The Oriental Insurance Co.Ltd. vs Meenakumari & Ors.

Both these cases are filed by the insurer, the Oriental Insurance Co.Ltd., being aggrieved by the awards passed by the Permanent Lok Adalat for Public Utility Services. In W.P(C) No.15214/2026, the petitioner is challenging Ext.P8 award passed by the Permanent Lok Adalat for Public Utility Services, Kozhikode in O.P. No.69/2024, filed by the respondents in the writ petition. Similarly, in W.P(C) No.21044/2026, the challenge is raised against Ext.P6 award passed by the Permanent Lok Adalat for Public Utility Services, Kozhikode in O.P. No.91/2023, filed by the 1^st respondent in the writ petition.

Since common issues are arising in both these writ petitions, the said writ petitions are heard together and being disposed of by way of a common judgment. In both these cases, the subject matter of the complaints was with regard to the denial of reimbursement of the medical expenses incurred by Government employees for the treatment availed by them or their immediate relatives. The common question that arises for consideration is in respect of the coverage of the scheme under which, the insurance policy was taken. The said scheme is a special package provided by the State Government for the benefit of public servants including retired public servants, to provide financial assistance for availing medical treatment. Ext.P1 in W.P(C) No.21044/26 is the said scheme formulated by the Government in this regard which is known as Medical Insurance Scheme for State Employees and Pensioners (MEDISEP).

In both these cases, the claims raised by the respective parties were declined, on the reason that, the respective persons have availed the medical services from hospitals, which are not empaneled under the scheme and therefore, not coming within the scope of the same. Apart from the above, another contention raised by the petitioner is that, in Ext.P1 scheme itself, there is a dispute resolution mechanism, which includes an original authority and an appellate authority, and it is stated that, the decision of the appellate authority shall be final and binding upon the parties. The case of the petitioner is that, in both these cases, the respective parties have approached the Permanent Lok Adalat for Public Utility Services, without resorting to the dispute resolution mechanism provided under Ext.P1 MEDISEP Scheme and therefore, the same could not have been entertained by the Permanent Lok Adalat for Public Utility Services.

I have heard Sri.George Cherian (Thiruvalla), learned Senior Counsel appearing for the petitioners in these cases, who argued the matter at length, by highlighting the various terms and conditions of the Scheme as well as the agreement, while asserting the contentions referred to above. The learned Senior Counsel also referred to the judgment in Shiva Kant Jha v. Union of India [MANU/SC/0369/2018], which formed the basis of the conclusions arrived by the Permanent Lok Adalat for Public Utility Services. It was pointed out by the learned Senior Counsel that, the facts and circumstances under which the said judgment rendered, were completely different.

According to the petitioner, even though, in the said decision of the Honourable Supreme Court, it was specifically held that, merely because of the reason that, a treatment was availed from a hospital which is not empaneled as per the scheme, the benefit of reimbursement cannot be denied, the said principles could not have been applied in these cases. It was pointed out that, the facts of the said case would reveal that, it was a case of cardiac arrest where, the party therein was compelled to avail the services of a non-empaneled medical institution under an emergent situation, and only by taking note of the aforesaid circumstances, such an observation happened to be made by the Honourable Supreme Court. According to the learned Senior Counsel, when coming to the facts and circumstances of these cases, such an emergent situation was not in existence and therefore, those observations were not relevant.

However, after carefully going through the impugned orders passed by the Permanent Lok Adalat for Public Utility Services, and examining the observations made by the Honourable Supreme Court in the above referred decision, I do not find any justifiable reason to accept the contentions raised by the learned Senior Counsel for the petitioner, for the reasons hereinafter mentioned.

As far as the maintainability of the complaint before the Permanent Lok Adalat for Public Utility Services raised by the petitioner is concerned, as mentioned above, it is raised on the ground that, there exists a separate and independent dispute resolution mechanism in the scheme, which was not resorted to by the respective applicants, before approaching the Permanent Lok Adalat for Public Utility Services. The relevant clause in Ext.P1 in W.P(C) No.21044/26 , is Clause 19, which reads as follows:

Of course, it is true that, going by the said clause, it can be seen that, there is indeed a dispute resolution mechanism. However, the crucial aspect to be noticed is that, the said clause does not contemplate that, without invoking the remedies contemplated in the said clause, the aggrieved party cannot approach any other forums. As far as a Permanent Lok Adalat for Public Utility Services is concerned, the same is created as per Chapter VI-A of the Legal Services Authorities Act, 1987, which was introduced, by way of an amendment brought by Act 37 of 2002 with effect from 11.06.2002. The same was brought in, for the purpose of providing an adjudicatory power to Lok Adalats by constituting Permanent Lok Adalat for Public Utility Services, as it was noticed that, mere passing awards based on settlements alone is not serving the purpose of the Legal Services Authorities Act. The provisions in the said chapter, namely, Chapter VIA, provide for constitution of a special forum named Permanent Lok Adalat for Public Utility Services, where an aggrieved party can approach the forum, in cases where the subject matter of the disputes falls within the “Public Utility Service” as defined under Clause (b) of Section 22A. The said provisions reads as follows:

