MEDISEP Reimbursement Claim Can't Be Rejected Solely Because Treatment Was Taken At Non-Empanelled Hospital: Kerala High Court

MEDISEP (Medical Insurance Scheme for State Employees and Pensioners) is a social security scheme of the Kerala Government that provides comprehensive health insurance coverage to all serving and newly recruited state employees, High Court employees, pensioners, and their families.

Justice Viju Abraham allowed the plea seeking expeditious consideration of his application for reimbursement of treatment expenses for Acute Myeloid Leukaemia.

The Court relied on the Apex Court decision in Shiv Kant Jha v. Union of India (2018) and held:

“The only reason for denial of the claim of the petitioner is that the petitioner has undergone treatment in a non-empanelled hospital. Going by the Apex Court judgment in Shiv Kant Jha's case…, that cannot be a reason for rejecting a valid claim… it is admitted that the treatment undergone by the petitioner is covered by the MEDICEP Scheme and the amounts are also admissible. If that be so, as already held, the claim of the petitioner cannot be rejected solely for the reason that the petitioner underwent treatment is a non-empanelled hospital.”

According to the petitioner, he was covered under the MEDISEP scheme but when he sought an oncology consultation at one of the covered centres, it did not have the requisite staff or equipment to treat him. On being referred to Amrita Institute of Medical Sciences, a non-empanelled hospital, he underwent treatment there. However, his reimbursement claim was rejected stating he underwent treatment at a non-empanelled hospital.

The petitioner then approached the District Grievance Redressal Committee. The respondents, including State authorities, admitted that the treatment was covered under the scheme but contended that he is ineligible for reimbursement due to treatment at non-empanelled hospital. Moreover, before admitting the claim, the authorities have to be satisfied whether the treatment was actually undergone.

Considering the submissions, the Court directed the Grievance Redressal Committee to consider the claim and admit the same after verifying whether the treatment has been undergone.

The Committee was also directed to take a decision on the same and disburse the admissible amounts within 1 month of the judgment after hearing the petitioner.

Case No: WP(C) No. 3703 of 2026

Case Title: X v. The State Medical Officer and Ors.

Citation: 2026 LiveLaw (Ker) 417

Counsel for the petitioner: Syam J. Sam

Counsel for the respondents: T.V. Ajayakumar, K.S. Santhi, George A. Cheriyan

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