The High Court of Kerala, through Justice C.S. Dias, adjudicated a dispute concerning medical reimbursement under the Employees State Insurance (ESI) scheme, directing the respondents to reimburse the petitioner for medical expenses incurred during her husband's emergency liver transplantation. The Court held that reimbursement could not be denied on the ground that the treatment was conducted at a non-ESI hospital, particularly when the procedure was necessitated by an emergent medical condition.

The Court observed, “It is well settled that medical reimbursement cannot be denied because the insured underwent treatment in a hospital not approved by the insurer. The respondents’ insistence on an emergency certificate to process the petitioner’s claim is untenable and hyper-technical.”

The petitioner, Mrs. Suma Sunilkumar, an insured employee under the ESI scheme, sought reimbursement for her husband’s liver transplantation. Her husband was initially admitted to an ESI hospital for liver disease treatment. The patient was subsequently referred to the Medical College Hospital, Thrissur, following recommendations by the Technical Committee and the Authorization Committee for Transplantation of Organs under the Transplantation of Human Organs and Tissues Act.

However, due to a sudden and critical deterioration in the patient’s health, he was transferred to Aster Medicity, a private hospital, for an urgent liver transplantation. The petitioner paid the medical expenses for the procedure and submitted her claim for reimbursement. The claim, however, was rejected by the ESI Corporation on the ground that the petitioner had not submitted an emergency certificate in the prescribed format and had not provided an internal ethical committee report.

The Court examined the factual matrix of the case, the documents submitted, and the legal provisions governing the claim. It was undisputed that the ESI hospitals lacked the facility to perform liver transplantation. The Technical Committee had earlier approved the procedure, acknowledging the absence of required infrastructure within ESI hospitals.

Justice Dias noted that the petitioner had submitted an emergency certificate from Aster Medicity, which confirmed that the patient was diagnosed with stage C cirrhosis—a life-threatening condition carrying a mortality risk of 50% to 60%. The Court stated, “There is no room for any doubt that the patient had to undergo emergency surgery for his survival.”

Citing the Supreme Court judgment in Shiv Kant Jha v. Union of India [(2018) 16 SCC 187], the Court underscored that the right to medical reimbursement cannot be denied on procedural or technical grounds if the treatment and its necessity are substantiated by medical records. The Court further clarified that requiring an emergency certificate in a prescribed format, in the absence of a statutory provision mandating such, is unjustified.

The Court held, “The respondents cannot turn around and say that they were ignorant of the patient's medical condition. The insistence on an emergency certificate to process the petitioner’s claim is untenable and hyper-technical.”

The Court addressed the respondents' objections regarding the claim. The Court observed that:

1. The petitioner was an insured employee under the ESI scheme, and the respondents were obligated to ensure her entitlement to benefits under the scheme.
2. The ESI hospital lacked the necessary facility for liver transplantation, and the petitioner had acted in accordance with the advice of medical professionals.
3. The Technical Committee had approved the liver transplantation, making the petitioner’s subsequent actions a direct result of the medical exigency.

The Court emphasized the objective of the ESI scheme to provide financial and medical security to insured individuals. It held that denying reimbursement in this context would amount to a breach of the respondents’ obligations under the statutory scheme.

The High Court allowed the writ petition and directed the ESI Corporation to process and reimburse the petitioner’s claim within 60 days. The Court mandated that the respondents afford the petitioner an opportunity for representation if necessary and complete the reimbursement in accordance with law.

The Court concluded that, based on the submissions, supporting documents, and statutory framework, the petitioner’s claim for reimbursement was lawful and justified. The Court further observed that denying reimbursement on procedural grounds in cases involving emergency medical treatment undermines the principles of equity and statutory duty.

Case Title: Mrs. Suma Sunilkumar v. State Medical Officer

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

Bench: Justice C.S. Dias