Kerala HC Orders MEDISEP Claim Consideration for Leukaemia Patient Treated at Non-Empanelled Hospital

The Kerala High Court held that a MEDISEP claim cannot be rejected solely because treatment was taken at a non-empanelled hospital, directing reconsideration within one month.

Justice Viju Abraham, sitting singly at the High Court of Kerala at Ernakulam, on 8 July 2026 disposed of a writ petition filed by Anilkumar B S, a 54-year-old resident of Kottarakkara, Kollam, who suffers from Acute Myeloid Leukaemia. The petitioner's reimbursement claim under the MEDISEP Scheme had been rejected on the sole ground that he received treatment at Amrita Institute of Medical Sciences — a hospital not empanelled under the scheme. Relying on the Supreme Court's judgment in Shiv Kant Jha v Union of India [(2018) 16 SCC 187], Justice Abraham held that non-empanelment of a hospital cannot, by itself, be a ground to deny a medical claim where the factum of treatment is established. The court directed the District Grievance Redressal Committee to verify and decide the claim within one month.

The Dispute Before the High Court

Anilkumar B S is covered under the MEDISEP Scheme, a health insurance programme for Kerala government employees and associated categories administered, in this case, with the involvement of the Employees State Insurance Corporation and the Oriental Insurance Company Limited. When the petitioner sought an oncology consultation for Acute Myeloid Leukaemia, no oncology centre covered under the MEDISEP Scheme had the requisite staff or equipment to treat him. He was accordingly referred to Amrita Institute of Medical Sciences, Kochi, which was better equipped to deal with his condition.

The petitioner underwent treatment at Amrita Institute and then applied for reimbursement under Ext.P6. The respondent Insurance Company rejected the claim through Ext.P7 on the ground that Amrita Institute is not an empanelled hospital under the MEDISEP Scheme. Aggrieved, the petitioner approached the District Grievance Redressal Committee by filing Ext.P8. With no resolution forthcoming, he moved the High Court by way of this writ petition seeking a direction for expeditious consideration of his reimbursement application.

Seven respondents were arrayed, including the State Medical Officer and Regional Director of the Employees State Insurance Corporation, the Insurance Medical Officer at Kottarakkara, the District Grievance Redressal Committee, Amrita Group of Medical Sciences and Research Centre, the State Nodal Officer for MEDISEP, and the Divisional Manager of Oriental Insurance Company Limited. The last two were impleaded pursuant to an earlier interlocutory order dated 6 February 2026 in IA 1/2026 in the same writ petition.

The Admissions in the Counter Affidavit

A detailed counter affidavit was filed by the additional sixth respondent — the State Nodal Officer for MEDISEP. In paragraph 9 of that affidavit, the respondent admitted that the treatment undergone by the petitioner falls within the Catastrophic Package of the MEDISEP Scheme. It was further admitted that amounts of Rs. 9.46 lakhs and Rs. 17 lakhs are admissible under that package.

Despite these admissions, the respondents maintained that because Amrita Institute is a non-empanelled hospital, the petitioner is ineligible to receive the benefits from the MEDISEP corpus fund. The Government Pleader also submitted that before admitting any claim, the authorities must be satisfied that the petitioner had in fact undergone treatment at the stated hospital.

The court noted the significance of those admissions: the scheme coverage was not in dispute, the applicable amounts were not in dispute, and yet the claim had been rejected entirely on the basis of the hospital's empanelment status.

The Legal Proposition: Factum of Treatment Over Empanelment

Justice Abraham anchored his reasoning in the Supreme Court's decision in Shiv Kant Jha v Union of India [(2018) 16 SCC 187]. The Supreme Court had, in paragraph 17 of that judgment, addressed a comparable situation involving denial of medical reimbursement because the treating hospital was not listed in a Government Order. The court extracted the relevant passage at length.

The Supreme Court had held: “The right to medical claim cannot be denied merely because the name of the hospital is not included in the Government Order.” The real test, the Supreme Court said, is the factum of treatment — whether the claimant actually underwent treatment and whether that treatment is supported by records duly certified by the doctors or hospitals concerned. Once that factum is established, the claim cannot be denied on technical grounds.

The Supreme Court in that case had criticised the officials of the Central Government Health Scheme for taking what it described as a “very inhuman approach” in denying full medical reimbursement and forcing the claimant to approach the court.

Justice Abraham also relied on Ext.P9, a judgment of the same High Court in WP(C) No. 21799 of 2024 dated 19 December 2024, which had applied the Shiv Kant Jha principle to a similar MEDISEP claim and directed that the claim be considered. The petitioner placed that precedent before the court as supporting authority.

Applying the same reasoning, Justice Abraham held that non-empanelment of Amrita Institute cannot be a basis for rejecting a valid claim, particularly when the respondents themselves had admitted in their counter affidavit that the treatment is covered under the Catastrophic Package of the MEDISEP Scheme and that specific amounts are admissible. The court observed that the petitioner had stated sufficient reasons for choosing Amrita Institute: the empanelled hospitals lacked the staff and equipment to treat Acute Myeloid Leukaemia, and the referral to Amrita Institute followed from that incapacity.

Directions Issued

Justice Abraham disposed of the writ petition with specific directions to the fourth respondent — the District Grievance Redressal Committee. The Committee was directed to consider the claim of the petitioner and verify whether he had in fact undergone the treatment as contended. If, on verification of the documents obtained in support of the claim and after affording an opportunity of hearing to the petitioner, it is found that he underwent the treatment as stated, the claim shall be admitted.

The court made clear that the claim cannot be rejected on the ground that treatment was taken at a non-empanelled hospital. The admissible amounts are to be disbursed within one month from the date of receipt of a copy of the judgment.

Order

WP(C) No. 3703 of 2026 was disposed of on 8 July 2026 by Justice Viju Abraham. The District Grievance Redressal Committee was directed to verify the factum of treatment, hear the petitioner, and if satisfied, admit and disburse the admissible amounts under the MEDISEP Catastrophic Package within one month of receipt of the judgment.