Case Note & Summary
The case involved a writ petition filed under Article 226 of the Constitution of India by a petitioner seeking reimbursement of medical expenses under the New Health Insurance Scheme, 2018. The petitioner, who had undergone treatment for Type 2 Diabetes Mellitus and related complications, claimed reimbursement of Rs.3,23,383/- after his treatment at a non-network hospital was rejected by the State Level Empowered Committee. The petitioner contended that the treatment was emergent and should be covered under the scheme. The respondents argued that the claim was not valid as it violated the policy conditions. The court noted that while the treatment was deemed emergent, the rejection was based on the non-network status of the hospital. The court referred to a precedent which stated that claims should not be rejected solely based on the treatment location if there were valid reasons for seeking treatment elsewhere. The court found the rejection order to be cryptic and lacking detailed reasoning, thus allowing the writ petition and directing the State Level Empowered Committee to reconsider the claim with a reasoned order within four weeks.
Headnote
A) Administrative Law - Writ of Certiorarified Mandamus - Jurisdiction to Review Administrative Decisions - Article 226 of the Constitution of India - The court examined the legality of the rejection of the petitioner's claim for reimbursement under the New Health Insurance Scheme, 2018, based on treatment received in a non-network hospital during an emergency. The court held that the rejection order was cryptic and required a detailed analysis, remitting the matter for fresh consideration with a reasoned order (Paras 12-13).
Issue of Consideration
Whether the treatment undergone by the petitioner is covered under the New Health Insurance Scheme, 2018.
Final Decision
The court allowed the writ petition, set aside the impugned orders, and directed the State Level Empowered Committee to reconsider the claim with a reasoned order within four weeks.
Law Points
- Writ of Certiorarified Mandamus
- New Health Insurance Scheme
- 2018
- emergency treatment
- non-network hospital
- reasoned order requirement
