ESI | Medical Reimbursement Can't Be Denied Merely Because Insured Person Got Treated At Hospital Not Approved By Insurer: Kerala HC Reaffirms

The petitioner sought reimbursement from the Employees State Insurance Corporation (ESI), since her husband had to undergo an emergency liver transplantation in a non ESIC hospital. And, his claim for reimbursement was not being processed even after submission of emergency certificate.

Justice C S Dias ordered for reimbursement and held thus:

“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.”

The petitioner, in this case is an insured employee who took her husband to ESI hospital for treatment of liver disease. The petitioner and her family are covered under e-Pehchan insurance card.

Her husband was recommended for liver transplantation an approval by the Technical Committee, he was referred to Medical College Hospital,Thrissur. The Authorization Committee for Transplantation of Organs also granted permission for liver transplantation under the Transplantation of Human Organs and Tissues Act.

However, her husband's health deteriorated and he had to undergo emergency liver transplantation at Aster Medicity, a private hospital which is not an ESI hospital.

The respondents submitted that private treatment from a non-ESIC or private hospitals could be reimbursed only after ascertaining the emergency and the entitlement as per the Central Government Health Scheme. It was submitted that surgery certificate was produced, instead of emergency certificate. It was also stated that internal ethics committee report was also not submitted.

The Court found that the technical committee of the ESI had already recommended the petitioner's husband for liver transplantation. It also took note of the fact that ESI hospitals do not have liver transplantation facility.

The Court noted that the petitioner submitted emergency certificate certified by Aster Medicity based on its orders. The emergency certificate showed that the beneficiary underwent live donor liver transplantation since he was in stage C cirrhosis, with mortality up to 50% to 60%.

Court thus said, “Therefore, there is no room for any doubt that the patient had to undergo emergency surgery for his survival.”

As such, the Court allowed the petition and ordered the ESI to process the petitioner's claim and reimburse the medical expenses.

Case Title: Mrs. Suma Sunilkumar v State Medical Officer

Counsel for Petitioner: Advocates K.S.Bharathan, Aadithyan S.Mannali, Aleena Sony, Vishal L.

Counsel for Respondents: Advocates T.V.Ajayakumar, P.Jayabal Menon, Rimju P.H., Jothis Chacko, Rekha Agarwal, Senior Government Pleader Deepa Narayanan

Case Number: WP (C) No. 21799 of 2024

Citation: 2024 LiveLaw (Ker) 814

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