On going through the same, it can be seen that, insurance service is one of the services included in public utility services and therefore, the services rendered by the petitioner herein, which is a General Insurance Company and the disputes arising therefrom, would amount to ‘public utility services’ in respect of which, the jurisdiction can be exercised by the Permanent Lok Adalat for Public Utility Services.

Moreover, Section 22C of Legal Services Authorities Act, 1987, specifically provides that, any party to a dispute, may, before the dispute is brought before any court, can make an application to the Permanent Lok Adalat for Public Utility Services for settlement of a dispute. Section 22D provides that, The Permanent Lok Adalat shall, while conducting conciliation proceedings or deciding a dispute on merit under this Act, be guided by the principles of natural justice, objectivity, fair play, equity and other principles of justice, and shall not be bound by the Code of Civil Procedure, 1908 and the Indian Evidence Act, 1872. Further, Section 22E provides that, the award of Permanent Lok Adalat will be final. Thus, it is evident that, the legislature intended to provide a mechanism for dispute resolution related to public utility services and a wide jurisdiction was conferred upon such forum, which has to be exercised by following the principles of natural justice, objectivity, fair play, equity and other principles of justice. Further, it was clearly provided that, such forum shall not be bound by the procedure laws as contemplated in Code of Civil Procedure Code or the other principles laid down in the Indian Evidence Act.

On going through the aforesaid provisions, it can be seen that, no pre-conditions are stipulated in the Act, for invoking the powers of the Permanent Lok Adalat for Public Utility Services, except that, such complaint should be submitted before the dispute is brought before any other court. Therefore, the only conclusion possible is that, the said provision confers an absolute right upon an aggrieved party, to invoke the jurisdiction of the Permanent Lok Adalat for Public Utility Services, once it is shown that, it is a dispute touching upon any of the matters referred to as “public utility services” as envisaged in subsection (b) of Section 22A of the Legal Services Authorities Act. Such a statutory right cannot be taken away, by virtue of a contractual term or a clause contained in a scheme formulated by the Government. This view finds support from a decision rendered by the Jharkhand High Court in The Chairman-cum-Managing Director, National Insurance Co and Ors v. Kisha Devi and Ors [ 2024 LiveLaw (Jha) 73].

Moreover, even if it is assumed that, Clause 19 referred to above in the said scheme is binding upon the petitioner, on carefully going through the stipulations in the said scheme, it can be seen that, even the said clause does not exclude the jurisdiction of any other authority. To be precise, nowhere in the said scheme, it is specifically or with necessary implication specified that, without resorting to the dispute resolution mechanism as contemplated in said clause, the party cannot approach any other forum. Thus, in the absence of any such clause, nothing would preclude the party, who is aggrieved by the actions of the insurance company, from approaching a forum, as part of invoking a statutory remedy available to such person. The mechanism provided in the said scheme is only an enabling clause provided to the party, to get the dispute settled, by availing the same and it would not exclude the invocation of statutory remedies available to such party. Hence, merely because of the reason that, the petitioner did not resort to the dispute redressal mechanism as referred to above, the other remedies available to the petitioner as per the statute would not be foreclosed.

Of course, the learned Senior Counsel placed reliance upon the observations made by this Court in W.P(C) No.37967/2023, where, this Court made certain observations with regard to the necessity to invoke the dispute redressal mechanism under the scheme. However, on carefully going through the observations in the said judgment, it can be seen that, the said judgment was passed in respect of a claim raised by the petitioner therein, based on the terms and conditions in the MEDISEP scheme, by invoking the powers of this Court under Article 226 of Constitution of India. It was in those circumstances it was held that, it is only proper for the petitioner therein to invoke the alternate dispute redressal mechanism before invoking the extra ordinary jurisdiction vested upon this Court. The said observations cannot be made applicable to the facts and circumstances of these cases, in view of the fact that, as far as the jurisdiction vested upon the Permanent Lok Adalat for Public Utility Services is concerned, that is a statutory right available to the complainants, and in the absence of any specific stipulation excluding the invocation of such jurisdiction without resorting to the procedure contemplated under the scheme, such right cannot be denied to the complainant. Therefore, I am of the view that, the contention raised by the learned Senior Counsel on this ground is not sustainable.

