Madras High Court

P.Thamotharan vs Employees' State Insurance ... on 9 October, 2025

                                                                                          W.P No. 11802 of 2022

                                   IN THE HIGH COURT OF JUDICATURE AT MADRAS
                                              DATED : 09.10.2025

                                                           CORAM

                    THE HONOURABLE MR.JUSTICE HEMANT CHANDANGOUDAR

                                                   W.P No. 11802 of 2022

                P.Thamotharan                                                              ..Petitioner
                                                   Vs
                1. Employees' State Insurance Corporation,
                Rep. By its Deputy Director (Benefit)
                Sub-Regional Office (Coimbatoe),
                1897, Trichy Road, Ramanathapuram,
                Coimbatore -641045.

                2.The State Medical Commissioner,
                Employees' State Insurance Corporation,
                Regional Office, No. 143, Sterling Road,
                Nungambakkam, Chennai-600034.

                3. The Director General,
                Employees' State Insurance Corporation,
                CIG Marg, New Delhi-110002.                                              ..Respondents


                       Writ Petition is filed under Article 226 of Constitution of India, praying
                for issuance of a Writ of

                                  For Petitioner  : Ms. P. Jayalakshmi
                                                   For E.Maragatha Sundari
                                  For Respondents : Ms.G.Narmadha




                1


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                                                                                        W.P No. 11802 of 2022

                                                    ORDER

The captioned writ petition has been filed seeking the issuance of a Writ

of Certiorari, to quash the communication dated 09.07.2021 issued by the 2nd

respondent, whereby the claim of the petitioner for reimbursement of medical

expenses incurred towards the treatment of a head injury sustained in a road

accident was rejected.

2. The petitioner, while employed as a Fitter in M/s. KPR Mill Ltd.,

Kittampatti, Karumathampatti (Post), Coimbatore District, was enrolled under

the Employees’ State Insurance (ESI) Scheme with effect from 21.01.2017,

bearing Insurance No. 5606500985.

3. On 01.08.2018, while travelling on a two-wheeler, the petitioner met

with a road accident and sustained severe head injuries. He was admitted to Dr.

Muthu’s Hospital, Singanallur, Coimbatore by an unknown person and

remained under medical supervision. The petitioner underwent surgeries on

08.08.2018 and 14.08.2018, and was discharged on 03.09.2018.

4. Subsequently, the petitioner submitted an application dated 19.11.2018

to the 3rd respondent seeking reimbursement of medical expenses incurred

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towards his treatment. However, by the impugned communication dated

09.07.2021, the said claim was rejected.

5. Ms. P. Jayalakshmi, learned counsel for the petitioner, submitted that

although the hospital in which the petitioner underwent treatment was not an

empanelled ESI hospital, the petitioner is nonetheless entitled to reimbursement

of medical expenses, considering the emergency nature of the case and the life-

threatening head injuries sustained.

6. It was further contended that the ESI Hospitals did not possess the

required facilities for Neurosurgery/CTVS Specialties, as is evident from the

certificate issued by the Government Medical College and ESI Hospital,

Coimbatore. Learned counsel also argued that the denial of medical

reimbursement on the technical ground that the treatment was availed in a non-

empanelled hospital is unjustified. In support of her submissions, reliance was

placed on the judgment of the Hon’ble Supreme Court in Shiva Kant Jha v.

Union of India (Writ Petition (Civil) No. 694 of 2015, dated 13.04.2018),

wherein it was held that reimbursement cannot be denied merely because

treatment was taken in a non-empanelled hospital, particularly in emergency

situations.

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7. Ms. G. Narmadha, learned counsel for the respondents, submitted that

the petitioner was not eligible for medical reimbursement since the treatment

was taken within two years of his employment. She relied on Section 57 of the

Employees’ State Insurance Act, 1948 (“the Act”) read with Regulation 96(A)

of the Employees’ State Insurance (General) Regulations, 1950 (“the

Regulations”), which stipulates certain conditions regarding eligibility.

