HC tells insurance co to reimburse surgery bill in non-network hospital

Madurai: Madras high court has directed an insurance company to pay medical reimbursement to a woman who underwent surgery in a non-network hospital. The court was hearing an appeal preferred by the state challenging the single bench order, which directed consideration and passing of orders for reimbursement.

S Dhanalakshmi was a BT assistant at a school run by Madurai corporation when she suffered a gum infection in the upper and lower jaw while she was in Nagercoil. As the doctor there advised her to undergo surgery immediately, she agreed, incurring an expense of Rs1.22 lakh, though it was a non-network hospital.

Her claim for reimbursement was taken up by the District Level Empowered Committee (DLEC) in December 2018. However, it was not implemented on the ground that the petitioner took treatment in a non-network hospital. Hence, she filed a petition before the HC, which, in 2019, directed that the matter be considered afresh.

DLEC directed that the petitioner's claim for reimbursement could not be rejected. Since it was not implemented, she once again filed a petition in 2019, and the single bench directed the authorities to pass appropriate orders. Challenging the order, the present appeal was preferred by the state.

The special govt pleader submitted that the govt could not be saddled with financial liability to make reimbursement and that it was the insurance company that had to pay. The insurance company's counsel said that since the nature of the ailment did not appear to be a case of emergency and the woman took treatment in a non-network hospital, the company could not be called upon to make the payment.

A division bench of Justice G R Swaminathan and Justice S Srimathy observed that the nodal officer of United India Insurance Company, Madurai, was also a party to the committee meeting. If the insurance company was aggrieved by the positive recommendation made by the committee in favour of the woman, it ought to have filed an appeal before the State Level Empowered Committee. Such an appeal was not filed.

The court is of the view that the insurance company is squarely bound by the recommendation. Upholding the stand of the govt in the appeal, the judges directed the authorities to forthwith implement the committee's recommendation. The amount of Rs1.22 lakh shall be paid by the insurance company to the woman within eight weeks, the judges directed, and disposed of the appeal.