'Rules Condone A Situation Where Patient Avails Emergency Treatment In Non-Empanelled Hospital': Kerala HC On Reimbursement Claim In Liver Transplant Case

The Kerala High Court recently directed the state government to reconsider its decision in a case where an application for reimbursement was rejected because Apollo Hospital, where the patient had gone for treatment in 2011, was a non-recognized hospital under the Medical Reimbursement Scheme and no prior permission had been obtained for availing the treatment there.

Justice Devan Ramachandran said the incident happened in 2011 "when surely our systems were far behind from what we see today". No decision could have been taken by the government without making a proper investigation as to whether treatment availed of by the petitioner was absolutely necessary or whether he had any alternative in Kerala, said the court.

Directing the competent authority to rehear the petitioner and take a fresh decision on the application, the court asked it to ascertain whether the urgency of the petitioner for medical treatment in 2011 was so grave that the obtention of a prior permission for availing treatment from Apollo Hospital was difficult, if not impossible.

"Since the petitioner's claim has been pending for more than 10 years, I am certain that reconsideration will have to be swift and concluded within a strict time frame," said the court, while granting three months to the authority.

The petitioner suffered from a debilitating liver disease in 2011 and was rushed to a government hospital for treatment. The hospital referred him to Amrita Institute of Medical Sciences at Ernakulam. Since the latter did not have the requisite facilities for the treatment, the patient, after some treatment there, was advised to go to another hospital.

Pursuant to this, the petitioner went to Apollo Hospital at Delhi where he underwent treatment and became well. However, he had to spend nearly Rs.20 lakhs on medical expenses.

When the petitioner applied for reimbursement under the applicable Rules, it was rejected on the ground that Apollo Hospital was not a recognized hospital under the Medical Reimbursement Scheme and that no prior permission had been taken for availing treatment there.

The petitioner, represented by Advocate Sajeev Kumar K. Gopal, challenged the order issued by the AYUSH department, and prayed that the competent authority be directed to reimburse the amount claimed within a fixed time period.

Government Pleader Parvathy K. argued that the petitioner himself had admitted that he had approached Apollo Hospital without a reference from either the government hospital or Amrita Hospital. The question whether such a course could inure to him the medical reimbursement is doubtful, she added.

The Court noted that the applicable Rules condone a situation of emergency whereby a patient is forced to avail treatment even in a non-recognized or non-registered hospital.

Taking into consideration the state of health infrastructure in 2011, the court observed the explanation given by the petitioner could not be used against him as he honestly admitted since no hospitals in Kerala were equipped to conduct liver transplantation in 2011 and considering his grave diagnosis, he was forced to approach Apollo Hospital.

"This does not ipso facto mean that the choice to go to the 'Appolo Hospital' was his alone and I am certain that this would have been guided by the references and advice offered by the hospitals in Kerala", the court observed, while directing the competent authority to reconsider the matter without any further delay.

Case Title: Dr. R. Prakash v. State of Kerala & Ors. 

Citation: 2022 LiveLaw (Ker) 538

Click Here To Read/Download The Judgment