ESIC claim refused as we claimed from different insurance

Dear All,

I would like to inform you that one of our employees has been working with us for 5 years. Recently, he had a heart problem and immediately went to a nearby hospital where he was admitted for an open-heart operation. However, he did not inform us or ESIC (Employee State Insurance Corporation) at that time. Only after 3 to 4 days did he inform us. The total bill amounted to Rs. 250,000, out of which he claimed Rs. 70,000 from a different insurance provider.

We have now approached ESIC to claim the remaining balance, but the ESIC dispensary has refused to pay because we had already claimed Rs. 70,000 from a different insurance provider. The ESIC doctor stated that if any amount, even Rs. 1, is claimed from another insurance company, ESIC dispensary will not pay.

Please advise on how we should proceed in this situation.

Regards,
Purushothaman
**Location**: Bengaluru, India

Understanding ESIC Claim Rejection Due to Multiple Insurance Claims

In this scenario, the ESIC dispensary's refusal to pay the remaining balance after the employee has already claimed Rs. 70,000 from a different insurance provider is based on their policy regarding multiple claims. Here's how you can proceed:

1. [Icon] Review ESIC Policies: Check the ESIC guidelines and policies regarding claim settlements and multiple insurance claims. Understanding the specific rules will help you navigate the situation more effectively.

2. [Icon] Communicate with ESIC: Engage in direct communication with the ESIC authorities to get a clear understanding of why the claim was rejected. Seek clarification on the exact policy provision that led to the rejection.

3. [Icon] Employee Notification: Ensure that the employee is informed about the situation and the reason for the claim rejection by ESIC. Transparency and clear communication with the employee are crucial in such cases.

4. [Icon] Explore Alternatives: Consider discussing the matter with the different insurance provider from whom the employee claimed Rs. 70,000. Check if there are any possibilities of revising the claim or seeking reimbursement for the amount claimed.

5. [Icon] Legal Consultation: If necessary, seek legal advice to understand the legal implications and options available to address the situation. A legal expert can provide guidance on the best course of action to resolve the claim rejection issue.

6. [Icon] Appeal Process: In case you believe that the claim rejection is unjust or there are grounds for appeal, follow the formal appeal process outlined by ESIC. Provide all necessary documentation and evidence to support your appeal.

7. [Icon] Employee Support: Offer support to the employee during this process, including guiding them on potential next steps and assisting in resolving the claim rejection issue.

By following these steps and actively engaging with the relevant authorities, insurance providers, and legal experts, you can work towards a resolution regarding the ESIC claim rejection due to multiple insurance claims.