REIMBURSEMENT DENIED
Court quashes 91 state orders rejecting insurance claims of govt employees
TIMES NEWS NETWORK
Chennai:29.05.2019
The Madras high court has pulled up the state government for rejecting reimbursement claims of government employees and pensioners under the Tamil Nadu Government Employees Health Insurance Scheme for unjustified reasons.
Justice R Suresh Kumar quashed 91 such orders, passed by district-level committees, rejecting the claim applications on flimsy, unworthy and unsustainable grounds. The committees have been directed to reconsider the applications and order reimbursement by the insurer with 6% interest.
According to the petitioners, who are either government employees, pensioners or their kin, are covered under the compulsory government insurance scheme which is notified once in four years.
As per the terms of the present scheme, cashless treatment can be availed of by the members in the network hospitals. If the hospital is not in the network, reimbursement can be claimed. The state deducts the premium for the insurance directly from the employee’s salary account.
The petitioners had undergone treatments in various non-network hospitals across the state and their reimbursement claims were rejected by the committee prompting them to approach the court.
Many of the claims were rejected mainly on the ground that non-emergency treatment was availed through non-network hospitals which is not permissible as per the scheme condition.
Refusing to concur, Justice Suresh Kumar said, “This court wants to remind once again that courts have taken the view that it is for the medical expert to decide as to which case is an emergency one to be attended immediately and which case is not. Neither the administrators nor this court has got any expertise to decide as to whether a particular case was to be treated immediately at the given point of time or could have been postponed for some time enabling the patient to approach the network hospital and it is the matter to be solely decided only by the medical experts.”
Court quashes 91 state orders rejecting insurance claims of govt employees
TIMES NEWS NETWORK
Chennai:29.05.2019
The Madras high court has pulled up the state government for rejecting reimbursement claims of government employees and pensioners under the Tamil Nadu Government Employees Health Insurance Scheme for unjustified reasons.
Justice R Suresh Kumar quashed 91 such orders, passed by district-level committees, rejecting the claim applications on flimsy, unworthy and unsustainable grounds. The committees have been directed to reconsider the applications and order reimbursement by the insurer with 6% interest.
According to the petitioners, who are either government employees, pensioners or their kin, are covered under the compulsory government insurance scheme which is notified once in four years.
As per the terms of the present scheme, cashless treatment can be availed of by the members in the network hospitals. If the hospital is not in the network, reimbursement can be claimed. The state deducts the premium for the insurance directly from the employee’s salary account.
The petitioners had undergone treatments in various non-network hospitals across the state and their reimbursement claims were rejected by the committee prompting them to approach the court.
Many of the claims were rejected mainly on the ground that non-emergency treatment was availed through non-network hospitals which is not permissible as per the scheme condition.
Refusing to concur, Justice Suresh Kumar said, “This court wants to remind once again that courts have taken the view that it is for the medical expert to decide as to which case is an emergency one to be attended immediately and which case is not. Neither the administrators nor this court has got any expertise to decide as to whether a particular case was to be treated immediately at the given point of time or could have been postponed for some time enabling the patient to approach the network hospital and it is the matter to be solely decided only by the medical experts.”
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