MADURAI/SIVAGANGA: Unable to get full settlement for medical expenses incurred under State health insurance scheme, TN government employees have urged authorities to revise the terms and conditions of the insurance scheme to ensure that their medical expenses are covered in full.
According to sources, the State health insurance scheme was launched several years ago for providing healthcare assistance on a cashless basis to government workers and their family members. At least 203 treatment procedures and surgeries in 1,169 empanelled hospitals across the State are covered under the scheme. Each employee pays Rs.300 per month to a central government entity, which has a third-party agreement with a private agency, under the State government’s insurance scheme.
Recently, a school headmistress from Sivaganga district was admitted to a private hospital in Madurai for kidney transplantation. Though she was eligible for a reimbursement of Rs 10 lakh under the scheme, the government-approved insurance agency provided her only Rs 3.6 lakh for a bill running up to Rs 7.5 lakh. According to sources, the hospital pressured the patient to vacate her bed during the final stage of treatment when negotiations were under way with the agency for a full reimbursement. She was discharged from the hospital after she paid the bill in full but the agency refused to reimburse her fully. Similarly, a police constable from Madurai district said his wife underwent a gallbladder surgery at a private hospital and the bill came to around Rs 75,000. The insurance company, however, paid only Rs 20,000 and the remaining amount had to be paid by the constable.
Sources said the private agency entrusted with the responsibility of operating the scheme has fixed costs for treatment procedures and facilities. "If a patient chooses an air-conditioned room during treatment, the room rate may not be covered under the scheme. They have several such terms and conditions. It is impossible to verify all these terms before availing of an emergency medical procedure. They have also varying rates for different cities and different hospitals. Even when we demand approved reimbursements, they come up with several other excuses to avoid paying the claim in full," employees said.
According to officials, if employees are not satisfied with the insurance coverage, they could file an appeal with the administration, and officials will try to secure them full reimbursement based on genuineness of each case.