Insurer under health scheme cannot be denied reimbursement:HC

Insurer under health scheme cannot be denied reimbursement:HC

The Madras High Court has ruled that an insurer covered under health insurance Scheme cannot be denied reimbursement of treatment cost merely because the ailment is not included in the list of insurance schemes.

"Once a person is validly covered by the health insurance scheme and when he has taken treatment in an accredited hospital, he cannot be denied the reimbursement of cost of treatment", Justice T Raja said.

The court ruling came on a petition by one G Simon Cristudoss, an Assistant in Little Flower Higher Secondary school of Annamangalam area here.

Concurring with submissions of petitioner's counsel that the District Education officer, a competent authority, had unfairly denied his client's claim, saying the disease is not covered in the list of the scheme of Insurance, the Judge said the approach of the officer is unreasonable.

Counsel said Simon has been regularly paying subscription for government employees health fund scheme monthly since 1998. He underwent an opthalmology surgery at Vijaya Hospital in 2008 on the advice of doctors to so or risk losing vision. He paid Rs 1.17 lakh as costs.
When he submitted the bills and application for reimbursement, the DEO rejected it saying the disease 'eye pressure' is not included in the list of the scheme.

Faulting the rejection order, the judge said authorities should not have rejected the claim when Simon is a regular subscriber and the hospital an accredited one for specialized advanced surgeries.

He then directed the authorities to pay the entire claim amount with eight per cent interest to the petitioner.

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