Next question to be considered is with regard to the lack of empanelment for the medical institutions, from where, the respective complainants availed the treatments. This contention is raised by the learned Senior Counsel mainly by distinguishing the observations made by the Honourable Supreme Court in Shiva Kanth Jha v. Union of India [MANU/SC/0369/2018], where, the Honourable Supreme Court was considering a case in which, the party therein was compelled to avail service of non-empaneled medical institution on an emergency situation owing to cardiac ailments. It was contended that, that was an emergent medical situation, which justified the action of the petitioner therein, and that, therefore, the principles laid down by the Hon'ble Supreme Court in the said decision, cannot be applied to the facts and circumstances of the present case.

On going through the observations made in the said judgment, it is clear that, the Honourable Supreme Court observed that, merely because of the reason that the treatment was availed by the patient from a non-empaneled hospital, the benefits of the reimbursement of the medical expenses cannot be denied. In the facts and circumstances of that case, the treatment was availed in an emergent situation, which appears to be one of the factors that prompted the Hon'ble Supreme Court to accept the contention of the petitioner therein and directing reimbursement of the medical expenses. However, that would not mean that the emergency referred to by the Honourable Supreme Court would be confined to the cases where, treatment was availed due to the injuries sustained in an accident or for any other serious emergent medical situation like cardiac aliments and cerebral stroke. This court in Prasad K. G. v. State of Kerala [2023 KHC OnLine 664] , Suma Sunilkumar v. State Medical Officer [2024 KHC OnLine 7340], Anilkumar B. S. v. State Medical Officer, Thrissur [2026 KHC OnLine 2080], held medical reimbursement cannot be denied on the ground that the beneficiary underwent treatment at a non - empanelled hospital.

Emergent situations will have to be identified, with regard to the circumstances in which the treatment was availed. While deciding the question as to whether there is/was an emergent situation, the same has to be considered from the point of view of the person who faced the situation. The panic and anxiety that arises from the event that necessitates the medical treatment is certainly one of the most relevant factors, that must be taken into account, while determining the question whether, the situation was, in fact, emergent. In such cases, the proper test to be adopted is to find out whether, what decision a prudent man would take in such circumstances and the same cannot be determined, from the point of view of an insurer, who is ascertaining or evaluating the gravity of the situation, after happening of all the events, and after the emergent situation is managed by the insured. In this regard, the decision rendered by High Court of Delhi in Union of India v. Joginder Singh [2023 SCC OnLine Del 2707], becomes relevant , reads thus;

While considering the instances involved in these writ petitions in that perspective, I find that, under no circumstances, it can be held that the situation was not emergent. When coming to the facts and circumstances in W.P.(C).No.15214 of 2026, even going by the averments contained in the writ petition itself, it is seen that, the patient therein was admitted to hospital on four times. First time, it was on account of COVID-19, secondly, the patient admitted in the hospital on 04.09.2022 with up-rolling eyes, decreased response, seizure etc. Later, she was discharged on 07.09.2022. Again, she was admitted after some days with the symptoms of hematemesis preceded by episodes of seizure, vomiting blood etc. After treatment, she was discharged on 03.03.2023. Again on the 4^th occasion, the patient was admitted on 06.06.2024 in a critical condition and she was diagnosed with aspiration pneumonia, urinary tract infection, early sepsis and break through seizures. In all these occasions, there were situations that require emergent treatment as sufficient reasons were there for the parties involved, to get panic and therefore, the fact that, the patient did not opt for an empaneled hospital at the relevant time, by itself cannot be a reason to deny the claim made by the patient. As mentioned above, emergency will have to be weighed from the facts and circumstances of each case and to be taken into account from the point of view of the persons who had undergone it. For every patient suffering from the symptoms as referred to above and for his relatives, it can be an emergency situation, where the circumstances create a genuine impression in their minds that emergent medical attention is required. Moreover, while undergoing such a situation, the priority of the person concerned, would be to avail the treatment at the nearby hospital or at the hospital in which the petitioner was already undergoing the treatment for the diseases. In such emergent situations, insisting that the parties should search for an empaneled hospital, would amount to an inhumane approach. Therefore, merely because of that reason, the relief cannot be denied.

When it comes to the facts and circumstances in W.P.C.No.21044 of 2026, the patient is seen to have availed the medical treatment, consequent to abortion and mental problems. The very same observations made in the earlier case are applicable to this case also. Symptoms of abortion could happen at any time and therefore, as far as the persons who are in involved in such a situation are concerned, there priority may be limited and no one could be expected to make an attempt to find out the empaneled hospital for the purpose of availing the claim as mentioned above at that point of time. The utmost priority in such circumstances, would be to secure medical assistance at the earliest possible opportunity. Therefore, merely because, the patient opted to avail treatment at a non-empaneled hospital, the benefits to which the person was otherwise entitled, cannot be denied.

