Kerala High Court Rules Medical Reimbursement Claims Cannot Be Denied For Non Empanelled Hospitals

The High Court of Kerala has delivered a significant ruling clarifying that the right to medical expense reimbursement cannot be restricted solely on the basis of whether a hospital is listed under a government-approved empanelment list. Justice Viju Abraham, presiding over the matter, emphasized that the fundamental test for any reimbursement claim must be the actual receipt and factual verification of treatment.

The Dispute of Necessary Care

The petitioner, Anilkumar B.S., a beneficiary of the Medical Insurance Scheme for State Employees and Pensioners (MEDISEP) , sought specialized oncology consultation for Acute Myeloid Leukaemia. When he attempted to utilize facilities covered under the MEDISEP scheme, he found that the available empanelled centers lacked the necessary infrastructure and specialized staff required for his specific medical condition.

Consequently, the petitioner sought life-saving treatment at the Amrita Institute of Medical Sciences in Kochi. Although the treatment was successful, his application for reimbursement was rejected by the authorities, who cited the hospital’s status as a non-empanelled facility under the scheme, despite acknowledging that the ailment fell under the catastrophic package of the MEDISEP scheme.

Legal Precedents and Principles

The Court turned to the landmark decision of the Supreme Court of India in Shiv Kant Jha v. Union of India , which established that patients are often in no position to choose or dictate the facilities for specialized care. Justice Viju Abraham highlighted that the ultimate decision regarding medical necessity rests with medical experts, not administrative policy books.

"The right to medical claim cannot be denied merely because the name of the hospital is not included in the Government Order," the court observed, citing the directive that authorities must verify the " factum of treatment " through certified records rather than relying on narrow technicalities.

Key Observations

The judgment offers a firm directive regarding the priorities of welfare schemes:

• "The ultimate decision as to how a patient should be treated vests only with the Doctor, who is well versed and expert both on academic qualification and experience gained."
• "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."
• "Clearly, in the present case, by taking a very inhuman approach, the officials... have denied the grant of medical reimbursement in full... forcing him to approach this Court."

Court Directive and Implications

The High Court has directed the District Grievance Redressal Committee to re-examine the petitioner’s claim. The authorities are mandated to verify that the petitioner received the reported treatment and, upon such confirmation, must process the reimbursement of admissible amounts. The court has set a strict one-month timeline for the completion of this process, ensuring that the beneficiary is not left to struggle with the financial burden of his care. This ruling serves as a vital safeguard for employees and pensioners, reinforcing the principle that procedural technicalities in insurance schemes cannot supersede an individual's right to life and medical care.