The Kerala State Consumer Disputes Redressal Commission (KSCDRC) has ruled that government employees covered under the Medisep health insurance scheme cannot be denied reimbursement for emergency accident treatment received at a non-empanelled hospital. The commission also held that such claims cannot be restricted to the tariff rates applicable to empanelled hospitals.
The ruling came while dismissing an appeal filed by Oriental Insurance Company (OICL), which administers the Medisep scheme for Kerala government employees and pensioners.
The case involved a government employee from Wayanad who sustained injuries in a road accident in March 2023. After receiving initial treatment at a district hospital, she was referred to Aster MIMS Hospital in Kozhikode, where she underwent emergency surgery for a fractured lower jaw. The treatment cost amounted to Rs 2.04 lakh.
The insurer rejected her reimbursement claim on the grounds that the hospital was not part of the Medisep network. The employee subsequently approached the District Consumer Disputes Redressal Commission, which directed the insurer to compensate her for the treatment along with compensation and litigation costs.
Challenging the order, OICL argued that the matter should have been addressed through the scheme’s internal grievance mechanism and that reimbursement should be limited to the tariff prescribed for empanelled hospitals.
The state commission rejected both arguments. It observed that the Medisep scheme permits beneficiaries to seek treatment at non-empanelled hospitals in emergency accident cases and held that the employee’s decision to undergo immediate surgery at the nearest advanced care facility was justified.
While upholding the district commission’s decision, the KSCDRC revised the reimbursement amount to Rs 2.04 lakh, matching the actual hospital bill. The compensation, litigation costs and interest awarded by the district forum were left unchanged.
The ruling is expected to provide greater clarity for government employees covered under Medisep who require emergency medical treatment outside the scheme’s empanelled hospital network.
