Insurance Claim: Karnataka HC Backs Cancer Patient in ₹2.85 Lakh Dispute
Insurance Claim: Karnataka High Court has backed a cancer patient in a ₹2.85 lakh dispute, providing relief to the policyholder.
Insurance Claim: Karnataka High Court backs a cancer patient in a ₹2.85 lakh insurance dispute.
Insurance Claim: The Karnataka High Court has dismissed a writ petition filed by National Insurance Company challenging a Permanent Lok Adalat order that directed the insurer to reimburse medical expenses incurred by a 72-year-old retired Vijaya Bank officer for post-chemotherapy injections. Justice Suraj Govindaraju, in an order passed on September 1, held that an insurance company cannot adopt an unduly restrictive interpretation of a health insurance policy merely because treatment for a serious ailment can be administered without hospitalisation.
Insurance Claim: Background Of The Case
The petitioner, Padmanabha Shetty G., a retired Vijaya Bank officer, held a medical insurance policy with National Insurance Company under the Indian Banks’ Association (IBA) group insurance scheme, a group health cover extended to bank employees and retirees across India. Shetty was diagnosed with Stage IV prostate cancer and was undergoing treatment under the supervision of his treating oncologists.
As part of his ongoing cancer management, the oncologists prescribed Zoladex and Xgeva, two injections used respectively to suppress hormone-driven tumour growth and to protect bone density in cancer patients whose disease has progressed to the bones. These medications are commonly administered as part of continuing cancer care alongside chemotherapy.
While National Insurance Company reimbursed the expenses Shetty incurred for his inpatient chemotherapy sessions, it repeatedly rejected his claims totalling ₹2,85,470 for the Zoladex and Xgeva injections, despite these forming part of the same course of cancer treatment prescribed by his doctors.
Also Read: Can’t deny insurance claim over alcohol habit, rules consumer commission
Insurance Claim: Insurer’s Argument
National Insurance Company argued before the Permanent Lok Adalat, and subsequently before the High Court, that the injections did not qualify for coverage because they were administered without 24-hour hospital admission and without the use of general or local anaesthesia. The insurer contended that this rendered the treatment “outpatient treatment,” a category it said stood excluded under the terms of the policy.
On this basis, the company maintained that its repeated rejection of Shetty’s claims for the two injections was consistent with the policy’s terms and did not warrant reimbursement, even though the broader chemotherapy treatment of which these injections formed a part had already been accepted and paid for under the same policy.
Insurance Claim: Proceedings Before The Permanent Lok Adalat
Aggrieved by the repeated rejection of his claims, Shetty approached the Permanent Lok Adalat, Mangaluru, seeking reimbursement of the ₹2,85,470 spent on the Zoladex and Xgeva injections. The Permanent Lok Adalat ruled in his favour and directed National Insurance Company to reimburse the disputed claim amount in full.
National Insurance Company subsequently challenged this order before the Karnataka High Court by way of a writ petition, arguing that the Permanent Lok Adalat had erred in directing reimbursement for treatment it classified as falling outside the scope of the policy’s coverage.
Insurance Claim: High Court’s Findings
Justice Suraj Govindaraju, hearing the writ petition, examined whether the Permanent Lok Adalat’s order suffered from any error of law or jurisdiction that would justify interference by the High Court in exercise of its writ jurisdiction. The Court held that no such error existed, and that the Permanent Lok Adalat had not taken a view that warranted correction.
In its order, the Court observed that an insurance company cannot adopt an unduly restrictive interpretation of an insurance policy solely on the ground that treatment for a serious ailment of the insured person can be administered without hospitalisation. The Court’s observation addressed the insurer’s core contention that the absence of 24-hour hospital admission and anaesthesia was sufficient, on its own, to classify the treatment as excluded outpatient care.
Having found no infirmity in the Permanent Lok Adalat’s order, the Karnataka High Court dismissed National Insurance Company’s writ petition. The Court additionally imposed a cost of ₹50,000 on the insurer.
