Insurance company told to reimburse liver transplant cost of Medisep beneficiary at non-empanelled hospital
Though the Medisep scheme came into existence with effect from July 1, 2022, the insurance company had not published the list of empanelled hospitals then, the pensioner said in his complaint. The total hospital expenses was Rs 20,54,901. He also had a health insurance policy issued by New India Assurance. As the claim under Medisep was not allowed, he submitted a claim with New India Assurance and the latter remitted Rs 3,69,367 at the hospital. He paid the balance amount. However, due to chronic ailments, he was hospitalised two times again for which Rs 1,21,656 was spent. These claims too were rejected by Medisep.
The Additional Chief Secretary (Finance) submitted that the petitioner was not entitled to claim benefit for treatment at a non-empanelled hospital. Liver transplant was a planned procedure and not an emergency procedure (for which non-empanelled hospitals will be considered). The insurance company rejected the allegation that the list of empanelled hospitals was not published at the time.
The case was considered by the Lokpal bench comprising members V N Radhakrishnan and E Mohammed Shereef. The petitioner was represented by advocates S Reghukumar, P Babu and Threya J Pillai.
The Lokpal observed that the surgery was done in an emergency situation as there was no alternate option for the petitioner's survival. The insurance firm failed to empanel two private hospitals for transplant surgeries under Cluster-3 of the Medisep Scheme. At the time, the organ of a deceased donor was available only at the hospital where he sought treatment. Hence, the petitioner is entitled for the reimbursement of treatment expenses up to the package cost in Annexure-2 of the scheme. It directed the firm to pay Rs 18 lakh to the petitioner with 6% interest from April 18, 2023, and Rs 10,000 as costs.
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