Thus, from the factual situations referred to above also, I find that in both these cases, there is no scope to conclude that, there was no emergent situation to avail the medical treatment from a non empanelled hospital, warranting denial of the coverage of policy as per Ext.P1 scheme.

Moreover, Ext.P1 scheme is provided as a welfare measure to the benefit of the Government Servants including the retired employees, based on the Constitutional principles enshrined under Articles 21 and 47.Right to health is an integral to right to life. Government has a Constitutional obligation to provide the health facilities. Thus, it becomes the bounden duty of the State and its machineries to ensure that such reimbursement for genuine causes is not denied, based on technicalities as observed in Swati Yadav v. State of Haryana [2026 SCC OnLine P&H 13335], where it was observed as follows;

Sanskrit principle of —may all be happy; may all be free from illness. The principle underlying this timeless invocation is that the well being of society is inseparable from the health and dignity of its people, and it embodies a foundational principle of governance. The State must ensure that policies serve the cause of justice rather than obstruct it, as beneficial schemes must advance their remedial purpose. Medical reimbursement, being an instrument of social welfare, should therefore receive a humane and purposive construction, consistent with the constitutional vision of a just and caring society.

Similarly in G.Latha v. M.D. India Health Care Services [2017 SCC OnLine Mad 23635 ] , wherein it was observed ;

Therefore, the interpretation of the relevant clauses in the scheme, has to be made liberally, so as to promote the real purpose behind the introduction of the scheme and as far as possible, the same has to be in favour of the beneficiary. Thus, in the light of the observations and principles as discussed above and the factual circumstances referred to above, I am of the view that the challenge raised by the petitioners against the awards are not legally sustainable. It is also to be noted that, in paragraph No.13 of the Judgment in Siva Kanth Jha’s case, following observations were made by the Honourable Supreme Court.

The said observations are clearly applicable to the facts and circumstances of this case.

In such circumstances, I do not find any merit in these writ petitions and are accordingly dismissed.

Exhibit P1 THE TRUE COPY OF COMPLAINT SUBMITTED BY ONE MRS.VIJAYALAKSHMI BEFORE THE PLA KOZHIKODE

Exhibit P2 THE TRUE COPY WRITTEN STATEMENT FILED BY THE SOLE RESPONDENT

Exhibit P3 THE TRUE COPY ADDITIONAL WRITTEN STATEMENT FILED BY THE SOLE RESPONDENT

Exhibit P4 THE REPUDIATION LETTER ISSUED BY THE SOLE RESPONDENT DATED 28.12.2022

Exhibit P5 THE REPUDIATION LETTER ISSUED BY THE SOLE RESPONDENT DATED 6.7.2023

Exhibit P6 TRUE COPY OF DISCHARGE SUMMARY DATED 09.07.2022

Exhibit P6(a) TRUE COPY OF DISCHARGE SUMMARY DATED 07.09.2022

Exhibit P6(b) TRUE COPY OF DISCHARGE SUMMARY DATED 03.03.2023

Exhibit P6(c) TRUE COPY OF DISCHARGE SUMMARY DATED 13.06.2024

Exhibit P7 THE TRUE COPY OF LIST OF HOSPITAL EMPANELLED UNDER MEDISEP SCHEME IN KOZHIKODE

Exhibit P8 TRUE COPY OF THE AWARD IN O.P. NO.69/2024 DATED 18.10.2025

Exhibit P9 MOU EXECUTED BY THE GOVERNMENT OF KERALA AND THE PETITIONER

Exhibit P10 THE NOTIFICATION NO 18/2023 DATED 17/02/23 OF THE FINANCE DEPARTMENT

Exhibit P11 THE NOTIFICATION NO 1/2024 OF FINANCE DEPARTMENT DATED 05/01/24

Exhibit P1 A TRUE COPY OF MEDISEP SCHEME INTRODUCED BY GOVERNMENT OF KERALA

Exhibit P2 TRUE COPY OF THE COMPLAINT DATED 23.10.2023 SUBMITTED BY THE 1ST RESPONDENT BEFORE THE PLA KOZHIKODE

Exhibit P3 TRUE COPY OF THE WRITTEN STATEMENT FILED BY THE PETITIONER BEFORE PLA KOZHIKODE

Exhibit P4 TRUE COPY OF THE REPUDIATION LETTER DATED 11.08.23 ISSUED BY THE PETITIONER

Exhibit P5 TRUE COPY OF THE REPUDIATION LETTER DATED 15.11.23 ISSUED BY THE PETITIONER

Exhibit P6 A TRUE COPY OF THE ORDER IN O.P. NO.91/2023 DATED 18.10.2025 ON THE FILES OF PLA KOZHIKODE