THIRUVANANTHAPURAM: In a significant ruling, the Kerala State Consumer Disputes Redressal Commission (KSCDRC) has said that claims under Medisep scheme on emergency accident treatment at non-empanelled hospitals could not be rejected, neither could they be capped at the tariff rate for empanelled hospitals.
Medisep is the state government’s health insurance scheme for its employees and pensioners implemented through Oriental Insurance Company Ltd (OICL).
The ruling was issued on an appeal filed by OICL against a government employee based in Wayanad, who met with an accident while riding her scooter in March 2023. She was first taken to the District Hospital in Mananthavady from where she was referred to an advanced care centre. Subsequently, she was taken to Aster MIMS in Kozhikode where she underwent a mandible (lower jawbone) surgery the same night. The hospital bill came to Rs 2,04,841.
Her claim was rejected on the grounds that MIMS was not an empanelled hospital under Medisep. She moved the District Consumer Disputes Redressal Commission in Wayanad, which ruled in her favour and ordered a payout of Rs 2.2 lakh towards treatment, Rs 20,000 as compensation and Rs 8,000 as litigation costs.
OICL appealed the ruling before the state bench, comprising KSCDRC president Justice B Sudheendra Kumar, judicial member Ajith Kumar D and member K R Radhakrishnan. OICL’s counsel argued that the complaint could not be filed directly before the consumer forum as the scheme had an in-house grievance mechanism under a 2022 government order.
The KSCDRC rejected the argument citing the lack of a statutory body to handle Medisep claims. OICL’s argument that the state government was a necessary party to the case since her monthly premium was deducted from salary and routed to Medisep through government machinery was also rejected by the commission which said the government’s role was limited to processing the payment.
The KSCDRC found that the Medisep’s scheme document permitted beneficiaries to seek treatment at non-empanelled hospitals in cases of accidents. Since the employee’s injury arose from a road accident and required urgent surgery, her decision to seek treatment at MIMS was justified.
Dismissing OICL’s appeal, the commission upheld the district commission’s findings, but reduced the treatment amount from Rs 2.2 lakh to Rs 2.04 lakh to match the employee’s actual hospital bill. The compensation, litigation costs and default interest ordered by the district forum were left untouched.
No tariff cap
In its appeal before the KSCDRC, the OICL had argued that the treatment cost should be capped at Rs 88,300, the rate fixed for facial bone fractures under its tariff list. However, the commission noted this tariff applies only to empanelled hospitals. Since accident victims are permitted to seek treatment outside the network, the employee was entitled to the actual amount she spent, KSCDRC held