Insurance company denied compensation on technical grounds
Both employees were covered under the new health insurance scheme but denied reimbursement on procedural violations. (PHoto: DC)
Chennai: The Madras high court has directed the state government to reimburse the eligible medical expenses incurred by a court staff for his 6-year-old son who suffered from cancer and subsequently died, and to a teacher whose husband underwent surgery.
Both employees were covered under the new health insurance scheme but denied reimbursement on procedural violations. Justice N. Paul Vasanthakumar was disposing of petitions from K. Srinivasan and S. Jalaja.
Disposing of the petitions from Srinivasan and Jalaja, Justice Vasanthakumar directed the government to sanction and reimburse the eligible medical expenses, by receiving claim from the petitioners and pay it with 9 per cent interest from the date of remittance of amount to the listed hospitals till date of payment, within four weeks.
Srinivasan, working as an assistant in the establishment section of the high court enrolled himself under the new health insurance scheme (NHIS) in June 2012. His son was diagnosed with cancer but died on November 22, 2012. Since the hospitals insisted that he make payment in advance, he paid Rs 2.98 lakh.
After the death of his son, he applied for reimbursement but the insurance company denied this on technical grounds. Similarly, after Jalaja’s husband underwent surgery, she made a claim for '2.50 lakh but the insurance company denied reimbursement on technical grounds.
The United India Insurance Company contended that the scheme was a cashless model which means that no reimbursement is permissible. If at all the petitioners were eligible to get any amount, it would be from the government.
As per the rules, the petitioners were entitled to claim medical reimbursement from the government, the judge added.
The judge said a division bench of the court had earlier directed the state government to inform every network hospital that if any complaint from claimants regarding demand for money for admission or treatment was received, the hospital will be removed from the network.
But the government had not removed the hospitals from the approved list. Thus, the fault was entirely the government’s, he added.
( Source : dc )
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