Hospitals in Chennai faced the highest number of denials under the Chief Minister’s Comprehensive Health Insurance Scheme followed by Madurai, Tirunelveli, Thanjavur and Coimbatore. File
| Photo Credit: The Hindu
Claim denials on “flimsy grounds” under the Chief Minister’s Comprehensive Health Insurance Scheme (CMCHIS) remain a contentious issue for many government hospitals in Tamil Nadu.
Documents accessed by The Hindu show that during 2024-2025 (as of January 29, 2025), nearly 29,000 policy claims from various government hospitals amounting to around ₹36 crore were denied for reasons of delay in submission/re-submission/query response, discrepancy and liaison officer sign issues. Hospitals in Chennai faced the highest number of denials followed by Madurai, Tirunelveli, Thanjavur and Coimbatore. Hospital-wise, Madurai Medical College, Madras Medical College, Government Royapettah Hospital and Government Stanley Medical College Hospital were among the institutions with the highest number of claim denials.
Claim denials for government hospitals are high, a senior doctor, on condition of anonymity, said. “We looked at a number of policy claims that were denied, and found that the reasons cited for denial were petty. For instance, they say an X-ray image, which was to be uploaded yesterday, was uploaded the next day, or a CT scan report was not submitted within 48 hours,” he said.
A doctor in Chennai provided a closer look at the major reasons for denials. “It starts with spellings of names. If the spelling of the patient’s name in the CMCHIS card and Aadhaar card varies, it is immediately rejected. Patients/their attendants are told to make the correction and come. Imagine telling this to a critically ill patient and his/her family. Claims for repeat procedures and repeat hospitalisations such as for patients on dialysis in case they have infections are turned down. Similarly, pre-authorisation for post-operative complications are also rejected,” he said.
“If a patient grievously injured in an accident is being wheeled in, isn’t it inhumane to ask the patient/family member to bring their CMCHIS card immediately? Some may be unconscious or may require to be admitted to the Intensive Care Unit. Seeking pre-authorisation within 48 hours of admission is impossible in many cases. So, if we submit for pre-authorisation after 48 hours of admission, it is turned down,” a government doctor in a central district said.
Also read | Association urges Health dept to ensure patients without insurance cards are treated
“Claims should not be denied for reasons like mismatch in names and radiological images not clear,” another doctor said. A surgeon noted that in his department, denials were mostly due to late card submissions or technical grounds. “A simple spelling mistake in CMCHIS card and investigation reports also leads to denial.” If replies to queries are not within 48 hours, it is rejected, another doctor said, adding that the State government should conduct an audit of the claims rejected.
Pre-authorisation approvals are increasingly becoming difficult, another specialist said. “Different reasons are being cited. If the names are wrongly spelt on the CMCHIS card and ration card, then it is an issue. If family members named on the ration card had died and the names were not deleted from the card, it becomes a problem. In fact, pre-authorisation for single ration card holders are outrightly turned down,” he said. In addition, the amount approved is reduced and only half or less is given citing some reason or the other, he added.
“If the total claims exceed the total premium amount paid, the government will pay the amount. What needs to be done is simplifying procedures. These documentation works should not come under the purview of a clinician,” another senior doctor said.
In 2023, the State government had constituted a committee to streamline the implementation of CMCHIS. However, the outcomes remain unknown, doctors said.
Health Minister Ma. Subramanian said he would look into the issue.
Published – February 21, 2025 07:30 pm IST