Consumer Forum Can Hear Complaints Under Medical Insurance Scheme For State Govt Employees: Kerala Consumer Commission

The Kerala State Consumer Disputes Redressal Commission Bench has recently held that a Consumer Commission can entertain a complaint filed by an individual relating to a claim under the MEDISEP Scheme especially in absence of a statutory authority to deal exclusively with such claims under the Scheme.

The decision was rendered by the bench of Justice B. Sudheendra Kumar (President) and Ajith Kumar D. (judicial member) said:

“Consumer Commission is having jurisdiction to entertain a complaint relating to claims under the Medisep scheme, particularly when there is no statutory authority to exclusively deal with the matters relating to the claims under the Medisep scheme. For the said reason, the Consumer Commission is having jurisdiction to entertain the present consumer complaint.”

The Commission was dealing with a revision petition filed by Oriental Insurance company against the decision of the District Commission, Ernakulam.

MEDISEP (Medical Insurance Scheme for State Employees and Pensioners) is a social security scheme of the Kerala Government that provides comprehensive health insurance coverage to all serving and newly recruited state employees, High Court employees, pensioners, and their families.

The complainant was a retired head master and beneficiary of the Scheme. In 2024, due to a medical emergency, he was treated at Rajagiri Hospital where he had to spend more than Rs. 2 lakh.

The claim was submitted before the insurance company. On rejection of the claim by the insurer, the complainant approached the district commission with a consumer complaint.

The maintainability of the complaint was challenged by the insurance company before the District Commission stating that since there was Grievance Redressal mechanism under the Scheme, he ought to have submitted his grievance there first.

The District Commission, however, held that the complaint was maintainable under Section 100 of the Consumer Protection Act, 2019.

The revision petition before the State Commission was preferred against the said decision regarding maintainability.

The counsel for the insurance company argued that the consumer complaint was not maintainable in view of the inhouse mechanism envisaged under the Scheme.

The amicus curiae submitted that no statutory body was constituted to deal with the claims under the scheme and thus, there is no bar on approaching the district commission without resorting to the internal mechanism.

The State Commission looked into Section 100 of the Consumer Protection Act wherein it is provided that the provision of the Act is in addition and not in derogation of other laws.

The Commission observed that since there is no exclusive authority to deal with grievances related to the claims under the Medisep scheme, there is no bar on a Medisep beneficiary to approach the Consumer Commission.

It, therefore, held that the district commission was perfectly right in holding that the complaint was maintainable. Rejecting the plea, the Commission said:

“The District Commission shall proceed with the complaint in accordance with law. Needless to state that the District Commission shall consider all issues independently and untrammelled by any of the observations in the order passed by the District Commission.”