Can My Office Mate's Medical Claim for His Wife Be Approved Under Our Policy?

Request for Expert Advice on Medical Claim Policy

My office mate approached me regarding the medical treatment of his wife last month, which cost more than fifty thousand. After the treatment, he submitted a claim for the medical treatment amount. However, HR responded that, according to the medical claim policy adopted by the company, medical claims for dependents cannot be processed. The policy states that only medical claims for employee treatments can be processed, not for their dependents. (The firm is registered under the provisions of the Shops and Commercial Establishment Act, and the workplace of the company (site) in (Village) is not listed in the villages notified by ESIC).

Please provide clarity with your expert advice on the above matter.

Thank you.

Normally, Shops and Establishments Acts do not apply to villages unless specifically notified. Reimbursement of medical expenses under medi-claim insurance policies would be limited to the coverage offered by the insurer. If dependents are not included in the policy coverage, no reimbursement can be claimed.

Dear, Mediclaim policies may vary in terms of coverage, some covering only employees while others also include dependents.

As Umakant Sir rightly pointed out, the benefits align with the policy chosen, likely covering employees exclusively. To extend coverage to dependents, the employer would have to pay additional premiums.

On the day of the accident, it would have been advisable to inform the nearest ESI dispensary and seek recommendations for hospitals in the absence of ESI-listed facilities in your area. Alternatively, your employer could have contacted the ESI dispensary on your behalf.

It's important to note that 6.5% of your gross income contributes to ESIC for benefits in such situations. In the event of accidents, individuals should promptly notify and seek treatment at the nearest ESI facility. If ESI hospitals cannot provide permanent treatment, they can refer cases to other hospitals for which expenses are reimbursed under the ESI Act.

In your situation, given the absence of ESIC hospitals, by highlighting the urgency of the accidents to ESI personnel, you could have obtained recommendations for external hospitals and submitted bills for reimbursement.