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2024 Supreme(Online)(KER) 24909
HIGH COURT OF KERALA
Murali Purushothaman, J
K.C.RAMANI – Appellant
Versus
THE ADDITIONAL CHIEF SECRETARY – Respondent
WP(C) 30073/2024
THUSHARA V., C.VATHSALAN, K.RAKESH, ROSHAN T.M., YUSAFF
The court established that a structured grievance redressal mechanism must be followed before approaching the judiciary for relief.
Headnote:
Grievance - Medical Insurance - MEDISEP Scheme - Sections on Grievance Redressal Mechanism - The court emphasized the importance of the three-tier grievance redressal mechanism under the MEDISEP Scheme, directing the petitioner to appeal to the State Level Grievance Redressal Committee after exhausting the District Level remedy.
Fact of the Case:
The petitioner, a State Government employee, sought reimbursement for medical expenses incurred at a non-empanelled hospital after being referred from empanelled hospitals. Her claim was rejected, prompting her to challenge the decision in court.
Finding of the Court:
The court found that the petitioner had not utilized the available remedy of appeal to the State Level Grievance Redressal Committee, which is part of the MEDISEP Scheme's grievance redressal mechanism.
Issues: Whether the petitioner could seek reimbursement for medical expenses incurred at a non-empanelled hospital despite having a grievance redressal mechanism in place.
Ratio Decidendi: The court held that the petitioner must first exhaust the appellate remedy available under the MEDISEP Scheme before seeking judicial intervention.
Final Decision: The writ petition is disposed of with directions to appeal to the SGRC.
JUDGMENT
The State Level Grievance Redressal Committee, Represented by its Convenor, the Additional Secretary (Health Insurance Department), Government Secretariat, Thiruvananthapuram is suo motu impleaded as the additional 5th respondent.
2. The petitioner was a State Government employee in the Subordinate Judicial Service. She joined the Medical Insurance for State Employees and Pensioners (for short, ‘MEDISEP’) for cashless medical treatment.
The petitioner consulted for treatment at A.K.G Memorial Co-operative Hospital, Kannur and Fathima Hospital, Kozhikode which are authorised and empanelled private hospitals for providing MEDISEP facility. However, since the above hospitals did not have mechanism to conduct renograma test, the petitioner was referred to Baby Memorial Hospital, Kozhikode which was not empanelled under the MEDISEP Scheme . The petitioner had to undergo treatment and surgery at the said hospital. For which she incurred an expense of Rs.4,04,547.17/-. The claim for reimbursement of the treatment expenses was rejected by the Additional Chief Secretary (Finance) as per Exts.P4 and P4(a) communications. Aggrieved thereby, the petitioner approached this Court by filing W.P.(C) No.3628 of 2024 and this Court relegated the petitioner to avail the remedy under the grievance redressal mechanism under the MEDISEP Scheme by Ext.P7 judgment. The District Grievance Redressal Committee (DGRC), by Ext.P8 communication, rejected the claim of the petitioner for reimbursement. Accordingly, the petitioner has filed this writ petition to quash Exts.P4 and P4(a) communications and to direct the respondents to process her claim for reimbursement of the amount of Rs.4,04,547.17/- covered by Ext.P2 bills.
3. The MEDISEP Scheme provides for a three tier grievance redressal mechanism. The petitioner has exhausted her remedy before the District Level Grievance Redressal Committee (DGRC). There is a State Level Grievance Redressal Committee (SGRC) which acts as an appellate authority over the orders of the DGRC.
4. Since there is an inbuilt remedy of appeal to the SGRC provided under the MEDISEP Scheme , there will be a direction to the petitioner to submit an appeal to the SGRC within a period of two weeks from the date of receipt of a copy of this judgment. On receipt of the appeal, the SGRC shall consider the same within the statutory period of thirty days therefrom and orders shall be passed thereon in accordance with law, untrammeled by Exts.P4 and P4(a).
The writ petition is disposed of.
