Insurer Must Settle Any Medical Reimbursement Balance in Accordance With Committee Recommendation

The petitioner sought reimbursement of medical expenses incurred for his wife’s treatment and surgery at GEM Hospital, Coimbatore, between 9 and 17 March 2022.

The total claim was ₹2,68,262, of which ₹66,080 had been paid.

The District Level Empowered Committee had recommended settlement on 8 July 2022.

The insurer contended that the petitioner had not furnished the required records; the petitioner relied on a letter dated 27 July 2023 stating that he had submitted the documents.

He filed this Article 226 petition seeking the balance, with interest, and consideration of his representation dated 23 February 2024.

1. Whether the second respondent should be directed to settle any balance reimbursement in light of the District Level Empowered Committee’s recommendation and the petitioner’s submission of the relevant records.

2. Whether the petitioner was entitled to the specific reimbursement and interest sought in the writ petition.

The petition invoked Article 226 of the Constitution of India, under which the High Court may issue a writ of mandamus.

The Court did not cite any specific statutory provision, precedent, or separate substantive rule governing reimbursement.

It disposed of the petition without deciding the merits, directing the insurer to settle any balance in accordance with the District Level Empowered Committee’s recommendation.

The Court found no serious dispute about the treatment or the petitioner’s eligibility for reimbursement; the dispute concerned whether the required records had been submitted.

The petitioner produced the letter dated 27 July 2023 evidencing submission of the documents, and the respondents acknowledged that ₹66,080 had been paid.

In those circumstances, the Court directed the insurer to act on the Committee’s recommendation, while expressly leaving the merits undecided.

The second respondent was directed to settle any balance amount in accordance with the District Level Empowered Committee’s recommendation within four weeks of receiving a copy of the order.

The Court did not separately award the claimed 9% interest; no costs were ordered.