8. It was further contended that the hospital in which the petitioner

received treatment is not empanelled under the ESI Scheme. Therefore, under

the provisions of the Act and the Regulations, the petitioner is not entitled to

reimbursement. The learned counsel pointed out that although the petitioner

suffered injuries on 01.08.2018 and underwent surgery on 08.08.2018,

indicating that the case was not one of emergency, the treatment being availed

from a non-empanelled hospital disentitles him to claim reimbursement.

9. The learned counsel further argued that the decision of the Hon’ble

Supreme Court in Shiva Kant Jha (supra) is not applicable to the present case,

as it pertains to Central Government employees covered under the Central

Government Health Scheme (CGHS) and not to employees governed by the ESI

Act, 1948.

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10. The submissions of the learned counsel for both parties and materials

available on record are carefully considered.

11. It is not in dispute that the petitioner was employed on 21.01.2017,

enrolled under the ESI Scheme on the same day, and sustained serious head

injuries in a road accident on 01.08.2018, necessitating immediate medical

attention. The central issue for consideration is whether the petitioner, who

availed treatment in a non-empanelled hospital, is entitled to reimbursement of

medical expenses.

12. The Government Medical College and ESI Hospital, Coimbatore has

categorically certified that Neurosurgery and CTVS specialties are not available

in their institution. The certificate dated 21.09.2018 records the following

medical findings:

“B/L Temporal contusion. Right 6th, 7th, 8th, 9th rib fractures with hemothorax, poly trauma – prolonged mechanical ventilation treatment done at private hospital. Neuro surgery/CTVS Special is not available in GMC & ESI Hospital.”

13. The above certificate clearly establishes that the petitioner could not

have received appropriate treatment in the ESI Hospital, as the required medical

facilities were unavailable there. Moreover, the petitioner required immediate

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medical attention, having sustained severe head injuries, and was admitted to

the hospital by an unknown person while he was unconscious. Therefore, the

petitioner cannot be expected to have taken treatment in an empanelled hospital,

as it was a case of medical exigency.

14. Section 57 of the Employees’ State Insurance Act, 1948, stipulates

that an insured person or his family shall be entitled to receive medical benefits

only of such nature and to such extent as may be provided by the State

Government or by the Employees’ State Insurance Corporation. It further

clarifies that neither the insured person nor his family has a right to claim

medical treatment from any institution other than the dispensary, hospital,

clinic, or other medical establishment allotted to them by the State Government

or the Corporation, or as may otherwise be provided by the relevant regulations.

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15. A plain reading of the above provision makes it evident that

reimbursement of medical expenses can ordinarily be claimed only when the

treatment has been taken in a hospital or medical institution duly recognized or

authorized by the State Government or the Corporation. In the present case, it is

an admitted fact that the petitioner underwent treatment in a non-empanelled

hospital, which was not one of the institutions authorized by the Corporation.

16. Furthermore, Regulation 96(A) of the Employees’ State Insurance

(General) Regulations, 1950, provides that a claim for reimbursement of

medical expenses incurred by an insured person may be entertained, subject to

such terms and conditions as the Corporation may specify through a general or

special order. This implies that while the Corporation has the discretion to

consider reimbursement claims even in exceptional circumstances, such

reimbursement is contingent upon the fulfilment of the specific conditions

prescribed by the Corporation.

17. In exercise of these powers, the Corporation issued a communication

dated 07.11.2016, which reads as follows:

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“ ln ESIC Operational Manual 2015 for SST Services, it was decided that

"in respect of Children of Insured Persons (IPs) congenital diseases and

genetic diseases will be eligible for coverage up to the ceiling mentioned

earlier only in case the child is born after the IP had become eligible for

SST. Due to this clause hardship is faced by ESI beneficiaries for getting

treatment. Therefore, following has now been decided:-

"The IP should have been in continuous employment for the last two years as on the date of diagnosis for SST (other than the cases of employment injury) and at least 156 days contribution was paid by the IP during the immediately preceding four contribution periods with eligibility for sickness benefit in at least two benefit periods."

After completion of the above period the IP and family will be eligible for SST Including the children of IP with congenital diseases and genetic disorder.”

18 A careful reading of the said communication reveals that, according

to its terms, only employees who have been in continuous employment for two

years and have made sufficient contributions are eligible to avail themselves of

Super Speciality Treatment (SST). This eligibility extends to their family

members, including children suffering from congenital or genetic conditions.

