The Karnataka High Court has dismissed a writ petition filed by National Insurance Company Ltd. challenging an award directing reimbursement of medical expenses incurred by a retired bank officer for Zoladex and Xgeva injections prescribed during his treatment for advanced prostate cancer.
Justice Suraj Govindaraj held that the absence of hospitalisation, by itself, could not be treated as decisive when the treatment was medically prescribed and connected with the insured disease.
Background of the Case
Padmanabha Shetty G., a retired Vijaya Bank officer, was covered under the health insurance scheme for retired employees of member banks. His policy provided annual coverage of Rs.9 lakh for the period from November 1, 2021 to October 31, 2022.
Shetty was undergoing treatment for Stage IV prostate carcinoma, including chemotherapy at HCG Hospital, Bengaluru. His doctors subsequently advised Zoladex and Xgeva injections every three months. While the insurer reimbursed several medical expenses, it declined to reimburse expenses relating to these injections.
He then approached the Permanent Lok Adalat at Mangaluru seeking Rs.2,85,470. The Lok Adalat directed payment of the amount with 6% annual interest and also awarded Rs.25,000 as compensation.
Insurance Company's Argument
National Insurance argued that the injections did not require hospitalisation and therefore amounted to outpatient treatment. It relied on the policy definitions of “Day Care Treatment” and “Hospitalisation” to contend that the expenses were outside the policy coverage.
The insurer also argued that the Permanent Lok Adalat had not properly considered the policy terms and its repudiation of the claim.
Court's Observation
The High Court rejected the argument that reimbursement could be denied simply because the injections were administered without hospitalisation.
“Hospitalisation is not an end in itself; it is a mode in which medical treatment may be administered.”
The Court noted that Zoladex and Xgeva were prescribed as part of the continuing management of the insured's prostate cancer. It held that modern medical treatment cannot be denied coverage merely because advances in medicine have made hospitalisation unnecessary.
The Court also observed that requiring a patient to undergo medically unnecessary hospitalisation merely to satisfy an insurer's interpretation of the policy would not be reasonable.
Decision
The High Court found no legal or jurisdictional error in the Permanent Lok Adalat's award and declined to interfere with it.
The writ petition was dismissed with a nominal cost of Rs.50,000, payable by the insurer to Padmanabha Shetty within 30 days.
National Insurance was also directed to pay the medical expenses awarded by the Permanent Lok Adalat, along with up-to-date interest, within the same period.
Case Details
- Case Title: M/s National Insurance Co. Ltd. v. Padmanabha Shetty G. & Ors.
- Case Number: W.P. No. 14682 of 2024 (GM-RES)
- Judge: Justice Suraj Govindaraj
- Decision Date: September 1, 2026
