I have submitted my 8-year-old daughter's private hospital bills of Rs. 8,98,810/- on 02.02.2019. For this, they have reimbursed Rs. 4,29,103/-. This amount is less than 50% of my claimed amount.
Brief History
My daughter has been suffering from multifocal epilepsy since she was 7 years old. We have consulted various neurologists, including NIMHANS Bangalore, over the last 7 years. Finally, with the reference of our relative (who is a neurosurgeon in the same hospital), we consulted KIMS Secunderabad. They diagnosed the exact problem and suggested surgery. The surgery consists of two phases: the first one is Stereovideo EEG (to detect the exact location of the damaged brain part), and the second one is to remove the part. The estimation given was around 10-12 lakhs. Along with the estimation and request for permission letters, I met our local ESI hospital superintendent. They mentioned that they couldn't provide interstate treatment permission (KIMS Secunderabad), and I would have to seek treatment within the state at our tie-up hospital. However, there was no ESIC tie-up hospital with the facility for the surgery mentioned. Subsequently, our Hubli ESI hospital forwarded my request letter and surgery estimation letter to the Regional Director's office in Bangalore.
I personally took the forwarded letter and met the State Medical Officer at the RD office in Bangalore in June 2018, along with all the medical reports. They inquired about the surgery with various ESI tie-up private hospitals, but there was no facility available in Bangalore either. Initially, they did not approve the treatment due to it being interstate. Meanwhile, my daughter's condition was deteriorating, so I started following up regularly regarding permission. One day, the State Medical Officer called me and mentioned that I could proceed with the treatment, and they would try to reimburse around 75%. We underwent the 1st phase of surgery in September 2018 and the 2nd phase in January 2019, submitting the bills in February 2019.
After receiving a lesser amount, I called the State Medical Officer, who stated that they reimbursed according to government rates and that was the maximum help they could provide. I feel this is unjust since the treatment received is not available in any government hospital or ESIC tie-up hospital in my state. I have 7 years' worth of medical documents, with 2-3 neurosurgeons suggesting the surgery. One neurosurgeon specifically mentioned that the patient required Stereotype surgery, a facility not available in the entire North Karnataka region. I have also consulted many hospitals in Bangalore via email regarding this surgery, and they all replied stating that no facility was available. Now, can you suggest how I can fight for this?
From India, Bengaluru
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Brief History
My daughter has been suffering from multifocal epilepsy since she was 7 years old. We have consulted various neurologists, including NIMHANS Bangalore, over the last 7 years. Finally, with the reference of our relative (who is a neurosurgeon in the same hospital), we consulted KIMS Secunderabad. They diagnosed the exact problem and suggested surgery. The surgery consists of two phases: the first one is Stereovideo EEG (to detect the exact location of the damaged brain part), and the second one is to remove the part. The estimation given was around 10-12 lakhs. Along with the estimation and request for permission letters, I met our local ESI hospital superintendent. They mentioned that they couldn't provide interstate treatment permission (KIMS Secunderabad), and I would have to seek treatment within the state at our tie-up hospital. However, there was no ESIC tie-up hospital with the facility for the surgery mentioned. Subsequently, our Hubli ESI hospital forwarded my request letter and surgery estimation letter to the Regional Director's office in Bangalore.
I personally took the forwarded letter and met the State Medical Officer at the RD office in Bangalore in June 2018, along with all the medical reports. They inquired about the surgery with various ESI tie-up private hospitals, but there was no facility available in Bangalore either. Initially, they did not approve the treatment due to it being interstate. Meanwhile, my daughter's condition was deteriorating, so I started following up regularly regarding permission. One day, the State Medical Officer called me and mentioned that I could proceed with the treatment, and they would try to reimburse around 75%. We underwent the 1st phase of surgery in September 2018 and the 2nd phase in January 2019, submitting the bills in February 2019.
After receiving a lesser amount, I called the State Medical Officer, who stated that they reimbursed according to government rates and that was the maximum help they could provide. I feel this is unjust since the treatment received is not available in any government hospital or ESIC tie-up hospital in my state. I have 7 years' worth of medical documents, with 2-3 neurosurgeons suggesting the surgery. One neurosurgeon specifically mentioned that the patient required Stereotype surgery, a facility not available in the entire North Karnataka region. I have also consulted many hospitals in Bangalore via email regarding this surgery, and they all replied stating that no facility was available. Now, can you suggest how I can fight for this?
From India, Bengaluru
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Based on the situation described, it seems you have faced challenges with ESIC reimbursement for your daughter's surgery. Here are some steps you can consider to address this issue:
1. Review ESIC Policies: Check the ESIC policies and guidelines regarding reimbursement for medical treatments. Ensure you understand the criteria and rates for reimbursement.
2. Document Verification: Double-check all submitted documents to ensure accuracy and completeness. Any missing information or discrepancies could lead to reduced reimbursements.
3. Appeal Process: Inquire about the formal appeal process within ESIC for challenging reimbursement decisions. Follow the necessary steps to appeal the amount provided.
4. Legal Consultation: If necessary, seek legal advice to understand your rights and options. A legal expert can guide you on the best course of action to pursue fair reimbursement.
5. Medical Justification: Compile all medical reports, recommendations, and expert opinions supporting the necessity of the surgery. Present this information to strengthen your case for higher reimbursement.
6. Escalation: If initial appeals do not yield satisfactory results, consider escalating the matter within the ESIC hierarchy or to relevant authorities for further review.
7. Advocacy Groups: Explore support from advocacy groups or organizations specializing in healthcare rights. They may provide valuable assistance and resources in advocating for fair reimbursement.
8. Persistence and Communication: Maintain regular communication with ESIC officials, emphasizing the critical nature of the surgery and the financial burden faced. Persistence and clear communication can sometimes lead to a more favorable outcome.
Remember to approach the situation with patience and persistence while advocating for your daughter's medical needs.
From India, Gurugram
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581. Review ESIC Policies: Check the ESIC policies and guidelines regarding reimbursement for medical treatments. Ensure you understand the criteria and rates for reimbursement.
2. Document Verification: Double-check all submitted documents to ensure accuracy and completeness. Any missing information or discrepancies could lead to reduced reimbursements.
3. Appeal Process: Inquire about the formal appeal process within ESIC for challenging reimbursement decisions. Follow the necessary steps to appeal the amount provided.
4. Legal Consultation: If necessary, seek legal advice to understand your rights and options. A legal expert can guide you on the best course of action to pursue fair reimbursement.
5. Medical Justification: Compile all medical reports, recommendations, and expert opinions supporting the necessity of the surgery. Present this information to strengthen your case for higher reimbursement.
6. Escalation: If initial appeals do not yield satisfactory results, consider escalating the matter within the ESIC hierarchy or to relevant authorities for further review.
7. Advocacy Groups: Explore support from advocacy groups or organizations specializing in healthcare rights. They may provide valuable assistance and resources in advocating for fair reimbursement.
8. Persistence and Communication: Maintain regular communication with ESIC officials, emphasizing the critical nature of the surgery and the financial burden faced. Persistence and clear communication can sometimes lead to a more favorable outcome.
Remember to approach the situation with patience and persistence while advocating for your daughter's medical needs.
From India, Gurugram
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ESIC Form-Medical Expense Reimbursement.p df
Medical Reimbursement Format.doc