 11.11.2024, the Standing Counsel for respondents stated that there was no prescribed form for the emergency certificate, but it should be submitted on the letterhead of the hospital with all the essential details, including the signature of the Doctor and the seal of the institution.

4. Accordingly, this Court directed the 4th respondent hospital to produce the emergency certificate. Consequently, the petitioner has submitted Ext.P22 certificate issued by the 4th respondent certifying that the patient had undergone live donor liver transplantation since he was in stage C cirrhosis, which carries a one-year mortality of 50 % to 60%.

5. Heard: the learned counsel for the petitioner, the learned Standing Counsel appearing for the respondents 1 to 3 and the learned counsel for the 4th respondent hospital.

6. The petitioner is an insured employee. She