Thiruvananthapuram: Undercutting the state’s promise of cashless healthcare for its employees, pensioners and their dependents, nearly 1.25 lakh claims worth around ₹100 crore have been rejected under the MEDISEP health insurance scheme, official figures show.

Even more troubling is the larger number of cases where only a negligible amount has been sanctioned. By counting such cases among approved claims, insurance companies and the two third party administration (TPA) firms under them are effectively projecting an inflated approval rate, presenting a misleading picture to the government. However, there is little sign of intervention from the government.

Much like in the first phase of the scheme, several hospitals continue to levy steep charges in the second phase as well. Persistent technical glitches, largely attributed to outdated software systems, have become routine. Hospitals frequently cite these issues to deny cashless treatment and insist on advance payments. Even at the time of discharge, patients are often asked to settle bills, with software failures once again offered as justification.

Under the agreement with the government, hospitals are permitted to bill only a fixed amount for the treatment of each illness. However, many are inflating bills, claiming the sanctioned portion from the insurance company and recovering the balance directly from patients. Hospitals, on their part, maintain that the rates fixed by the insurer are too low.

In one such instance, a private hospital in Kochi billed ₹81,000 for treating paralysis in a dependent of a GST department official. Of this, only ₹24,000 was approved under MEDISEP, forcing the family to bear the remaining expense out of pocket.

Insurer denies stroke claim, cites ‘no need’ for admission
A MEDISEP claim filed by an 80-year-old man who underwent treatment at the Sree Chitra Tirunal Institute for Medical Sciences and Technology following a stroke has been rejected by the insurance company on the grounds that `hospitalisation was not needed'.

The claimant, K Ravindran, a native of Kadakkal and a retired Additional Labour Commissioner, was left aggrieved by the decision. Following this, he was forced to bear the entire treatment cost of ₹2.8 lakh out of his own pocket.

Ravindran suffered a stroke at his home on February 7 and was admitted with paralysis in his left leg to the KIMSAT Cooperative Hospital in Kadakkal. As his condition worsened, he was later shifted to the Sree Chitra Tirunal Institute for Medical Sciences and Technology on March 25 on doctors’ advice. He was diagnosed with a blockage in the blood vessels in his neck and subsequently underwent surgery.

However, when he later submitted his claim online along with bills and supporting documents, the insurance company rejected it, stating that inpatient treatment was not required. Ravindran is now preparing to file an appeal with the government.