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HC Slams Insurance Co, Allows Reimbursement for Unapproved Hospital

HC Slams Insurance Co, Allows Reimbursement for Unapproved Hospital

Getting treatment in a hospital not approved by the concerned insurance company does not become a ground for rejection of claims, implies a recent ruling made by the Madras High Court.

The court was seen directing the Director of Pension to sanction the medical expense that were incurred by a deceased  patient- a government employee for his treatment during his lifetime. It is reported that after the death of the patient, his wife tried to claim reimbursement for the treatment amounting to Rs 1.07 lakh . The claim was, however rejected by the under the New Health Insurance Scheme for Pensioners on the grounds that the treatment was not cashless and that  the employee underwent a surgery at a hospital which was not in the list of hospitals approved by the government for reimbursement of medical expenses.

Aggrieved with the decision, the patient’s wife filed a case in the high court challenging it. The single judge passed an order giving a direction to the Tamil Nadu government to reimburse medical expenses reports TOI, but , the state’s director of pension preferred appeal.

Dismissing the appeal the bench consisting of Justice M Venugopal and  Abdul Quddhose,  said

“Undoubtedly, the human being is to take necessary precautionary and protective measure for his body. The payment /retirement of medical expenses spent by the government servant concerned or his family is not a ‘bounty’, but it is an obligation of the state government to pay/disburse the said amount in question without harping on either technicalities or hyper technicalities. As such this court is of the considered opinion that the single judge was correct in directing the director of pension to sanction the medical expenses incurred by Sarada.”

The court directed the the government to reimburse the amount stating that during a medical emergency, the patient could not look for approved hospitals reports the hindu. Having said that,  the court reduced the interest to 6% per annum from 9% by saying that interest was slightly on the higher side.

Source: self
3 comment(s) on HC Slams Insurance Co, Allows Reimbursement for Unapproved Hospital

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  1. user
    Dr Nalam Seetaramji November 11, 2017, 12:47 pm

    This is a very very welcome decision from courts that go a long way in ameliorating emergency patients\’ vows. At the same time, hospitals/nursing homes must undergo quality control checks by Medical fraternity and Government agencies so that their standard of care is embedded in their systems, and Govt schemes are not misused.

  2. user
    Dr RAMESH VARDHAN November 11, 2017, 11:34 am

    WHAT ARE THE CRITERIA FOR APPROVAL OR DISAPPROVAL FOR TREATMENT SHOULD BE MENTIONED WELL , SO TO SELECT THE RIGHT HOSPITALS WITH FULL TIME COMMITTED DOCTORS. GETTING IN TO ILL EQUIPPED, PART TIME OR VISITING DOCTORS CAN MAKE THINGS BAD TO WORSE DUE NON AVAILABILITY OF THE FACILITIES AND SKILLED DOCTORS. THIS IS QUITE COMMON IN OUR COUNTRY. THE AYUSH , AND MANY MORE DUMMY OR SELF DECLARED DOCTORS ( QUACKS) .ARE RUNNING THE HOSPITALS. WHERE AS DOCTORS ARE RUNNING FROM ONE HOSPITAL TO OTHER , WASTING MORE THAN HALF OF THE ON THE ROADS. THIS KIND OF PRACTICE SHOULD BE STOPPED. BASED ON FULL TIME COMMITTED DOCTORS AVAILABLITY LICENCE TO ESTABLISH HOSPITALS SHOULD BE GIVEN. THE DISTANCE FROM THE HOSPITAL AND THE DOCTORS SHOULD BE WITH IN REACH , LESS THAN 10 TO 15 Minutes. . I SUGGESTED THE EDITOR OF MEDICAL DIALOGUE TO PUBLISH AN ARTICLE ABOUT THIS ISSUE – CRITERIA FOR SET UP THE HOSPITAL, OR OBTAIN A LICENCE, DETAILS OF THE LICENCING AUTHORITY,TYPES OF HOSPITAL, NUMBER OF FULL TIME COMMITTED STAFF, THEIR QUALIFICATIONS…….AND ALL OTHER RELATED ISSUES. I SEE EVERY NOOK AND CORNER OF THE TOWN HAVING A NURSING HOMES WITH ALL SORTS OF FUNNY NAMES, HORDING OF WHITE LADY AND CHILD WITH SEMI NUDE PICTURES, THE GREAT DOCTORS PHOTOS PROJECTING/ PROMOTING LIKE A FILM STAR. ( LOOKS CHEAP ,AT LEAST FOR ME). MOST OF THESE GUYS ARE THE RESIDENT DOCTORS / LECTURES FROM THE NEAR BY MEDICAL COLLEGES , WHO INVARIABLY DISAPPEAR SOON AFTER THE BIOMETRIC ATTENDANCE LIVING. O P D TO THE MERCY OF THE TRAINEES. UNFORTUNATELY THE COURTS AND LAWYER DON\’T LOOK INTO THESE MATTERS. WHO EVER HAVING A MBBS / any other damn DEGREE, wearing white coat, and stethoscope around the neck as decorative piece IS A CONSULTANT AND SUPER CONSULTANT.

  3. user
    Dr N K Chandrasekaran November 11, 2017, 8:55 am

    In connivance with Insurance companies the so called approved hospitals do all sorts of unwanted tests and procedures and deplete the amount. Patients can not and will not dare to question the validity of tests. After deletion of the eligible amount, the patient is forced to spend from his resources to clear the bill at the time of discharge. Serious monitoring is required by the concerned higher bodies.