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2024 Supreme(Online)(KER) 15817
HIGH COURT OF KERALA
Murali Purushothaman, J
SILVI VALANTINA – Appellant
Versus
STATE OF KERALA – Respondent
WP(C) 25252/2024
ADV S.M.PRASANTH, G.P. SRI.V.K. SUNIL, SC- SMT. K.S.SANTHI
The court affirmed that a prior government stance on a claim can bypass standard grievance procedures in the MEDISEP Scheme.
Headnote:
Pension - Medical Insurance Claim - [Clause 19 MEDISEP] - The court emphasized the grievance redressal mechanism outlined in the MEDISEP Scheme, directing the appellate authority to consider the petitioner's claim without requiring her to go through lower grievance committees, given the government's prior stance on the matter.
Fact of the Case:
The petitioner, a retired government servant, sought reimbursement for medical expenses incurred during an emergency aortic valve replacement. The insurance company rejected her claim, stating the hospital was not empanelled and the procedure did not qualify as an emergency under the MEDISEP Scheme.
Finding of the Court:
The court found that the government had already taken a position on the matter, making it inappropriate to refer the case to lower grievance committees. It directed the appellate authority to consider the petitioner's appeal directly.
Issues: Whether the petitioner should be required to go through the grievance redressal hierarchy of the MEDISEP Scheme after the government had already expressed its stance on her claim.
Ratio Decidendi: The court held that the established grievance redressal mechanism should be honored, but in light of the government's prior position, the appellate authority should directly address the petitioner's appeal.
Final Decision: The appellate authority must consider the petitioner's appeal within 30 days.
The petitioner is a retired Government Servant. According to the petitioner, she is getting only ex gratia pension. She has subscribed to medical insurance Scheme for the State employees and pensioners (MEDISEP) and she has been paying the premium regularly. The petitioner had to undergo an emergency aortic valve replacement at Lisie Hospital on 6.1.2024 and she was discharged from the hospital on 12.01.2024. The petitioner remitted an amount of Rs.6,87,646.81 towards hospital expenses as evident by Ext.P5 bill. The petitioner submitted Ext.P6 claim for reimbursement of the bills.
However, the Insurance Company, by Ext.P7, rejected the claim for reimbursement on the ground that the Lisie Hospital is not an empannelled hospital as per the terms and conditions of MEDISEP Scheme . It is stated in Ext.P7 that the hospitalisation of the petitioner for aortic valve replacement does not come under the purview of emergency case as defined in the MEDISEP Scheme . Aggrieved by Ext.P7, the petitioner has preferred Ext.P8 representation before the 2nd respondent. The petitioner challenges Ext.P7 in this writ petition.
2.Clause 19 of Ext.P1 Scheme deals with dispute resolution and grievance redressal of its members and provides for a hierarchy of remedies. The remedy at the first instance is before the District Level Grievance Redressal Committee. There is further appeal to the State Level Grievance Redressal Committee and to the Appellate Authority. According to the learned Standing Counsel for the Insurance Company, the petitioner has to prefer an appeal before the District Level Grievance Redressal Committee. The learned counsel for the petitioner submits that the Government has already taken a stand in the matter by virtue of Ext.P3 communication and therefore the District Level Grievance Redressal Committee as well as the State Level Grievance Redressal Commitee will be bound by the stand taken by the Government in Ext.P3.
3.Heard the learned counsel for the petitioner, the learned Standing Counsel for the Insurance Company and the learned Government Pleader.
It is true that Ext.P1 provides for a hierarchy of remedies against the rejection of the claim under the Scheme. However, as rightly pointed out by Sri. S.M.Prasanth, the learned counsel for the petitioner that since the Government had already taken a stand in Ext.P3 as regards the claim of the petitioner, it will not be proper to relegate the matter either to the District Level Grievance Redressal Committee or to the State Level Grievance Redressal Committee. Since the dispute regarding the claim of the petitioner has to be adjudicated under the Dispute Resolution and Grievance Redressal mechanism provided under Ext.P1, I direct the appellate authority constituted under Clause 19 (c) of the MEDISEP Scheme to consider Ext.P8 request of the petitioner treating it as an appeal filed under Clause 19(c) of the Scheme and pass appropriate orders as expeditiously as possible, at any rate, within a period of 30 days from the date of receipt of a copy of this judgment.
