The Kerala High Court has directed the District Level Grievance Redressal Committee under the MEDISEP Scheme to expeditiously dispose of an appeal challenging the rejection of a medical claim. The court reiterated that medical claims cannot be denied merely because treatment was availed at a non-empanelled hospital, relying on Supreme Court and High Court precedents.
Background & Facts
The Dispute
The petitioner, a 61-year-old resident of Kottayam, Kerala, underwent life-saving medical treatment at Caritas Hospital & Institute of Health Sciences, incurring an expenditure of Rs. 3,07,500. The petitioner sought reimbursement under the MEDISEP Scheme, a health insurance initiative by the Government of Kerala for state employees and pensioners. The claim was rejected solely on the ground that the hospital was not empanelled under the scheme.
Key Facts
- The petitioner underwent treatment at Caritas Hospital & Institute of Health Sciences, a non-empanelled hospital under the MEDISEP Scheme
- The total expenditure incurred was Rs. 3,07,500, as evidenced by the final bill (Ext.P8)
- The petitioner submitted an email/application for reimbursement on 09.04.2025 (Ext.P1)
- Follow-up emails were sent on 22.05.2025 (Ext.P2), 09.06.2025 (Ext.P3), and 17.08.2025 (Ext.P4)
- The 3rd respondent (Oriental Insurance Company Limited) issued a pre-repudiation letter on 31.10.2025 (Ext.P5)
- The claim was formally rejected on 20.02.2026 (Ext.P6), citing non-empanelment of the hospital
- The petitioner filed an appeal before the 4th respondent (District Level Grievance Redressal Committee, MEDISEP, Kottayam), assigned Token No. MG44585
Procedural History
- 09.04.2025: Petitioner submits reimbursement application (Ext.P1)
- 22.05.2025: Follow-up email sent (Ext.P2)
- 09.06.2025: Further follow-up email (Ext.P3)
- 17.08.2025: Reminder email sent (Ext.P4)
- 31.10.2025: Pre-repudiation letter issued by 3rd respondent (Ext.P5)
- 20.02.2026: Formal rejection of claim (Ext.P6)
- 2026: Appeal filed before 4th respondent, assigned Token No. MG44585
- 01.07.2026: Present writ petition filed before Kerala High Court
Relief Sought
The petitioner seeks:
- Quashing of Ext.P6 (rejection letter dated 20.02.2026)
- Expeditious disposal of the appeal pending before the 4th respondent
- Directions to the 4th respondent to consider the appeal in light of the Supreme Court judgment in Shiva Kant Jha v. Union of India and the Kerala High Court judgment in Prasad K.G. v. State of Kerala
The Legal Issue
The central question was whether medical claims under the MEDISEP Scheme can be rejected solely on the ground that the treatment was availed at a non-empanelled hospital, absent any other deficiency in the claim or treatment records.
Arguments Presented
For the Petitioner
The learned counsel for the petitioner relied on the Supreme Court judgment in Shiva Kant Jha v. Union of India and the Kerala High Court judgment in Prasad K.G. v. State of Kerala to argue that:
- The right to medical claim cannot be denied merely because the hospital is not empanelled under the scheme
- The real test for reimbursement is the factum of treatment, supported by records duly certified by doctors/hospitals
- The petitioner’s treatment records (Ext.P7 and Ext.P8) clearly evidence the expenditure and the necessity of the treatment
- The rejection of the claim without considering the merits of the treatment records is arbitrary and violates the principles of natural justice
For the Respondent
The learned Standing Counsel for the 3rd respondent (Oriental Insurance Company Limited) contended that:
- The MEDISEP Scheme guidelines mandate that reimbursement is permissible only for treatment availed at empanelled hospitals
- Non-empanelment of the hospital is a valid ground for rejection, as the scheme is designed to regulate costs and ensure quality through empanelled providers
- The petitioner’s reliance on Shiva Kant Jha and Prasad K.G. is misplaced, as those cases involved government orders and not a scheme with specific empanelment criteria
The Court's Analysis
The Court examined the rejection of the petitioner’s claim and the legal principles established in Shiva Kant Jha v. Union of India and Prasad K.G. v. State of Kerala. The Court observed:
"The Apex Court in Shiva Kant Jha v. Union of India has held that right to medical claim cannot be denied merely because name of the hospital is not included in the Government Order and the real test must be the factum of treatment supported by records duly certified by Doctors/Hospitals concerned."
The Court noted that in the present case, it is admitted that the petitioner underwent treatment at the said hospital. The only objection raised by the respondents was the non-empanelment of the hospital under the MEDISEP Scheme. The Court held that this ground alone is insufficient to deny the claim, especially when the treatment records are duly certified and the expenditure is evidenced.
The Court further relied on its earlier judgment in Prasad K.G. v. State of Kerala, which applied the same principle, to reinforce that empanelment status cannot be the sole criterion for rejecting a medical claim. The Court emphasized that the directions of the Apex Court in Shiva Kant Jha and its own judgment in Prasad K.G. must be duly considered by the 4th respondent while disposing of the appeal.
The Verdict
The Court disposed of the writ petition with the following directions:
- The 4th respondent (District Level Grievance Redressal Committee, MEDISEP, Kottayam) is directed to consider and pass orders on the appeal (Token No. MG44585) within an outer limit of two months from the date of receipt of a copy of this judgment
- The 4th respondent shall afford an opportunity of being heard to the petitioner and the 3rd respondent before passing orders
- The 4th respondent shall duly consider the directions of the Supreme Court in Shiva Kant Jha v. Union of India and the Kerala High Court in Prasad K.G. v. State of Kerala, copies of which shall be provided by the petitioner
What This Means For Similar Cases
Empanelment Is Not the Sole Criterion for Medical Claims
- The judgment reinforces that medical claims under government schemes cannot be rejected solely on the ground of non-empanelment of the hospital
- The real test for reimbursement is the factum of treatment and the authenticity of the records, not the empanelment status of the hospital
- Practitioners should argue that arbitrary rejection of claims based on empanelment violates the right to medical treatment and principles of natural justice
Precedents Strengthen the Right to Reimbursement
- The reliance on Shiva Kant Jha v. Union of India and Prasad K.G. v. State of Kerala provides a strong legal foundation for challenging similar rejections
- These precedents can be cited in cases where government schemes or insurance policies impose rigid empanelment criteria without considering the merits of the treatment
- The judgment underscores the need for scheme administrators to adopt a flexible approach when the treatment records are duly certified and the expenditure is evidenced
Expeditious Disposal of Appeals Is Mandatory
- The Court’s direction to dispose of the appeal within two months sets a strict timeline for grievance redressal committees
- This timeline can be cited in writ petitions to seek expeditious disposal of pending appeals or grievances under similar schemes
- Practitioners should emphasize the urgency of medical claims, especially in cases involving life-saving treatments or substantial expenditures
