The ₹4 lakh COVID-19 critical-care ceiling does not guarantee reimbursement beyond prescribed package rates and eligibility criteria.

The petitioner, who received treatment for COVID-19 at a private hospital, claimed to have incurred expenses of ₹4,89,438.

The fifth respondent insurer reimbursed ₹1,10,260.

Relying on G.O.Ms.No.280, Finance (Salaries) Department, dated 24 June 2020, and a letter dated 1 February 2021 referring to ₹4,14,500, the petitioner sought a further ₹3,04,240 by writ of mandamus.

The respondents maintained that the amount eligible under the applicable criteria had been paid.

Whether the petitioner was entitled to further COVID-19 medical reimbursement under G.O.Ms.No.280 beyond the ₹1,10,260 already paid.

Whether the first respondent’s letter referring to ₹4,14,500 established a final entitlement to that amount, irrespective of the applicable eligibility criteria.

G.O.Ms.No.280, Finance (Salaries) Department, dated 24 June 2020, provided for payment for COVID-19 critical care under applicable package rates, subject to a ceiling of ₹4,00,000 under Clause 4(i)(a); the Court read that provision harmoniously with Clause 4(ii) and the provisions concerning additional categories in Clause 4(i)(b).

The Court also referred to G.O.Ms.No.240, Health and Family Welfare (EAPI-I) Department, dated 5 June 2020, as governing the relevant existing critical-care package rates.

The petition was brought under Article 226 seeking mandamus; no judicial precedents were relied upon.

The Court held that the ₹4,00,000 ceiling was not an automatic reimbursement amount, but related to eligible critical-care package rates under the existing scheme.

The additional COVID-19 provisions addressed specified categories of expenses, and the insurer stated that it calculated the petitioner’s reimbursement using the applicable daily rate for his 12-day admission, resulting in payment of ₹1,10,260.

The first respondent’s letter, read as a whole, directed settlement according to eligibility criteria; its reference to ₹4,14,500 did not finally determine that sum as payable.

The Court therefore accepted the respondents’ position that the eligible amount had been settled.

It dismissed the writ petition for lack of merit, with no order as to costs.