Facing ESI Claim Rejection for High Medical Costs: Is This Justified?

ESI Claim Rejection Issue

One of our employees, who is registered under ESI, is suffering from a heart problem. In an emergency case, he visited a hospital (the hospital has a contract with ESI). The hospital was not willing to take the case as their long payment is due with ESI. The hospital said they would only take the case if the employee makes a cash payment and promised to assist in claiming from ESI. Now, all the payments have been made, and all the information has been provided to ESI. They also mentioned that they will make the payment.

We have completed all the paperwork for the claim, but ESI is stating they cannot accept the papers as the claim amount is too high (around 3.5 lakhs). My question is, even after following ESI's instructions, can ESI reject the claim on the grounds that the claim is too high? Then what's the need to contribute to ESI?

Thanks,

Abhishek Das

1. Sir, ESI has its own instructions and procedures, as well as rate contracts with the tie-up hospitals. Therefore, the bill that the insured person has submitted is to be examined by the competent authorities, keeping in view its procedures, rates, and instructions.

2. Since the employee has submitted his claim (as mentioned by you in the thread), it is better if the matter is regularly pursued with the authorities with whom the bill is pending.

3. In case of rejection or any part rejection of the claim, the claimant can appeal to higher authorities, including the Headquarters Office of ESIC in New Delhi. If considered suitable, the affected employee/insured person can also file a case for a claim under section 75 in the E.I. Court of the competent jurisdiction.