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19. The Employees’ State Insurance Act, 1948 is a social welfare

legislation enacted with the primary objective of providing comprehensive

protection and support to employees in the event of contingencies arising from

sickness, maternity, and employment-related injuries. The Act recognizes that

employees, being the backbone of industrial and commercial enterprises, are

often exposed to risks that may temporarily or permanently impair their ability

to earn a livelihood.

20. The overarching purpose of the Act is therefore to create a robust

safety net for employees, ensuring that no employee is left without adequate

medical care or financial support during periods of vulnerability caused by

health-related issues or occupational hazards. The legislation embodies the

principles of social justice and welfare, reinforcing the duty of both the State

and the employer to safeguard and promote the health, well-being, and

economic security of the workforce.

21. In the present context, the circular relied upon by the respondents,

which seeks to restrict reimbursement of medical expenses to employees who

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have completed two years of continuous employment, is clearly inconsistent

with the object and spirit of the ESI Act. The Act mandates that medical

protection and benefits commence from the very date of enrollment in the

insurance scheme, without any undue delay. Consequently, the said restriction

is arbitrary, discriminatory, and unenforceable, and cannot be invoked to deny

the petitioner’s legitimate claim for reimbursement, particularly in cases of

emergency or exigency where immediate medical treatment is required.

22. More particularly, in the present case, the petitioner has been

enrolled under the ESI Scheme from the very date of his appointment as a fitter

and has consistently made contributions towards the insurance policy. The

provisions of the Employees’ State Insurance Act, 1948, are intended to provide

medical protection and related benefits from the commencement of

employment, recognizing that insured persons contribute to the scheme from

day one.

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23. To restrict the entitlement to reimbursement of medical expenses only

after the completion of two years of continuous employment would be contrary

to the object and purpose of the Act, which is to create a comprehensive social

security net for employees from the outset of their employment. Such a

restriction would defeat the very intent of the legislation, as it would unjustly

deny medical benefits to a contributor who has fulfilled his obligations under

the scheme, particularly in cases where urgent or emergency medical treatment

is required.

24. Therefore, having made contributions from the date of employment,

the petitioner cannot be lawfully denied reimbursement of medical expenses

merely on the ground that two years of employment have not yet elapsed. Any

interpretation or circular seeking to impose such a restriction would be

arbitrary, discriminatory, and inconsistent with the welfare objectives of the

Act, and is thus legally unsustainable.

25. Further, the Hon’ble Supreme Court in Shiva Kant Jha (supra) held

that medical reimbursement cannot be denied solely on the ground that

treatment was taken in a non-empanelled hospital, particularly in cases of

emergency. The Court emphasized that once the fact of genuine treatment is

established, reimbursement cannot be refused on technical or procedural

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grounds. Though the cited decision pertains to Central Government employees,

the ratio decidendi can be applied by analogy to employees covered under the

ESI Act, which is a beneficial social welfare legislation.

26. An exception can therefore be carved out in cases of medical

exigencies, where the circumstances necessitate treatment in a non-empanelled

hospital, as in the present case. It is unreasonable to expect an unknown person

or an injured employee in an unconscious state to make inquiries regarding

whether a hospital is empanelled or not. To do so would place an employee

requiring immediate medical attention in an unnecessarily complicated and

potentially life-threatening situation.

26. It is also pertinent to note that the communication dated 07.11.2016

pertains only to Super Speciality Treatment (SST) and not to general or

emergency medical treatment. The Corporation cannot draw an artificial

distinction between the two for the purpose of denying reimbursement, as doing

so would defeat the very purpose of the welfare legislation.

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27. In view of the foregoing discussion and the materials placed on

record, this Court is of the view that the rejection of the petitioner’s claim for

medical reimbursement is unsustainable. Accordingly, the writ petition is

allowed with the following directions:

i. The 2nd respondent is directed to reconsider the petitioner’s claim only for computing the actual admissible medical expenses incurred towards the treatment of his head injuries, and reimburse the amount computed strictly in accordance with law and by taking into account the observations made in the preceding paragraphs.