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Insurance leaves scar on Professors post-surgery

Two beneficiaries of the NHIS pay more than Rs 50,000 each for treatment at private hospitals after United India Insurance firm rejects claims for reimbursement.

Published: 01st April 2013 10:42 AM  |   Last Updated: 01st April 2013 10:42 AM   |  A+A-

Teething problems in the implementation of the Tamil Nadu Government’s New Health Insurance Scheme (NHIS 2012) appears to be affecting some beneficiaries in availing cashless treatment at approved hospitals.

In recent months at least two college professors, who were covered under the NHIS for the block period July 1, 2012 to June 30, 2016, have been at the receiving end while making claims for medical reimbursement and seeking cashless treatment. The Association of University Teachers (AUT) has now taken up their cases with the State Government.

N Pasupathy, an Associate Professor of Electronics at the Erode Arts and Science College, an autonomous institution, was admitted to the Ganga Hospitals in Coimbatore in last August for a surgery to fix a fracture on his left leg. But when the hospital and he tried to get pre-authorisation of the United India Insurance Company Limited for treatment, they did not receive an affirmative response. Subsequently, Pasupathy paid `54,000 towards the hospital bills and got discharged.

Later, when he wrote to the insurance company seeking reimbursement, the company refused to pay up, stating that the treatment was taken without getting pre-authorisation approval. As per clauses, the scheme a “cashless’ scheme and therefore, no payment should be made to the approved hospitals by the insured employee. But Pasupathy said in his case, the failure to get pre-authorisation was not his fault.

In another case, professor V Kannan, Head of Department of Botany and Microbiology at the National College, an autonomous institution in Tiruchy, was denied full reimbursement of hospital bills. Kannan was admitted to the KMC Specialty Hospital, Cantonment in Tiruchy, last October after he sustained an injury on his left femur bone. He was operated by an orthopedic surgeon for correction of fractures and discharged from the hospital.

During the treatment he was reportedly informed by the hospital that the expenses incurred towards the surgery would be fully covered under the Orthopedic Surgery Category II listed in the NHIS 2012 and claimed from the United India Insurance Company.

However, when he was discharged, the hospital told him that the insurance company had sanctioned only `29,000 and he had to pay the balance `52,480 from his pocket.

Taken aback, Kannan then wrote to the United India Insurance Company to reconsider their decision and settle his claim in full. But the company refused to accept his claim.

In both cases, the insurance company forwarded the requests for medical reimbursements to the State Finance (Salaries) Department.

“When AUT State office bearers appealed to the Joint Secretary, Finance (Salaries), for favourable disposal, we were greeted with negative attitude,” says K Pandian, president, AUT (TN).

The AUT has now approached the State Finance Secretary urging him to intervene in the issue. Besides, it has asked him to take steps to disburse NHIS ID cards for all eligible employees.



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