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Can't deny insurance over unlisted disease: High Court

Non-listing of a disease in the ‘recommended diseases’ list cannot be a ground for rejection of insurance claim, the Madras High Court has ruled.

“Once a person is validly covered by a health insurance scheme and he has taken treatment at an accredited hospital, he cannot be denied reimbursement of the cost of treatment on the ground that the ailment has not been included in the ‘recommended diseases’ list for reimbursement,’’ Justice T Raja observed while allowing a writ plea from G Simon Christudoss.

Accepting the arguments of advocate D Prasanna that a school employee had been unfairly denied reimbursement of costs involved in his eye surgery conducted at a city hospital, the judge said it was not open to the DEO, the competent authority, to say that the employee was not entitled for reimbursement of medical expenses as the disease he suffered from was not shown as one of the diseases on the list. The approach of the officer was unreasonable, the judge said. Christudoss, an assistant in Little Flower HSS  at Annamangalam in Perambalur district, had been subscribing to the government employees health fund scheme (TNGEHFS) since 1998 by paying a monthly premium. He took treatment for his eye problem in Vijaya Hospital, an accredited institution, in 2008.

Prasanna submitted that on the hospital’s advice and warning that unless he underwent an operation immediately he could end up losing vision completely, Christudass underwent the operation by spending Rs 1.17 lakh. In January 2008, when he submitted the bills for reimbursement, the DEO rejected them, saying that eye pressure had not been included in the list of specialized treatments.

Faulting the rejection order, Justice Raja said Christudoss had been subscribing every month to the government’s health scheme and the hospital too figured on the list of accredited hospitals for specialised/advanced surgeries. While so, the educational authorities ought not to have rejected the reimbursement claim, the Justice said, and directed payment of the entire claim amount with 8% annual interest to Christudass.

Article referred: http://newindianexpress.com/cities/chennai/Cant-deny-insurance-over-unlisted-disease-High-Court/2013/09/22/article1797106.ece

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