Employee Medical Expense Challenge: Seeking the right solution

  • Employee Medical Expense Challenge: Seeking the right solution

    Posted by Shraddha Singh on September 13, 2023 at 5:08 PM

    Hi, I have a real situation. An employee is working with a company, and he was previously covered by the ESI (Employee State Insurance) policy. After his appraisal, he shifted to the GMC (Group Medical Coverage) policy.

    A medical exigency has arisen, and he visited the hospital. However, his medical expenses exceeded his eligibility under the policy. Now, he is requesting additional expenses because he was not aware of the policy or was not educated about it by any HR personnel, even though the policy was available in the employee self-service portal.

    In this case, as a company, what should we do? If we choose to help him, it may have an impact on other employees, and they might also misuse this practice.

    What is the right approach to assist him?

    Sunny Suman replied 2 months, 3 weeks ago 4 Members · 6 Replies
  • 6 Replies
  • Padmini Veeranki

    September 13, 2023 at 5:30 PM

    Dear Shraddha

    It’s important to address it with care and fairness.

    Firstly, we should review the circumstances and facts surrounding the case. If the employee genuinely wasn’t aware of the GMC policy or wasn’t educated about it despite the policy being available in the employee self-service portal, it indicates a potential communication gap. It’s crucial to investigate whether there was a breakdown in communication or if the employee was not provided with adequate information about the policy transition.

    Here’s a suggested approach:

    Review the Communication: Examine the records of communication regarding the policy transition. Ensure that the employee received the necessary notifications and had access to the policy details.

    Assess the Situation: Consider the medical exigency and the extent to which the expenses exceeded the employee’s eligibility. If the employee’s request is reasonable and genuinely due to a lack of awareness, it may be appropriate to assist.

    Educate and Communicate: If the review reveals a communication gap, take steps to educate the employee about the policy and its coverage. Ensure that they understand the policy details going forward.

    Consider Exceptional Assistance: In exceptional cases where it’s clear that the employee was genuinely uninformed, and the expenses are significant, you may consider assisting the employee with a one-time exception. However, clearly communicate that this is an exception and not a policy precedent.

    Policy Review: Use this situation as an opportunity to review your communication and onboarding processes regarding policy changes. Ensure that employees are adequately informed and educated about any transitions in timely manner

    Prevent Misuse: To prevent potential misuse, emphasize the importance of adhering to policies and procedures. Reiterate that exceptions will only be considered in cases of genuine lack of awareness.

    I hope the above helps


    September 13, 2023 at 9:11 PM

    Hello Shraddha

    Though Padmini’s suggestion seems helpful and exhaustive, yet I would just add on to few more.

    1. Review of communication as suggested ought to be reviewed in the light of limits of the expenses to be covered and the procedure for submitting the claims.

    2. Documentation Review- It requires the review of the requisite documents to be submitted towards the claim including invoices, receipts and medical reports. It is to clarify the nature of expense and the medical necessity.

    3. Policy Review- Ensure that your company’s medical expense policies are compliant with all relevant laws and regulations.

    4. Preventive measures- It includes the further clear communication of policy claims, setting the the claim limits which may also include pre-approval/ pre-authorization before medical expenditure especially high cost treatments, outlining the consequences of misuse of medical benefits like disciplinary action.

    Hope it helps


  • Padmini Veeranki

    September 13, 2023 at 9:26 PM

    Just to add

    In simple steps first check answers to the below questions,

    How was the GMC enrollment done, I am sure the employee would have been communicated about the coverage and limit before issuing the card. Which itself is evidence that the employee is aware of band movement ( out of ESI Bracket).

    Check whether the hospitalization was in ESI network hospitals. Then,

    Check why the employee didn’t flash an ESI card for hospitalization if he/she was not aware of the Band movement (this will give you the answer if the person is playing games).

    Second, In case the hospitalization in ESI based hospital you Check when the ESI was terminated, in most cases the ESI is active for 6 months even though payment has not been made. so if not terminated and the card is active, you can ask the employee to give his ESI card for a record to the hospital.

    Having said the above, You can resort to legal action or involve a labor expert to resolve this, which again involves consultant fees and legal fees. If the difference amount is not huge, take it as a special case and clear the same from management on a compassionate basis.

    Hope this helps. In case you need to discuss this in length I am available please drop me a note at veeranki10@gmail.com

  • Shraddha Singh

    September 16, 2023 at 6:28 PM

    Thanks Padmini, for your valuable insight.

  • Shraddha Singh

    September 16, 2023 at 6:30 PM

    Thanks Mohit,

  • Sunny Suman

    September 17, 2023 at 9:50 AM

    Hello @shraddhasingh

    Thank you for sharing this real-life HR challenge. It’s a situation that many organizations may encounter, and addressing it appropriately is crucial. I think you have already received the guidance.

    In this case, considering the employee’s genuine lack of awareness about the policy change and the medical exigency, it’s important to balance compassion with fairness and consistency.

    Here are some steps you might consider:

    1. **Review the Policy:**

    First, ensure that the policy documents clearly outline the transition from ESI to GMC and the associated coverage limits. Verify that the policy information was indeed available in the employee self-service portal.

    2. **Communication:**

    If it’s found that the policy information was accessible, use this as an opportunity to improve communication within the organization.

    REINFORCE the importance of employees actively reviewing policy changes during transitions and regularly accessing the self-service portal for policy updates.

    3. **Assisting the current Employee:** While upholding the policy, consider offering some assistance to the employee as an exception in this case, given their genuine lack of awareness. However, make it clear that this is a one-time exception due to the unique circumstances. Emphasize that in the future, all employees are responsible for understanding their coverage. And NO ONE is to receive the benefits more than as per their eligibility.

    4. **Policy Reinforcement:** Use this incident as an opportunity to reinforce the policy and communication procedures. Conduct sessions or workshops to educate employees about their benefits and policies during transitions.

    5. **Monitor and Prevent Misuse:** To prevent potential misuse by other employees, closely monitor similar situations. Implement checks to ensure that employees are informed about policy changes and their responsibilities.

    By addressing this case with a balanced approach, you can assist the employee in need while reinforcing the importance of policy awareness. It also allows the organization to maintain fairness and consistency in benefits administration.

    Thank you for sharing this valuable real-world scenario, and I encourage other HR professionals in our community to share their insights and experiences on how they would handle such situations.

    I believe everyone else’s input are along similar lines. I want everyone to contribute so that we have maximum input and you get to choose the best answer @shraddhasingh what do you think?

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