Court rules that modern medical advancements allowing outpatient administration of prescribed injections for advanced prostate cancer do not exclude coverage under health insurance policy; refuses to remit case for conciliation due to insurer’s categorical refusal to settle
In a significant judgment delivered on September 1, 2026, the Karnataka High Court dismissed a writ petition filed by M/s. National Insurance Co. Ltd. challenging an order of the Permanent Lok Adalat, Mangaluru, which directed the insurer to reimburse medical expenses incurred by a retired bank employee for prescribed injections administered as part of his advanced prostate cancer treatment. The Court also imposed a nominal cost of Rs. 50,000 on the insurer for adopting an unduly restrictive interpretation of the insurance policy.
The dispute arose when respondent Padmanabha Shetty G., a retired officer of Vijaya Bank (now merged with Bank of Baroda), claimed reimbursement for the cost of two injections—Zoladex (Goserelin Acetate) and Xgeva (Denosumab)—administered as post-chemotherapy treatment for Stage IV prostate cancer. While the insurer had reimbursed hospitalisation and chemotherapy expenses, it denied coverage for the injections on the ground that these were administered without hospitalisation or anaesthesia and thus constituted outpatient treatment not covered by the policy.
The Permanent Lok Adalat, after conciliation efforts failed, adjudicated the dispute and ruled in favor of the insured, directing the insurer to pay Rs. 2,85,470 along with interest and compensation of Rs. 25,000 for inconvenience caused. The insurer challenged this award before the Karnataka High Court, contending that the injections did not fall within the defined terms of “Day Care Treatment” or “Hospitalisation” under Clauses 2.10 and 2.19 of the insurance policy, which required hospital admission or anaesthesia for coverage.
The Court carefully analyzed the legal provisions and the facts. It acknowledged the importance of conciliation under Section 22-C of the Legal Services Authorities Act, 1987, but refused to remit the case for conciliation because the insurer had categorically stated its unwillingness to offer any settlement or payment, making further conciliation futile.
On the merits, the Court held that the insurer’s technical objection was untenable. It observed that advances in medical science now permit treatments that previously required hospitalisation to be safely administered on an outpatient basis. Denying coverage solely because the injections did not require hospital admission or anaesthesia would produce an anomalous result, effectively penalizing insured persons for medical progress.
The Court emphasized that the injections were medically prescribed as part of the continuing treatment of the insured’s advanced prostate cancer and were directly connected to the insured disease. It held that the policy definitions must be interpreted in light of their purpose—to provide coverage for necessary medical treatment—and not in an unduly narrow or restrictive manner that defeats insurance coverage based on procedural technicalities.
Ultimately, the Karnataka High Court upheld the Permanent Lok Adalat’s award, directing the insurer to reimburse the amount due with interest and imposed a nominal cost on the insurer for unnecessarily prolonging litigation. The judgment reaffirms the principle that health insurance coverage should reflect the realities of modern medical treatment and protect insured persons from hyper-technical denials.
Bottom Line:
Health Insurance - Claim for reimbursement of medical expenses for prescribed injections under the insurance policy upheld despite absence of hospitalisation, as treatment was part of continuing care for advanced prostate cancer.
Statutory provision(s): Legal Services Authorities Act, 1987 Section 22-C, Code of Civil Procedure Section 152
M/s. National Insurance Co. Ltd. v. Padmanabha Shetty G., (Karnataka) : Law Finder Doc Id # 2972636
