{"id":337830,"date":"2024-12-24T10:00:09","date_gmt":"2024-12-24T04:30:09","guid":{"rendered":"https:\/\/www.scconline.com\/blog\/?p=337830"},"modified":"2024-12-31T12:38:59","modified_gmt":"2024-12-31T07:08:59","slug":"kerala-hc-esic-reimburse-medical-expenses-husband-treatment","status":"publish","type":"post","link":"https:\/\/www.scconline.com\/blog\/post\/2024\/12\/24\/kerala-hc-esic-reimburse-medical-expenses-husband-treatment\/","title":{"rendered":"\u2018Medical reimbursement cannot be denied for treatment in hospital unapproved by Insurer\u2019; Kerala HC directs ESIC to reimburse medical expenses"},"content":{"rendered":"
\n

Kerala High Court:<\/span> In a writ petition filed by the petitioner-wife seeking reimbursement of medical expenses for her husband’s surgery and processing of her insurance claim, a single judge bench of C.S. Dias, J. allowed the writ petition, pointing out that Employees State Insurance Corporation (‘ESIC’) cannot on the grounds of technicality i.e. demanding an emergency certificate, try to avoid processing the claim. Further, the Court directed ESIC to immediately process the petitioner’s claim and reimburse her for the medical expenses incurred for her husband’s treatment at any rate, within a period of 60 days from the date of receipt of a certified copy of this judgment.<\/p>\n

Background<\/h3>\n

The petitioner wife had taken her husband to the Employees State Insurance hospital for treatment of his liver disease. After undergoing treatment for a few days at the said Hospital, the patient was referred to the Medical College Hospital, Thrissur.<\/p>\n

The Superintendent of the ESI Hospital advised the patient for liver transplantation, and he was referred for approval to the Technical Committee of the hospital.<\/p>\n

When, the patient’s health deteriorated, he was shifted to the hospital for an emergency liver transplantation. The patient underwent the transplantation on 4-10-2023. The petitioner wife had paid the medical expenses for the transplantation. Post surgery, the wife submitted her claim for reimbursement to the Insurance Medical Officer, Employees State Insurance Corporation Dispensary(‘IMO’)<\/p>\n

Despite sending several representations to the ESIC, including a lawyer notice claiming reimbursement, ESIC did not process her claim(s).<\/p>\n

IMO informed the petitioner wife that due to the non-submission of emergency certificate for undergoing transplantation, her claim could not be processed. Immediately, she submitted the emergency certificate. Still, ESIC have neither processed the claim nor paid the reimbursement.<\/p>\n

Analysis and Decision<\/h3>\n

After taking note of Shiv Kant Jha<\/span> v. Union of India<\/span>, (2018) 16 SCC 187<\/a>, the Court reiterated that medical reimbursement cannot be denied because the insured underwent treatment in a hospital not approved by the Insurer.<\/p>\n

The Court noted that in the present case, the ESI hospitals lacked the necessary facilities for liver transplantation, which was a critical medical requirement for the patient. Based on a recommendation from the ESI Hospital, and with their concurrence, the patient was transferred to another hospital equipped to provide the required treatment. Given this sequence of events, the Court ruled that ESIC could not claim ignorance of the patient’s medical condition.<\/p>\n

The Court further remarked that “ESIC’s insistence on an emergency certificate to process the petitioner wife’s claim is untenable and hyper-technical<\/span>”.<\/p>\n

Thus, the Court directed ESIC to immediately process the petitioner’s claim and reimburse her for the medical expenses incurred for her husband’s treatment at any rate, within a period of 60 days from the date of receipt of a certified copy of this judgment.<\/p>\n

[ Suma Sunilkumar v. Employees State Insurance Corporation, 2024 SCC OnLine Ker 7449<\/a>, decided on 19-12-2024.<\/span>]<\/p>\n\n

Advocates who appeared in this case :<\/p>\n

For the Appellant(s)-<\/span> Adv. K. S. Bharathan, Adv. Aadithyan S. Mannali, Adv. Aleena Sony, Adv. Vishal L.<\/p>\n

For the Respondent(s)-<\/span> Adv. T. V. Ajaykumar, Adv. P. Jayabal Menon, Adv. Rimju P. H.. Adv. Jothis Chacko, Adv. Rekha Aagarwal<\/p>\n<\/div>\n","protected":false},"excerpt":{"rendered":"

“ESIC’s insistence on an emergency certificate to process the petitioner wife’s claim is untenable and hyper-technical”<\/p>\n","protected":false},"author":67011,"featured_media":316393,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_jetpack_memberships_contains_paid_content":false,"footnotes":""},"categories":[3,10],"tags":[49319,36510,49275,2617,2523,45852],"class_list":["post-337830","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-casebriefs","category-highcourts","tag-employees-state-insurance","tag-employees-state-insurance-corporation","tag-esi","tag-insurance_claim","tag-Kerala_High_Court","tag-medical-insurance"],"yoast_head":"\nKerala HC orders ESIC to process claim and reimburse medical expenses for husband's treatment<\/title>\n<meta name=\"description\" content=\"Kerala High Court ruled that ESIC cannot deny medical reimbursement merely because insured received treatment at hospital unapproved by insurer, directing reimbursement for medical expenses incurred by wife for husband's treatment.\" \/>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/www.scconline.com\/blog\/post\/2024\/12\/24\/kerala-hc-esic-reimburse-medical-expenses-husband-treatment\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"\u2018Medical reimbursement cannot be denied for treatment in hospital unapproved by Insurer\u2019; 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